Low back pain is the single leading cause of disability worldwide and pain is the most common reason people seek medical help. 20% of Australians under the age of 65 experience persistent pain (pain that lasts beyond expected healing time) and this prevalence increases to 33% of people over the age of 65.
Pain is an important protective response. It acts to warn us of harm (or potential harm) and dangers to our health, protecting us against further injury or death. Unfortunately though, pain can persist for longer than expected, often without an obvious cause.
Persistent pain (or chronic pain) is a complex, multi-factorial problem that goes beyond the simple belief that tissue damage to some part of the body is causing pain. All pain is real no matter the cause, however, pain becomes a less reliable indicator of tissue damage the longer it persists.
This is why chasing a diagnosis for persistent pain can be problematic. The conclusions of scans like an MRI are often described using threatening language like disc bulge, joint degeneration, bone spurs etc. and this is unhelpful at best. It can even make the pain worse via a concept called “pain catastrophising”. This is a cognitive process characterized by a lack of confidence and control, and an expectation of negative pain outcomes.
Interestingly, countless studies have shown MRI findings to be poor predictors of pain. They can simply describe normal, age-related structural changes also seen in people who do not experience pain. The table here shows the prevalence of imaging findings (of the spine) across all ages.
Find your age bracket on the chart to get some understanding of what are normal changes to the spine and surrounding tissues.
Remember, these percentages are for people who are experiencing NO back pain.
So there are many factors other than tissue damage (as listed above in the table) that contribute to persistent pain. These include anxiety, fear, mood, past pain experiences, thoughts and beliefs about pain, what other people say (including therapists), social pressures, employment status, what you know about your pain/injury, pain medications and many more.
As pain persists, the body adapts by becoming more protective. Such interpretive changes occur in the brain and nervous system, heightening sensitivity to danger signals. This is akin to a car alarm being set off by a leaf landing on the bonnet.
A normal response to persistent pain is to avoid physical activity for fear of a “flare up”. Unfortunately, this is counterproductive. Muscles and connective tissue weaken and/or become less supple. Energy levels drop, fatigue increases, mental health declines and all of this leads to a vicious cycle, an in-ability to perform activities of daily living and an increase in pain and likely depression.
The good news is that an overprotective nervous system can be retrained, effectively de-sensitising the system and thus reducing pain sensations.
Exercise and movement are essential ingredients in the management of persistent pain and low back pain. Many pain researchers and health professionals recognise that increasing physical activity levels can improve pain, function, and wellbeing across a range of persistent pain conditions including osteoarthritis, back and neck pain, shoulder pain, fibromyalgia and post-surgery pain.
Learning to exercise in a way that is right for you as an individual has a positive effect on the pain system. With increased exercise tolerance, pain sensitisation reduces meaning fewer, less severe flare-ups as your system becomes less sensitive.
Other benefits of exercise for persistent pain include:·
Improved sleep – poor sleep has been linked to higher levels of pain.
Improved mood and reduced stress/anxiety – improved release and responsiveness to naturally produced hormones/neurotransmitter like dopamine can reduce perception of pain.
Improved immune function – exercise reduces systemic inflammation through
Improved circulation and changes in immune system function. Increased inflammation promotes pain and low mood.
Improved self-efficacy - a growing feeling that all is not hopeless, that you can improve and that you are doing better. An attitudinal change from "glass half empty" to "glass half full".
Summary:
All pain is real, however persistent pain is multifactorial and searching for one single cause via MRI scans and the like is too simplistic, usually misleading and possibly harmful.
Findings on MRI are also seen in the pain free population which questions the conclusion of cause and effect.
As pain persists, the body becomes more protective. Adaptive changes occur in the brain and nervous system that heighten sensitivity to danger signals, despite there being no real danger present.
Exercise and physical activity tailored to suit the needs of individuals (designed by experts like us!) in a safe and supportive environment is effective in increasing exercise tolerance and re-wiring the brain and nervous systems interpretation of pain.
If you or someone you know needs help managing persistent pain we can certainly help.
Give our office a call to book in an assessment with one of our Exercise Physiologists. We have had some great success in recent times helping people manage their pain.
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