Traumatic LBP aside, there are (6) possible categories to organize LBP contributors. Classical orthopedic exams would likely not rule out these:
(#5) Mental & (#6) Behavior contributors:
“It hurts when I think about it.”
Low back pain does not exist in isolation. When we look for LBP contributors, we should be careful not to neglect the entire person that is having the experience of symptoms and interruptions to enjoying their usual lifestyle. Mental contributions might be overlooked for a variety of reasons in the clinician’s office: office scheduling issues, scope of practice issues, clinician experience issues, and course of care issues. Regardless of the reasoning for the issues, the clinician should provide an unhurried overview of the patient’s mental and behavior presentation of habits, values, expectations, and biases.
Non-physical contributions can make LBP worse. ‘Expectation Modulation’ describes a fearful patient; a patient may present with guarding, antalgia, fearing certain motions or body positions. These actions should not be casually oversighted, since these actions and shapes describe an entire person consumed by their pain. The patient may have an emotional history with LBP, or with any pain possibly related to depression, anxiety, and fear that can exacerbate their LBP, and that can lead to Sympathetic Syndrome and amplification. Since emotionality is connected to gut health, the patient may exhibit chronic gut complaints and symptoms, furthering fears about ‘complete and unmitigated pain and illness.’ Certain patients are prone to ‘back-pain ownership’; “My stupid back pain”, “My sciatica from 10 years ago.” The patient may blame the LBP as if had attacked them from outside their body, an invader, verbalizing it in the third person rather than as a lived experience; the back pain is a literal thing.
With time, LBP fuels patient frustration, and it takes two forms: (1) frustration with the pain itself, (2) frustration with the medical system’s inability to help the patient feel & get better. Good and excellent clinicians should have no problem satisfying any LBP patient in a few visits managing 6-8 weeks of conservative care that includes primarily patient education & home exercise.
Frustration is easy to avoid in the clinician’s office if the doctor simply says, “I promise you ___(patient’s name)____, LBP is very well understood within the scope of medicine, and I promise you that you will be feeling much better very soon, and able to___(live life better somehow)_____ with no problem, I promise.” I say this to every patient for four reasons: (1) it reassures the patient that their symptoms will be under control, (2) it reassures the patient that their complaint is under control because it is not a mysterious, potentially untreatable disease, (3) it puts my personal word on the line to do good work, (4) it makes me feel like an amazingly good doctor. Patients fear delays in care, and for getting lost in the system. They fear gaps in employment or job loss. They fear for the day that they have to go back to work with LBP, and push through their back pain, praying that it will just “Go away!”
Behaviors can change when a patient is dealing with long-term unresolved LBP. They may develop ‘health-identity distortion’ (HID); the idea that someone else is responsible for their health…become a victim, become aggressive with their doctor, and blame others. They may not eat enough food fearing the ability to afford food to pay medical bills, or due to loss of work. They may stop exercising, become less active with their family, miss family-time altogether, or fear movement due to expectation of pain. Sports patients may not commit to full training programs, or reduce recovery programs. Athletes with LBP may fear for the inability to compete, fall behind, or to be cut from the team… and may train secretly, or succumb to the coach’s insistence that the athlete continue to train anyway.
Physicians can be certain that ‘pain is not the only problem.’ Patients are less of a biological study, and more of an emotional study… pay attention the important mental and behavior contributors to LBP. And by all means, promise them anything that you think will help them feel and get better.
LBP Blog General information
These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.
Dr. Dean Bio
Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020. www.preformancecxs.org
© Copyright 2021 SpineSync, Forester Dean, DC
Duplication with permission only