Chronic Lower Back Pain, Stress and Trauma: Is It Time to Think Differently About Pain?
As many as 85% of cases of chronic lower back pain have no identifiable physical cause for the pain
Therapist and personal trainer Andy Keefe explains how mind and body connect, and how trauma, stress and depression can cause back pain
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Chronic Lower Back Pain (CLBP) is a condition of the mind as much as the body: anxiety, stress, depression, trauma and other mental health issues can actually cause physical pain and make existing pain worse. So you might notice that your pain feels worse when you’re worried or feeling down, or struggling with a trauma.
Recovery requires working with both mind and body and NICE (the National Institute for Clinical Excellence) recommends a combination of physical treatment, including exercise, and psychological therapies (especially where more traditional approaches have been tried unsuccessfully before).
This article explores how mental or emotional experiences can cause and exacerbate physical pain and how a combination of exercise and therapy can help.
The spine and lower back pain
There are many ways pain can be caused in the spine physically, especially in the lower back or lumbar spine: the disks between vertebrae, designed to absorb shock and enable movement in the spine can push out of their casing and press on the nerves running down the spine; spending too long sitting down increases the load on the spine by 40% compared with standing, putting pressure on disks and vertebrae; poor posture and movement patterns – how we stand and sit, how we move, walk and lift weights; trapped nerves – if the sciatic nerve is impeded as it leaves the spine, this can cause referred pain in the back, gluteal muscles and all the way down the legs (known as Sciatica); poor conditioning in your core muscles or muscular imbalances elsewhere in the torso; too much driving, certain kinds of sports and smoking – all of these are clearly identifiable causes of lower back pain.
In perhaps as many as 85% of cases of chronic lower back pain, there is no physical reason for the pain – examination by a medical professional can find no structural damage or impairment to explain the pain. Stuart McGill, Emeritus Professor of Spine Biomechanics at the University of Waterloo in Canada and a leading authority on spinal health, in his book Low Back Pain does dispute this, as he believes the issue is more to do with the poor diagnostic technique of the medical professionals concerned, but there is considerable evidence that psychological and emotional issues do play a role in the creation and maintenance of chronic pain. Cases have been recorded of people with actual structural damage (such as protruding disks impacting on nerves), who do not feel any pain at all, while cases of Phantom Limb Pain, where someone “feels” pain in a limb that has been amputated, would also seem to indicate there is a psychological or mental element to pain.
In 1965, Melzack & Wall developed “Gate Theory” to explain the brain’s role in the management of pain: in this theory, muscles, joints and other tissues affected by actual or potential damage, send signals to the brain via the nervous system, through a process called “Nociception”. These signals need to pass through a series of “gates” along the spinal cord, to reach the brain. At each gate, the brain decides whether the signal is important enough, (given the nature of the harm and the current circumstances of the individual), to be allowed through to the pain sensors in the brain, to be experienced as pain. The brain’s priority at all times is to keep the body alive, so it may decide not to allow the signals to pass if this would put the body at further risk. This is why soldiers often report not feeling wounds or injuries during combat, only noticing once the battle is over and they are safe enough to feel the pain and seek treatment.
The brain contains a Body Map, with neurons corresponding to each area of the body, so that the brain knows which part of the body is affected. (It may feel like it's your left hand which is painful, but actually the pain is being registered in the area on the brain’s Body Map which corresponds to the left hand.)
Sometimes, damage to the nervous system can leave the pain sensors for certain areas of the body left “switched on”, causing the pain to last longer.
The brain therefore has an essential role in deciding whether the body should feel pain and where the brain is concerned, we think also of thoughts, emotions, feelings, the Mind/Body and brings us back to the question of how issues in the mind can cause physical pain. There are many answers.
Poor mental health
Living with chronic pain for months and years can get you down and lead to depressive feelings. People living with depression often report a lack of energy or motivation to do anything, spending most of their time sitting or lying at home.
If you sit more and move less, the muscles of your core weaken and tighten which makes lower back pain worse and you can find yourself in a downward spiral of pain. Others believe lower back pain and depression are actually the same thing, with one being the physical manifestation of distress and the other its emotional equivalent.
Depression (and anxiety) lowers level of the neurotransmitter serotonin in the blood stream. Serotonin raises our mood but is also a natural pain killer. Levels of “Substance P”, a hormone which regulates our sensitivity to pain increases in the body when we are depressed or anxious, making us more sensitive to pain at the very moment levels of pain killers in the body are falling.
Trauma and pain
Trauma is a physical experience – the original traumatic incident may have involved violence, injury and pain and so pain will be part of remembering or re-experiencing the event. But the body is involved in any incident where the Fight, Flight or Freeze mechanism is triggered: when we are in a threatening, scary or dangerous situation, the brain’s alarm system, the amygdala, will take in information about the threat, decide how serious it is and organise the body’s response, instructing it – via the release of stress hormones – to prepare to literally fight the danger, run away from it, or to freeze, in the hope the danger will not notice you and pass you by. This option can be selected where either of the other two are not possible, where the person concerned is trapped for instance (such as in an abusive, controlling relationship), or they are held down. Stress hormones signal the heart to beat more quickly, the lungs to bring more air in and the working muscles to prepare for action.
Where something happens to remind the amygdala of the original incident, it thinks it’s happening again, as it does not have a sense of time or place, sending out the same stress hormones, engendering the same emotional and physical experience in the body, which will clearly include pain if pain was a feature of the original assault or abuse.
The brain also processes emotions and physical pain in the insula, the area of the brain which connects the mental experiences of the mind with the physical experiences of the body: when the insula is stimulated by the experience of powerful emotions such as fear or helplessness, this will magnify the experience of physical pain. Studies have shown that where helplessness or powerlessness is a feature of the original trauma, this will make the survivor much more sensitive to pain in later life.
Mark Grant, in his book Pain Control with EMDR (Eye Movement Desensitisation and Reprocessing) also shows us how in certain types of dissociation, a trauma survivor might cut themselves off from the emotional causes of the pain, focussing on seeking a physical explanation for it to protect themselves from the full impact of the trauma.
Poor early attachments
Research has shown there is a link between attachment styles and the experience of chronic pain: people who perhaps grew up in dangerous, neglectful or chaotic home environments and developed anxious or fearful attachment styles are more likely to experience chronic pain and to higher levels than people with more secure attachment styles.
If someone did not receive the care, attention and understanding they needed when they hurt themselves as a child, perhaps because their parents/caregivers were not well enough attuned to their needs, this will impact on how they manage pain as adults.
Trauma, cortisol and chronic pain
When the Fight or Flight Mechanism is triggered, adrenaline is released from the adrenal gland, to stimulate the Sympathetic Nervous System and get the body ready to fight or run.
Adrenaline is followed by cortisol, responsible initially for calming the immune system to keep the body in homeostasis – a state of balance. If the traumatic / stressful situation persists, so much cortisol is released that the cells in the immune system cease to take any notice of it, meaning inflammation of the immune system increases and inflammation leads to pain.
Neuroplasticity, chronic pain and referred pain
Norman Doidge, in his book The Brain’s Way of Healing, shows how neuroplasticity is the vehicle for the spread of chronic pain: if a vertebral disk is pressing on a nerve, this will cause signals to be sent along the spinal cord to pain sensors on the Body Map in the brain which correspond to that particular disk. The more often the disk protrudes, the more signals will be sent and the more neurons on the Body Map will fire. The pain system will become sensitised with neurons beginning to fire when there is less pressure from the disk on the nerves and eventually when there is none at all. Neurons will fire signals to their adjacent neurons which represent adjacent areas of the body on the map and the pain will spread to other areas of the body as “referred pain”: this is how pain can spread from lower back to gluteal muscles to the legs.
Doidge shows how many of the areas of the brain which process chronic pain also process emotions and emotional disturbance: the amygdala processes emotional memory and pain, the hippocampus narrative memory and memories of pain; the posterior parietal lobe, sensory, visual and auditory information and pain (though it cannot do both at the same time) and the insula connects emotion with bodily sensation and also processes pain.
Engaging these areas of the brain in other activities can stop the firing of the pain neurons, reversing neuroplasticity and reducing the experience of pain.
Therapy and fitness to relieve lower back pain
Exercise and movement can relieve depression, anxiety and trauma and therapy of the mind can help relieve pain in the body, so it makes sense to use both when dealing with chronic pain, where linked to psychological or emotional disturbance:
Where to start? The traditional view that an episode of lower back pain required two weeks of bed rest is now regarded as counterproductive as it will just weaken and stiffen muscles and joints, making the pain worse. People living with CBLP are now encouraged to keep moving and to become “active participants” in their own recovery. Movement loosens and strengthens muscles and joints, relieving pain directly – many forms of exercise will help but its best to begin with a programme which builds the strength and endurance of your deep core muscles, adding more challenging routines once the lumbar spine and pelvis are stabilised.
If you are depressed though, exercise may be the last thing you want to do: depression may leave you exhausted, with little energy and negative thoughts may be telling you not to bother, that its too hard, it will make the pain worse. Working with a therapist at the same time as a Personal Trainer (PT) may be the solution.
So, what is the best way to start?
First, if your back is stiff and sore, go and see your GP, just to rule out any deeper, more serious issues and to check out if its ok to exercise.
Next – see a psychotherapist who specialises in chronic pain – they can help you understand whether any of the psychological issues (stress, anxiety, trauma, depression, attachment issues) we looked at are factors in your pain and can help you address them. A therapist can also help you find the motivation to begin to exercise, countering the negative thoughts and addressing any anxieties you might have about exercise.
Then – find a PT with additional training in working with lower back pain – look for someone with a Level 4, Lower Back Pain Specialist Qualification: they will have the knowledge to assess whether there are any physical factors affecting your back – there could be issues with your posture, the way you sit, stand or lift heavy objects; you might have a muscle imbalance (if you sit down all day, you might have tight hip flexor muscles, which will pull down on the lumbar vertebrae, pressing down on the disks, pushing them against the nerves in the spine, for instance); your pelvis could be out of line…
The PT can understand where you are and help you start from there, designing a gentle exercise programme to get you moving again: easy movement to build core strength and stabilise the spine and pelvis; they can teach you how to stand properly and use your core to take pressure off the disks, placing the least demands on muscles and joints and how to use your legs, knees and hips to lift heavy objects and spare the spine. Cardio can help too: cycling on an indoor bike, walking, gradually introducing load-bearing exercise.
Movements to loosen the back – stretches, mobilisations, all will help release tension and help you feel more confident.
And as you start to move again, levels of endorphins and serotonin in the blood stream (both natural pain killers and anti-depressants) will rise - pain levels will decrease and your mood will rise, also helped by the work you are doing with your:
Therapist to address and process the experiences, traumas and memories causing your depression, anxiety or trauma, which will calm mind and brain, reducing activity in the pain-processing areas of the brain and further reducing pain.
Growing research evidence demonstrates the effectiveness of EMDR in resolving the psychological aspects of CLBP: EMDR can be used to process the memories and experiences which cause the depression, anxiety and trauma driving the pain. It can also target pain directly: it could be that while one part of your brain believes the body is in pain and continues firing pain signals, there could be another part that knows you are not in danger and there is no need to feel the pain as whatever physical damage there was before has now healed. If the two areas of the brain are on in contact, the pain signals will continue. EMDR uses eye movements, tapping and other forms of “bilateral stimulation”, to connect left brain with right brain so the part of the brain which knows you are not in physical pain can speak with the part that thinks you are and help to calm it, so the pain signalling can be switched off.
Other pain-relieving activities a therapist can help you with include:
Feeling anxious or stressed can lead to shallow, fast breathing patterns, using the upper chest and not the diaphragm. Too much Carbon Dioxide gets expelled this way, making the blood more alkaline (See Nick Potter’s book, The Meaning of Pain for more on how this impacts our health generally) and leading to achy muscles and joints. Learning to breathe properly – slowly, deeply, till the lungs fill with air, the diaphragm is pushed down, the stomach pushed out, using the lower abdominal muscles, not the chest – relaxes tension out of the muscles, calms the nervous system and can relieve aches and pains.
The Posterior Parietal Lobe (PPL) of the brain processes pain and visual information, as noted above, but Doidge shows us that it can’t do both at the same time. So, filling the brain with a visualisation, particularly one on the theme of pain relief, switches the attention of the PPL away from pain, reducing its impact.
The insula, (responsible for pain and the link between brain and body), is also the area of the brain we use when in meditation or Mindfulness, which is why these practices can also help relieve pain.
Chronic Lower Back Pain is a condition of Mind and Body and working with mind and body in the ways we’ve explored really can make a difference. In conclusion: Move More / Talk More!