Sensitization and Chronic Low Back Pain 2

Sensitization and your continuing back pain part 2.

I discussed last week why you might have continued back pain and that sensitization might be a cause. This week I will discuss the ways research has suggested you may be able to deal with this sensitization to try to help reduce how it impacts your life.

It is thought that you would benefit from a combination of treatments, of course, depending on the issues that you also present with. Of course the pain could still be coming from a continuing problem in the tissue with or without sensitization but I am just going to discuss the implications of sensitization here.

Physical help from a chiropractor is a good way to start. It might be all you need!

We will help to optimise joint function and check for muscle weakness etc so that when you move you are not overloading your discs, joints, muscles, tendons or ligaments. We will help by providing reassurance

If this is not enough and you are anxious or depressed or worried then you might benefit from additional therapy or lifestyle changes and here are some examples of helpful activities.

  1. Cognitive Behavioural Therapy (CBT) May help as part of a multidisciplinary biopsychosocial pain management programme if you have psychological issues. It helps you to change the way you think and behave. It is most helpful for people with anxiety and as I said last week, anxiety is linked to the limbic system, and signals from the limbic system feed back to the spinal cord and can add to sensitization. If you can be taught to develop your own personal coping strategies you can change how you react to pain.

You learn how to think about why you are anxious and change any irrational thoughts that affect how you behave and you develop your own coping skills. You can go from thinking “I am never going to get better” or “I can’t bear this much pain” to being able to think differently about the pain. Gatchel and Rollings in Spine 2008 Jan-Feb;8(1):40-44 studied the effect of CBT for chronic pain management and said that “it serves an effective role in dealing with the psychological component of chronic low back pain, however, it needs to be combined with other therapeutic components, such as physical therapy”.

In a well know experiment, a researcher looks into how people react to pain. The scientist says that they are going to strike a match and hold it against the person’s skin and time how long they can bear the pain. The person is blindfolded. The match is struck; they can smell the match burning. The person is told “I am about to hold the burning match to your skin”. The scientist then takes a piece of ice and holds that against the person’s skin NOT the burning match. Nearly everyone screams and says they can’t bear the pain… then when they take the blindfold off and see the ice they just cannot believe that it was just ice!

This demonstrates the power of thought to influence our perception of pain very effectively. Thoughts such as “I am going to be in pain if I bend over so I won’t bend over” or “I lifted that heavy object, I am going to be in pain” are some of the ways we try to cope with fear of pain and they can actually add to the pain we feel but the good news is, they can be changed.

  1. Help with other problems that are known to be associated with sensitization can reduce the amount of input to the sensitized cells.

If you have irritable bowel syndrome for example or fibromyalgia, temporomandibular joint dysfunction, these are all things that the research has indicated can form part of this sensitization experience that the patient is having. In fact it was found that there are 27 known conditions that can contribute to central sensitivity. Woolf presented research into central sensitization in the journal Pain Vol 152 No 2 Supp S2-15 Oct 2010.  He found that changes in pain sensitivity that contributed to central sensitization were also present in patients with osteoarthritis, headache, TMJ (jaw) disorders, dental pain, fibromyalgia, chronic fatigue syndrome, also posttraumatic stress disorder, visceral (gut) problems and multiple chemical sensitivities. Younes found links with tinnitus, palpitations, mould allergies, parasite problems, Meniere’s disease too. The list is quite significant.

The thing that all of these have in common is that they are described as being essentially psychosomatic. In other words the world of medicine has not found sufficient clinical grounds to be able to effectively say, “There is an objective cause that we can measure.”

Younes prefers to call these problems “central sensitivity syndrome”. The point is that probably one of those things on their own doesn’t mean you are sensitized but if you have a few of these issues then it could mean you are and that is maybe why your back pain isn’t going away.

Why Do These Conditions Add to Sensitization

There are descending drives coming down from the limbic system in the brain, which is essentially the part of the nervous system that processes emotions so if someone is anxious or depressed, and that coupled with the central sensitivity that it is happening at the cord level from the area of Low Back Pain plus potential parallel influences from the gut if you have irritable bowel syndrome, say means that there is a convergence of those drives that seems to create the sensitization.

Nutrition is also said to influence the conditions that are optimal for sensitization to arise. The standard Western diet, is said to be quite pro inflammatory, which is a perfect kind of milieu to initiate sensitization.

Muscular strength is also thought to help to resolve sensitization so any treatment should include the rehabilitation via the transversus abdominis and multifidus rehabilitation exercises are performed as I discussed last week.

Why Do You Need to Change How You Think?

What has emerged from this research is that whereas in the past we thought that it was posture, and biomechanics, and poor ergonomics, that were responsible for the continuing sensations of chronic low back pain, and we would have focussed only on the physical causes of the persistent pain, now emerging research is increasingly suggesting that these are not necessarily major factors, and that statistically speaking, they are not very significant, particularly in more persistent or chronic pain cases. In fact, anxiety and depression and sleep and other lifestyle factors, are now thought to actually have a much stronger association with chronic low back pain than does biomechanics.

So What DO You Do To Help Yourself?

Nobody is saying that posture and thinking about how you do what you do are not important but if you are someone who has persistent pain and you have tried ‘everything’ but nothing has worked then maybe you are trying the wrong things! If sensitization is the key to your continued discomfort, you should be having a combination of some or all of the following:

Physical treatment; Rehabilitation exercises; Eating less pro inflammatory foods; Addressing anxiety, worries or depression issues in your life that you may believe you are coping with but you really are NOT; Getting enough sleep; Working to your abilities not overdoing it ‘just because everyone else is’.

You must remember that sensitization lowers your pain thresholds, and it increases your pain sensitivity. Remember the match experiment … you think something is going to hurt – it WILL – so train yourself to be careful not anxious and it might hurt less!

Is It All In My Mind?

Between 95 and 99 percent of our cognitive function is unconscious so what that means is that what we perceive with our conscious minds is a very small fraction of what’s actually going on within us governs most of what you do daily. You don’t decide that “I’m going make this hurt”; it just hurts. But it’s that process of pain perception that stops you from sitting in too long, which can irritate a nerve – this perception gives you a nudge and says you need to move because you had been sitting on it too long. That’s unconscious processes that are occurring.

When you are trying to make lifestyle changes; trying to change your nutrition, do exercise programs, go to bed earlier or to think more positively, this kind of thing, it’s really the unconscious that you are trying to change. Mindfulness has been talked about a lot recently to help us with the unconscious.

There are lots of different healthcare professionals that together can benefit someone with sensitization. Chiropractors; Nutritionists, psychologists, CBT specialists; Counsellors; Yoga Teachers; Sleep Therapists etc should all work as a team.

Remember, about 80 percent of people have disc bulges but they’re all asymptomatic so the disc bulges can’t be causing ALL of the pain. It needs to press on something sensitive to cause pain. Don’t allow your brain to let you think ‘I have a disc bulge or arthritis or degeneration or whatever, so I will always be in pain’. This is when your brain can work against you so you need to understand your problem not be defined by it. If you are worried – ask one of the chiropractors. They will reassure you and help you to understand what really IS going on. Less worry means less irritation of the nerves that can contribute to sensitization don’t forget!

More ways to help next week!