Most of us are vaguely aware that Low Back Pain can be related to stress but if someone were to ask us why we would be hard-pressed to give an explanation. So what is the relationship? And why is it important for Osteopaths and other health professionals to treat not only the immediately painful areas but to address any other features of the experience of the problem?
To make a distinction, the painful area may be the Lumbar Spine or Low Back, but the experience may be a Mum or Dad with two small children to look after, unable to bend down farther than a few degrees, in near-constant pain which is accompanied by a strange sense of loss of control and vulnerability, who who is therefore off sick and therefore losing income, who is losing sleep because of the pain therefore feeling low and unable to think clearly, finding it difficult to make decisions effectively, and feeling out of control….it is unpleasant to even think about!
But I would think anyone who has experienced back pain would recognise at least two of those features.
We now have a better understanding than ever before of the mechanisms which entangle these features of the experience of pain together, and this understanding illustrates the integrated and multi-directional nature of the way we function in our environments and in ourselves.
Central sensitisation is a neurological term which refers to the increasing sensitivity of nerves connecting our body tissues to our spinal cord during an episode of low back pain. When a tissue is injured – in the case of the low back, this could be a spinal joint for instance- a pain signal is transmitted from from this tissue to the spinal cord and onwards to the brain. In some circumstances, the connecting nerves between the two regions become increasingly sensitised and start to transmit non-painful signals with increasing ‘noise’ to the brain. The brain sometimes begins to interpret these ordinary signals as painful and this is one of the means by which we can experience a diffuse, spread out sensation of discomfort and pain, or perhaps pain in areas which seem distant from the injured area.
What is fascinating about this is the circumstances under which the connecting nerves are more likely to become sensitized. Low Back pain sufferers who are already low in mood or high in stress, short of sleep, bereaved, afraid or overworked – to name but a few – are all more likely to experience this sensitization. This is not a mystical or obscure phenomenon. It is a biological one, and it is due to another mechanism known as ‘pain modulation’. In everyday life our hormones and nerves are being constantly stimulated by the experiences we process and the activity of these regulates the degree to which sensory signals are dampened or exaggerated. People who suffer with Depression are often prescribed drugs which increase the mood regulating hormone, Serotonin. But Serotonin also performs this dampening function. So this biological connection between these separate spheres of environment, hormone or nerve, spinal cord, and pain is really telling the story of whole person’s experience.
The concept of Osteopathy is really what defines the therapy – if you were to observe a Physiotherapist, a Chiropractor and an Osteopath you would see many of the same techniques being used albeit in perhaps a different style, but the thinking behind how I treat, prescribe exercise, and advise reflects an integrated, holistic view of the person. We are always mindful that we are treating not only the epicentre of the pain, but the whole person. Rarely am I manipulating a spinal joint without considering the effect this will have on the mood of a patient, or prescribing breathing exercises for stress without thinking about the benefit this will have for the joints and tissues which connect the ribs to the thoracic spine.
This is the reason why we consider using techniques which not only relieve local pain or discomfort but also aim to calm the person down, reduce stress levels and, hopefully, reduce the nervous system’s sensitivity to sensory stimulation. Equally though, by encouraging a calmer state, the person will hopefully be better positioned to deal with the every day stressors which are being magnified by the pain they are in- and the difficulty in performing everyday tasks. Therefore throughout a course of treatments – whether the patient only needs to come a couple of times or for longer – I will usually be using a combination of gentle stretching, massage and articulation or manipulating the joints in the spine, but also working gently into perhaps the ribs or diaphragm (the principle muscle of respiration) or the muscles of the neck and head – where psychological tension may manifest as physical tension.
This rationale is then carried forward into the exercise and self-care advice I give to each of my patients. For example, if I considered that my patient was a shallow breather- a type of breathing associated with stressful situations – I would continue the work I had begun with gentle stretching of the diaphragm by teaching breathing exercises which help to lower the pulse and respiratory rate. By using techniques which allow us to breath more deeply we also take in more oxygen for each breath. This would be accompanied by exercises which specifically support the injured area, for example strengthening of the core muscles which provide integrity to the Lumbar Spine, or use of the muscles of the legs to spare the spine and also increase the sense of control you have over your body at a time when things can feel very out of control. This combination of listening to the person, the body, using techniques and prescribing exercise or giving advice in a way which always addressed more than one problem reflects my view as an Osteopath- that to treat the painful area is just the start of the journey – a whole, integrated person needs an integrated treatment.
The idea of integration also extends beyond my consultation room. It is an essential part of my practice to collaborate where possible, and with the consent of my patients, with other professionals. This begins from the moment I take a patient’s case history. I am bound by my statutory regulation and standards of practice to screen for health conditions which may require referral to GPs or other medical specialists. But as the management of the patient’s complaint continues, I will consider whether it would benefit you to be referred to a podiatrist or to a personal trainer or to a pilates instructor, yoga teacher, counsellor, acupuncturist, nutritional therapist, pregnancy physiotherapist, cranial osteopath, meditation class, mindfulness class, sports club or book club etc ! This collaborative approach to healthcare is something we are particularly keen on at Make Me Feel. But whoever or wherever I think you may benefit from being referred to, this is a decision we make together – patient and practitioner. I offer you the insight and you make the decision.
Will Westwood is the newest member of the team at Make Me Feel. As an Osteopath he provides treatment, advice and referral for Spinal Pain, general aches and pains and common musculoskeletal injuries, and has special interests in Headache and Pregnancy.
Click here to book a consultation with Will
References
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Meeus M, Nijs J (2007), ‘Central sensitization: a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome’. Clinical Rheumatology 26: 465-473
Nielsen LA, Henriksson KG (2007) ‘Pathological mechanisms in chronic musculoskeletal pain (fibromyalgia): the role of central and peripheral sensitization and pain disinhibition’. Best Practice and Research Clinical Rheumatology, 21: 465-80
Staud, R. Craggs, JG, Robinson ME, Perlstein WM, Price DD (2007) ‘Brain activity related to temporal summation of C-fiber evoked pain’, Pain 129: 130-142.
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Zhuo M (2007), ‘A synaptic model for pain: long-term potentiation in the anterior cingulated cortex’, Molecules and Cells 23: 259-271
(All in Booth, Doherty, Morris, Osteopathy Today, July/August 2015, The Institute of Osteopathy)
Devereux, Theresa, ‘Pain and the Brain’, Osteopathy Today, July/August 2015, The Institute of Osteopathy.
