Treating Nonspecific Low Back Pain
David Hanscom, MD, was just completing his training as a spine surgeon at Twin Cities Scoliosis Center in Minneapolis, Minnesota, in 1985, when his own horrible spine pain overtook him. “I was spiraling down,” he says. “Back pain, neck pain—I didn’t know how it hit me.”
Dr Hanscom had surgery for a ruptured disc, but it took him until 2002 to figure out that he could only escape the pain by controlling his stress and reprogramming his thoughts. Now working at Swedish Neuroscience Specialists in Seattle, Washington, Dr Hanscom offers a range of such therapies to his patients with chronic spine pain and prides himself on helping them avoid surgery altogether.
Nonspecific low back pain—that is, back pain without a specific diagnosis—has become a major public health problem worldwide, with a lifetime prevalence as high as 84%. And the prevalence of chronic low back pain is about 23%.
Evidence is mounting for the efficacy of treating nonspecific chronic pain not with surgery or narcotic medications, but with therapies drawn from psychology and meditation. The research supporting cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) is particularly robust.
But these approaches, particularly CBT, remain out of reach for many of the people who need them, says epidemiologist Dan Cherkin, PhD, MS, senior scientific investigator at the Group Health Research Institute in Seattle.
For one thing, not many psychologists are trained to offer CBT for pain management, Dr Cherkin notes.
For another, “a lot of the things that have been found effective for nonsurgical pain are not covered by insurance and not widely available,” he says. “It’s a wide social problem, and a training and reimbursement issue, that prevents patients from trying things that are shown to be effective.”
Reducing Pain by Changing Thoughts
Progress may depend on a more widespread understanding that the division between mind and body is artificial, says Dr Cherkin. Although its roots go back at least as far as the Greek Stoic philosopher Epictetus (55-135 AD), who stressed the importance of self-knowledge, CBT was developed by psychologists and psychiatrists in the mid-20th century as a treatment for mental health disorders.Unlike many psychotherapies, CBT is guided by empirical research and focuses on solving problems in the present rather than uncovering trauma in the past.
The researchers who developed CBT began with the premise that people can change unwelcome feelings and behavior by countering distorted thoughts behind them.
This process has a biochemical dimension. The emotional stress of pain may cause the release of adrenalin and cortisol, which increases conductivity of nerves, increasing the pain, Dr Hanscom explains. Over time, the nervous system may also adapt in such a way that the pain persists even after any physical trauma is healed.
“Anxiety is simply a chemical response to sensory inputs,” Dr Hanscom says. “The problem with thoughts, compared with the other stimuli, is that you can’t escape your thoughts. The harder you try to fight them, the worse it gets.”
With CBT, people can learn strategies for putting their fears into perspective. The therapy takes multiple forms, including one-on-one conversations with trained therapists, group treatments, reading, and writing. Multiple studies have shown CBT to be effective in reducing back pain.
In contrast, the origins of MBSR lie in Buddhist meditation and yoga. Molecular biologist Jon Kabbat-Zin, PhD, developed the first class in MBSR at the Massachusetts Medical Center in Worcester, Massachusetts, in 1979. In MBSR, the practitioner seeks to increase awareness and acceptance of such experiences as discomfort and negative emotions. Although MBSR is less well-studied for back pain than is CBT, the research so far suggests that it may also be effective.
Studies using MRI suggest that CBT and MBSR cause some brain remodeling