Fifty-seven percent of adults have had chronic or recurrent pain in the last year.1 Seventy five percent of all adults make adjustments to their life due to pain.1 Spinal fusion rates have increased by 77% from 1993 to 2001 – costing 16.9 billion dollars.1 This was staggering as comparatively, as Dr. Flynn notes this is more than the US puts into foreign aid in a year, and eight times more than we put into cancer research.
Back pain will be prevalent in most people’s stories – how we respond to it is a choice that can define the outline of this story. We can change sensory input, social work environment expected consequences, beliefs, knowledge, along with impairment seen on a physical exam as physical therapists.1 Cognitive behavioral therapy, and pain science has caught some steam in the physical therapy world over the past few years. This trend is eloquently placed as therapists spend more time with patients than most of our healthcare counterparts. Unfortunately, this knowledge was not started in doctoral programs, or in my undergraduate degree but as flourished since graduation. I do think this trend has changed since my departure from the educational system, as it seems obvious that as therapists treat pain – we should have a vast understanding of what it is and how to modulate it.
Pain science has grown in understanding from its conception of a linear approach of stimulus, afferent input and response to a neurological matrix that involves multiple factors that change perception and experience of painful stimulus.1,3,13 The complexity lies as there is not one area that controls pain in the brain – thus tracking responses are integrated in numerous areas.14 We know that a chronic low back pain patient has hyperactive cortical responses that are telling the system that there is a constant threat and alert.1,3,13,14 Dr. Mosley gave an excellent understanding of how this process can be distorted as he runs through the difference between a first time response compared to pain experience of a threatened and previously heightened system.13 As physical therapists, we need to understand the difference between these two and how this changes our outcomes.
For example, patient A is a 45-year-old female presenting with chronic low back pain that has been managed by chiropractic care since she was 15. Fear Avoidance Beliefs Questionnaire Work (FABQw) within intake is 36, which is elevated. Patient states that she gets monthly imaging of her spine to ensure alignment and she gets an adjustment which makes her feel better and can return to activity. Side note, an FABQ < 19 is part of the CPR to identify patients who will be more successful with manipulation – which this patient falls way above. Not saying she isn’t appropriate for manipulation – but something a clinician should address. Patient states that she knows that exercise is helpful for weight loss but regardless makes her low back hurt. Pain is worse with all rotation, all core exercises, and all weight bearing lifting – she continues to complete these but know every time she will mal-align her spine and return to chiropractic for care. This cycle occurs monthly – or less.
So what has happened with her nervous system is beautifully outlined by this weeks readings, and then I will transition to what I will now change based on these findings.
Patient A has a self-limiting condition of chronic low back pain. As most structures heal within weeks to months, why does she have pain? Initially Patient A had an initial stimulus and possibly a primary hyperaglesia case. This was then stimulated with a patho-anatomical model and repeat x-ray imaging placing importance of a “mal-alignment” of her spine. During pain, immune activity is modified, the hypothalamus-pituitary-adrenal axes and sympathetic nervous system is altered and as the visuomotor systems are activated, thus pain is the cortical output at its highest priority.3 Pain is now at the forefront of her attention. During this process, trunk muscle studies have demonstrated that pain reduces modulation of muscle activity during dynamic movements, which drives higher splinting of the lumbar spine. This is speculated to create some pseudo-stiffness from muscular guarding. This response is driven by a hypersensitive higher center orders to maintain co-contraction of the lumbopelvic muscles to protect in those painful ranges: i.e – core exercises, lifting weights, and twisting.3 This appears to be motivated by an exaggerated withdrawal motor reaction to pain. This leads to high levels of compressive loading across articulations of the spine, rigidity of her movement patterns, thus resulting in a mechanism for tissue strain and ongoing peripheral nociceptor sensitization telling the body it is in danger. Overall, this means – guarding makes the spine stiff – and especially if someone incorrectly images the spine and develops a patients fear of mal-alignment – the upper cortical processing system overdrives this process and modulates her to feel pain every time.
It is important to achieve the following in therapy: reduce the threatening input (nociceptive mechanisms and non nociceptive mechanisms) with education and non-threatening rehabilitation.2 It has been demonstrated that mal adaptive coping strategies, negative thinking, pathological fear, anxiety regarding pain, avoidance behavior, catastrophizing, and hypervigilance has been shown to increase levels of pain, disability and muscle guarding.2 Therefore, it is my job to tap into her nervous system and with the help of the patient we can cut down these behaviors and expectations.
Notably so in clinic – I have noticed the emotional strain it can take to enter therapy for chronic low back pain, especially with high fear avoidance behaviors, and pre conceived notion that a pathology based impairment is a driver of all symptoms. To achieve optimal outcomes, an interdisciplinary approach is best. In my practice, I work with a few pain psychologists to assist in emotional triggers, pain coping strategies to overall assist in “unwinding” the nervous system. Second, I have patients buy “Explain Pain” to help generalized understanding of what pain is. Then lastly, I venture into graded-pain free exercise routines to promote movement, and decrease guarding.
Dr. George did an excellent job at reminding me of factors I am missing in this puzzle. Including, to really take the time to identify the factors that create fear for the spine then strip them down to the basic components and sending them home to experience. Also, manual techniques for these patients should match their sensitivity. If they are fighting back or guarding within the technique – this can add into the nociceptive pain response. Lastly, Dr. Badell’s article discusses words that harm or healing – this is another point of improvement. He reminds us that healing language can be silent to allow the patient to consider the suggestions and allow time for the patient to ask follow up questions is explicitly important in this population as the chronicitiy of their system can impair cognitive functioning.6,3,4 Silence is not my virtue – something to improve. Patient A requires what Dr. Fersem recommends where we shift away from a biomedical model to viewing her chronic low back pain as a biopsychosocial disorder and we need to treat the beliefs and behaviors to achieve outcomes desired.7 Therefore, consideration of activity pacing, problem solving, cognitive restructuring, goal setting, attention diversion and management strategies should be on the horizon for management of chronic low back pain.8
This patient continues to see great outcomes but this is a challenge as the paradigm shift for her is changing 30+ years of beliefs.
My last question is how do I identify these patients to run through this added concept? Dr. Benecuik provides an excellent paper that discusses items that can be possibly used in clinic including: FABQ, SBT, TSK-11, and the Pain Catastrophizing Score (PCS). Initial screening with the SBT can provide prognostic information about the treatment of chronic low back pain to assist in minimizing pain and disability.9,10 Using these tools may assist in identification process of patients with fear avoidance scores. As Calley et al demonstrated, we don’t have the ability to identify these patterns in clinic as well as these tools do – thus administering the test is vital to finding the patient that can benefit from either cognitobehavioral adaptations in clinic or an interdisciplinary approach to managing their behaviors.
Hopefully, future management for patients as discussed would catch the harmful words at its origin. If we could only catch Patient A at age 15 to say that back pain can be normal – not to worry – you are in good hands here and we will get this figured out but in the meantime continue to move. Maybe then we can save the deleterious affects that are to come of 30 years or more of developing sensitivity to lumbar spine pain. Thus, we are now answering the question that her nervous system may be a container full of lies and misconstrued information.
“Bad things do happen; how I respond to them defines my character and the quality of my life. I can choose to sit in perpetual sadness, immobilized by the gravity of my loss, or I can choose to rise from the pain and treasure the most precious gift I have – life itself.” Walter Anderson.
Original post: February 9, 2014
- Dr. Tim Flynn. Stop The Pain, Stop The Madness. Lecture performed by Evidence in Motion. February 11, 2014.
- Osullivan P. Diagnosis and classiﬁcation of chronic low backpain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Manual Therapy. 2005; 10: 242-255.
- Moseley G. A Pain Neuromatrix Approach to Patients with Chronic Pain. Manual Therapy. 2003; 8: 130-140.
- Dr. Tim Flynn. Chronic Low Back Pain Management. Lecture performed by Evidence in Motion. February 11, 2014.
- Dr. Steven George. What to do when Pain Doesn’t Go Away: Graded Exercise and Graded Exposure. Lecture performed by Evidence in Motion. February 11, 2014.
- Bedell. Words That Harm, Words That Heal. ARCH INTERN MED/VOL 164, JULY 12, 2004.
- Fersum K, O’Sullivan P, Skouen J, Smith A, Kvale A. Efficacy of Classification-Based Cognitive Functional Therapy in Patients with Non-Specific Chronic Low Back Pain: A Randomized Controlled Trial. EIP. 2012; doi:10.1002/j.1532-2149.2012.00252.
- Rundell S, Davenport T. Patiend Education Based on Principals of Cognitive Behavioral Therapy for a Patient With Persistent Low Back Pain: A Case Report. JOSPT. 2010; 40: 492-500.
- Benecuik J, Bishop M, Fritz J, Robinson M, Asal N, Nisenzon A, George S. The Start BAck Screening Tool for Individual Psychological Measures: Evaluation of Prognostic Capabilities for Low Back Pain Clinical Outcomes in Outpatient Physical Therapy Settings. 2013; 93: 321-333.
- Nicholas M, George S. Psychologically Informed Interventions for Low Back Pain: An Update For Physical Therapists. Physical Therapy. 2011; 91: 765-787.
- Calley D, Jackson S, Collins H, George S. Identifying Patients Fear Avoidance Beliefs by Physical Therapists Managing Patients with Low Back Pain. JOSPT. 2010; 4: 774-784
- Dr. George. Psychologically informed Practice and Psychosocial Considerations. Lecture performed by Evidence in Motion. February 11, 2014.
- Lorimer Mosley. Pain? Is it All in Your Mind? Lecture performed by Body in Mind. May 12, 2011. http://www.bodyinmind.org/knowledge-works-unisa-lecture-lorimer-moseley/
- Elliot Krane: Mystery of Chronic Pain. Lecture by TED Talks. May 2011.http://www.ted.com/talks/elliot_krane_the_mystery_of_chronic_pain.html