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The shocking new ways to think about back pain...

Many people present to healthcare professionals and receive information that is out of date, is inconsistent with best evidence, or focused on primitive/simplistic explanations that are not relevant to their back pain (1). Unfortunately, this has impacted patients and can worsen outcomes for you, the patient.

What does that mean for you? Well, for starters, it may increase the amount your back pain bothers you, both in the short and long term. Also, it may lead to behaviours that are known to be associated with worse outcomes. A lot of the newer theories regarding back pain require letting go of old beliefs and behaviours, and exploring new ways of thinking about the pain. It requires both courage and curiosity. Of course, this is not an easy task.

Guidelines now recommend education as part of the treatment of back pain (2). But what does contemporary evidence suggest we teach patients about their pain?

A recent, internationally recognised program called the GLA:D Back program teaches the following verbal cues for clinicians to educate patients. (2)

1) Posture and spinal abnormalities are common 2) Pain equals alarm - not harm 3) The spine is made for movement 4) Natural movements inhibit pain 5) Training strengthens the back 6) Action precedes improvement 7) The back is strong 8) The brain can turn the pain up or down

Of note, there is a shift away from structural abnormalities that may show up on scans. Why? Well, structural changes are just as often absent in people who have pain, or present in people who do not have pain! The take home message? Structure and posture are less associated with pain than you might have been led to believe in the past.

Instead, a focus on contemporary pain neuroscience suggests we focus on the whole human experience. We now know so much more about pain, which is considered an output of the brain rather than tissue damage only. In fact, it may be helpful to think of pain similar to a car alarm. Tissue damage from an injury, such as too much lifting, sets off an alarm cascade system in our body, which is first detected by nociceptors. Nociceptors are specialised cells that first detect tissue damage, and second, send signals along our nerves to the brain. Third, the brain sets offsets off our cascade of the pain experience and the associated suffering.

However, have you ever tripped a car alarm by accident without actually causing damage to the car? Perhaps a windstorm or heavy rain storm shakes the car, sounding the alarm but in the absence of pain? Perhaps it sounds because you press the wrong button? Or maybe there is a programming error in the car itself and its sensors are too sensitive? Well, it is well understood now that the human brain can often trip off the pain experience in the absence of tissue damage. This is very common in people with persistent pain. The alarm continues to make a sound, long after, or in the absence of, any tissue damage which would potentially have been a threat.

We have a few more tools to deal with this now. Movement, especially safe movement that does not cause sharp sensations, will allow the brain to de-sensitise. Therefore, a healthcare professional should offer you a variety of ways to move. There is no universally right or wrong way, it's highly individualised. Furthermore, one will need to act out the behaviour; "doing"the action is very different from knowing we have to do the action. Another associated finding is that taking action is part of the treatment. So, you'll need to try new things in order to get better...this is opposed to an older model of resting until you feel better...and then commencing a rehab program. Action proceeds improvement.

Finally, it's important to keep things in context. Simply put: the spine is one of the strongest structures in the body. Regarding back pain, here is a simple fact. Our bodies are incredibly resilient. Your back is strong! You will have to trust your body, and this may require working with a healthcare professional who is well aware of the recuperative powers of the body. Finding ways with your chiropractor or other healthcare provider to work at the edges of discomfort, but safely, will further strengthen your body and help you recover. Furthermore, your process through the experience of pain can provide you with ongoing resilience training and education to leave you in a position to better manage your back pain going forward.

Sources: 1) Zadro J, O’Keeffe M, Maher C. Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. BMJ Open. 2019;9(10):e032329.

2) Fernandez, M., Young, A., Kongsted, A. et al. GLA:D® Back Australia: a mixed methods feasibility study for implementation. Chiropr Man Therap 30, 17 (2022).

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