Chronic Back Pain Mind Games

The mystery of chronic back pain and the brain’s pivotal role is revealed.

Written by Kelly Rehan

In Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery (2017), author Cathryn Jakobson Ramin investigated the mystery of chronic back pain. This unique and complex type of pain, she writes, exists not in the spine but in the brain.
When doctors identify a structural source of back pain, such as a herniated disc, the treatment is straight forward. But, what happens when the pain persists after the physical ailment has been addressed?

If there’s no more injury, why is pain still there?
Ramin shares a hypothesis: “Persistent back pain with no obvious mechanical source does not always result from tissue damage. Instead, that pain is generated by the central nervous system (CNS) and lives within the brain itself.”

How Chronic Pain Is Different from Other Types of Pain
People who suffer from chronic pain know that it’s not the same type of pain caused by a sprain in your lower back. Ramin, who herself has chronic back pain, writes that all pain isn’t created equal. In fact, there are 4 categories of pain:

  1. Nociceptive pain: Though it can be severe, this pain does not last long. Scraping your knee on the sidewalk is an example of nociceptive pain.
  1. Inflammatory pain: This pain occurs as a response to injury or infection.
  1. Neuropathic pain: This pain involves your nerves, and it causes sensations like burning, stinging, electric-like pain, and weakness. It tends to “travel”—it can feel like it’s moving from your neck down to your fingers, for example. This pain is also called radiculopathy.
  1. Chronic pain, or central sensitization: If pain persists once an injury or infection has healed, you may suffer from chronic pain or central sensitization. As Ramin puts it: “Central sensitization is a condition in which even mild injury can lead to a hyperactive and persistent response from the CNS.” The CNS (central nervous system) consists of the spinal cord and the brain.

Connecting the Brain to Back Pain
To answer her own questions, Ramin dug into the existing pain research—from centuries-old theories to the latest evidence.

In one study by neuroscientist A Vania Apkarian, PhD, scientists found that chronic pain affected 2 specific parts of the brain: the prefrontal cortex and the limbic regions. The prefrontal cortex is involved in goal-setting and decision-making, and the limbic regions, which include the hippocampus, dictate memory, motivation, and pleasure.

“In a revelation that set the international media abuzz, Apkarian’s group found that the anatomy of the human brain in patients who suffered from chronic pain was abnormal,” Ramin writes.

“In those who had suffered for five years, both the hippocampus and the prefrontal cortex were structurally transformed, sacrificing 5 to 11 per cent of their grey matter density,” she continues. “That was important because the prefrontal cortex, in concert with the hippocampus, dictates how optimistic or depressed patients feel about their prospects, how well they can cope, and make decisions about treatment.”

Another researcher, Clifford Woolf, MD, PhD, found that both environmental and genetic factors likely affect the development of chronic pain.

Shedding light on why chronic pain often runs in families, Woolf and his colleagues identified an inherited DNA variation that relates to elevated sensitivity to pain from sciatica, osteoarthritis, and lumbar disc degeneration.

“In other words, whether your intervertebral disc is going to rupture has much to do with your physiology and physical condition,” Ramin writes. “But how much it’s going to bother you, and for how long, is likely to be a matter of genetic predisposition.”

While research is limited, the notion that certain people are predisposed to pain sensitivity and chronic pain conditions based on their genes is becoming a widely accepted notion.

Bringing in the Brain: A New Chronic Pain Treatment Plan
Despite the recent surge in criticism against them, opioids are among the most commonly prescribed treatments for chronic back pain. But, Ramin notes that extended use could actually create more pain.

“Long-term use of opioid analgesics, especially high-dose extended release drugs such as OxyContin and methadone, have been associated with the development of a particular type of central sensitization called ‘opioid-induced hyperalgesia’, resulting in abnormal sensitivity to pain.”

While the controversy around opioids may be years from a solution, a growing number of pain specialists are turning to non-drug therapies to manage chronic back pain. Ramin notes exercise and cognitive behavioral therapy (CBT) as 2 examples.

The struggle with CBT, Ramin writes, is getting patients to see their pain as psychological and not simply structural.

“I listened to hundreds of back-pain patients explain their chronic pain: They spoke of degenerative disc disease, herniated discs, pinched nerves, sciatica, spondylolisthesis, scoliosis and spinal stenosis,” she writes. “But I never encountered a single patient who described his or her struggle in terms of central sensitization, or had heard of terms commonly used in behavioral psychology, such as ‘guarding’ (walking with an attention-getting limp) or ‘fear-avoidant behavior’ (eschewing activities that might tax back muscles, thereby making them progressively weaker) or ‘pain catastrophizing’ (ruminating over how severe the condition is likely to become, ruining any hope of a productive future).”

The goal of CBT is to help the people manage their pain by helping them change certain thought patterns to a more positive outlook, learn how to problem solve, and conquer fears. To accomplish this, CBT slowly exposes patients to the things they fear.

“With back-pain patients, the fear of pain might seem life-threatening,” Ramin says. “The job is to let patients know that, in the case of chronic back pain, hurt does not typically mean harm.”

CBT programs vary, but chronic back pain patients may be asked to start a hydrotherapy program, play beach volleyball, even haul a heavy crate (all under supervision, of course). All activities that patients may assume will exacerbate their pain.

“The grimacing, the groaning, the odd body mechanics – all of them must go,” Ramin writes. “Strengthening must follow. And when it does, the patient is rewarded with a sense of mastery over his or her own body, and no longer feels like a helpless victim.”

Cathryn Jakobson Ramin is an independent journalist, essayist, and author. Her work has appeared in The New York Times, The New Yorker, Scientific American, and NPR, among others. Her latest book is Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery (2017). She lives in California.

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