It can be natural for people with persistent back pain to avoid being active, for fear of making things worse, but often, this can be counter-productive.
As Dr Grahame Brown, a consultant in persistent musculoskeletal pain, and David Rogers, a physiotherapist who specialises in spinal pain, explain, tissue and muscle injuries heal within weeks, and even fractures usually get better within a few months – and so injuries alone don’t give us the full picture, when it comes to chronic back pain.
The duo, who both work at Birmingham’s Royal Orthopaedic Hospital, explore this further in their new book, Back To life: How To Unlock Your Pathway To Recovery, which they hope could help thousands of persistent back pain sufferers better understand their symptoms and ultimately “get their lives back”.
While it may feel hopeless when pain won’t let up, as the authors stress: “Persistent pain is not necessarily permanent and previous function can be restored.”
No single cause
They point out that the vast majority of people with persistent low back pain have no identifiable underlying disease, so their pain’s referred to as ‘non-specific’. The book is aimed at these people, rather than those who have a new injury, ongoing tissue damage or disease.
“People are commonly given very negative and unhelpful messages about their back, such as ‘your discs are crumbling’, which will naturally make them perceive their back as weak or damaged,” says Rogers.
“These messages aren’t based on any reliable scientific evidence. Disc bulges or degenerating discs and many of these negative labels people are given about their back are just as common in people without back pain.”
Research based on MRI scan findings suggests that 90% of people in their 60s who’ve never had bad back pain have degenerating discs, and more than 50% of people in their 40s who’ve never experienced bad back pain will have disc bulges, along with 20% of people in their 20s.
“Many common findings on an MRI scan are just as likely to be found in people who have never had an episode of back pain,” note the authors. “The link between common spinal changes as identified on MRI or X-ray and persistent back pain and poor function is weak.”
Changes such as degenerating discs can, of course, contribute to back pain, but the point is, they don’t tell the whole story about why it sometimes persists.
Instead, there are three factors Brown and Rogers believe play a key part – biological, psychological and social. Namely, the biopsychosocial approach.
Twists and turns
“For a long time, health professionals have believed persistent pain is due to a long-term injury that hasn’t healed. People will have been told this and naturally assumed it to be correct,” says Rogers. “However, more recent evidence, particularly in the field of neuroscience, has helped us to understand that ongoing persistent pain has less to do with actual ongoing injury and more to do with the sensitivity of the nervous system.”
He explains that injured tissue naturally heals within a fairly short time – skin within a few days, muscles, ligaments and tendons within weeks.
“It’s really important to understand that the body repairs itself from injury within a few months at most,” Rogers stresses. “For a variety of reasons, the volume dial for pain in the nervous system remains set at a high level, and although it feels like the tissues are still injured, it’s highly likely they aren’t.
“The signalling system between the injured area and the nervous system and brain is the system responsible for an ongoing pain. Therefore, if there is no actual injury or ongoing tissue damage, it’s safe to get going.”
Many biological changes occur when back pain is experienced, involving the central nervous, endocrine and immune systems, plus musculoskeletal areas.
One example of such changes is in the sympathetic nervous system. An initial back condition or injury prompts the system to release adrenaline in response to the pain threat as part of the body’s danger-alert system, leading to muscles tensing as the body prepares to fight or flee.
While helpful in the short-term, if the response remains switched on, the continuing muscle tension can contribute to persistent pain, leading to muscle cramps, prompting more danger signals to be sent to the sympathetic nervous system, ultimately resulting in a “vicious cycle of pain”.
In addition, the endocrine system may release cortisol when the danger-alert system’s switched on, diverting oxygen to the muscles so we can flee if necessary. If cortisol levels are elevated for a prolonged period, problems – including poor sleep, fatigue, depression and poorer physical performance – can occur (all of which, again, contribute to chronic and greater perception of pain).
When sensors in the back keep sending danger messages to the spinal cord, the nervous system creates more danger-alert neural pathways.
“The result of this is that your pain experience becomes stronger, and your back starts to hurt even more.”
Fear of causing further damage to the back means people often avoid physical activities they previously enjoyed too, and may even stop working. This can be detrimental for their mood and quality of life, makes it more difficult to relax, and can actually delay recovery.
Family, friends, employers and colleagues over-protecting people with persistent back pain, and doing everything for them, can also hinder recovery, because it prevents increasing activity step-by-step, which is the best path to recovery.
Back to life
Keen to ‘unlock’ your troublesome back pain? Here are some of David Rogers and Dr Grahame Brown’s top tips…
When back pain persists for more than a few months and various treatments have had limited benefits, research suggests that focusing less on getting rid of the pain and more on getting back to meaningful activities leads to better functioning and quality of life, and less pain.
Do activity gradually and expect to feel worse initially – this is normal. Don’t overdo it, and review your plan weekly.
Start simple, low-level cardiovascular, strengthening and stretching exercises, building up gradually.
Family conflict and stress can affect recovery and should be resolved if possible.
Staying in work is likely to help your back, not only because of potentially moving more, but also because research shows having a purposeful role leads to people having fewer problems with daily activities.
While medication can be beneficial, as it can help people with persistent back pain get moving, Rogers and Brown say it can sometimes prove counter-productive and make recovery more difficult, so being aware of the potential pitfalls of medication is important. Always discuss changing medication with your doctor.
Prioritise sleep, take regular breaks from what you do during the day, and relax through breathing exercises, mindfulness or hobbies. Relaxing can stimulate natural analgesics.
Be aware that painful flare-ups are very unlikely to be caused by damage to the spine. Don’t let a flare-up make you much more cautious, thus slowing overall recovery.
Identify flare-up triggers, which aren’t necessarily physical movement but can be linked to stress, feelings or even the environment.