Treatment of Chronic Back Pain
Dr. Jerry Sobel understands that acute and chronic pain syndromes are very different and therefore should be treated quite differently. In acute pain their is a specific tissue injury that occurs. Modifying activity levels, minimizing bed rest and using ice and anti-inflammatories can be helpful. Acute injuries generally heal within a few months. When the pain from that injury does not resolve after the expected healing time, usually about three months, it becomes a chronic pain problem. The longer the lower back pain, neck pain or joint pain go on the more resources it takes to heal or lessen the impairments and disabilities that result from the pain.
Factors that Influence Chronic Pain Syndromes
Chronic pain syndromes are influenced by many factors beyond the original tissue damage. After several months of pain, individuals develop secondary problems that for many people become a bigger barrier to recovery than the original injury. For example, chronic pain sufferers develop significant loss of physical conditioning from a combination of reduced activity and the fear of causing further harm to themselves. Those who have to deal with chronic pain syndromes can become quite anxious and/or depressed because they have not recovered, and if they have not been able to work, become financially distressed as well. Many of these individuals end up frustrated after seeing a series of doctors that are not able to help them. Eventually, the pain begins to take on a life of its own.
Principles of Pain Management for Chronic Pain
Bio-medical Model of Disease
There are two basic pain management treatment approaches for chronic pain syndromes. The oldest of these is the bio-medical model of disease. In this model of pain management, the main focus of treatment is on finding the body part that is causing the pain and either through medication, injections, implantable simulators or surgery, make it hurt less. This is by far the most common form of pain management. This can be an effective as long as one can find the pain generator. Unfortunately, this can be hard to do in many chronic pain sufferers who have been dealing with their pain for months or years.
Bio-psycho-social Model of Illness
The second model of therapy, and the one favored by Dr. Jerry Sobel is known as the bio-psycho-social model of illness. As the name implies, this is a multidimensional treatment paradigm focusing on the physical issues- bio, the anxiety and depression that develop as a result of months of pain- psycho, and how the injury has resulted in a changed lifestyle as it relates to society, i.e. family discord and lost of work- social.
I found a good summary of the differences between the two forms of treatment: The bio-psycho-social model is a broad view that attributes disease outcome to the variable interaction of biological factors (genetic, biochemical, etc), psychological factors (mood, personality, behavior, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.). The bio-psycho-social model counters the biomedical model, which attributes disease to roughly only biological factors or pathological abnormalities.
As can be seen in the above diagram, the treatment of chronic lower back pain must consider all of the potential factors that affect recovery. If only biological factors are addressed many times patients do not reach their maximal potential. In my experience the items under the psychological factors heading are some of the most critical to address especially “fear avoidance beliefs.”
Fear Avoidance Beliefs
In the treatment of a person with a chronic pain syndrome such as involving chronic sciatica or chronic lower back pain sometimes the fear of movement and the fear of re-injuring the already painful body part become bigger barriers to recovery than the original tissue injury. Below is a diagram that conceptualizes the concept of fear avoidance behavior and its effects on a person’s ability to recover from a painful condition.
As per the diagram below a person develops a painful condition such as neck pain or sciatica and they experience the pain. Some individuals will have no fear of the pain and will continue to try and move and function as best as they can. The movement and a focus on trying to perform normal or near normal daily activities can actually help with recovery. The second group of people when experiencing pain from an injury will almost immediately or soon thereafter start to have “worst case” scenario thoughts or become fearful of moving and feeling the pain because they believe that the pain indicates something “bad” is going on. As a result of this fear the person significantly curtails normal daily activities and if this goes on long enough then he/she loses physical conditioning which can result in more pain. Increased pain levels can lead to greater avoidance of activity and with that an even greater loss of physical capacity. For some, depression and anxiety develop which can worsen the pain experience which can lead to great fear and so on and so on.
Breaking the Fear Avoidance Cycle
Breaking this fear avoidance loop can be critical to the recovery for some individuals suffering from chronic pain. For some patients breaking this cycle is as easy as educating them that their pain is “safe.” By safe I mean that if a person with chronic lower back pain performs an activity that increases their pain the increased pain does not an indication that further harm is occurring. In fact, movement is medicine and helps with the healing process. Check out the movement is medicine video I have on a blog post.
I would like to make a point that this is not a one size fits all model. I have seen countless patients over my career that have had chronic lower back pain and other chronic pain syndromes that improved substantially with just addressing the primary physical problem. My point is that each person needs to be evaluated individually and given a customized treatment program that address the primary barriers to recovery.