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 For anyone with even a basic knowledge of pain, the biomedical model will be deemed outdated and lacks any use for understanding persistent pain.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.

Functional Pain Syndromes — e.g./ IBS, headache, migraine, fibromyalgia

Functional Pain SyndromesFunctional pain syndromes (FPS) are not uncommon and there are likely to be people living their lives putting up with a range of aches, pains and symptoms without knowing.

More common in women than men, though this maybe in part due to more women seeking help, functional pain syndromes account for a great deal of suffering.

Functional pain syndromes include:

  • Irritable bowel syndrome
  • Headaches/migraines
  • Chronic back pain
  • Chronic neck pain
  • Pelvic pain
  • Fibromyalgia
  • Chronic widespread pain
  • TMJ dysfunction
  • Bladder dysfunction (interstitial cystitis)

These are often accompanied by anxiety, depression (or low in mood but not actually depressed), hypermobility, perfectionist traits, early life stressors and complex lifestyles with demands or stress and difficulties that reverberate through the body as painful conditions.

In this recently published article, Richmond looks at functional pain syndromes, which can be overcome with the right understanding and action.

Article here

Andy Murray wins despite back pain

karlnorling | https://flic.kr/p/d5cPyA

Andy Murray wins despite back pain, a classic example of how the meaning and situation flavours the lived experience. Simon Briggs of The Telegraphsaid: “Not many players are capable of winning three points in a Davis Cup semi-final, as Andy Murray did to put Great Britain into the trophy match against Belgium in late November. But to do so with a bad back – an issue that Murray revealed only once the combat had finished – was a different story again: a quite exceptional feat of courage and stamina”. Pain is not well related to the state of the body tissues (joints, discs etc) but instead the perception of threat detected by body systems that protect us: nervous system, immune system, autonomic nervous system, endocrine system, sensorimotor system — one only has to consider phantom limb pain to realise this fact. One of the biggest reasons why persisting pain is feared is the belief that the severity equates to more damage or something more serious. You may also consider that some cancers remain painless and this is certainly serious. Pain is a protective device that motivates thinking and action to reduce the threat and restore normal physiological activity (homeostasis); it is a need state lived by the whole person — with ‘back pain’, it is the person who is in pain, not their back.

In Murray’s case, he was quite capable of focusing on the game, his body allowing this due to the context and the significance. There are many stories of sportsmen and women sustaining injuries and only knowing when the game is finished. We also had the scenario a few years ago when Messi collided with the keeper and experienced such pain that he thought his career was over. It was a bruise and he played the next weekend. The pain was still severe at the time though, reflecting the situation and the need as deemed by his body systems that protect. It works both ways.

Between games Murray may well have felt some stiffness, but he was able to re-focus. A few simple movements to nudge fluids around, ease off the muscular tension that is initiated and executed by the brain sending signals down via the spinal cord, perhaps a few reflexive messages contributing alongside the immune and autonomic activity. Context remained king though, as it was wholly more important to put all his attention on what was required to win than to start worrying about his back. That could be dealt with later, and indeed this is what happened as Murray did what he knew he needed to do to be victorious. All those top down signals, cultivated and delivered from a neuroimmune system, which countered those danger signals coming from his back (not pain signals — there are no pain signals or pain centres) — top down signals generated from his beliefs, expectations, mastery of focus and attention, as he hit flow, that state of being utterly in the moment. That’s a wonderful place to be and not a room where pain can enter.

Now that the game has finished, familiar aches and pains will flood Murray’s consciousness. There maybe additional and new feelings that evoke new thoughts and a need for re-assessment for the next best steps. These steps will need to include consideration of how Murray’s neuroimmune system and other systems that protect have learned to react (priming or kindling), the possibility of sub-conscious and environmental cues, expectations and of course an assessment of tissue health and function. From thereon in, a comprehensive treatment, training and coachng programme can address movement, body sense, neuroimmune-sympathetic-sensorimotor interactions to name but a few. It is worth pointing out here that such a programme is not unique to elite sports people, but a modern approach to pain and injury that should be accessible to all.

Richmond Stace

Richmond is the co-founder of a pain awareness campaign called UP | Understand Pain. Together with Georgie, they are using music and song to deliver the right messages about pain, particularly chronic and persisting pain; which are:

  • Pain can and does change
  • You can overcome pain and lead a meaningful life when you really understand it and know what you can do