The term chronic back pain does not refer to any kind of diagnosis. ‘Chronic’ is a medical term used to refer to any type of problem that has lasted longer than 3 months. Recent research into back pain has identified that defining back pain as chronic is not helpful in establishing a cause, a diagnosis or effective treatment solutions, so it is a phrase we no longer use. Instead – we refer to ongoing back problems as ‘persistent back pain’ and we look to be more specific in our diagnosis and management.
What we do know about chronic back pain is that the pain associated with many of these types of problems is often different to the pain that results from an injury or sudden onset back pain, which is referred to as ‘acute back pain’. When someone has acute back pain, the pain signalling processes work to alert our brains to the presence of damaged or inflamed tissue that needs protecting. In acute back pain, there are very specific actions that will make someone’s back more painful, and there are things that can be done to ease the pain. The pain experienced is also very consistent in location and behaviour.
When pain persists, the pain signalling processes change; our nervous systems become more sensitive and pain results from activities and events which are not harmful to our bodies. Injured tissue normally heals within a 6 week period, therefore ongoing pain is often not associated with tissue damage or inflammation.
There are several things that we know influence the development of chronic pain including a lack of physical exercise, negative beliefs and thoughts about pain and healing, depression and anxiety and high levels of stress. It is clear that this situation can quickly become a vicious cycle – for example — people are less likely to exercise when they are in pain and being in pain commonly causes high levels of anxiety in people.
When people have persistent pain as a result of altered pain processing, the nature of the pain is different from that in acute cases. The sensitised nature of the nervous system means that pain can be triggered with very minor activity one day and not at all with vigorous activity the next. Sometimes people say things like “I only have to think about lifting my bag and my back starts to hurt” or “I only have to look at someone bending over and my pain starts”. There is a very logical explanation for this – both thinking about an activity and seeing someone else do it, trigger the nervous system to activate nerve cells in the brain that are virtually identical to those that would be activated through doing the task. Because the nervous system has become sensitised, the brain interprets these signals as damaging and sends out a pain message to try and protect the body. In the same way, minor actions result in a pain response due to the increased sensitivity of the nervous system.
As well as increased sensitivity, people with chronic pain have pain that can vary in the location within the body from one day to the next and can have days or even weeks with no pain, followed by really terrible periods. This can be frustrating as there often seems to be no reason for the pain.
As most people with persistent pain do not have any evidence of tissue damage or inflammation, medication like paracetamol and anti-inflammatories (Ibuprofen, Nurofen, Naproxen) are ineffective, both short term or long term. When pain persists, patients are sometimes prescribed stronger opioid painkillers such as codeine. Not only are these medications not effective, as they do not tackle the heightened sensitivity of the nervous system that is the underlying cause of chronic back pain, but they are also highly addictive substances, which have significant side effects.
To help reduce the sensitivity of the nervous system a group of medications called Neuromodulators are used. Three of the most common ones are Amitriptyline, Gabapentin and Pregablin. They all act in different ways and were originally developed for different types of conditions, which can make things confusing. For example, when people ‘google’ amitriptyline it is usually referred to as an ‘anti-depressant’. People can take it as an anti-depressant but it would be prescribed in a different dose for this condition compared to the way in which is it prescribed for persistent pain. These drugs are not ‘painkillers’ so the effect is not immediate. Instead, they need to build up in the body’s system over a few weeks to gradually reduce the sensitivity of the nervous system. People often worry about taking a drug for a long period of time, but I argue that these drugs are a lot safer than taking lots of anti-inflammatories, which can have significant effects on the lining of the stomach and on kidney function.
The most important aspect of any treatment programme for chronic or persistent back pain is education. All of the information contained within this article is completely new to most people and often contradicts what they have been told about their pain problem or what they understand about how pain works. Unless people understand what is going on with their body and their nervous system, they will never engage effectively with their management plan. Understanding and acceptance of the many other factors that can influence back pain such as a lack of physical activity, stress and anxiety is essential to dealing with the problem is a comprehensive fashion. I often recommend these two videos to patients to watch to help with their understanding.
Addressing the psychological elements
Understanding how pain works and what influences it is also important to help treat chronic back pain. Recognising that emotional factors such as stress, depression and anxiety can contribute to pain is not enough – patients need to work with their clinical team to find ways to deal with these issues as well. This can be tough. We all want a quick fix to our problems – to have something ‘cracked back into place’ or to take some medication which will calm everything down, but none of these work for chronic pain. Dealing with lifestyle factors that contribute to stress or depression requires time and commitment. For these reasons, your clinician may recommend involving a psychologist in your care. Other strategies that may be helpful include meditation and mindfulness, yoga or tai chi. There is no right or wrong treatment – different individuals respond to different things. The key thing is to be open-minded and to persist with a variety of strategies until you find the one that works for you.
Physical activity is one of the foundations of any management programme for chronic back pain. Not only does it increase the circulation to all the tissues of the body to ensure they are healthy, but it has a strong ability to influence the mind, induce relaxation, reduce depression and anxiety and release endorphins; the ‘happy hormones’. Your clinical team will discuss the most appropriate type of exercise for you and put together a structured programme that you can undertake with confidence.
The causes and treatment for persistent pain in the upper back region or thoracic spine are no different to those causing and contributing to chronic low back pain. A thorough examination looking at how you are using your upper back and how the muscles in this area are working to support your spine is key to establishing a diagnosis. As with low back pain, a scan or X‑ray may be used to rule out any reason for the persistent pain, but it is rarely diagnostic. A comprehensive management plan including manual therapy, exercise and education should be established with you to reduce the episodes of pain and help you re-establish control over your symptoms.