Chronic Low Back Pain – The Psychological Factors
If you are a regular reader of MCR, you know that the number of people suffering from low back pain is quite staggering. The national statistics is that one out of every 5 persons suffers from lower back pain at any one time and that there is an 80% chance of a person having low back pain sometime in their lives. One of the key things in treating chronic low back pain is the correct classification of it and understanding the contribution factors. Of these factors less often addressed by physiotherapists is the psychological factor.
With chronic low back pain (classified as those persisting 3 or more months from the onset of pain), the treatment approach needs to be multi-dimensional as there are many factors that perpetuate the pain. Some of these factors include
- Pathological changes in the structure of the spine – e.g. joint degeneration, disc herniation (slipped disc), fractures
- Mechanical loading of the spine- possibly due to the type of work that the back pain sufferer has to perform
- Poor control of the muscles around the spine
- Sensitivity of the nervous system- the brain and the nerves are over sensitised to pain, projecting pain greater than it really is
- Psychological factors- clients’ emotions e.g. fear, anxiety depression, their beliefs that if they do a certain activity that their backs will go, being wheelchair bound or something catastrophic, and often wrongly reinforced by a healthcare professional.
The relative contribution and dominance of the above factors to a client’s chronic low back pain will differ for each patient. It is important to understand which factors are dominant and whether the client has adapted to the disorder positively or negatively so we can address the disorder more specifically.
One of the more common types of chronic low back pain we see are clients who have really stiff backs and have difficulty bending. Usually the original cause of the pain is due to some bending activity like lifting a child or reaching over to retrieve something. These clients may or may not have significant changes in their MRI of the spine. These people are often told that bending is bad for you and that they must hold their back upright all the time and to sit up tall, otherwise, their discs will get worse. This results in the clients’ belief that they must never, ever bend, hence, their back muscles continually contract to maintain those positions.
Muscles are not meant to constantly contract, it should contract when it needs to and relax when it doesn’t need to. These clients often never ever relaxes their muscles in fear that by doing so, their backs will give. Because of the constant contraction of the back muscles, the back muscle becomes overly strong and tight and can no longer switch off, leading to an excessive compression of the spine (the back muscles will approximate the vertebrae closer together, resulting in increase loading and compression). At this stage bending activities will hurt, not because of the original problem, but because the muscle now cannot relax to allow the vertebrae to move freely. These types of chronic back pain sufferer will often be spotted NOT lounging into the chair, they will instead sit up tall without support and will have very defined back muscles. These clients have adapted negatively to their disorder, prolonging the pain.
The solution to these types of chronic low back pain is to change their belief, to assure the client that bending is fine, especially now that the pain is not caused by the original cause. To show them that in a relaxed stretched position that the pain actually reduces, rather than increase. This is usually done by releasing the offending muscles and testing the aggravating posture- bending or squatting. Specific exercises will be taught to facilitate the stretching and relaxation of the overactive tight muscles.
There are many other types of presentation of chronic pain, the above is only one. The concept of the treatment of chronic pain is simple- understand the underlying pain mechanism i.e. what is driving the pain and solve it as best as we possibly can. Those with a dominant psychological driver, often, a psychologist is needed to help change their beliefs.