Living with chronic back pain is bound to make you tetchy.
This is the unpredictable pain that develops because of an injury – be it from a sudden awkward movement, or a car crash, poor posture or age-related wear and tear – that has flared and twinged for more than three months.
In most cases, no cause can be determined – and yet it’s a common cause of disability worldwide.
What’s become apparent in recent years is that chronic lower-back pain is a monster with two heads: One that has a physical element, and a psychological element.
It’s become widely accepted that exercise is the foundation of treating chronic back pain – with different people needing different types of exercise, as determined and supervised by a physiotherapist.
But there’s also a growing acknowledgement that psychotherapy – notably cognitive based therapy (CBT) – is required to enable the exercise plan to be adhered to by the injured patient.
A new study investigated the overall success rate in back pain treatment using a combination of exercise and CBT – and determined which of these had the most impact on getting a higher success rate.
It’s exciting – and we’ll get back to it.
The psychological bind
There is understandable resentment among people with chronic back pain that their condition might be best explained as a problem in the brain, and not in the spine. But the evidence is mounting.
In September, we reported on a new study that concluded that we need to take a radical step away from the traditional way we treat chronic back pain.
Researchers at UNSW Sydney and Neuroscience Research Australia (NeuRA) argued that we should no longer look at chronic back as a disc, bone or muscle problem, instead recasting it as a modifiable problem of the nervous system.
This idea does away with drugs and treatments that focus on the back such as spinal manipulation, injections, surgery and spinal cord stimulators.
Just about anyone who has chronic back pain will complain that those treatments offer short-term relief at best, and do little to fix the attendant disability.
The new treatment focuses on retraining how the back and the brain communicate – and has been shown to bring clinically meaningful benefits in a 12-week randomised controlled trial.
But it’s early days. The treatment was found to be superior to the use of opiates, by a modest degree.
Placebos lower the pain for some people
In 2018, we reported that scientists had found they could reliably predict which patients suffering from chronic back pain will respond to a sugar pill or placebo.
People with particular brain structures and psychological traits were found to enjoy a significant reduction – up to a third – in the intensity of their pain.
And the benefits were enjoyed even when the patients were told they weren’t receiving pharmaceuticals.
“Their brain is already tuned to respond,” said senior study author A. Vania Apkarian, professor of physiology at Northwestern University Feinberg School of Medicine.
“They have the appropriate psychology and biology that puts them in a cognitive state that as soon as you say, ‘This may make your pain better’, their pain gets better.”
Some hard realities
Meanwhile, there are realities that people with chronic back pain must deal with – evidence that the way they think about and behave toward their pain causes problems.
For one thing, there’s the exhaustion that comes with living on tenterhooks, where you’re nursing every movement – and your everyday functioning is compromised.
Of course, and any suggestion that you’re imagining this pain can leave you feeling belittled, insulted, enraged and – to add injury to insult – hurting more than ever.
But the difficult truth is, these attempts to protect yourself, coupled with the nervous expectation that the pain is lurking behind every corner, indeed causes the pain to be even more severe.
The exercise challenge
The other difficult truth is that exercise is widely regarded as the most effective intervention in the management of chronic lower-back pain – or at least the starting point for most patients.
If you have a half-decent doctor, they will explain the bind you’re in – movement is a key component to managing your chronic back pain, but you’re scared of movement because you expect it to hurt you.
And with that expectation, then yes, it will likely hurt you.
Chances are you’ll hobble out of your GP’s office with a sheet of stretching exercises, perhaps some painkillers for when things get rugged, and some advice on how to push through your anxieties.
No doubt the doctor has urged that if you can’t be bothered with the suggested stretches and strengthening exercises, do some regular walking – which isn’t bad advice.
It’s better than nothing
The GP will most likely have offered you a referral to a physiotherapist – and it pays to see one at least once or twice, because different people need different exercise programs. And it’s not straightforward.
As a 2016 systematic review of the effects of exercise and physical activity on non-specific chronic low-back pain found, too much or too little physical activity can be associated with low-back pain, suggesting that physical activity as an intervention is complex.
The authors note that, broadly, it is recommended for patients to remain physically active, as long periods of inactivity will adversely affect recovery.
They note that physical activity to increase aerobic capacity and muscular strength, especially of the lumbar extensor muscles, is important “for patients in assisting them to complete activities of daily living”.
Other exercises focus on core stabilisation, muscular strength and flexibility programs.
However, the most effective form of exercise as a method of rehabilitation for chronic low-back pain “is unknown”.
The simple answer, most likely, is it all comes down to what a particular patient needs. There is no one simple answer.
The new study
According to a new meta-analysis from Goethe University Frankfurt – in which the data of more than 10,000 patients were combined and analysed – therapies for chronic back pain that are “tailored specifically to a patient’s individual requirements, the chances of success are far greater than with standard forms of treatment”.
The success rate in pain relief was 38 per cent higher than with standard treatment.
“The higher effort required for individual treatment is worthwhile because patients benefit to an extent that is clinically important,” said lead author Dr Johannes Fleckenstein from the Institute of Sport Sciences at Goethe.
That standard treatment being painkillers and some exercise.
But this is where it gets interesting
When the individualised physical therapy is accompanied by cognitive behavioural therapy (CBT), “the pain can be alleviated even more effectively”.
Through CBT, patients learn to change the way they handle pain.
“They stop being afraid to move or are taught tactics for coping with pain,” the researchers said.
“This makes them realise that they are by no means helpless.”
OK, but what real difference does CBT make?
Analysis of the data revealed that when an individualised approach and CBT were combined, the success rate in terms of pain relief was an extraordinary 84 per cent higher than with standard treatment.
This more than demonstrates that the psychological aspect of chronic back pain is highly significant. As much exercise, it is key.
