Chronic back pain is a pervasive issue affecting millions worldwide, particularly among middle-aged adults. It can be debilitating, affecting daily activities, work productivity, and overall quality of life. Understanding the root causes of chronic back pain and exploring a multidisciplinary approach to treatment can offer significant relief and improve well-being.

Causes of Chronic Back Pain

Chronic back pain can be complex, with multiple factors contributing to its development, but it usually starts with a mild injury.  This could be a strain on a muscle or a ligament, or it could come from the disc bulging and pushing on nerves.  Ordinarily, an initial injury would improve in the typical tissue healing time frames, but chronic pain, commonly described as pain lasting longer than 3 months, doesn’t just go away.

Pain Science studies the interactions between our body, our mental state, and our environment to help us better understand why a person who should get better sometimes ends up with chronic pain.

For many therapists and patients, pain is often seen as a mechanical issue: something is pinching, so it needs to be moved to alleviate the pain. This is why a surgeon might operate on a herniated disc to remove the part pressing on a nerve, aiming to relieve the pain. However, this model doesn’t always produce the desired results. For example, it is common to see herniated discs in people who do not have pain (1), and there are well-documented cases of phantom limb pain where the person experiences pain in an area that isn’t even there.
Conversely, there are people who have debilitating pain with no visible structural cause seen on MRIs.  So, we can’t say that the ‘mechanical model of injury = pain’ is reliable.

Thanks to the research of experts like Gordon Waddell, a spine surgeon who screened patients before surgery for factors that might impede their recovery, we now understand that issues such as lawsuits for compensation, depression, and severe pain without tissue injury can all contribute to chronic pain (2). But why is this?  What is happening in the body to cause this, and what can we do about it?

I really like reading the work of the physiotherapist Louis Gifford.  He spent most of his career thinking about chronic pain and how to treat it better.   He used models to help explain some of these complex topics, and one of the models he referred to was the Mature Organism Model or MOM. In this model, the brain is seen as a ‘scrutinizing’ organism that constantly analyzes information from the body, external environment, and memories.  It uses information from these 3 areas and overlays them on our innate evolutionary reflexes to make some decisions.

When it works well, it goes something like this:

A person is running in a race, takes a misstep, and sprains their ankle. The brain processes the pain information from the ankle and compares it to past experiences. This individual has had a mild sprain before that healed quickly, and the current pain feels similar. Assessing the environment, the brain notes that it’s only a few kilometers to the finish line, and overcoming the sprain will make for a good story. The person gets up, finishes the race, and feels proud. The next day, the ankle is swollen, but they continue their daily routine, which helps reduce inflammation and keeps the muscles strong. Within a few days, they forget about the injury. The combination of information from the injury, past experiences, and the current environment contributes to a swift recovery.

But how does someone go on to develop a chronic condition?

Consider Dave’s situation: he has just slipped at work and is now lying on the warehouse floor, experiencing excruciating back pain that immobilizes him. His brain is processing the pain signals from his back, trying to interpret them, especially since he has never previously injured his back. Recalling his uncle’s experience of a work-related slip resulting in long-term disability benefits, Dave begins to fear he has sustained severe damage. The warehouse supervisor notices Dave’s distress but lacks experience with back pain, unaware that back injuries often cause more intense pain than injuries to other parts of the body and that pain severity doesn’t always correlate directly with the extent of injury. Dave is advised to remain still “just in case it’s serious,” and emergency services are summoned. 

As time passes, Dave’s muscles begin to stiffen, worsening his pain. Eventually, he is taken to the hospital, where he receives a clean bill of health and is instructed to rest. However, due to the severity of his pain, Dave remains convinced that something has been overlooked. Luckily, his wife and kids rally around him, and he doesn’t have to lift a finger in the house. However, we might be able to see trouble ahead for Dave for the following reasons:

1. He’s got a family member who had a bad outcome from an injury to his back at work (negative memories)
2. His medical team told him to rest, and we have a family that will facilitate that. (Lack of movement)
3. Dave didn’t really like his job, and his boss told him to take as long as he wanted to recover (No motivation to heal)
4. A couple of the other lads at work think he should sue for damages. (Motivation to stay in pain)
5. After a week of rest at home, Dave realizes that his back muscles have weakened, and he experiences nearly constant pain when he moves. Convinced that more rest is necessary, he decides against returning to work and contemplates legal action (Negative association between movement and pain)
6. No one at work really misses Dave, and they don’t contact him to see how he is doing, and he feels depressed by that. (Depression can lead to increased sensation of pain).

Can you see how this is setting Dave up for chronic pain?

What is the best way to help Dave?

A Multidisciplinary Approach to Treatment

Treating chronic back pain often requires a comprehensive, multidisciplinary approach.  This could be delivered by a team of healthcare experts, or many of these components could be delivered by a well-trained therapist.

Here are some key components of such a strategy:

1. Exercise Therapy: Most therapists offer a structured exercise program tailored to the individual to improve flexibility, strength, and endurance. According to a study published in the Journal of Orthopaedic & Sports Physical Therapy, exercise therapy is a cornerstone in managing chronic back pain (3).
2. Medical Management: This can include medications for pain relief, such as nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, or even corticosteroid injections for severe pain. A review in The Lancet highlighted the role of combination pharmacotherapy in managing chronic pain, emphasizing the importance of individualized treatment plans (4).
3. Cognitive Behavioral Therapy (CBT): As we can see, chronic pain is not just a physical experience but also a psychological one. CBT can help manage the mental health aspects of chronic pain. Research published in Pain Medicine indicates that CBT can effectively reduce pain and improve psychological outcomes for chronic pain sufferers (5).
4. Complementary Therapies: Practices such as osteopathy, acupuncture, chiropractic care, and massage therapy can provide additional relief, but it’s important to understand that a good therapist wouldn’t just deliver massage or manipulation without addressing all the other components listed here.
5. Lifestyle Modifications: Weight management, proper posture, quality sleep, and stress reduction techniques can all help reduce chronic back pain.

The Importance of a Personalized Approach

Chronic back pain can significantly impact your life, but understanding its causes and exploring a multidisciplinary approach to treatment can make a substantial difference. By combining physical therapy, medical management, cognitive behavioral therapy, alternative therapies, and lifestyle modifications, you can effectively manage and alleviate chronic back pain.  If you want to discuss your specific situation with me, please contact me via the Contact Us page. We’ll see if we can make ‘your lifestyle your medicine.’

References:

1. https://www.ncbi.nlm.nih.gov/books/NBK441822/#:~:text=In%20many%20instances%2C%20the%20herniation,six%20weeks%20of%20persistent%20symptoms.
2. https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-tools/orthopaedic-and-musculoskeletal/acute-low-back-pain#:~:text=Whilst%20the%20presence%20of%20red,term%20disability%20and%20work%20loss.
3. https://www.jospt.org/doi/10.2519/jospt.2021.0304
4. https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(13)70193-5/abstract
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5999451/#:~:text=Previous%20studies%20have%20shown%20that,%2C%20stress%2C%20and%20chronic%20pain.&text=Additionally%2C%20CBT%20has%20been%20reported,pain%2C%20arthralgia%2C%20and%20fibromyalgia.

 

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