5.Once a bad back, always a bad back
Back pain is the single most common reason for disability in the United States, which causes people to be unable to work or perform regular activities of daily living. Back pain accounts for roughly 264 million missed days of work per year. That is the equivalent to two full days of missed work for every single full-time worker in the US! The good news is that the vast majority of people with back pain do not have serious conditions such as an inflammatory condition, fracture, infection, or cancer. Another bit of good news is that relief from pain usually always happens, but reoccurrence is an issue to be addressed. With new research emerging from the field of pain science, we now know that pain is much more complex than we originally thought.
“Treating pain is about treating the individual. Pain is a perception that is different for everyone. No one can feel your pain. Good treatment has to recognize this and tailor a program that is specific to you. We know that many factors influence how people feel pain thus different approaches should be used in a treatment program.” Dr. Greg Lehman, DC
The notion that back pain is caused only by tissue damage such as a sprain/strain, disc issue, or arthritis is not even close to telling the whole story. While tissue damage can cause pain, pain is almost always multifactorial in nature. The biopsychosocial model of pain identifies pain as a unique experience dependent upon the dynamic interaction of biological, psychological, and social factors amongst the person experiencing the pain. It should be the responsibility of the clinician assessing your condition to take into account all of these factors as well as to be careful of the words they say to the patient. As a patient, the words of a doctor can cause a lifetime of doubt or uncertainty.
For example, let’s say you dropped out of high school and have worked construction for the last 25 years. You sustained an injury which caused pain to the low back and you are unable to perform their job duties. While there may be tissue damage to the area of pain, that is only part of the pain experience. Let’s say you are the head of their household and have children and a spouse to provide for. You start questioning what you are going to do if you can’t work construction? How will you provide for your family? How much debt are you in? Will you have to file for bankruptcy? Do you need to sell your house? These are all anxiety-driven questions that can actually exacerbate the feeling of physical pain. These questions would not even be relevant if you were a high paid CEO of a Fortune 500 company. This is an example of how biopsychosocial factors can influence the pain experience and affect treatment outcomes depending on individual factors outside of just physical damage.
“I have a bad back.”
“My doctor said it’s just arthritis and there’s not much I can do.”
“I can’t lift anything heavy, I had back surgery.”
“My doctor said I have a slipped disc at L4-L5, so I can’t bend forward to pick anything up anymore.”
“I was in a car accident as a teenager and my back has been bad ever since.”
I have heard every single one of these anecdotes in my office. When I hear these types of explanations, I can’t help but feel frustrated because it is the responsibility of the clinician to help our patients in every way possible. These patients have been told that the source of their pain is physical in nature. Trauma, arthritis(sometimes), and tissue pathology are all legitimate reasons for acute pain from a physical standpoint. What these patients have not been treated for is how to cope and manage these conditions on their own. These patients have not been reassured that they can live a life that’s not full of pain. They have not been guided in a direction to incorporate biopsychosocial coping strategies to help with their conditions. They have not been told how robust and resilient the human body is. They have been given a diagnosis and a goodbye. In my opinion, if patients are walking out of their appointments thinking any of these things, the clinician has failed to uphold their responsibility. As clinicians, we should be educating every single patient about self-coping strategies, increasing self-efficacy, and tips for self-management of pain. The research continues to pour out confirming that patient education and active rehabilitation lead to the greatest outcomes and lowest amount of reoccurrence of pain vs. any other type of conservative management.
This point of this post is not to say that all back pain can be resolved conservatively. There are many times when medication and surgery are necessary in the treatment of back pain. The point of this blog topic is to shed light on the fact that MOST musculoskeletal conditions can be managed conservatively, and should focus heavily on patient education, active rehabilitation, and assurance. Pain is usually always multifactorial and should be treated as such. The analogy I love to use with patients is the overflowing cup analogy by Dr. Greg Lehman. You can only fill your cup up so much with stress, anxiety, worry, inactivity, lack of/poor movement etc. before it starts to spill over. The spill over is when symptoms manifest. We are all strong and resilient and can benefit from some education and assurance along the way. Next time your cup runneth over, find a clinician that treats the person, not just the symptoms the person presents with. Cheers.
Stay strong. Stay recharged.
***No content on this site should be used as a substitute for direct medical advice from your doctor or other qualified clinician.***