Beliefs, Communication, And How This Impacts Our Patients

I’m sure I’m not alone when I say I’ve seen some horrific things in my practice.

Now, when I say this, it’s not in the sense of major catastrophic injuries, or gory blood scenes, or something like that.

What I’m referring to is what I’ve seen and heard from patients as a result of what another well-meaning practitioner said to them. 

A patient comes in, sits down, and starts crying because another therapist told them they will never get better.

Another person who has been dealing with chronic pain for several years comes in and equates the pain they’re feeling in their back to a “rib being out”, or “their S.I. Joint is out again”.

And in the more extreme ranges someone giving up a career they love, in exchange for a job they hate because two people told them they would never be able to do their job again because of the surgery they just went through. In fact, told them if they continued doing the job they loved (and were very successful at), the surgery they just had would pale in comparison to the one they would need.

While I know none of these practitioners would intentionally have someone change their job, believe they won’t get better, or would constantly relate pain many years later to a simple biomechanical diagnosis, the reality is, their words changed people’s lives. 

And not for the better!

So, why then does this happen? Why are these enduring effects of words having such a dramatic impact on patients? And, more importantly, how do we stop this?

When Well-Meaning Beliefs Go Wrong

When we say “well-meaning” practitioners I do believe it’s just that. I doubt there are many out there legitimately trying to say harmful things to their patients (although I do believe there are some who use less than scrupulous language as part of the rebooking process).

So, when we have these well-meaning professionals saying things to patients, part of why they are saying the things they are is because they truly believe it (even if modern research refutes it). Part of the issue is when these belief systems are passed on to our patients it can have a lasting effect in a negative way. 

Unfortunately, many of these belief systems can come from continuing education courses that haven’t been updated in years and are still preaching these outdated belief systems.

A great systematic review (1) looked at several medical and paramedical professions to look at how their belief systems, (including biomedical and biopsychosocial treatment, fear-avoidance beliefs, and attitudes) affected patient behaviours.

There were several things that stood out to me reading through this(1):

  1. High levels of fear-avoidance in practitioners are related to the same fear-avoidance in patients.
  2. Practitioner beliefs are associated with the education they give patients.
  3. Practitioners with a more biomechanical base are more likely to advise acute pain patients to limit work and physical activity.
  4. Those with high fear-avoidance beliefs are more likely to recommend bed rest (which we know is not good for low back pain) and are also more likely to recommend this if seen in a media campaign.

Now I realize it probably sounds like we’re bashing anything related to biomechanical explanations here but honestly we’re not.

As we have said so many times over the years, biomechanics are still important, it’s just one piece of the puzzle. What I’m taking from this review is that if we’re strictly relying on biomechanical explanations we’re more likely to also cling to fear-avoidance beliefs as well, which isn’t doing our patients any good.

Part of the problem here is that if a practitioner has these beliefs, they get passed on to the patients we see. One of the major issues with this (as pointed out in the review)(1) is these beliefs result in persistent disability but not necessarily a change in pain.

So, if these beliefs are held, the patient’s pain won’t always change, but there is an increase in disability. Imagine your patients coming in for care and strictly because of a belief system, not only does their pain not get any better, but they become more limited in the things they can do. 

In light of all this information, I look back and think about early in my career and how I was saying very similar things to my patients. There comes a time when we have to sit back and ask ourselves whether the information we are conveying is correct, but also, is it in their best interest?

This review showed that even though some health care professionals believed in the biopsychosocial framework (it was originally introduced over 40 years ago), they were still operating from a biomedical orientation. In the case of doctors, they understood how important psychosocial factors can be yet, they lack the time to properly integrate this into practice.

So, while I look back on my career and cringe at some of the things I used to say, I look at this information and see how beneficial this is for us as Massage Therapists. If we embrace new research and change our beliefs, we not only have the time to spend with our patients, we have the opportunity to create lasting change for what they are going through. 

Words Matter!

So, now that we understand the influence of both the patient and therapist beliefs, the question remains, where did these beliefs come from?

Quite often these beliefs are because of lived experience, observing others in pain, or things that have been told to them throughout their life. A big influence was just not having a framework or a reference of what they should do when experiencing pain.(2)

All too often we see patients going to Dr. Google for advice, however, while this is usually looked at cautiously, people do place higher importance on the advice of friends and family.(2) While people would often seek out care from a health care professional, they would sometimes reject the advice given as they questioned their competence, and would even keep their own beliefs if it conflicted with the advice of a professional.

Now, this isn’t necessarily a bad thing because there’s nothing wrong with a patient using their own intuition to choose what course of action is best for them. It’s important for patients to feel confident in the information being presented to them, in fact, it’s even possible for their symptoms to be influenced by their interpretation of the education they are given.(2)

However, even if we believe we are giving them a very simple explanation of what is happening, there can be an enduring impact. I can now hear my mother’s voice resonating from my childhood and what she would say every time my brother and I would fight: “it’s not what you say, it’s how you say it!”

This paper has several examples of the lasting effect of what we say, which I think are important to highlight.

When a doctor gave a simple diagnosis of a sprain in an attempt to decrease the seriousness of the injury, the patient understood this to mean they had moved in such a way they had strained the muscle and they would make it worse by continuing to move the same way.

In the case of a person getting help from an orthopedic specialist, the result was well…horrific:

[The orthopedic specialist] looked at my back MRIs for a little while and turned around with a grin on his face and said, “You’re a builder, aren’t you?” and I said, “Yes,” and he said, “You’re [expletive], ha ha ha,” and went back to his computer again…. So, you know, I think that was his rather odd specialist way of breaking the news to me that I wouldn’t be working as a builder for very long…. Every time I felt a little bit wrong [after that], I started to sort of add it up in my head. And then my usual way of thinking, “Oh, that’s fine, that’s nothing, that’ll go away, that’s not major enough to stop me working, I’ll carry on [changed]”…him saying that was definitely the point, because I probably would have just carried on(2)

This person actually ended up changing careers as a result of what was said to them! Sadly as I mentioned, I’ve seen the same result in practice as well.

Another example that stood out to me in the same paper was equally as life-altering:

Basically all I’ve kind of been told to do by physios is to work on my core…I’ve been tested by various different physios, and Pilates, and I’m apparently ridiculously weak…. I had an abortion because I didn’t think I could have a baby. I didn’t think I could handle it…carrying it, and having extra weight on my stomach(2)

Can you imagine what this woman went through dealing with this?

Again, I’m sure these were well-meaning practitioners but when our communication is focused more on the things we can’t do as opposed to the things we should do can have compounding long-term effects. If we shift this line of thinking and encourage movement, provide reassurance, and show people how they are safe to remain active it can (and most likely will) have the reverse effect of the quoted stories we shared.

While many practitioners have a belief in the biopsychosocial model, many are still using biomechanical explanations of tissue damage, etc in an attempt to help their patients. As we have seen this can be detrimental to the patients well being. So it’s important to have a discussion around how to change these beliefs in practitioners. Many of us went through college and learned these things (I know I learned many of these explanations in school) and unfortunately, there are many continuing education courses still offering these kinds of explanations. This becomes our responsibility as a profession to change this, and really it starts with each one of us. It doesn’t even mean you have to spend thousands on new courses, it can mean just reading blogs like this, or a new research paper a week (it doesn’t take that long I promise), because we must change our beliefs in order to have a better impact on the people we are seeing in practice. When our beliefs (and our messaging) start to change we can slowly change our patient’s beliefs for better outcomes. Then, hopefully…hopefully, patients feel safe to return to their careers or have babies, or just return to an activity they love.

 

References

  1. Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. European Journal of Pain. 2012 Jan;16(1):3-1
  2. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. The Annals of Family Medicine. 2013 Nov 1;11(6):527-3

Have We Ballsed Up The Biopsychosocial Model?

One of the most widely discussed topics in healthcare and especially in pain circles of late is the Bio Psycho Social model conceived by George Engel.  The BioPsychoSocial (BPS) model was developed in reaction to the dominant biomedical viewpoint that involves reducing medicine to specific diseases or pathologies that can be identified and treated and this model forms the backbone of most western healthcare systems.

Engel felt the biomedical model:

“does not include the patient and his attributes as a person, a human being”

But the question is, have we misinterpreted the BioPsychoSocial model?

Are we simply applying it in the same way as the biomedical model it was trying to replace?

It’s People Not Just Pathology!

We know that people’s experiences of pain and pathology differ. The same painful problem may manifest as huge issue for one person disabling them from work and reducing dramatically their quality of life, whilst another person may remain relatively unaffected. This has to be taken into account both in treating the problem but also how the person is TREATED by their healthcare professional, their family and social network and the wider healthcare system.

We can see below from Engel’s view that it is a bi-directional model that involves the layers in which we exist rather than discreet treatment targets as we now see.

Download 4We could perhaps determine this interaction between layers as the wider impact OF the problem rather than just as impacting ON the problem. Rather than seeing the BPS as a direct treatment model where we dissect the three domains to find new pain ‘drivers’ to treat, the BPS perspective should really be seen as a CLINICAL philosophy and guide that can be used for improved patient care.Here is another interpretation from a recent paper ‘How do physiotherapists solicit and explore patients’ concerns in back pain consultations’

“underpinning the bps model is patient-centred care (pcc) which involves incorporating the patient’s perspective as part of the therapeutic process”

One of the issues that are often encountered in healthcare however is that clinicians AND patients want solutions and treatments rather than philosophies and the conversion into a treatment model conforms to the biomedical perspective that dominates healthcare.

Maybe the BPS asks us, as clinicians to better understand our patients and their subjective experience? And it may be better defined as a model of care rather than a model of treatment. Now, this does not mean we cannot involve a BPS thought process IN specific treatment but remember that this is just not really the major focus of the model, certainly as I understand it anyway.

So it is really treating people and their overall existence, not just treating their painful problems. These differing aspects cannot just be separated and simply targeted without an understanding of the person and the context they exist in, doing that for me is the biopsychosocial model in biomedical clothing.

Other commentators such as Leventhal have looked at concepts such as the disease and the illness *HERE*. The disease being the specific issue and the illness being the wider issues surrounding the problem, in my interpretation, this is similar in concept to the BPS. How is this PERSON individually affected by the problem that may even BECOME the problem itself?

Just Treat The Pain?

I can already hear some readers shouting, “Just treat the pain – then you will not have any more problems”

Well, that is the biomedical view in a nutshell!

Firstly we have been attempting to do this for ages, hence why there has been a call for a different model. Often treatments for pain are not successful and people need help in other ways and we treat pathology but pain persists. Perhaps the interaction with healthcare even makes the problem worse!

Can we treat the person and pain? Yes, I believe so. We should not forget this, just realize our limitations at doing so and also avoid pain being the only focus.

The question is do we often attempt to treat the person AND the pain? I don’t think this happens as much as we would care to admit.  Maybe treating people rather than their pain can lead to reductions in pain? Maybe we cannot have an impact on people’s pain but affect suffering, disability, and quality of life? We may not be able to do this in a pain-focused model and why we end up with repetitive surgeries and the opioid epidemic?

People can still have pain and live a positive life; the BPS model is really well placed to help them do so and does life simply return to normal even after pain has reduced for all? I would hazard a guess that for many people their lives are fundamentally changed even AFTER persistent pain has decreased.

BPS Model Of Pain

A pain-oriented BPS model has emerged more recently and two examples of this can be found *here* and *here*. These interpretations should NOT be confused with Engel’s model I feel, and perhaps misses the essence of what he was reaching for. Maybe an issue with the BPS model is its breadth and how far-ranging it is? It is quite easy to place our interpretation anywhere within it.

The pain focused model looks at how Biological Psychological and Social factors can influence pain.

This diagram is a great example with the arrows pointing solely inwards.

Screen Shot 2019 08 21 At 07.34.26(Figure Fillingim 2017)
The problem here is that it is a return to a biomedical view in which the person is less of a focus and instead the disease (in this case pain) has returned to become the primary focus. Instead of being a comprehensive BI-DIRECTIONAL clinical philosophy, it has in many cases become a unidirectional treatment model.  We also have much more evidence for BPS aspects being associated with pain than we do actual data to support treatment for pain using these BPS aspects.Seeing PsychoSocial factors simply as pain influencing factors is missing the wood for the tree’s I feel. This would be a multifactorial pain treatment model, not the BPS model set out by Engel.This has drawn critique, and rightly so, of the BPS model and its interpretations. A recent paper from Stilwell and Harman can be found here called “An enactive approach – Beyond the BPS model”(Thanks to the authors for the full-text link!). This critique, I feel and highlighted by the authors, is not really of the Engel’s model but instead, the pain focused interpretation that has evolved. We may not need to move beyond the BPS model, more just apply it in its intended way. Let’s try to do that before we think beyond it.Stilwell and Harman go on to say

“Pain is…..a process that emerges or unfolds through a whole person who is inseparable from the world”

but we should also consider the BPS perspective already to consider the whole world and our existence within it and not just its effect on pain!

The very essence of the BPS model was NOT to delve further and further into the microscopic components of biology but instead to also zoom out to encompass the other factors that may be at play in both pain and quality of life.  I have written about this *HERE*. But if we consider most of the discussion, theories, and dominant messages around pain they focus on the reductionist view that Engel was trying to get away from.

As an example please insert any painful problem here ‘XXXXX’. Even the most uni-factorial biological one you can think of… let’s say a fracture.

How does their perception and knowledge, sense-making, around the issue affect them and their behaviors?

How does the injury affect their work and family life?
What are their perceived implications for the future?
How confident are they to return to sport or activity?

How motivated are they to engage in rehab or treatment?

This is considering the PERSON and heir engagement and embodiment in the world not just breaking down pain ‘drivers’ as the trend seems to have become and accusations of people forgetting the bio (eye roll).

Straight Lines & Trichotimies

Some of the criticisms of the BPS pain model focus on the division into three distinct components biological, psychological, and social as well as a perceived linear causality between the associated factors and pain.

My view of Engel’s work is that he objected to a linear causality model. Emergent properties such as pain NEVER have simple linear relationships with causes (whatever they are?). Again this is a misinterpretation and application specifically to pain of the original work. Linear causality is a criticism of previous Cartesian pain models but appears to be alive and well in the BPS.

The term ‘non-linear’ means that small things can give large effects but also large effects in one area may also give rise to no effects in the targeted area.  There are so many interactions occurring that can affect each other that the same treatment may give rise to DIFFERENT positive or NEGATIVE outcomes dependent on the current state of the organism.

We seem to be happier for this to be the case now biomechanically, but less so biopsychosocially. If we are being honest then we have many more associations WITH pain from what is termed BPS factors than actual data from using these factors to treat pain.

The trend of splitting pain into separates categories of Biological, psychological, and social to diagnose and treat is another critique that Stilwell and Hartman highlight in their paper and neatly term a trichotomy. I feel Engel’s point was not that they exist distinctly as pathologies to treat but in their own right but to consider these things within the wider appreciation of the patient’s experience.

Conclusion

  • We should really see the BPS model as a CLINICAL PHILOSOPHY and way of incorporating the patient into healthcare.
  • It is intended to understand patients, their lives, and contexts.
  • The biopsychosocial model COULD be used as a pain treatment model, but this is probably not how it was intended. This may be better termed a multi-dimensional pain treatment model.
  • There is not really much data on outcomes from treatment using a BPS pain model.
  • BPS factors are not simply linear treatment targets.
  • We may need to better apply the BPS model rather than move beyond it.

How Beliefs And Communication Can Influence Pain

I was listening to a podcast today where the host was talking about successful entrepreneurs.

Since we’re all entrepreneurs I couldn’t help but notice how the information applied to us as therapists.

While the host wasn’t directing the information at healthcare professionals, the main point he was talking about was being good coaches. His biggest point was that being a good entrepreneur meant being a good coach and communicator.

This is especially true in our profession.

The way we communicate and “coach” our patients can have a profound effect on the results we get with them. Both in a negative and a positive way.

The words we use can have both a positive and negative effect, which sometimes can last for years, depending on how it’s delivered.

As we have been preaching about the evidence-informed practice and implementation of the BPS framework for some time, we felt it important (and it was also requested) to look at how the words we use affect patient outcomes.

Fortunately, Darlow et al. has done a number of papers on this so we can draw from some of the research that has been done!

For now, we’ll look at how not only our beliefs and communication but also our patient’s beliefs can affect outcomes.

Patient Beliefs About Their Back

When we look at the BPS framework of pain it can sometimes be difficult to separate what the differences are between psychological and social influencers that could be causing a patient’s pain.

This first paper(1) lays it out quite nicely and shows that psychological influencers include; fear-avoidance beliefs, catastrophization, self-efficacy beliefs, depression, emotional stress, and outcome expectations. Now, this can certainly be a lot to take in if it were someone’s first visit to come and see you, so don’t think you have to get it all figured out on the first visit.

When they looked at much of the data collected in this paper, they further broke down the information into five main themes.

  1. The vulnerability of the back
  2. Special nature of back pain
  3. Prognosis of back pain
  4. Activity and back pain
  5. Influences upon beliefs

Vulnerability Of The Back

Not surprisingly most of the people in this study(1) equated their back issues to physical injury, damage, or dysfunction.

While most were not sure what exactly was damaged they also believed it was possible to hurt their back without being aware they were causing any damage, they also believed that an increase in pain meant more damage, while a decrease in pain equaled recovery.

The interesting part is that while most participants didn’t understand what caused the pain or “injury”, they also came to the conclusion that somehow their back was vulnerable, or designed poorly due to a variety of factors that included genetics, previous injury, or misuse.

There was also a belief where activities that included bending, twisting, and sitting were dangerous things that could cause further injury or pain. In reality, how many times a day do we do these things which are quite safe activities!?

In addition to all these beliefs, many of the patients tended to catastrophize about the possible explanations about the cause.

The Special Nature Of Back Pain

This is another area that brought about some surprising results (at least for me).

People believed that pain was a function of the back and in order to protect itself, it was forcing the person to stop any activity. There were even beliefs associated with the back being its own entity that could achieve its own goals which a person had absolutely no control over.

While this hindered simple things like walking, it also became a threat to people’s financial security as they did not think they would be able to work at their secular jobs.

An interesting consideration was that back pain was difficult to understand without personal experience, however, it was acknowledged that their psychological well-being was affected making people feel old, depressed, and irritable even to the point of impacting their relationships with other people.

The Prognosis Of Back Pain

While the previous sections demonstrated getting a prognosis was important to patients there are some things that proved worrisome for patients.

Some things that stood out were the back’s ability to heal, timeframes, and the quality of healing. This was influenced due to thoughts of vulnerability, not sure if the back could heal, and also because of seeing how back pain affected those with chronic back pain. Most thought due to the type of injury they had, or because of not doing the right things their own back was not going to heal.

The paper(1) concentrated on those three topics, but in just looking at the beliefs around that, is it any wonder people end up developing chronic pain when their belief systems are basically telling them there’s no way they can get better?

Client, Clinician, and Community

To continue on the topic of back pain and beliefs Darlow(2) looked at three different entities that influence our beliefs about back pain, the client, clinician, and community.

We know that psychological factors play a role in all pain but do we really understand why? Because if we did, we could more positively change patient’s beliefs and decrease things like catastrophization, for better outcomes.

As mentioned earlier there are different themes which influence how a patient perceives their back pain. Things like genetics, previous injury, and worries about movement reinjuring the area and are seen as dangerous. So a person can weigh out the risk vs. benefit of not only engaging in activity, but also seeking out care.

As pointed out in this paper (2) almost half of those experiencing back pain don’t seek out care, but for those who do, they see more than one healthcare professional. The things that do cause people to seek care are things like high levels of disability, pain, and maladaptive beliefs like catastrophization.

Now, this is where we can play either a positive role…or sadly, a negative one.

This is because the beliefs of the therapist can influence the beliefs of the patient. Remember, those who are seeking care are typically experiencing disability, pain, catastrophization, so they want more information from a trusted source…YOU!

If we are providing a strictly biomechanical explanation, this can seem threatening as most of those explanations involve things like muscle strain, discs out, hip rotated, the rib is out, etc. In turn when these kinds of explanations are given, if the person feels pain in the area weeks, months, or years down the road, they equate the pain to that biomechanical explanation they were previously given. I’m sure we’ve all seen this in practice when someone comes in and automatically equates the pain they’re experiencing to that “same old injury” that has been going on for years.

Since we know it is likely they are seeking care from multiple professionals, if they are getting different explanations, this can result in not only frustration but increased uncertainty about their capacity to get better.

Interestingly, while very well-meaning professionals give instructions on proper lifting or moving techniques, this can be understood as a need to protect the back creating hyper-vigilance about movement.

However (as we have preached so many times on this blog) providing reassurance, validating a patient, showing that movement is safe, can empower a person not only now, but in the future.

When they looked at community in the study (2) some things that stood out were how messages stemming from places like schools, workplaces, media, and the internet had an influence on people’s beliefs. These actually influenced the amount of support given by friends, family members, and even colleagues. As it turns out, a spouse’s beliefs about pain can actually influence the amount of support or care they give to their significant other.

Now, if your beliefs about pain can actually influence the amount of care you give to someone you love, imagine how this is influenced in the workplace!?

In my past life (before becoming an RMT) I was an industrial first aid attendant in a sawmill, I would see this first hand (although I didn’t understand it at the time). When people were injured at work (keep in mind this was a very bravado-filled environment) people were called wimps (and a host of other names I dare not repeat on this blog), or it was commonly believed they were just trying to get an insurance claim.

If a person is facing this in the workplace, and say their spouse isn’t overly supportive, combined with bills piling up due to the added stress of not working, imagine how this influences not only a person’s beliefs around pain but also the amount of pain they’re in.

The spouse can also have a directly negative effect by emphasizing what the injured person can and cannot do. They can become overbearing in trying to do too much for the person, or by doing too little, again, this comes down to their beliefs.

Part of the issue is that so many of these beliefs don’t match what the current evidence says.(2)

A great example of how this can be changed is the pain revolution cycle tour put on by noigroup. Every year they do a cycling tour to different communities in Australia where opioid usage is high. They visit these communities and put on education events about pain and have seen significant reductions in opioid usage through their education and changing people’s beliefs. 

So, imagine what we could do with each of our patients by just providing a little education!?

We’ve heard so many times practitioners saying things like “I don’t need research, my work speaks for itself, I get results”. One small part of the issue with statements like this is that many times a practitioner has been practicing for years and hasn’t updated themselves, or their beliefs, so are still saying things that are way out of date. While they are very well-meaning (and yes probably have some good results) they are still instilling beliefs like “my pelvis is rotated, rib is out, bad back due to genetics etc. etc.” which as we have seen is actually harmful to a person. We have a golden opportunity to provide education to patients that will change this narrative and alter their belief system in a very helpful way. (2) If we can confidently sit in front of someone and provide reassurance that they aren’t broken and concentrate more on education that will be interpreted positively by not only the patient, but their significant others will bring about far more lasting benefit. However, the only way we can gain the confidence to do this, is by reading current research and staying on top of new information and resources like the ones we’ve cited here. Because really, while you owe this to your patients, you also owe it to yourselves.

If you’d like to learn more about how to incorporate these kinds of things in your practice, we have an upcoming course on the low back, hips, and pelvis we are offering via zoom in February where we will be discussing many of these strategies as well as therapeutic exercise that you can check out by clicking HERE

References

  1. Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A. Easy to harm, hard to heal: patient views about the back. Spine. 2015 Jun 1;40(11):842-50.
  2. Darlow B. Beliefs about back pain: the confluence of client, clinician and community. International Journal of Osteopathic Medicine. 2016 Jun 1;20:53-61.

 

In Defence Of The Advice To Remain Active For Back Pain

There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!

Firstly this HERE is from the folks over at Cochrane.

“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”

It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.

Now I am going to give you a bit of my opinion as well!

Being active, IMO : ),  is NOT a treatment. It’s about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.

It’s About Belief

Certainly, we don’t want to demonize the idea of resting or taking it easy if things are too painful, that is not evidence-based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.

This is highlighted in the two papers below that look at people’s opinions around what affects pain in the positive AND negative.

Darlow 2014 – Beliefs about back pain: The confluence of client, clinician and community.

Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives

We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self-reported perspective of what triggers back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare-ups

Costa 2019 – What Triggers an LBP Flare? A Content Analysis of Individuals’ Perspectives

Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.

Suri 2018 – Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

The implication might be that when we ask people to remember what triggered their back pain it is a simple ‘go-to’ blame physical activities (especially when other things are not considered), but when the flare-up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare-ups seems to decrease.

This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!

It’s About Positive Messages

Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.

I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple, and important message from my perspective.

There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.

But could our short term attitudes impact on the longer term?

Short Vs Longer Term

What we do seem to have some data on is that having low pain self-efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster – 2010, we see that low pain self-efficacy is related to worse disability outcomes at 6 months.

The question is how do our own attitudes, and other people’s attitudes as well, towards our backs influence our behaviours? Food for thought perhaps?

Key Messages From Advice To Remain Active

Hurt does not equal harm – It’s OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.

Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.

Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.

To Predict Chronic Pain, Look to the Brain

Low back pain is extremely common. In fact, if you don’t have at least some back pain every year or so, you’re kind of abnormal. (Not that you’re really missing out on anything.)

Fortunately, if you do get back pain, your chances of getting rid of it in fairly short order are excellent. More than 90% of acute back pain resolves on its own in just a few weeks or months without any specific intervention. But for some people, pain becomes chronic, lasting for years. Why does the course of back pain differ so much between different people?

The answer probably cannot be found by looking solely at the back itself. Experts have tried for years to explain back pain outcomes in reference to the results of physical examinations. But collecting evidence about posture, core strength, or the condition of vertebrae and discs does very little to help you make good predictions. Posture and MRI results correlate poorly with pain, and a single structural/physical cause for back pain is rarely found.

More recently, there has been more emphasis on subjective factors – pain intensity, negative mood, catastrophizing, depression, or job satisfaction. Accounting for these factors will help you predict back pain outcomes quite a bit better than just looking at the physical condition of the back. But a good deal of mystery would remain.

Some recent research from the lab of Vania Apkarian has led some very smart people to wonder whether he has discovered the “Holy Grail” of explaining pain –  the precise factors that cause some people to develop chronic pain and others to recover.

If Apkarian is right, the grail is in the brain. (An important reminder and caveat: even when the brain is a major player in pain, this does not imply that pain is “in your head”, that pain is your fault, that you can just think pain away, or that the body doesn’t matter.)

Following is a collection of quotes from several papers from Apkarian’s lab. (See the bottom of the post for cites. Full text for each is available free online.) These help summarize the results and interpretations of his very interesting research, which mostly involves scanning the brains of people with and without back pain, and at various stages of recovery or chronicity.

The Relationship Between Nociception, Acute Pain, Movement, and Emotion

Pain is a conscious subjective experience that is most commonly driven by nociceptive activity. Baliki 2015.

Conscious acute pain perception is highly malleable … pain perception can reflect moment-to-moment shifts in value judgments. Baliki 2015.

The emotional limbic brain plays a critical role in bridging nociception and pain perception. Baliki 2015.

[N]ociceptors can be active in the absence of pain perception . . .The primary reason I fidget in my chair while writing this article is because nociceptors innervating my skin, muscle, and bone command that my posture needs adjustment. Baliki 2015.

The nociceptive control of behavior routinely occurs in the absence of consciously perceived pain, rendering it “subconscious.” Baliki 2015.

Daily motor movements could easily produce injury and tissue damage if one exceeds their natural range of motion . . . which supports the conclusion that motor behaviors are collectively inhibited by nociceptors. Baliki 2015.

We argue that nociception continuously occurs in the absence of pain perception and it is a fundamental physiological process . . . we presume that behaviors modulated by nociception, in the absence of pain, are contingent on already established habitual repertoires. In contrast, when pain is evoked it gives rise to new peripheral and spinal cord nociceptive learning/ sensitization, as well as emotional learning that is potentiated by the salience and perceived value of the aversive event. Baliki 2015.

The Transition From Acute To Chronic Pain

[O]nly a fraction of subjects who experience an acute painful injury develop chronic pain. Hashmi 2013.

The majority (>90%) of individuals with acute low back pain recover full function in days or weeks with little or no lingering pain. Apkarian 2009.

The 2 critical questions that the field has yet to address regarding chronic pain are 1) Who is vulnerable to developing it? and 2) What underlies this vulnerability?  Hashmi 2013.

Earlier clinical studies have identified a long list of risks for chronic pain, such as demographics, affective states, lifestyle, comorbidities, and others, yet collectively such parameters account for a relatively small amount of variance for chronic pain (10% to 20%). In contrast, the brain’s anatomic and functional properties predict development of chronic pain at 80% to 100% accuracy. Hashmi 2013.

Ample evidence now shows that the anatomy and physiology of the brain in chronic pain is distinct from that of healthy subjects experiencing acute pain. Vachon-Presseau 2016.

An accumulating body of animal and human literature has identified the cortico-limbic system, which is central to reward and motivated behavior, as a modulator for acute pain and as a mediator for chronic pain. Vachon-Presseau 2016.

In a longitudinal brain-imaging study, individuals who developed an intense back pain episode were followed over a 1-year period, during which pain and brain parameters were collected repeatedly. At the time of entry into the study, strength of synchrony between the medial prefrontal cortex and nucleus accumbens (i.e. functional connectivity) was predictive (>80% accuracy) of individuals who subsequently transition to chronicity 1 year later. Apkarian 2016.

Persistently enhanced functional connectivity between the mPFC and NAc may be interpreted as an increased emotional salience signal. Vachon-Presseau 2016.

There is now good evidence that all components of the corticolimbic system are either affected by or control or amplify persistent pain states. Vachon-Presseau 2016.

Redefining Chronic Pain

The definition of chronic pain remains tautological, as it simply asserts that it is a long-lasting pain, or a pain persisting past the normal healing period. Baliki 2015.

We propose a novel definition of chronic pain. Rather than defining pain by its sensations, we propose a definition that emphasizes the neurobiological mechanisms that control behavioral adaptations, and we hypothesize that persistence of pain is likely mediated through the reorganization of the cortex by corticolimbic learning mechanisms. (Baliki 2015)

Long-term shifts in the threshold mechanisms that gate the conversion from nociception to pain also underlie the transition to chronic pain. We further propose that the threshold shift is dependent on limbic circuitry invoking synaptic learning-based reorganization. Taken together, these ideas can be simplified as a lowered mesolimbic threshold for the conscious perception of pain, which functionally renders the brain addicted to pain. (Baliki 2015)

The Connection Between Chronic Pain and Negative Mood

Just as nociception and pain protect against bodily injury by limiting behavior, negative moods minimize exposure to danger and promote survival by inhibiting behavior as well. (Baliki 2015)

Just as chronic pain conditions are associated with decreased hippocampal volume, a rich parallel literature indicates that depression is associated with hippocampal volume decrease. (Baliki 2015)

It is therefore not surprising that these conditions are often comorbid, and indeed, there is now a small but emerging literature regarding the interaction between negative moods and acute and chronic pain. (Baliki 2015).

Implications and New Questions

How does this research add to what we already know? We have known for a while that chronic pain involves central sensitization and brain changes. But it was still possible that those changes were driven by persistent peripheral input. Apkarian’s research seems to suggest that peripheral nociception is not the central driver of chronic pain.

It should be noted that some of Apkarian’s research needs to be replicated and that others may interpret his findings differently.

Apkarian was a featured speaker at the 2018 San Diego Pain Summit, I spoke there a few years ago and wrote about my experience attending here.

I was sure to ask Apkarian some questions which are basically unanswered in his various papers: if chronic pain is mostly about the brain’s emotional systems, what can we do, as a practical matter, to help treat or prevent it? And for people who do recover from chronic pain (like me and many others), how did their brains change? Did they revert or evolve?

I suspected there are no simple answers that apply to everyone, and that success for any particular person involves somehow changing the way their brain subconsciously connects movement, threat perception, and a sense of value or meaning.

Resources/Citations

Apkarian, A Vania, Marwan N Baliki, and Melissa A Farmer. 2016. “Predicting Transition to Chronic Pain” 26 (4): 360–67. doi:10.1097/WCO.0b013e32836336ad

Hashmi, Javeria A., Marwan N. Baliki, Lejian Huang, Alex T. Baria, Souraya Torbey, Kristina M. Hermann, Thomas J. Schnitzer, and A. Vania Apkarian. 2013. “Shape Shifting Pain: Chronification of Back Pain Shifts Brain Representation from Nociceptive to Emotional Circuits.” Brain 136 (9): 2751–68. doi:10.1093/brain/awt211.

Vachon-Presseau, E, M V Centeno, W Ren, S E Berger, P Tétreault, M Ghantous, A Baria, et al. 2016. “The Emotional Brain as a Predictor and Amplifier of Chronic Pain.” Journal of Dental Research 95 (6). International Association for Dental Research: 605–12. doi:10.1177/0022034516638027.

Baliki, Marwan N, and A Vania Apkarian. 2016. “Nociception, Pain, Negative Moods and Behavior Selection” 87 (3): 474–91. doi:10.1016/j.neuron.2015.06.005.Nociception.

Apkarian, A.V., Balik, M.N., Geha, P.Y. 2009. “Towards a Theory of Chronic Pain.” Progress in Neurobiology 87 (2): 81–97. doi:10.1016/j.pneurobio.2008.09.018.Towards.