We know that in chronic pain situations, changes occur in the nervous system that render the system more likely to create and send nociceptive signals. Changes occur in the brain whereby nociceptive signals are given more attention and pain can be produced by the brain even in the absence of nociception. We also know that our thoughts play an important role in maintaining pain states in many instances, and that those “yellow flags” will often give us an idea of which patients are more likely to have dysfunctional thoughts around their condition. However, you probably have seen patients in persisting pain who seem to have minimal catastrophising thoughts around their condition and who also seem to be exercising often, sometimes even at an elite level. In these cases, you will often find that mechanical or tissue factors are playing a larger role than you might have otherwise expected, given the chronic nature of the issue.
The best example I have to demonstrate this scenario is that of my aunt, who is an extremely fit and active lady in her late 50s. She had a disc bulge in her lumbar spine around 17 years ago which was very painful and disabling at the time, but healed within the time frame that was expected. She returned to her exercise routine within months and regained her fitness. However she continued to have frequent acute flare ups of back pain in the ensuing years. These were often catastrophic and disabling, occasionally requiring an ambulance, but never with any nerve root involvement. They were what we would call mechanical back pain. Over the years the acute episodes became more frequent and about a year ago she called me to chat about it, extremely frustrated. I was initially a bit perplexed as to why this kept happening as her pragmatic, no nonsense approach to life did not put her into a yellow flag category. I was also aware that she was exercising regularly and to a high intensity in a program that included functional weightbearing exercises, cardio, swimming and walking. On further questioning I found out that she was opting out of many of the exercises that were prescribed for the class – anything that involved flexion or core activation. She also mentioned that she never ever bent (flexed) her back in any activities, always preferring to bend her knees and keep her back straight. As it turned out, following her initial injury she had been told never to use lumbar flexion for any movement – that she needed to bend from the knees at all times, use a lumbar roll for the car etc. She was also taught to brace her abdominal muscles when doing any activities such as rolling over or lifting objects. The advice to avoid flexion in that acute healing phase was probably helpful, and the bracing or core engagement advice was fast becoming popular for low back pain at the time. However…….. when it healed, she never went back to the initial therapist and therefore continued to think that flexion was taboo. She was still even using a long armed brush and shovel when cleaning up so that she didn’t have to bend to the floor! Therefore on examination, 17 years later, her range of motion of lumbar flexion was incredibly restricted and she had some serious overactivation of her abdominal muscles. It was no wonder she often set off these acute episodes by getting into the car or putting on her socks!
We spent some time on education about the spine and reassuring her that her disc injury had well and truly healed and that flexion was a normal movement for the spine. I suggested that she start doing some gentle flexion stretches for the lumbar spine and lower limbs and she was diligent with these, often doing 20 minutes of stretching, five times a week. I also suggested that she start trying some of the exercises she had been avoiding by starting within a smaller range, beginning with small numbers and working up from there. We went through this process about a year ago and she hasn’t had an acute episode since. When we recently chatted about it she said “when you told me it was healed, you gave me permission to do stuff again. It completely change my thinking about myself and I was suddenly confident about trying things again”.
The patient’s understanding of their condition plays a massive role in the progression of that condition. Getting it right from the start is so important, but it is never too late to dig deeper into their understanding and make some improvements. Then, you will find things will fall into place much easier.