I hear doctors aren’t treating low back pain like they used to. I saw a TV special that said most low back pain is caused by psychosocial issues. Just exactly what does that mean anyway? Do I have back pain because I am a social misfit?

Not at all. The new understanding of low back pain looks at the total person — not just the biology and biomechanics of your spine. Back pain whether from an injury or unknown cause is very real. But the stresses and strains of the body as well as the stress on the mind are both part of the picture.

It’s clear now that the broader view of life helps explain why pain becomes chronic lasting more than a few weeks. For example there is the fear of reinjury. This is one very important psychosocial factor in chronic back pain. The person in pain is afraid to move because it will hurt. Or maybe the pain is getting better but the patient is still avoiding certain motions or activities to keep from getting hurt again. This leads to a cycle of pain – no movement – pain.

Sometimes the psychologic or emotional distress of pain leads people to blow it out of proportion. This is called pain catastrophising and is another psychosocial variable.

Doctors realize now it’s best to be aware of all aspects of pain. Keep moving and don’t let pain rule what you do or don’t do. In other words, don’t let fear keep you from getting better.

I’m 52 and things are starting to fall apart. First I had neck pain that wouldn’t go away. I finally got rid of that, and now I have shoulder pain on the other side. Is there any way to tell if this will eventually go away too?

It’s fairly normal to have some aches and pains along the way especially in midlife and beyond. When one thing after another starts to bother you, it might be time to have a physical exam. There could be some medical condition causing your symptoms.

The doctor may be able to tell you the outcome of this new shoulder pain, too. Doctors use a guideline called Clinical Prediction Rules to help predict what might happen. Based on studies of many patients with shoulder pain, researchers have been able to find a couple factors that predict outcome.

For example, patients with neck and shoulder pain are more likely to still have shoulder pain six weeks later. Patients with back and shoulder pain together are more likely to have continued pain six months later. For the most part, intense pain of long duration at the time of a medical visit suggests a poor prognosis. The client is more likely to have symptoms longer than expected.

Other factors are also taken into consideration such as repetitive movements and psychologic problems.

I’ve been going to a special pain clinic to help me get better from my chronic back pain. I took a bunch of tests on paper and answered a lot of questions. The results say I just made the cut off for having the normal amount of fear. They say I’m not avoiding movement out of fear of pain like some people do. How in the world do they decide what the magic cut off number is? Can one number really make the difference between normal and not-so-normal?

You may have taken the Fear Avoidance Behavior Questionnaire (FABQ). This survey is a tool to help doctors and physical therapists identify patients who are afraid to move normally. Either fear of pain or fear of reinjury rules how or when they move.

There are really no known cut-off scores for this test. Studies done on back pain patients have given us a range of expected values. Some researchers group FABQ scores into high and low based on the physical activity scale in the test. The total score for that section is 24 points. Getting less than 15 is a low score. It means there’s a low risk for elevated fear-avoidance beliefs. More than 15 is high and signals a high level of fear-avoidance.

As you say the difference of one or two points doesn’t make sense. It may be best to look at the scores as being somewhere on the same line rather than dividing them into low or high.

I went to my doctor for new symptoms of shoulder pain. She wants to use the wait-and-see approach. She says most shoulder pain goes away by itself. Is this a standard way to treat this problem? I’m a little dubious.

Actually the wait-and-see approach is part of a protocol called Practice Guidelines for Shoulder Pain used here in the United States and in other countries. The practice guidelines have only been around for the last five years or so. This treatment is useful in the first two to four weeks after the start of symptoms.

Some doctors may prescribe analgesics or even anti-inflammatories during this waiting period. Treatment decisions are based on the physical exam and known factors for a poor outcome. Studies have shown that the longer you’ve had the pain and the more intense the pain is at the time of your first doctor’s visit, the poorer your results will be.

In cases like this, instead of recovering in two to four weeks, it takes six weeks to six months (or more) to get back to normal. Even with a short wait-and-see approach, earlier treatment with drugs or physical therapy can make a difference in the long run. Make sure you go back to the doctor if your symptoms aren’t resolved by the end of a month’s time.

I come from a Hispanic background. I notice that many of my aunties seem to have an extreme response to everyday aches and pains. Many of them are doctoring for chronic pain that doesn’t seem very real to me. Is this an ethnic thing?

Measures of pain have been reported for many population groups. Researchers often try to include patients with a variety of backgrounds. African-American, American Indian, Alaskan Native, and Hispanic are just a few of the groups used by the U.S. Census. Social researchers tend to use these same groupings.

In the last 25 years it’s become clear that pain is not just a biologic or medical experience. Emotional, cultural, and social factors are equally if not more important. The passion with which your aunties express their pain may be more behavioral than physical. It may or may not be based on their ethnic background.

Some psychologists look for pain with an emotional overlay. This means patients who have pain respond to it in a different way because of their emotional or psychologic make-up. They tend to describe their pain using phrases like “it’s killing me” or “the pain is torturing me”. Other emotionally based words might be “frightening,” “vicious,” or “miserable”.

Whether or not there is a physical or biologic reason for pain doesn’t matter to the person’s experience. Everyone of any ethnicity feels the pain just as if it were very real.

My doctor told me there are quite a few theories about what causes CRPS. I didn’t want to ask too many questions during the office visit but I’m wondering what are some of these ideas?

Complex regional pain syndrome or CRPS is a painful condition that affects the arm and hand or leg and foot. It usually occurs after trauma of some sort, including surgery. Most people think the syndrome occurs after healing is complete. But one theory is that there is ongoing inflammation. The inflammation causes nerve endings to become extra sensitive.

Another theory is that changes in brain function occur. Which area(s) of the brain and why remain unknown. It may be possible that CRPS is a psychiatric problem. Psychosomatic or a mind-body response occurs after trauma leading to a stress-induced condition of pain and other symptoms.

Most recently several studies have been published pointing to nerve damage as the primary cause of CRPS. But the studies were small. The authors themselves said they couldn’t be sure the changes measured happened first or after CRPS.

The more we can find out about this condition the sooner effective treatment can be developed. It’s entirely possible that there is more than one mechanism involved. The complex interactions between brain, body, and peripheral nervous system support this theory.

Good grief. I just came back from taking a very long survey about my chronic pain at a pain clinic. Now my back pain is worse from all that sitting. Was that really necessary? How’s it going to help me?

The test results will help you in the long run. Right now the doctors, nurses, and therapists at the clinic need some information to help them put together a plan of care for you. This means understanding your pain experience — where does it hurt? When does it hurt? What makes it better or worse?

Knowing how you think and view your pain will help guide the pain management portion of the program. Often patients will say they think one way but their inner thoughts and “self-talk” suggest something else. Positive self-talk is a fairly new treatment method being studied. Finding which patients each treatment technique will help is the key to success.

Whenever a survey or tool of this type is used there are trade-offs. Too few questions may not give the total picture of the patient. Too many questions can turn the patient off to the process.

For the moment it’s good to know that someone is taking a close and careful look at your experience. The more they know about you and how you function, the more likely you’ll get the help you need.

I have some kind of problem with my arm and hand. One doctor told me I have something called reflex sympathetic dystrophy. Another doctor says I have complex regional pain syndrome. How can I find out what I really have? Could I have both problems at the same time?

Complex regional pain syndrome (CRPS) and reflex sympathetic dystrophy (RSD) are the same thing. RSD is the old term used for the problem. It’s been updated now to CRPS based on research in the last 10 years. The change came about in naming this condition when researchers were able to identify the problem a little more clearly.

Dr. S. W. Mitchell first reported CRPS in 1872. Back then it was called causalgia from burning pain in wounded soldiers. Symptoms of intense pain, swelling, and skin changes were common. Less involved injuries got the label reflex sympathetic dystrophy.

A similar problem called shoulder-hand syndrome was identified after heart attacks. Years ago anyone who had a heart attack was treated by six weeks of bed rest. There is a known connection between the heart and shoulder. The enforced immobility fired up those connections resulting in shoulder pain, loss of motion, and symptoms in the arm and hand.

New efforts are being made to understand this complex syndrome. Finding out what causes it will be a big step toward finding better ways to treat it and perhaps even prevent it from happening.

I was part of a study giving chronic pain patients a survey to find out about our pain. It seemed like many of the questions were the same, just asked a little differently. Are these trick questions to see if we answer them the same each time?

A good survey is brief but comprehensive. It gets the answers to questions from a variety of viewpoints. In this way it can seem repetitive. Sometimes more than one question asked in a similar way helps to validate the person’s response. In other words, it shows if that’s how the person truly feels. Conflicts of thought are brought out by questions repeated in different ways.

Many pain surveys begin with a description of the pain. Patients try to match words to their experience. The location, frequency, duration, and intensity are all measured. Use of medications is often included. Beliefs about disability, control, and function come out with the right questions.

The person giving you the test may have given you special instructions before starting. Often the patient is told to answer each question as honestly as possible without looking back at previous answers. It’s not meant to trick patients as much as to get a clear picture of the patient’s thoughts about the pain.

I’ve been doing some reading about CRPS. I’ve just been diagnosed with this problem. I see there are two kinds. How can I tell which kind I have?

The signs and symptoms of CRPS are the same with both Type I and Type II. The only real difference is that with Type II (also known as causalgia), there is a known nerve lesion or nerve damage. Type I has no identifiable nerve trauma. Type I has been called reflex sympathetic dystrophy until this distinction was made several years ago.

You may be able to figure out for yourself which type you have based on your history. If not, ask your doctor to explain which type you have and why. Type I is most common after some type of soft tissue trauma. Type I is also possible after a period of immobilization such as after an accident, injury, or stroke. Something as simple as having blood drawn or a bug bite can also result in Type I CRPS.

Type II occurs when the nerve has been cut, damaged, or injured in some way. This could happen as a result of an accident or surgery.

I confess I’m a nervous Nellie kind of person. I hurt my back at work and now I’m really worried about re-injuring myself. What can I do to get over this?

Avoiding certain activities or movements that might cause pain or reinjury is called fear-avoidance behavior. This may be what you are describing about yourself. And you are right to be concerned. Chronic pain can be disabling.

The Fear-Avoidance Model of Exaggerated Pain Perception (FAMEPP) was first introduced in the early 1980s. The idea is based on studies that show a person’s fear of pain (not physical problem) is the most important factor in how he or she responds to low back pain. Fear of pain commonly leads to avoiding physical or social activities.

Education is the key to injury prevention and fear avoidance behaviors. You’ve already taken the first step to getting over this problem: you’ve seen it! A physical therapist may be able to help you. First you’ll be tested for fear avoidance behaviors. A series of questions are asked to find this out. When a patient shows signs of fear-avoidance beliefs, then the therapist’s management approach will include education.

The therapist can teach you about the difference between pain and tissue injury. Chronic ongoing pain does not mean tissue injury is taking place. This common misconception is another reason why patients use movement avoidance behaviors. Then you’ll be given a graded approach to exercise. The therapist will guide you through the activities and movements that cause you the most fear.

What is pain catastrophizing? I saw the term on a poster in a pain clinic.

Pain catastrophizing refers to a negative view of the pain experience. It is exaggerated or blown out of proportion. Sometimes it refers to a patient who actually has pain already. In other cases the person isn’t even in pain yet — he or she is still just anticipating it might happen.

The staff at a chronic pain clinic are trained to test for and recognize the signs of pain catastrophizing. Studies show that without intervention these behaviors can lead to chronic pain and disability over time.

Catastrophizing or expecting the worst to happen increases pain. Catastrophizing boosts anxiety and worry. These negative emotions stimulate neural systems that produce increased sensitivity to pain. It can become a vicious cycle.

Two years ago I had an operation that has left me in chronic pain. I tend to be a worrier. Now I’m worried that my worrying is what has kept me from getting better. Is this possible?

There’s a known link between pain and worry — even for people who don’t worry normally. Studies don’t support the idea that worrying prevents patients from healing or getting better. In fact, when compared with patients who have been diagnosed with mood disorders such as anxiety or depression, the chronic worrier comes out ahead.

The worrier’s path takes a little different twist if he or she thinks that the only successful outcome is a cure for the pain. Seeing the problem to be solved by cure alone makes a person even more aware of the pain. When every effort to get “better” doesn’t bring about a chance in pain, then the patient becomes frustrated. Frustration can lead to negative thinking about oneself.

There is help available if you think your worrying is a problem. Behavioral counseling has helped many people rein in their worry habits. Even if it doesn’t change your pain, your quality of life may be improved.

How can I tell if I am worrying too much about my back pain? I’ve had it for six months and it doesn’t seem to be going away. That worries me.

Worrying is a problem if it interrupts your thoughts, your sleep, or your relationships with others. Worry that is intense and uncontrollable is too much. This type of worry makes matters worse not better. It adds another problem when you’re already dealing with the problem of chronic pain.

Worry of this type may keep you from finding acceptable solutions to the problem at hand. In fact you may not be able to see answers that are right in front of your face if worry gets in the way.

There are some short-term solutions that can help you break the pain-worry cycle. Sometimes medications are helpful. In other cases distractions work well enough. Various methods can be used such as exercising, calling a friend and talking about anything except your worries, listening to calming music, or reading a book.

If after trying these distractions you still can’t get a thought out of your mind, seek help in finding some effective solutions. Learning to live without obsessive worrying is a good life skill to have.

My sister has had chronic neck and back pain most of her adult life. As she gets older she seems to get worse — or maybe her attitude is just worse. The family is having a hard time being patient with her. She’s still looking for a magic medical cure. What can we say that will help?

When patients look for a cure and define it as being ‘pain free’ after years of pain — the result is likely going to be frustration. Repeated attempts to solve the problem with one treatment after another often cause the person to become more and more negative.

Negative thoughts can lead to what’s called catastrophic thinking. Pretty soon the person is thinking about the pain all the time. The general trend of their thoughts is toward the worst case scenario. They play this over and over in their minds.

Your sister may need more than just a few key phrases from her family. If she is open to the idea perhaps an appointment with a behavioral psychologist might help. If nothing else, encourage her to talk with her doctor about coming up with a better plan to manage the pain.

Many times it takes a team of health care professionals to help patients retrain their thoughts and manage their pain. The goal to reduce pain is replaced by goals to increase function. This can help improve the patient’s (and the family’s) quality of life. Time spent together becomes less focused on one person’s health and pain and more enjoyable again.

Is it true that older people have less pain than younger people?

It appears that there may be a general trend for aging adults to have less pain with the same stimulus compared to younger adults. Scientists are unsure how to explain this. It could be a function of age with pain receptors becoming fewer and less functional.

Or it could be that an increased number of pain experiences over the years helps the older adult tune it out more effectively.

A recent study of attachment styles has shed some light on this subject. Attachment styles describes how secure or insecure someone may be in relationship to others. A more securely attached adult has less anxiety and less pain when compared to someone with an insecure attachment style.

In fact, younger, more fearfully attached adults are more likely to have greater pain and less pain tolerance when exposed to the same amount of pain as a secure or dismissive adult.

With all the other senses declining in old age, the decrease in pain perception may seem like a good thing. But pain is a protective mechanism to help warn and guide us. Only in cases of chronic pain would a reduced pain sensation be to anyone’s advantage.

I notice my 80 year old grandparents are so calm about everything. Even when they are in pain from their arthritis they hardly ever complain. Are all older people this calm about pain and suffering?

Not always. Some people catastrophize pain all throughout their lives. This means they focus on their pain and the negative aspects of it. They imagine the worst is going to happen and dwell on those thoughts day and night.

Emotionally secure adults are better able to face suffering and upsets. In fact adults who are secure in their relationship with one another often report less pain intensity than those who have insecure attachments. This is true even when there are high levels of pain involved.