Back Pain Isn't in Your Head

Introduction
Pain is a sensory as well as subjective emotional experience, one that can be modulated by the brain. Pain is a universal condition, but the extent to which one suffers, or is disabled by it, varies from person to person and culture to culture. The International Association for the Study of Pain Defines pain as "...as unpleasant sensory and emotional experience associated with actual or potential tissue damage..."; this is true for acute as well as chronic pain.

Pain is also a "hot topic." The controversy of whether it is appropriate to withhold narcotic analgesics from patients with chronic non-malignant pain is getting a great deal of play in the lay as well as professional literature. Pain also costs our country vast amounts of money each year in disability income and lost wages. Two percent of all work-related injuries account for 86% of all disability costs. The psychological factors that contribute to the development of a chronic pain problem, how we diagnose and treat it, are the topics of this talk.

Development of chronic non-malignant pain syndrome
The Chronic Pain Syndrome (CPS) is characterized by intractable pain along with marked changes in behavior, affect, restriction of daily activities and an over utilization of health care resources. What patients think about themselves and their condition, what they are told either implicitly or explicitly by their physician and the incentives to return to a productive lifestyle, are the primary psychological issues in the development of CPS.

Often, CPS starts with nothing more than a minor injury, a lumbo-sacral strain/sprain, or some equally vague diagnosis. In fact, according to Deyo, et al (1992), over 3/4 of patients with low back pain cannot be given a verifiable diagnosis, and the incidence of whiplash in Lithuania, where there is no litigation system for personal injury, is 0% (Schrader, et al. 1996). The first problem for the patient is that they received a diagnosis at all, for it is with a diagnosis that they can start to worry and to believe that there is something that is really very wrong with them. Most people recover from these minor mishaps but in the patient who is vulnerable because of pre-existing social/psychological problems, or for someone who believes that medicine is more a science than an art, the receipt of a diagnosis has a greater relevance than it should. A patient may reason if there wasn't anything wrong, there would be a name for it. To make matters worse, often numerous diagnostic tests are done despite normal exams. The patient reasons that they are sure something terrible is going on, after all, if there wasn't why the doctor order an MRI, CT scan, ultrasound and EMG etc. the tests may go on to reveal a bulging disc, a very common but not necessarily important finding. When the doctor reveals the finding of a bulging disc, the "at risk" patient interprets this as a significant pathological finding, fueling their fear and anxiety, despite the fact that the physician may even try to give a benign interpretation.

Job satisfaction has a lot to do with predicting return to work following an injury. (Disability in physician's, prior to managed care used to be a rarity. Recently, it has increased dramatically.) Sooner or later, the patient begins to define themselves as disabled, unable to work, unable to do the chores around the house, and unable to participate in recreation. And, as they do less, they become deconditioned and are able to do even less, thus reinforcing the concept that they are disabled; they become depressed, anxious, frustrated and irritable, spending more of their time in the house, resting instead of being out in the world, involved in activities that reinforce the image of a competent, successful human being.

Cognitions and pain
What we tell ourselves about ourselves plays an important role in how we feel not only emotionally but physically. If we see ourselves as incompetent failures, we are much less likely to be successful than if we believe we can succeed. What we tell ourselves is often programmed early on in our childhood by our parents, teachers and siblings. If we were told that we can be anything we want to be, do anything we want to do, when we are confronted by adversity such as injury or illness, we view it as a temporary setback rather than an affirmation of our self as a failure. Negative cognitions fuel depression. Cognitions can fuel pain as well. If we tell ourselves that we are in agonizing, torturing, unbearable, nauseating, crushing and terrifying pain because our nerves are trapped and being pinched, we are more likely to experience more pain than if we conceptualize it differently.

Diagnosing chronic pain syndrome
Once you have identified the problem, outcome studies have shown that the most cost effective approach to the treatment of CPS is a behaviorally focused comprehensive, interdisciplinary chronic pain rehabilitation program. Rehabilitation takes place in an environment that reinforces wellness and ignores pain and sickness behaviors. Therapy must include the family because they are the ones that will provide reinforcement after treatment. The family and the patient must be educated about the patient's pain; what it means, and more importantly, what it doesn't mean. Relaxation, biofeedback and self-regulation training may help the patient learn there is a lot they can do to control their pain level as well as their reaction to stress. Relaxation helps not only directly by reducing muscle tension, by helping patients learn the link between emotional arousal and pain, but also as a way to release endorphins. Chemical dependency issues may be addressed as well. Many patients who come in on narcotics leave, comfortably, without them. Many patients self-medicate with alcohol, and this needs to be addressed as well. Physical and occupational therapy prove directly to the patient what they are capable of doing. As patients' behavior change, their self-concept changes as well and they can move from seeing themselves as disabled and helpless to someone who can function and take some control over their lives, instead of waiting to be fixed.

Conclusion
CPS may be, at least in part, an iatrogenic condition facilitated by a well-meaning doctor, who has tried to treat the patient's pain, which represents only the tip of the iceberg, while ignoring the underlying psychological issues. Effective treatment includes education, behavior modification and empowering the patient. In effect, helping them to get their life back.

Copyright 1995-2005 The Cleveland Clinic Foundation. All rights reserved

 

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. For additional health information, please contact the Center for Consumer Health Information at the Cleveland Clinic (216) 444-3771 or toll-free (800) 223-2273 extension 43771. If you prefer, you may visit www.clevelandclinic.org/health/ or www.clevelandclinicflorida.org. This document was last reviewed on: 9/20/2000

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