Analysis: our thoughts about stress, anxiety and worry can make us more prone to getting back pain and less likely to recover from it

Back pain is very common and is a major problem for some people, making work, hobbies and overall life difficult. Imagine how frustrating it is to be in that situation, and then for some back pain "expert" like your physiotherapist, GP or surgeon to suggest your pain is "all in your head". Unfortunately, this happens sometimes – I have probably insulted someone like that myself! 

So why this might be happening - and how this situation could be improved? First of all, the short answer is no, your back pain is not "all in your head" in terms of your pain being imaginary or fake. Pain is a subjective experience. No other person, and no test, can tell who is or is not in pain, or how severe the pain is. Put simply, if you feel pain, it is real - end of discussion. But the longer answer is partially yes, but probably not in the way you might think.

From RTÉ Radio 1's Drivetime, Kieran O'Sullivan discusses a new study on back pain treatments

This seems contradictory so let me try to explain two different ways in which our thoughts can influence back pain. First, hundreds of studies have shown that things like stress, worry, anxiety and low mood make us more likely to get persistent back pain. Importantly, these studies show not just that back pain causes distress, but that distressed people get more back pain. This is similar to how these factors are linked to headaches, cold sores and irritable bowel syndrome. In other words, being run down by things like stress and worry has a very real effect on our physical health. This is not imaginary, this is real biology!

Secondly, when you develop back pain, your medical care can add to your existing worries. This is because we now have tests such as MRI scans which can detect things in our back that sound scary, even if they are not related to our back pain. For example, most middle-aged people will have the equivalent of grey hairs or wrinkles on a back MRI scan, but calling these changes "degenerative" is far from reassuring. Similarly, well-intended manual handling and ergonomic advice reinforces the idea that the back is a vulnerable structure which is easily damaged. 

A RTÉ Brainstorm video on back pain and tips to deal with one of the most misunderstood sources of pain

In summary, we now know that the stuff in our head, either relating to stress and worries, or what we have been told about the vulnerable state of our spine, makes us more prone to getting back pain, and less likely to recover from it. However, addressing these issues in a person with back pain could be annoying or even insulting if not communicated clearly. In fact, healthcare professionals and patients frequently avoid discussing these issues, due to the potential for stigma and conflict.

So how do we fix this?

More time would help

Helping a patient with back pain identify the various triggers for their back pain can take time. This is often because patients focus initially on perceived physical causes, instead of other risk factors seen as irrelevant, or too sensitive to discuss. Discussing these issues is easier when a good rapport has been achieved, and rushing these discussions in a 10 minute appointment can lead to patients feeling dismissed or judged. Right now, it is often quicker and simpler for a GP to order an inappropriate MRI scan than to spend time identifying such triggers, and then explaining how they relate to back pain. 

From RTÉ Radio 1's Ray D'Arcy Show, Kieran O'Sullivan answers listeners' questions about back pain

Change beliefs about pain

We need everyone - healthcare professionals, people with back pain and wider society - to better understand pain. If as a society we think that persistent back pain reflects the kind of tissue injury that scans can detect, then X-Rays and MRI scans will continue to be over prescribed. Similarly, the focus on trivial physical risk factors in many office environments reflects this belief that pain reflects tissue damage.

Since scans rarely identify something significant, and traditional "be careful" ergonomic advice is of little help in treating back pain, these should play a much smaller role. If scans are to be used or desired by patients, then we need to better explain the results. A scan which shows nothing, or shows the routine stuff seen on most adults without pain, should be reported as good news and remind us to consider all other factors which influence pain.

Support non-physical care as much as physical care

Where relevant, people with back pain should be allowed, and funded, to access supports to address these factors. This could include a role for exercise to reduce stress, enhance sleep, increase mood and reduce a person's sense of fragility.

We need everyone - healthcare professionals, people with back pain and wider society - to better understand pain

However access to psychological, social, occupational and lifestyle professionals is equally legitimate in the management of pain. Unfortunately, current employer, health funder and medico-legal policies and practices do not always facilitate this, and further de-legitimise patients with such issues. At what point will a sore back due to high stress and poor sleep be as acceptable and deserving of our support as a sore back from lifting a box?

Reward good care

Current funding often rewards being busy rather than being effective or efficient. Rather than blaming GPs and health professionals for not spending enough time with patients, and ordering inappropriate tests, we need to look at how policy and funding strategies could encourage better practice. Similarly, we need to discriminate between treatments and professions, as each healthcare profession likely offers a range of treatments which are not all equally beneficial. 

READ: All you ever wanted to know about back pain

Finally, if as a patient you think someone is saying your back pain is "in your head", then please tell them, and check that you are on the same wavelength. It is unlikely they are saying you are pretending to be in pain. Instead it might be just be a poor – or rushed – attempt by them to reassure you that your spine is not very badly damaged, your test results appear fine, and therefore it could be useful to look at your overall health broadly to help you recover from back pain. 


The views expressed here are those of the author and do not represent or reflect the views of RTÉ