Back pain

In a recent Daily Mail Good Health, an article boldly claims that an ingenious new approach to back pain could transform your life. This is indeed a big statement to make about one of the largest ‘public health’ issues — chronic pain and depression are the top 2 global health burdens.

The authors describe the biopsychosocial model for pain (BPS) that incorporates factors relating to the biology, psychology and sociology of pain. This is the model claimed for most modern pain services, although whether all are fully addressed in an integrated manner is a separate point. It is good for the BPS model to gain some air time as it is certainly a step forward in the right direction compared to the dominant biomedical model that would suggest we need to look for a structural or pathological reason for pain. For anyone with even a basic knowledge of pain, the biomedical model will be deemed outdated and lacks any use for understanding persistent pain. This is simply because pain cannot be explained by a structure or pathology.

For the first time, perhaps ever (in my memory), I was delighted to read about danger signals rather than pain signals in the public press. This is a vital piece of information as we do not have pain signals or pain centres, instead we have a biological system that detects salient events and orientates our attention — termed the salience network by Giandomenico Iannetti and colleagues. Conjoining this model with current models of consciousness, AI and brain (e.g. predictive processing) and you are getting somewhere near a very, very good way of thinking about pain. Of course we have some way to go yet and need to be careful about how we frame the current knowledge in terms of existing data.

There are many biological and behavioural changes that occur when we have back pain and other on-going pains. We change with every moment as every moment is unique. We feel that we are the authors of our own inner dialogue and this often means drifting into the past or future, becoming embroiled with what has been (as far as we can recall) and what may be, but of course neither actually exist despite the embodied sense we have in that moment. Keeping a close eye on what is in front of us, also known as being present, helps us to see what is really happening versus a story that we construct. By regularly thinking about a painful event in the past, we can easily ‘prime’ or sensitise this moment. Equally by anticipating pain or projecting ourselves forward by imagining that a movement will hurt, we change our way of moving and the sense of our body as anxiety and tension emerge. This is one of the reasons why awareness of one’s own breathing helps.

An important aside: It is important to clarify here that although we talk about the mind, thinking and emotions in relation to pain, the actual experience of pain emerges in the person and is felt in the body or the space in which the body should reside (for many biological reasons). The notion that pain is in the brain or in the head is nonsense. And, we are more than a brain.

Turning one’s attention to breathing means that you are being aware of this moment, now. There are other important ways of cultivating this skill, which allows you to think clearly about what action you can take to create a new experience, a better experience that takes you towards your desired outcome. Additionally, on the out-breath we naturally relax as the parasympathetic nervous system increases its activity. This is opposite to the sympathetic that is involved with protection in the face of perceived threat. And this is really what pain is all about.

In the face of a predicted perceived threat, we can feel pain as part of a whole person defence strategy. There is no pain system. Instead systems that have a role in protection: musculoskeletal system, sensorimotor system, immune system, endocrine system, autonomic system. Then consider how systems support each other as they are all integrated: the gastrointestinal system’s role in providing nutrients to energise the other systems — consider how many people with persisting back pain also have digestion issues as their resources are diverted away from digestion and towards protect. So, more threat to ‘me’ (the self — that’s a huge area to discuss alongside consciousness), more pain. Less threat to me, less pain. How often will a person report an increase in pain when they perceive to be in a threatening situation. The beauty of this is ‘perception’, because we can change it. So in changing our perception of threat we can change our pain. We are designed to change so we can use this biological advantage and with practice become good at it. Remember, pain and injury have a poor or absent relationship — consider phantom limb pain. There is no body part yet there is most certainly pain.

Our understanding of pain has moved on enormously over the past ten years. We are in a very exciting time now as we draw upon many areas of science and philosophy to advance this knowledge, asking new questions and gathering new data. The biomedical model is not sufficient and the BPS model has been a useful step forward but now we need to think about pain in terms of a public health issue. People need practical ways of overcoming their pain moment to moment, coaching themselves so that increasingly they generate their own better and better experiences driven by internal messages as they motivate themselves to a healthier life. This is the reason for my term ‘Pain Coach’ as the individual becomes their own coach using continuously updated thinking and actions to get better, overcome pain and resume a meaningful life.

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