According to a recent study in JAMA Psychiatry Sept 6th 2017, anxiety can be prevented!
This is an exciting idea as anxiety has been linked to chronic low back pain for years and although CBT (cognitive behavioural therapy) works really well, the problem is that there are far more people suffering from anxiety than there are practitioners to help them.
Chiropractors are taught CBT for musculoskeletal disorders – i.e back, neck and joint pain, however, we can only help once we think that a patient is exhibiting anxiety – we don’t know how to prevent simple back pain from becoming a chronic (long lasting) pain and worry for the patient.
This study therefore caught my eye because I would love for people to avoid going down that route of developing chronic low back pain. You may well have thought “If I do that, I’m bound to get back pain – it was horrible and I will do anything not to get it again” so you end up not doing things – this is called fear avoidance behaviour. “Last time I bent over I caused a disc problem – it hurt – I must never bend over again” – similar way of thinking and wrong.
There is a big difference in coming in for treatment because you HAVE irritated part of your back, neck or other joint.
What should happen is that
- You are treated to allow the joint to function optimally again and also to encourage the healing process.
- The chiropractor observes just how you are doing the things you do to see if you are actually irritating your joints over and over again without knowing. You can then be retrained to do what you need to do in a better way that does not overload the tissues.
- You then perform some appropriate exercises to strengthen the muscles that are inevitably weakened around an irritated joint.
- You get on with your life again with confidence.
What often happens is that
- You injure your back. You hate the pain. You don’t have any treatment. It does not go away.
- You have x-rays or a scan because the pain hasn’t gone. You are told or shown that you ‘have degeneration’ or ‘arthritis’ or ‘a disc problem’ or ‘sciatica’ or ‘misalignment’. These words are all concerning for you the patient when you don’t understand how much they will impact your life.
- You go away and think ‘Well that’s me – I have degeneration – I will always be prone to back pain – I’d better take it easy’.
- You do no exercise to improve the strength of your muscles; you don’t change how you do things so you are not overloading your tissues; you just do the same old things the same old way and worry and wait until it comes back again.
- You always have back pain.
But what IS the pain?
Chronic pain is different to acute pain as I have discussed before. Chronic pain is in the brain, NOT in the tissues you think are “so degenerated that you will always hurt”. You ‘centralise’ the pain and as Clifford Woolf, a neurologist at Harvard Medical School wrote “It becomes increasingly more difficult and less relevant to identify the initial source”.
What actually happens is that the brain itself begins to generate the pain. A different part of your brain is active when you have chronic pain than when you have acute pain. Chronic pain activates the prefrontal cortex (where higher level thinking is dictated – including goal setting and decision making) and limbic regions of the brain ( which governs memory, motivation and pleasure).
In 1999 Vania Apkarian, a professor of physiology anaesthesiology and physical medicine at Northwestern University School of Medicine in Chicago, found that the actual anatomy of the brain in those with chronic pain is abnormal. Therefore if there is less grey matter in those areas just mentioned – all of the functions I have mentioned are going to be compromised, and he said that between 5 to 11% of their grey matter was missing in those suffering chronic low back pain. Thus you can see how those with less grey matter in those areas would be less efficient at coping, making decisions, being optimistic etc. Furthermore the remaining grey matter is rearranged in those with chronic back pain .
None of this means mean you are imagining the pain. AND the good thing IS – that you CAN manage it. Come in to see one of the chiropractors; find out what you have really done and why it happened. Be treated and DO exercise to get stronger and more confident. By having someone you trust to help you with the exercises and activities of daily living you will realise how you got the problem and how to avoid it. But what if you could prevent the fear fromdeveloping in the first place?
Woolf in the Journal of Pain in 2016 said that the development of chronic pain may occur because of a combination of genetically based susceptibility factors as well as local pathological factors. This means that whether you bend over and rupture your disc is down to how your back tissues can cope with you bending over – lots of people do this every day and never develop a disc problem. The big issue here is how much that injury is going to affect you mentally. How much it is going to impact your life and for how long might be genetically driven. A lot more research needs to be done to see if the genes that control chronic pain can be altered.
Anxiety, stress and depression are problems for between 30 and 45% of patients with chronic back pain. Until genetic ‘tweaking’ is possible, I am still interested in how we can train our brains to prevent chronic pain developing.
This is why I was excited by this study. It is the first paper to examine prevention of anxiety disorders looking at a wide range of age groups. It suggests that we can prevent anxiety disorders effectively regardless of people’s age. You can develop anxiety at any time in your life. I had a back problem that was longer lasting and more painful than I had ever had, back in 2005. I, myself developed anxiety – I was petrified of the pain coming back and although I hadn’t actually bent over to cause the problem, I decided that bending over was an irritation to a disc and I must never to so again. This in a person who HAD studied anxiety; had advised patients about it; had told patients over and over again that they should not become fixated by back pain etc etc – and I fell under its spell. I only got over it with treatment from someone I trusted; exercises and CBT.
Prevention
This should be started in schools according to this study. I agree but what is not known is whether this preventative intervention is better carried out by trained professionals rather than teachers or people in the workplace.
The interventions that were studied in particular were CBT, psychoeducation and acceptance and commitment therapy (ACT).
Prevention can be implemented by offering information on anxiety through lectures or fact sheets; ‘psychological intervention’ or an attempt to find out how people think by using a variety of strategies such as CBT or interpersonal therapy. A colleague of mine Pat Partington has produced a series of wonderful videos that simply explain how chronic pain develops and how to deal with it yourself – go to http://great-minds.thinkific.com/courses/calm-your-anxiety-with-cognitive-hypnotherapy .
However, prevention is about using these tools before you have developed chronic pain and anxiety. If one of our chiropractors sees that you might be at risk of developing chronic pain and anxiety about your back pain, this paper leads us to understand that there is benefit in trying to prevent the anxiety disorder from developing rather than just waiting and ‘hoping for the best’ that you won’t develop it.
Furthermore interventions to prevent anxiety may be less complex and intense than those used for the treatment of anxiety disorders. However, never fear! If you DO have chronic pain – you can get past the terror that you are about to make it hurt again and gain control over your body – you do not need to feel ‘helpless’ all your life!