Back Pain.

How is a person's experience of back pain influenced by psychosocial factors and what is the psychological impact of back pain.

. We are all aware of the fact that pain is defined by the International Association for the Study of Pain as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.' . Thus, the experience and perception of pain is subjective and is contributed to significantly by a number of social and psychological factors ranging from personality to past experiences of injury1. . Chronically, pain can present in a variety of ways and it is estimate to affect 10% of the population. Back pain affects 80-90% of adult men and women between the ages of 30-50 years and it is often poorly managed in primary and secondary care2. . It presents a potent challenge medically as it is common, resource intensive, of huge economic cost (due to direct costs such as house modification and indirect costs such as absences/disability claims) and a major cause of physical, psychological and social disability. . Lower back pain is estimated to cost the UK economy £6 billion per yr3. Recently it has been put forward that there has been a demographic shift in the victims of back pain from manual labourers to office based employees2

How psychosocial factors influence the experiencing of back pain. . Previous work by Melzack and Wall (1999), have highlighted the efficiency of the gate control mechanism where the experience of pain is modulated by downward neural pathways from the brain, enabling the psychological regulation of pain1. . It is well documented that factors such as having knowledge about the condition, a sense of control over it, happiness, contentedness, good sleep, distractions, a strong family/relationship ties and a wide support network all act positively in decreasing the perception of pain. . Pain perception may be augmented by factors which are the opposite of those listed above and through mechanisms such as PNS sensitization which act in creating the 'wind-up' phenomenon resulting in hyperalgesia, allodynia, and spontaneous pain (through the increased excitability of neurone pathways). Pain memory may also play an effect as it creates a neural imprint of past painful experiences.1 . Learning relaxation techniques greatly increase the sense of control over the pain. It is through this method that the cycle of pain, (producing increased frustration and irritability, raised adrenaline levels, increased spasm and thus the lowering of pain thresholds) can be broken1 . Fear of pain can lead to decreased mobility and lower levels of fitness. If it is believed that chronic pain is a signal of harm then patients will be less likely to do things that will bring on pain. . This also causes secondary problems in addition to the ones mentioned above such as postural changes, stiffness in joints, or the lack of use of an affected limb. This belief feeds anxiety and noticeable unhelpful behavioural changes. The influence of health beliefs have been documented as having a profound effect on a person's symptoms and their expectations of treatment and the success of the treatment . Psychosocial barriers to active rehabilitation may increase the risk of the condition becoming prolonged. . Medically, these are called yellow flags and they should be addressed in order to strive for a positive outcome. Examples of yellow flags which hinder a timely outcome include2:

Box 1 Yellow flag for prolonged treatment and a poor outcome

. High physical workload and job dissatisfaction increase the risk of absence due to back pain. Thus we can see the psychological factors are important. Furthermore certain indication of poor health such as smoking and obesity increase the risk of back pain. How back pain creates psychological impacts . Chronic, unrelenting back pain, if it is not treated adequately, can lead to an inability to work and early medical retirement. Even with today's demographic changes it is apparent that the people most at risk of this development is people who are male, low skilled manual workers and less educated2 . A loss of employment can consequently lead to increased financial restrictions, an inability to carry out normal day-to-day activities, which may in-turn affect lead to relationship difficulties and reduced quality of life. Often a person's self-esteem and self-worth is linked to being in gainful employment, and being out of work leads to the development of depression, hopelessness and reduced sense of control1. This in turn feeds back on the patient's perception of his or her back pain. . Constant pain may create difficulty sleeping, reducing the ability to concentrate and thus augmenting irritability. Studies have highlighted that this can impact on sexual activities and lead to thoughts of suicide1. . By decreasing social participation be they through paid employment or socially, there is increased marginalisation, poorer mental health, increased social isolation. Furthermore, this will impact by creating associated comorbidities such as weight gain, increased alcohol consumption etc4. . Pain can lead to behaviour shaped by operant conditioning, whereby 'good days' lead to doing too much and trying to catch up on tasks that need to be completed. This will normally cause 'bad days' where little can be done while waiting for the pain to settle. Consequently mood is low and misery, anxiety and stress is high. To mitigate this it is advised to do activities which do not cause pain to flare up and which achievable activity levels can be set as goals. . The MDT team has changed its treatment of back pain in the past few decades and the advocating of early mobilisation and to work through the pain and overcome it. Exercise is shown to promote recovery and to prevent recurrences3. Health professionals are increasingly now told of the need to reassure the patient there is no serious malignancy present (in mechanical lower back pain) and that the pain does not mean harm is occurring3

References 1. Alder, B. et al (2009) Psychology and sociology applied to medicine. 3rd Eds. Elsevier: London 2. Patient.co.uk. Last accessed online at 9/5/11 at http://www.patient.co.uk/doctor/Assessment-and-Management-of-Low-Back-Pain.htm 3. Lecture notes-Mr Peter Merry 9/05/11 4. Marsland, D. and Kapoor, S. Crash course: Rheumatology And Orthpaedics. 2nd Ed. Mosby Elsevier: London