Whether it's a niggling pain that won't budge or a sudden twinge that becomes excruciating, back problems are a big deal.



Lower back pain is now the leading cause of disability in the world, affecting one in 10 people and increasing with age, according to a large study published in 2014 in the Annals of Rheumatic Diseases.

Until recently, treatment was fairly routine - painkillers, massage, physiotherapy, electrotherapy and, in extreme cases, spinal surgery. But a new approach claims psychological and social factors play a key role in causing and exacerbating back pain, and that help for it should start primarily in the mind.

David Rogers, a physiotherapist with 20 years' experience, has been practising this psychological approach at the Royal Orthopaedic Hospital in Birmingham for six years. In his new book, Back to Life, he brings together a large body of research that shows how thinking patterns affect back pain and different techniques that can help.

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A DIFFERENT STRATEGY

"Research has identified that psychological and social factors, such as the way patients think about their back pain, as well as depression and anxiety are stronger predictors of long-term pain and disability than physical factors," says Rogers. He uses a new "biopsychosocial" approach that targets back pain not only with traditional exercise or manipulation methods but also using tools from cognitive behavioural therapy.

First used by a spinal surgeon, Gordon Waddell, who, in 2006, wrote a detailed review in the journal Oxford Clinical Psychology about the beliefs and psychological obstacles that can worsen back pain and hinder recovery, Rogers's approach is aimed at people whose back pain is persistent.

In the four-week programme (three hours every week in two group sessions), patients learn simple breathing exercises to manage any anxiety they feel about their back pain along with easy stretches. Patients are also taught to identify the thinking patterns that could be making their pain worse - these include believing that back pain is severely disabling, avoiding movement and activity, and a tendency to low mood or withdrawing from social interaction (as many of us do when our back goes).

In one study of 85 patients undertaking Rogers's programme, 73 per cent were taking less or no medication when it ended and, of those, 92 per cent were still off medication nine months later. Indeed, other studies suggest that such an approach may even work as well as spinal surgery.

A study published in the British Medical Journal in 2009 found that people with long-term back pain showed fewer improvements after spinal fusion surgery than with cognitive intervention with targeted exercises, such as the approach Rogers uses. In fact, draft National Institute for Health and Care Excellence guidelines, released in March this year, recommend group-based psychological approaches be used alongside physical treatments for back pain, especially in people for whom previous treatments haven't worked.

THE PSYCHOLOGY OF BACK PAIN

Fear of moving in case you'll cause damage, having a "catastrophic thinking" style, losing confidence, distress, anxiety and depression are all key psychological factors that can make back pain worse.

"These present to varying degrees in people with persistent back pain and have been ignored by the medical community," says Rogers. But how? "When you injure yourself, the pain you experience is a response in a part of the nervous system called the danger alert system," he says. "It's made up of nerve fibres called neurons and these link our sensors to the spinal cord and our central nervous system."

The danger alert system is your first protection against potential harm, activating when you touch a hot oven or fall over and injure your back, telling your brain: "There's a problem here and you need to do something about it."

Fascinatingly, research has found that when someone has ongoing back pain, often the actual tissues from the initial injury have healed, yet pain persists.

"This is more to do with a dysfunction of the nervous system," says Rogers. "People with back pain are often given some threatening information at the point of diagnosis about the results of their MRI scans, their future and their ability to work. Psychologically, that keeps their danger alert system in protective mode, generating fear, avoidance and anxiety that sticks around long after their actual injury has got better."

This is because such threatening information activates the "fight or flight" stress response system in the brain, so you stay in "high alert", with more muscle tension and tightness, priming you for a bad episode of pain.

"In this stressful bodily state, a patient can get a severe case of back pain from a relatively small movement. That explains why two people can get the same injury but one person's episode can last much longer, be more severe or keep coming back," says Rogers. It also explains why back pain can often flare up when there are other stressful events going on in someone's life, such as divorce or bereavement and is the reason why breathing exercises feature highly on his programme.

CHANGE YOUR THINKING, HELP YOUR BACK PAIN

Some thoughts could be making your back pain worse, for example, during a flare-up, thinking, "I'll never get over this, I need to get to A&E now". "Such thinking can exacerbate pain and thwart recovery," says Rogers. He suggests first trying 7-11 breathing: breathe in for a count of seven and out for a count of 11 for five to 10 minutes. This relaxes the nervous system. Then add some gentle stretches, such as the cat-cow from yoga, or gentle rolling of the spine with bent knees, ensuring you don't hold your breath. During an episode of lower back pain, the muscles go into a protective spasm and these two techniques can relax the body enough to stop the pain from worsening or from going into cramp. Try replacing "catastrophising" thoughts with "This will pass eventually" and "I've been here before, it will get better soon".

Another unhelpful behaviour is avoiding exercise and activity because you're worried about doing more damage, says Rogers. "A large body of evidence now suggests stretching, yoga and gentle cardiovascular exercise, such as walking and swimming, can be great help."

IS YOUR MIND MAKING YOUR BACK PAIN WORSE?

Check with your doctor to ensure you don't have any other warning signs, such as back pain after a violent injury or fall, a history of cancer, a high temperature, unexplained weight loss, or if walking has become unsteady, the spine has developed an unusual shape or the pain is worse at night.

If your GP has cleared you of these and you remain on painkillers, Rogers suggests asking yourself the following questions: are you worried you will damage your back if you increase your activity? Do you feel less confident about day-to-day activity? Have you stopped doing things you feel passionate about because of your back pain? Do you feel depressed or anxious about how it's affecting your life?

If your answer is yes to many of these questions, you are a good candidate for biopsychosocial treatment. Though not all clinical commissioning groups offer access to physiotherapists trained in the treatment, it's worth asking your GP for a referral to a practitioner or centre.

Back to Life by David Rogers and Dr Grahame Brown is published by Vermilion.