Back pain may be 'in the mind'

Back pain may be all in the mind, according to researchers

who recommend sufferers should seek psychological
counselling.
In a study, patients given the therapy showed double the improvement of
those who received standard treatment.
Researchers believe that the counselling, or cognitive behavioural therapy
(CBT) sessions, works because if you can help people to change their
thoughts, it will help them to change the way they feel.
CBT is already used to treat a range of problems from phobias and panic
attacks to stress at work. Practitioners aim to help patients avoid dwelling on
negative thoughts and to find ways to overcome them.
Professor Sarah Lamb, of the University of Warwick, said: "Effective
treatments that result in sustained improvements in low-back pain are
elusive.
"This trial shows that a bespoke cognitive behavioural intervention package
is effective in managing subacute and chronic low-back pain in primary
care."
Lower back pain is a very common problem affecting one in three adults in
the UK each year, with an estimated 2.5 million people seeking help from
their GP.
For many people the pain goes away in days or weeks. But for some, the
pain can persist for a long time and become debilitating.
Senior research fellow Zara Hansen said psychological counselling for back
pain could even go online.
Although the study involved face to face meetings with therapists the
treatment could be adapted to be delivered over the internet, she said.
"There is no panacea for lower back pain but when you consider up to 80 per
cent of people will have it at some time in their lives a programme that can
deliver improvement for so many can have a massive impact," he added.
During the study 468 patients were given six sessions of group CBT, while
another 233 were not and were to act as a control group.

Those receiving the CBT saw pain and disability levels fall twice as much as
the other group.
The findings were published by the Lancet Journal.

The Psychology of Pain

Submitted by Alina M Clavijo-Passik, PhD on November 26th, 2008
Question: I'm in constant, terrible pain (it peaks at 8 every day), and I've lived with this chronic
back pain for close to 15 years. I've tried the best I can to keep a good attitude and stay
optimistic, but it's hard, so hard. Just recently, my doctor referred me to a psychologist. Why
would he do that? Does he think I'm going crazy and making up my pain? What good will a
psychologist do when it's my body that's in pain?

Answer: I can understand how it would feel that way. However, being sent to a psychologist
isn't a sign that your doctor believes that you've made up 15 years of intense pain. Instead, it's a
sign that he's taking a multi-disciplinary approach to your chronic pain treatment.
Usually a physician will include a psychologist in your treatment because he or she believes that
a multi-disciplinary approach is the best way to address your chronic pain treatment. Using this
approach, experts from different disciplines work together on a treatment team with the goal
of decreasing your pain and increasing the things you can do. This is known as your
functionability.
These multi-disciplinary treatment planssuch as the ones developed at the practice where I
work (the Center for Pain Management in Indianapolis, IN)take into consideration how the
chronic pain is keeping you from fully living and functioning the way you'd like. The treatment
team works together to provide you with the tools to improve your functionability.
After all, chronic pain takes a toll on your life, as I'm sure you know from first-hand experience. It
is a constant stressor to be in pain all the time. Furthermore, giving up many of the things you
used to do because of the chronic pain can cause symptoms of anxiety and depression.
Depending on how disruptive it is to your life and roles, this can lead to anxiety, depression, and
panic disorders. In short, chronic pain is about more than thephysical experience of pain, so an

optimal chronic pain treatment plan will probably need to include more than just treatments that
target the physical pain.
Let me explain briefly what I do in the first appointment. This may help assuage your concerns
about being sent to a psychologist.
During the first appointment, I try to get an idea of how the pain is affecting the patient's life. As I
mentioned before, many patients come to me feeling depressed or dealing with anxiety. Living
with a chronic medical condition creates another level of stress in a patient's life. So I use this
time to assess how they have adjusted to living with their chronic medical condition and what
adjustments they have not been able to make. In this initial meeting, I also evaluate if there are
tools and/or techniques I could provide the patient with to help him or her cope with the pain.
After the first appointment, the multi-disciplinary team at the Center for Pain Management sits
down to discuss treatments plans for particular patients. For chronic pain patients, I find it very
useful to be part of this team approach: all the specialists are focused on improving the patient's
quality of life, and we can stay abreast of all of the treatments a patient is receiving. Working
together, we can make the best recommendation to the patient. Of course, as with any
treatment approach, acceptance of the treatment is always up to the patient.
Not every patient needs a follow-up appointment (or appointments) with me. Each treatment
plan is individualized, so this depends upon the needs of the patient.
For example, after my evaluation of the patient, I may believe that he or she could benefit from
learning some relaxation techniques. Perhaps living with chronic pain has made his or her body
and mind very tenseunable to adequately relax. That tension can actually amplify the daily
experience of pain.
In my work with this patient, I might teach him or her various relaxation techniques,
diaphragmatic breathing, and meditation that the patient can use to calm the body and mind.
These are techniques the patient can then use on his or her own in daily life to manage the pain
and stress. Being less fraught with tension may make it easier for the patient to do some of the
"daily life" things that had become difficult, thus in turn decreasing his or her pain
and increasing the things he or she can do with less pain.
Your appointment with the psychologist shouldn't make you feel that the doctor questions your
mental status, but actually it reflects that your doctor was really listening to you and heard that
you have been suffering from chronic pain for a long time. I hope that through my brief
explanation of the role of a psychologist in chronic pain treatment, you may see that this referral

may, in fact, be beneficial to your overall treatment. The psychologist will work with you to figure
out what works best so that you can get through the day with a better handle on your pain and
get back to your life.

How can counselling help?

Looking after your psychological well-being can be especially important when
you are experiencing physical problems. Maintaining a positive mindset and
lowering stress levels can improve your quality of life and can even help to
reduce your pain.
Talking therapies such as counselling are especially helpful to those suffering
from depression and/or anxiety. There are several psychological treatments
that may help you, these include:
Cognitive behavioral therapy (CBT)
CBT is becoming an increasingly popular technique to help with a range of
issues, including chronic pain. The therapy is based on the principle that the
way you feel about things depends partly on the way you think about them.
CBT aims to break down overwhelming problems into smaller, more
manageable segments. It also looks at negative behaviour patterns (i.e. how
you react when symptoms of pain first appear) and looks to change them
over time.
Mindfulness
Another therapy that is gaining popularity is mindfulness. Often used as a
meditation technique, mindfulness helps you to focus on the present, rather
than worrying about the past or future. For those with chronic pain,
mindfulness can help you to judge your pain levels more accurately and may
help to reduce anxiety about future attacks/episodes.
Supportive counselling
In many cases, those with chronic pain benefit simply by talking to someone
about their experience. An individuals counsellor will be able to explore your
feelings (whether these are related to your pain or not) and help you to
figure out new ways of coping or reacting to the pain. Some people who
suffer from chronic pain are also counsellors - so you may even be able to
find someone who understands what you're going through in more detail.

What should I be looking for in a counsellor or psychotherapist?

There are currently no laws in place stipulating what training and
qualifications a counsellor must have in order to treat those with chronic
pain. However, the National Institute for Health and Care Excellence (NICE)
have developed a set of guidelines that provide advice about the
recommended treatments for those with a chronic illness suffering from
depression, including the following:
Treatments for depression include psychological treatments and
antidepressants. The decision about what type of treatment to have will
depend on your preference and a number of other factors.
If your physical health problem means that you are unable to have
psychological treatment face to face, you may be offered an antidepressant
or psychological treatment by phone.
If you have a learning disability or other problem that may affect your
understanding, you should be offered the same treatments as other people
with depression and a physical health problem. The treatment may be
adapted to suit your needs.
If you have both depression and anxiety, you will be treated first for the one
that causes you the most problems. Because treatments for anxiety and
depression are similar, treatment for one condition can often help the other.

Chronic Pain Coping Techniques - Pain Management

Clinicians who specialize in treating chronic pain now recognize that it is not
merely a sensation, like vision or touch, but rather chronic pain is strongly
influenced by the ways in which the brain processes the pain signals.
Chronic pain can provoke emotional reactions, such as fear or even terror,
depending on what we believe about the pain signals. In other cases (such as
in sports or another engaging, rewarding activity), chronic pain may be
perceived by the individual as merely a nuisance, a feeling to be overcome in
order to be able to continue in the activity.
The important role the mind plays in chronic pain is clearly recognized in the
medical literature, as well as in the International Association for the Study of

Pain's definition of pain, which states that pain is always subjective and is
defined by the person who experiences it.
The corollary is that the brain can also learn how to manage the sensation of
pain. Using the mind to control chronic pain, or coping strategies, for
managing persistent pain, may be used alone or in tandem with other pain
management therapies.
Ideally, use of the chronic pain management techniques outlined in this
article can help patients feel less dependent on pain killers and feel more
empowered to be able to control their pain.

Managing Chronic Pain

Of course, the first step in coping with chronic back pain or other types of
persistent pain is to receive a thorough medical evaluation to determine the
cause of the pain.
In some situations, such as a herniated disc in the spine, it may be important
to pay attention to the level and type of pain so that it can serve as a
warning signal of impending damage.
In other cases, especially when the back pain is chronic and the health
condition unchangeable, one goal can be to try and keep the chronic pain
from being the entire focus of one's life.
Whatever the medical condition, there are a number of effective strategies
for coping with chronic back pain. These techniques generally include:
Relaxation training: Relaxation involves concentration and slow, deep
breathing to release tension from muscles and relieve pain. Learning to relax
takes practice, but relaxation training can focus attention away from pain
and release tension from all muscles. Relaxation tapes are widely available
to help you learn these skills.
Biofeedback: Biofeedback is taught by a professional who uses special
machines to help you learn to control bodily functions, such as heart rate and
muscle tension. As you learn to release muscle tension, the machine
immediately indicates success. Biofeedback can be used to reinforce

relaxation training. Once the technique is mastered, it can be practiced

without the use of the machine.
Visual imagery and distraction: Imagery involves concentrating on mental
pictures of pleasant scenes or events or mentally repeating positive words or
phrases to reduce pain. Tapes are also available to help you learn visual
imagery skills.
Distraction techniques focus your attention away from negative or painful
images to positive mental thoughts. This may include activities as simple as
watching television or a favorite movie, reading a book or listening to a book
on tape, listening to music, or talking to a friend.
Hypnosis: Hypnosis can be used in two ways to reduce your perception of
pain. Some people are hypnotized by a therapist and given a post-hypnotic
suggestion that reduces the pain they feel. Others are taught self-hypnosis
and can hypnotize themselves when pain interrupts their ability to function.
Self-hypnosis is a form of relaxation training.

Psychological Therapy
Experiencing Pain
Psychological Therapy
Pain can mean different things to the person experiencing it and to the
doctor being consulted. Pain tends to interrupt a persons thoughts and
actions and to dominate their attention.Many patients have insufficient or
unhelpful information about what the pain is, and/or perceive it as a serious
threat, and are unable to cope with it.Patients may feel that their doctor does
not understand their pain, or has not appreciated their problems, and are
less likely to accept and adhere to treatment if they feel is not helpful.Often
patients attempts to cope with their pain will be undermined by concerns
that they may be making their condition and therefore their pain worse.
Psychological techniques in chronic pain
Biofeedback

Diverting or competing stimuli can improve pain levels during the

biofeedback procedure and during intervals afterwards.The basic pain
biofeedback system is a demonstration to the patient, of the effect of
internal emotional states on global physiological functions. Example: skin
resistance, pulse, respiratory pattern, EEG; and focal processes, that is,
electromyography [EMG] activity in regions of pain.Studies of several
conditions have demonstrated the positive effects of this approach, usually
combined with other physical therapy modalities.
Virtual Reality Biofeedback in Chronic Pain and Psychiatry.
Cognitive Behavioural Therapy
Cognitive behavioural approaches aim to improve the way that an individual
manages and copes with their pain.The approach is very much related to
problem solving and returning control to the sufferer.Many patients state that
the pain rules their lives and cannot see how this can change without a
medical cure. However, with appropriate instruction in a range of pacing
techniques, cognitive therapy to help identify negative thinking patterns and
the development of effective challenges, stretching and exercising to
improve physical function, careful planning of tasks and daily activities, and
the judicious use of relaxation training, many people find the treatment
enables them to take back control of their lives.

Coping Strategies
Professionals who treat chronic back pain recognize it is not merely a
sensation, but is strongly influenced by the ways in which the brain processes
pain signals.
There are a number of techniques including relaxation training, hypnosis,
biofeedback and guided imagery. Techniques for coping with long-term pain
make use of four types of skills:
1. Deep Muscle Relaxation.
2. Distraction- moving your attention away from pain signals.

3. Imagery - visual, sound or other pictures and thoughts that

are pleasant and relaxing to you.
4. Dissociation - the ability to separate normally connected
mental processes, leading to feelings of detachment and
distance from the pain.

Pain Management Programmes (PMP)

A Pain Management Programme (PMP) is a psychologically-based rehabilitative
treatment for people with chronic pain which remains unresolved by other
treatments currently available.
It is delivered in a group setting by an interdisciplinary team of experienced health
care professionals working closely with patients.
The aim of PMPs is to reduce the disability and distress caused by persistent pain
by teaching physical, psychological and practical techniques to improve quality of
life.
It differs from other treatments provided in Pain Clinics in that pain relief is not the
primary goal, although improvements in pain following participation in a Pain
Management Programme have been demonstrated.