Low back pain is one of the most common reasons that people schedule a visit with their healthcare provider and it is the second leading cause of disability in the US.
Some of the most common causes of low back pain are improper lifting of heavy objects, injuries, and muscle strains and sprains.
Interestingly, the causes of low back pain can be very different from one person to another which is one of the reasons why every case of low back pain should be looked at individually to see what is causing it.
A Unique Response To Pain
While lower back pain is very common, it is also very unique, as people often respond very differently to this condition. One of the reasons for this unique response is the fact that people often respond to pain very differently with the pain experience being very subjective.
What this means is that even when two people have the same pain levels, their response to pain can be very different, often because of their outlook and attitude. When we look at modern pain management techniques, managing pain from a psychological perspective is showing significant promise.
It is important, therefore, that we consider different psychological interventions for managing low back pain.
Key Psychological Interventions For Chronic Low Back Pain
What are some of the key psychological interventions for chronic low back pain management? Some key interventions are:
1. Cognitive Behavioral Therapy (CBT)
Lower back injuries can be a scary experience. Low back pain often happens suddenly and without warning. One day you are digging happily in your garden - the next you can’t stand up straight.
Over time repetitive movements can lower your threshold for muscle tension and can lead to what seems like a “sudden” and “unexpected” injury. This sudden onset can cause distress and worry which, in turn, can actually make your pain worse.
Fear Avoidance
What’s more, our personal thoughts and beliefs around pain and health can have a significant impact on our experience of pain as well as on our recovery. If you are already someone who struggles with anxiety, you can experience increased levels of catastrophic thinking, as well as fear-avoidance when it comes to getting moving again. Stress and a lack of movement have been shown to make pain levels worse, and increase the time to recovery.
Brain Chemistry
Some more science behind our pre-existing psychological attitudes towards pain looks at abnormalities within our brain chemistry with dopamine being one of the main regulators.
When our brain chemistry is off, functions like emotional control and anxiety are dis-regulated and it becomes hard to control our anxiety and distress causing our pain levels to increase, our perception of pain to be heightened, and our focus to be solely on our pain. It becomes all we can think about.
What Is CBT?
This is where cognitive behavioral therapy comes in. CBT is a type of psychotherapy that helps us challenge negative patterns of thought about ourselves and our environment in order to treat mood disorders like depression, and helps alter our perceptions of things like pain. You can attend CBT sessions individually, or in a group; in-person, or via telehealth.
The main goal of CBT, when treating low back pain, is to replace a person’s maladaptive coping skills, thoughts, or behaviors, with “better”, “healthier” ones.
CBT is often part of a multidisciplinary pain program and it has been shown to help reduce the pain and anxiety around chronic low back pain. CBT is also an effective way of helping prevent low back pain from turning into chronic low back pain.
Common CBT Techniques:
Motivational self-talk
Relaxation techniques
Biofeedback
Goal setting
Distraction
Imagery
How CBT Works - Changing Our Thoughts
When we get stuck in negative thought patterns around pain like, “I am never going to get better”, “I can’t possibly exercise or move without making things worse” or “I am a failure because I can’t do anything with this much pain” it can cause us to get stuck, and it hinders the healing process.
In CBT, the therapist encourages their client to challenge these thoughts and to question how true they really are. Clients are taught ways of dealing with these negative thoughts and beliefs as they come up and help them look at things from a different perspective, replacing negative thoughts with positive ones such as “This pain is just temporary and I am going to get better.” or “I am more than just my back pain.”
Studies have found that CBT “is an effective component in the overall treatment of chronic low back pain”. No longer should treatment look just at the physical aspect of low back pain, but looking at the client as a thinking, feeling person with thoughts and feelings around pain is an important part of treatment.
2. Mindfulness-Based Stress Reduction
According to The American Institute of Stress, about 33 percent of people report feeling extreme stress; 77 percent of people experience stress that affects their physical health; 73 percent of people have stress that impacts their mental health; and 48 percent of people have trouble sleeping because of stress. Unfortunately, for about half of all Americans, levels of stress are getting worse instead of better.
The brain plays a central role in stress and pain processes. As individuals interact with their environment, physical and psychological stressors can lead to adaptive or maladaptive neural and hormonal responses.
There is a sequence of events that occurs in your body in response to stress that includes physical responses from your body. These responses can include increases in pain threshold, changes in your locomotor activity (how you move) and even changes in your body temperature.
How MBSR Works For Back Pain
Mindfulness-based stress reduction (MBSR) is a type of therapy that has been demonstrated to help reduce back pain and to help improve emotional control. The practice of mindfulness activates your brain relaxation pathway by helping people control the “noise” and “distractions” in their bodies and their environment by encouraging a focus on breathing.
MBSR trains clients to focus on increasing their awareness and acceptance of things that are happening in the moment, like pain, depression, or frustration. It helps people move past their feelings of pain and realize that there are other things to focus on.
Formal MBSR programs do not focus just on pain. Classes generally include things like:
Body scans
Yoga
Meditation
Breath work/ breathing
The purpose of the training is to be able to sit with emotions, feelings and thoughts that come up without judging them or trying to change them. When it comes to non-pharmacological treatments of low back pain, MBSR is becoming increasingly popular, especially since it is one of the treatments with the most evidence to support its effectiveness.
The Effectiveness Of MBSR
One study that was done found that at 26 and 52 weeks, patients who practiced MBSR had “greater improvement in function and back pain compared to the group that remained in standard care”. They also found that individuals who practiced MBSR “continued to see improvement”.
A 2011 systematic review of studies on MBSR found that “acceptance-based interventions such as MBSR have beneficial effects on the physical and mental health of patients with chronic pain, comparable to those of CBT”.
MBSR is another excellent way to manage chronic low back pain without the use of medication or surgery with two year data now also showing its long term effectiveness in managing this chronic condition, and positive data reflecting low to no experiences of side effects with this treatment.
3. Progressive Muscle Relaxation
Progressive Muscle Relaxation (PMR) is a relaxation technique used by healthcare providers to help clients control their levels of stress and anxiety. Research has also found that this technique can be used to reduce the symptoms of certain types of chronic pain.
PMR works by focusing on one muscle group at a time and having the client tense the muscles, tighten them, and then relax and release the tension. If you have ever done a body scan then you will probably have participated in PMR. The tense and relax steps are repeated with different muscle groups until the whole body is relaxed.
How PMR Works
The main aim of PMR is to help clients become more aware of their bodies and to help them practice both mental and physical relaxation techniques. Knowing that chronic low back pain is made worse by stress and tension, PMR has been studied extensively with the research supporting the idea that PMR can “relieve low back pain and improve flexibility”.
Because non-pharmacological treatments such as PMR have few to no side effects, the treatment is perfect for people with health concerns such as pregnant women. One particular study looked at the effectiveness of this therapy in pregnant females and found that the group who received PMR treatment experienced a “greater decrease in perceived pain and improved QOL than the control group”.
Further studies have confirmed the effectiveness of this treatment in helping to manage low back pain and there is overwhelming data to support the fact that PMR for low back pain is generally associated with a “reduction in perception of pain, stress and improvement in well-being”.
Conclusions
With the current war on opioids and the rising cost of medical procedures, it is more important than ever to find non-pharmacologic ways to effectively manage chronic low back pain. It is also crucial that we remind ourselves that low back pain is not a purely physical condition. Our psyches and environment play a key role in the management of disease.
Some doctors are dismissive of the psychological component of low back pain, while others use it as an excuse when nothing else seems to work and end up dismissing the patient and making them believe that everything is just “in their head”.
While it seems clear that low back pain IS in your head, this is not something to dismiss or to take lightly. Clients need to be given effective psychological interventions to help them manage their condition and to assist them in living full, productive and positive lives.