The Mind Game in Low Back Pain

How back pain is powered by fear and loathing, and greatly helped by rational confidence

One of my chronic low back pain patients reported that he’d had a brief relapse after a hard fall on his tailbone. He was playing hockey and got slew footed (tripped). Over the course of the evening, his back seized up into a nasty imitation of previous episodes. Fortunately, by the next morning he had recovered — a testament to his progress.

Many people with back pain are essentially living in that over-reactive, seized-up state — their back reacts to just about everything like that. What was a temporary setback for my client is a continuous reality for someone who has a more serious chronic low back problem. Either that, or they have a “hair trigger” back that may be fine most days, but gets set off by nearly any provocation.


Two key underestimated factors in low back pain

There are two key differences between someone whose back reacts to everything like this, and someone who only reacts to more serious stresses and also recovers more quickly:

  • The number and severity of muscular trigger points in the region.
  • The confidence of the victim that they are not really fragile and that there is nothing serious wrong.

Time and time again, it is the people who buy into the idea that their back is structurally unsound who get a case of “fraidy cat back” and react to every challenging stimulus as though it were a lumbar cataclysm — they fear and loathe their own backs.1

It is those who have some confidence that their spine is basically a sturdy structure who are relatively immune to stressful incidents.2

It can take an enormous amount of de-programming to convince people that their backs aren’t actually fragile, disaster-prone structures. Mental habits are incredibly strong, and all the more so under stress. When we are in pain, we are likely to revert to the most familiar thought patterns. This is why I place such a strong emphasis on the “mind game” in low back pain treatment. It’s not that back pain is “all in your head” — it’s not; there absolutely is pain in your back — but it is very much affected by what’s in your head.


Model of doom & gloom

Lumbar spine models like this almost all show a herniated disc. Some go a step further & show discs slipped so far they’ve completely left the spine!

Here’s pain researcher Lorimer Moseley making this point in a great TED talk. He’s talking about how pain is always worsened when you believe that there is danger … and plastic models of slipped discs are much too persuasive.
Any piece of credible evidence that they are in danger should change their pain … And they are all walking into a hospital department with models like this on the desk: what does your brain say when it sees a disc that’s slipped so far out it’s sitting on it’s own? If you’ve ever seen a disc in a cadaver, you can’t slip the suckers — they’re immobile, you can’t slip a disc — but that’s our language, and it messes with your brain. It cannot not mess with your brain.

Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33

Don’t miss that video. So good.

What if it’s a tumour or an aneurysm brewing? Obviously we should not ignore the red flags that might warn us of the ominous causes of back pain. If you’re worried, just read up on it. Putting those concerns to rest is often the first and best step in the mind back of low back pain.

Greg House on false positives

It is almost impossible emotionally to see anything that looks “bad” on an X-ray or MRI and not worry about it. It’s also almost impossible to get a reliable MRI report3 or a completely healthy-looking scan of anyone. TV’s Dr. Greg House has commented on this…
House: Give him a whole body scan.

Cameron: You hate whole body scans.

House: Because they’re useless. You could probably scan every one of us and find five different doodads that look like cancer.

House, Season 1, Episode 17, Role Model, written by Matt Whitten

Or low back pain. And yet most visible defects are clinical red herrings, about as worrisome as a birthmark, and signify nothing at all except the power of modern medical technology to scare you silly if you aren’t armed to the teeth with confident knowledge to the contrary.

I provide numerous examples from the scientific literature elsewhere, but one of the best examples is the most personal: my wife suffered an extraordinary fracture of her spine, and has a lot of titanium and unevenly healed bone in her back today … but minimal back pain. If you can be more or less pain free with that going on your back, you can rest assured that a little joint degeneration is not the cause of severe back pain.

Greg House: one of my critical thinking heroes.
(Cameron ain’t too shabby at it either.)

The science has my back

Time and time again, the most respected medical experts in low back pain have emphasized the importance of psychological factors in low back pain, instead of the scary-looking things that show up on scans. “

For instance, consider the case of Dr. Nikolai Bogduk, a mainstream physician, a man who is much more inclined to criticize a fringe theory than to champion one: and yet Dr. Bogduk believes that the most important thing a health care professional can do to stop acute back pain from becoming chronic is to “treat the patient nice and convincing him that there is nothing so horribly wrong.”4

In 2009, the American Pain Society published new guidelines for low back pain interventions, and their first recommendation — top of the list — was that “rehabilitation emphasizing cognitive-behavioral approaches should be considered”5 — and “cognitive-behavioral approaches” is basically doctor talk for “treat the patient nice and convince him that there is nothing so horribly wrong.”

Low back pain is not all in your head … but it is affected by your head

The mind game in low back pain is so important not because it’s a psychosomatic condition, but because the psychological element is a powerful lever. The mind game is a way to break vicious cycles — just as it has the power to negatively influence back pain, what you think and feel also has the power to help back pain.

You are much likelier to feel better if you know that:

  • there is no structural problem (or no serious one)
  • the “bark” of low back pain is almost invariably worse than it’s “bite”
  • you probably won’t need surgery
  • stress is a root cause of low back pain and affects it, but doesn’t have to be “eliminated” (which is unrealistic) but can be mitigated
  • you probably don’t have to give up playing tennis (or squash, or golf, or whatever it may be)

Tip of the low back pain iceberg!

This has been a brief introduction — the tip of an iceberg — to a central idea in low back pain therapy. There is a great deal more to learn. Most back pain patients can’t begin to really assimilate and make use of this perspective without much more persuasion. You need a mountain of persuasive evidence. That mountain of evidence exists in the form of my extremely detailed low back pain tutorial. One of the only criticisms I’ve ever received about this tutorial was, “It’s overwhelming. It’s overkill. You had me in the first few sections.” I can live with that criticism!

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