Physio Weekly Brings the Pain!

If you haven’t noticed already, I’m a total pain geek. I love learning about pain, and the research continues to surprise me. Nerdiness aside, learning more about pain helps us serve those suffering from it — and that is what we’re here to do. 

Should the Spine Be Scared Straight?

I remember getting screened for scoliosis as a child and feeling terrifyed — as if having this disease would ruin my life. Teachers banned us students from carrying our backpacks between classes, claiming they were protecting our backs.

But, do backpacks actually cause back pain in children and adolescents?
Probably not. A recent systematic review found no relationship between carrying backpacks and having back pain. Though the American Academy of Pediatrics recommends that backpacks should be no heavier than 10-20% of bodyweight, one study reported that even an average of 19.9% of bodyweight in backpacks still had no association with pain in middle school children.

So, what causes back pain in children and adolescents?
Calvo-Munoz and colleagues published a systematic review of 61 studies that assessed 35 possible risk factors for low back pain in children and adolescents. The authors concluded that the evidence disputes the thought that back pain is related to the number of hours spent sitting, BMI, backpack weight or method, or spine morphology.

Indeed, there isn’t much evidence for any association between scoliosis and pain, with one study following patients for 50 years and still finding no association between pain and degree of scoliosis.

Instead, Calvo-Munoz and colleagues found that involvement in sports is associated with higher likelihood of back pain, and older age is associated with higher incidence of pain, possibly because older children are more likely to play sports at a higher intensity.

The Paradox of Persistent Pain

Acute pain serves obvious purposes. Pain helps us to survive. But what about persistent pain? It doesn’t offer the same survival benefit at all. Instead, it is massive detriment — and the leading cause of disability in the world.

Chronic pain arises from several psychological processes. Steve Linton and colleagues describe four tenets that inform clinicians how acute pain can turn into chronic pain — and what we can do about it.

  1. Chronic pain is a developmental process. Persistent pain is often cyclical and recurrent, rather than simply an acute pain episode that extends beyond expected recovery time.
  2. Contextual cues set the stage. The context of the pain experience can determine the negative (or positive) effects of behaviors, thoughts, and emotions. 
  3. Transdiagnostic processes serve as drivers. There are always other underlying psychological processes that may help or hinder the pain experience such as fear, catastrophic thinking, resilience, or childhood adversity.
  4. The fundamental role of learningClassical conditioning may lead people to associate certain actions or activities with pain, and operant conditioning may reinforce certain pain behaviors or avoidance.

So what can we do to treat chronic pain?

Linton and colleagues assert that the psychology of pain means that we should use psychology in our treatment. “We suggest,” they write, “that exposure training for fear-avoidance or cognitive-behavioral therapy for depression will be more successful than indirect methods, such as analgesics or manipulation, that mainly help to reduce pain” (p. 322).

Do you use cognitive-behavioral therapy in the clinic? Tell us about it in the Facebook group.

The Diagnostic Trap of Widespread Pain

Sometimes it’s easy to fall into a trap THINKING that persistent pain is mostly psychosocial. It’s even easier to discount biological contributions when pain is widespread. What are some of your differential diagnoses when you see widespread pain in the clinic?

A recent case in JOSPT illustrates how our clinical reasoning should consider potential non-musculoskeletal contributions to pain. In this case, a 30 year old woman reported constant pain in her lower back and upper back, with a 15 year history of low back pain. She also reported that pain spread to all four extremities within the previous year. 

Her pain had gradually intensified and the physical therapist’s examination led the therapist to suspect possible aortic abdominal aneurysm (AAA) after detecting an atypical abdominal pulse and constant throbbing pain that was exacerbated by lying supine. The resident’s differential diagnosis included AAA, gallbladder pathology, gastrointestinal pathology, and gynecological pathology. At the emergency department, AAA was ruled out.

After further testing and a diagnoses of symptomatic cholelithiasis and fertilization without implantation, the patient underwent laparoscopic cholecystectomy. Postoperatively, the patient still had low back pain though. Then after another evaluation post surgery, the patient’s back pain fit the pattern mechanical low back pain without any signs of continued systemic contributions.

This paper is really enlightening to me because it reminds the physio that there can be both neuromusculoskeletal and systemic reasons for pain — at the same time. When pain is widespread, it can be easy to suspect central sensitization, neglecting other body systems along the way.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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