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Talkback l summer 2013

Back pain doesn’t killAll too often we’re told that back pain and chronic back pain is too expensive, costing billions in NHS treatments and disability benefits. True as this may be, it tends to detract from the humanity and human cost of pain. Patients suffering chronic pain are at high risk of suffering long-lasting emotional disturbances characterized by persistent low mood and anxiety2. In fact, they carry three times the average risk of psychiatric disorders3, and 22% of cases lead to depression4. Perhaps most unsettling is that a review of a dozen different studies conducted in 2006 showed that chronic pain doubles the risk of suicide – around one in five chronic pain patients think about suicide, and one in ten will attempt to take their own life5.

In fact, several studies have shown the profound impact of chronic pain on mortality. Chronic pain doubles the all-cause death rate, independent of socio-demographic factors (such as

The chronic pain epidemicSo it appears that chronic pain is far more lethal and destructive than is often realised, but how common is it? Well, there are an estimated 100 million chronic pain sufferers in Europe13, including one third of adults in England7. In America, one third of the entire population is estimated to suffer chronic pain14. So that’s around a quarter of a billion people in just the Western world. Chronic pain is certainly a global issue and by several accounts it’s getting worse.

In Britain, the prevalence of total back pain increased across all age groups, social classes and regional areas from 35% in 1987 to 50% in 199715. Between 1992 and 2006, the prevalence of chronic lower back pain (CLBP) in North Carolina more than doubled, from 4% to 10% – increasing in all age, gender and ethnicity groups16. An identical more-than-doubling (also from 4% to 10%) was recorded between 2002 and 2010 in the medium-sized Southern Brazilian city of Pelotas – growing fastest in younger individuals with more years of education and higher economic status17.

The 2011 Health Survey for England revealed that 15 million adults in England have chronic pain, but this appears to be a rapidly growing figure. In 2009, former Chief Medical Officer Sir Liam Donaldson reported that more than five million people develop chronic pain in the UK every year, from which a third will never recover. Put another way, a further 8% of the UK population succumb to chronic pain every year. If news broke tomorrow that a new treatment resistant virus, carrying an increased risk of heart attack, cancer and suicide was infecting millions of people a year, I think we’d all be rather alarmed.

If news broke tomorrow that a new treatment

resistant virus, carrying an increased risk of heart attack, cancer and suicide was infecting millions of

people a year, I think we’d all be rather alarmed.

Part 3

Prevention is better than cure

Rethinking chronic pain

“Prevention is better than cure”, so the old adage goes. And when it comes to safeguarding our future health and preventing illness, a lot of what’s important for healthy backs is also beneficial for our overall health.

In this latest instalment of the ongoing educational series, we’ll be reviewing and rethinking chronic pain – its meanings, consequences and resistance to mainstream medical approaches.

Back pain represents half of all chronic pain1, so it’s certainly pertinent for us and not surprising that back pain has informed the majority of thought and research on this topic.

Every year, five million people in the UK will develop chronic pain.That’s a further 8% of the population succumbing to chronic pain every year.■ 75% will get divorced■ 25% will lose their job■ 22% will develop depression■ 20% will consider suicide■ 10% will attempt suicide

If their chronic pain becomes “highly disabling”, their risk of death is greatly increased:■ 50% increased risk of terminal cancer■ 90% increased risk of fatal heart attack■ 250% increased risk of fatal lower respiratory disease ■ 370% increased risk of fatal coronary heart disease

SnapShot: The human cosT of chronic pain

21talkback research

Talkback l summer 2013continued on p22

More than 1 in 10

is highly disabled by

chronic pain

age, gender, education, income and occupation)6. Sufferers who are highly disabled by their condition (33%7) are at even greater risk of death, particularly from heart attacks, coronary heart disease and lower respiratory diseases8.

The slogan, “back pain doesn’t kill, it tortures” wasn’t coined by BackCare but we did adopt it in several instances over the last couple of years as a means of highlighting the fact that back pain continues to destroy so many lives. However, upon delving more deeply into the research literature, we find that even this seemingly stark slogan is an underestimate, particularly in the context of chronic back pain – in short, it literally increases death rate. And if it doesn’t kill you, pain and disability impacts every area of life. According to the Chronic Pain Policy Coalition, one quarter of sufferers will lose their jobs. The impact upon daily functioning can be severe and the strain placed on relationships can reach

breaking point. Around 40-50% of all marriages in the UK and America end in divorce9, 10, but this figure rises to more than 75% where one partner is chronically ill11.

“Physical pain, psychological distress and the deleterious effects of medical procedures all cause the chronically ill to suffer as they experience their illnesses. A fundamental form of that suffering is the loss of self in chronically ill persons who observe their former self-images crumbling away without the simultaneous development of equally valued new ones. As a result of their illnesses, these individuals suffer from (1) leading restricted lives, (2) experiencing social isolation, (3) being discredited and (4) burdening others”12. In conclusion, it has been said that “back pain doesn’t kill”, but chronic pain is, in fact, associated with an increased risk of death, disability, depression, divorce, and numerous other direct and indirect sequelae.

As discussed, around a third of people have chronic pain, a third of these are highly disabled by their condition and this disablement carries a dramatically increased risk of death from heart attacks, coronary heart disease, lower respiratory diseases (such as chronic bronchitis and emphysema). Astute readers may have spotted that these particular diseases are classically associated with stress, smoking, physical inactivity, unhealthy diet and drug dependence. Indeed, chronic pain sufferers are at higher risk of opioid18 and alcohol19 dependence. Smoking is three-times more prevalent among chronic pain patients than the general population – 60%20 and 20%21, 22 respectively – and causes 80% of chronic bronchitis and emphysema cases 23. Indeed, the full consequences of pain are so often overlooked.

There is a tendency within our modern mainstream conception

of medicine to classify disease as something that happens to the body and within the body. Making any medical progress at all is in part dependent upon mustering the “escape velocity” needed to leave behind this antiquated definition. Chronic pain is not simply something that happens to and within the body; rather it is the common name for syndrome or pattern of interrelated processes that encompass physical, psychological and social dimension. In no uncertain terms it controls how the person thinks, feels, behaves and functions. Obviously, not all chronic pain patients are addicted to cigarettes, alcohol and prescription painkillers. The point is that these, and an entire catalogue of far less obvious negative behavioural adaptations, serve as coping mechanisms for the ongoing experience of pain, disability and loss of self. These cannot be considered somehow separate from the pain itself.

Rethinking chronic pain

Talkback l summer 2013

talkback research22

from p21

The physical fixationWhile most people experiencing headache do not tend to attribute it to a physical problem with their head, our assumptions about back pain are quite different. It is common for back pain patients to absolutely fixate on relatively insignificant physical and anatomical details, often from an over-interpretation of diagnostic imaging results.

Most pain-free people have some form of spinal disc degeneration (including bulges, herniations, protrusions, prolapses) from harmless wear and tear and as a normal part of aging24-26. A patient may classify their issue as “I slipped a disc at L4-L5 in 1995” rather than grasping that the chronicity of their pain is far more significant than its bodily location. In short, if a patient has had constant pain or recurrent episodes of pain for a long period of time (from three months to years), then their primary issue and the biggest medical threat to their future health and to their life itself is “chronic pain” not “slipped disc”. In fact, as shown by Professor Sir Simon Wessely and colleagues at the Institute of Psychiatry, you are almost 70% more likely to develop and suffer from medically unexplained symptoms (such as chronic back pain) if you attribute your condition to physical causes rather than lifestyle and behavioural factors27.

We have fallen foul of modern science’s tendency to “atomise” reality – cutting our experience into smaller and smaller fragments to be labelled with the hope of better understanding our world. Chronic pain has not escaped the resulting

obfuscation as we now have at least six different labels that identify parts of this syndrome: chronic, persistent, long-term, recurrent, non-specific, and medically unexplained. No, they don’t all mean the same thing, yet they are all facets of the chronic pain syndrome. And yes, even with a slipped disc or similar imaging-based diagnosis, the pain is non-specific and medically unexplained as normal spinal degeneration does not constitute adequate or plausible cause for lasting pain.

Adaptations of the brainThe last decade has seen considerable research associating specific skills and traits to brain structure. A rather elegant demonstration of this is that London taxi drivers who have “the knowledge” (i.e. learned the entire roadmap of London) show altered structure in the anterior hippocampus of the brain by MRI scan28. Even political orientation has been found to relate to distinct structuring of the brain: greater liberalism is associated with greater grey matter in the anterior cingulated cortex (a part of the brain involved in empathy and impulse control), whereas greater conservatism is associated with increased grey matter in the right amygdala29 (a part of the brain that mediates subconscious fear30, 31).

In a recent breakthrough, Professor Sean Mackey and colleagues at Stanford University found they could detect chronic lower back pain with 76% accuracy by brain scan32. Chronic lower back pain sufferers were found to exhibit restructuring of the cerebral cortex (a part of the brain

involved in perception, awareness and thought). We have long known that the brain changes its physical structure as an adaptive, learning response to stimuli – a process termed “neuroplasticity” – but this new research supports the understanding that the chronic pain syndrome is an adaptation (arguably a maladaptation) acquired in the same way as other capacities are learned.

Single-site chronic pain is rare and 92% of chronic back pain sufferers feel pain in other parts of their body1. For example, chronic lower back pain (CLBP) accounts for 25% of all chronic pain, but single-site CLBP is only 3%. Of course, it needs to be appreciated that it is common to experience referred and radiating pain. However, even when all lower limb pain is included with lower back pain, the figure only rises to 7% (falling well short of the 25% mark). In brief, more often than not, the chronic pain syndrome manifests pain in multiple sites of the body (even when we account for referred and radicular pain). This is important because it supports the emerging understanding that chronic pain is a systemic syndrome primarily driven by the brain.

Unlearning the maladaptive stress responseAs noted, our mainstream conception of medicine harbours the notion that disease is something that happens to the body and within the body. A further misconception, again very much deleterious to progress, is that physical symptoms can only be

1 D, Carnes. “Chronic musculoskeletal pain rarely presents in a single body site: results from a UK population study.” Rheumatology (PMID:17488750), 2007: 1168-70.

2 C, Alba-Delgado. “Chronic pain leads to concomitant noradrenergic impairment and mood disorders.” Biological Psychiatry (PMID:22854119), 2013: 54-62.

3 Harvard Medical School. “Depression and pain.” Harvard Mental Health Letter, September 2004.

4 Chronic Pain Policy Coalition; http://www.policyconnect.org.uk/cppc/

5 NK, Tang. “Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links.” Psychological Medicine (PMID:16420727), 2006: 575-86.

6 HI, Andersson. “Increased mortality among individuals with chronic widespread pain relates to lifestyle factors: a prospective population-based study.” Disability and Rehabilitation (PMID:19874076), 2009: 1980-7.

7 The Health and Social Care Information Centre. The Health Survey for England 2011. NHS, 2011.

8 N, Torrance. “Severe chronic pain is associated with

increased 10 year mortality. A cohort record linkage study.” European Journal of Pain (PMID:19726210), 2010: 380-6.

9 Office for National Statistics; http://www.ons.gov.uk/10 PolitiFact; http://www.politifact.com/11 National Centre for Health Statistics; http://www.cdc.

gov/nchs/12 K, Charmaz. “Loss of self: a fundamental form of

suffering in the chronically ill.” Sociology of Health & Illness (PMID:10261981), 1983: 168-95.

13 H, Breivik. “Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment.” European Journal of Pain (PMID:16095934), 2006: 287-333.

14 Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. IOM, 2011.

15 KT, Palmer. “Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years.” British Medical Journal (PMID:10845966), 2000: 1577-8.

16 JK, Freburger. “The rising prevalence of chronic low back pain.” Archives of Internal Medicine

(PMID:19204216), 2008: 251-8.17 RD, Meucci. “Increase of chronic low back pain

prevalence in a medium-sized city of southern Brazil.” BMC Musculoskeletal Disorders (PMID:23634830), 2013.

18 C, Littlejohn. “Chronic non-cancer pain and opioid dependence.” Journal of the Royal Society of Medicine (PMID:14749399), 2004: 62-5.

19 M, Egli. “Alcohol dependence as a chronic pain disorder.” Neuroscience and Biobehavioural Reviews (PMID:22975446), 2012: 2179-92.

20 DA, Fishbain. “Are chronic low back pain patients who smoke at greater risk for suicide ideation?” Pain Medicine (PMID:19254332), 2009: 340-6.

21 Action on Smoking and Health; http://www.ash.org.uk/22 Centers for Disease Control and Prevention; http://

www.cdc.gov/23 National Clinical Guideline Centre. “Chronic obstructive

pulmonary disease: management ~”. National Institute of Health and Clinical Excellence, 2010.

24 MC, Jensen. “Magnetic resonance imaging of the lumbar spine in people without back pain.” New

Prevention is better than cure: rethinking chronic pain

RefeRenceS

Talkback l summer 2013

23talkback research

caused by physical problems and can only be adequately met with physical interventions such as drugs, surgery or hands-on therapies. The research, however, tells a very different story.

In 1995, researchers at the University of Texas started tracking 421 employees with acute back pain to understand better why some people don’t recover33. Using a psychological test, they were able to classify who would be disabled by chronic pain a year later. The test had a predictive accuracy of 91%.

In 2000, researchers at Sydney University recruited 694 nursing students to learn about the factors that precede and predict lower back pain34. Volunteers were assessed every six months for four years with measures of physical (body weight, strength, flexibility), psychological (stress, nervousness, health perception) and lifestyle factors (exercise, smoking). The only factor found to predict new cases of lower back pain was acute psychological distress.

In 2001, researchers in Germany recruited 51 volunteers through local newspaper advertisements and subjected them to low-velocity “placebo” rear-end car collisions with no actual biomechanical potential for injury35. The 10 volunteers who had scored highest on their psychometric test reported the symptoms of “whiplash injury” at the follow up appointment three days after the placebo collision. By true definition, the researchers had effectively re-created a “nocebo” effect, whereby a harmless stimulus generates actual harm.

Although the term “placebo effect” has

become highly popularised in modern culture, there is actually a gross under-realisation of the brain’s significance, and, indeed, the mind’s significance, in physical health. What we have to remember is that non-specific pain refers to pain for which there is no recognised physical cause and which is likely to be stress induced. Note, “stress induced” (which suggests that stress is activating physical pain-related processes in the body) should not be confused with “imaginary” (which suggests that there is absolutely no relationship between the pain perception and bodily processes). The brain – which automatically breathes for you while you sleep, automatically raises your pulse rate in response to fear, and automatically increases blood flow through the face (blushing) in response to embarrassment

– can certainly activate pain pathways. The brain is simply the master organ of the body, and its “software” (the largely unconscious mind) holds predominant governance. In fact, physical pain is a very common symptom of psychological stress. Around 96% of people will experience headache during their lifetime and nearly 90% of these will be stress induced tension headaches36. Similarly, as many as 84% of people will experience lower back pain during their lifetime and around 90% of these cases are stress induced non-specific back pain37, 38.

The symptoms of several chronic diseases including chronic pain, cancer and diabetes are improved by general stress reduction39. However, while general stress reduction may allow the patient to get more comfortable within their chronic illness, it does not appear to foster recovery outright. There is a world of difference between effective pain management and actual recovery. It is already well accepted that stress influences physical health. Nevertheless, despite all the evidence, it is not widely realised that chronic and non-specific pain is caused and driven by the brain, and that recovery must ultimately be psychological.

Research from the emerging field of “post-traumatic growth” 40, 41 suggests that recovery from chronic pain may involve specific new learning and growth by the patient – in essence, to “unlearn” the maladaptive stress response. Sadly, this remains unbelievable, and thereby out-of-bounds, to most people at this time in our development.

England Journal of Medicine (PMID:8208267), 1994: 69-73.

25 M, Matsumoto. “Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects.” European Spine Journal (PMID:22990606), 2013: 708-13.

26 SJ, Kim. “Prevalence of disc degeneration in asymptomatic korean subjects. Part 1 : lumbar spine.” Journal of the Korean Neurosurgical Society (PMID:23440899), 2013: 31-8.

27 C, Nimnuan. “Medically unexplained symptoms: an epidemiological study in seven specialities.” Journal of Psychosomatic Research (PMID:11448704), 2001: 361-7.

28 K, Woollett. “Acquiring “the Knowledge” of London’s layout drives structural brain changes.” Current Biology (PMID:22169537), 2011: 2109-14.

29 R, Kanai. “Political orientations are correlated with brain structure in young adults.” Current Biology (PMID:21474316), 2011: 677-680.

30 L, Lanteaume. “Emotion induction after direct intracerebral stimulations of human amygdala.” Cerebral

Cortex (PMID:16880223), 2007: 1307-13.31 J, Gläscher. “Processing of the arousal of subliminal and

supraliminal emotional stimuli by the human amygdala.” Journal of Neuroscience (PMID:14614086), 2003: 10274-82.

32 H, Ung. “Multivariate Classification of Structural MRI Data Detects Chronic Low Back Pain.” Cerebral Cortex (PMID:23246778), 2012.

33 RJ, Gatchel. “The dominant role of psychosocial risk factors in the development of chronic low back pain disability.” Spine (Phila Pa 1976) (PMID:8747248), 1995: 2702-9.

34 AM, Feyer. “The role of physical and psychological factors in occupational low back pain: a prospective cohort study.” Occupational and Environmental Medicine (PMID:10711279), 2000: 116-20.

35 WH, Castro. “No stress--no whiplash? Prevalence of “whiplash” symptoms following exposure to a placebo rear-end collision.” International Journal of Legal Medicine (PMID:11508796), 2001: 316-22.

36 BK, Rasmussen. “Epidemiology of headache in a

general population--a prevalence study.” Journal of clinical epidemiology (PMID:1941010), 1991: 1147-57.

37 LA, Machado. “Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials.” Rheumatology (Oxford, England) (PMID:19109315), 2009: 520-7.

38 M, Krismer. “Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific).” Best Practice and Research. Clinical Rheumatology (PMID:17350545), 2007: 77-91.

39 AK, Niazi. “Mindfulness-based stress reduction: a non-pharmacological approach for chronic illnesses.” North American Journal of Medical Sciences (PMID:22540058), 2011: 20-3.

40 G, Skaczkowski. “Complementary medicine and recovery from cancer: the importance of post-traumatic growth.” European Journal of Cancer Care (PMID:23730795), 2013: 474-83.

41 S, Joseph. “An Affective-Cognitive Processing Model of Post-Traumatic Growth.” Clinical Psychology and Psychotherapy (PMID: 22610981), 2012: 316-25.

The brain: the master organ

the only factor found to predict

new cases of lower back

pain was acute psychological

distress.

Prevention is better than cure: rethinking chronic pain