The psychology of low back pain

Srini Pillay, MD
Srini Pillay, MD, Contributor

Follow me at @srinipillay

Low back pain is the second most common cause of disability in the U.S. Over 80% of people will experience an episode of this pain at some point in their lives. The most common reasons for low back pain are disc injuries, sciatica, lifting heavy objects, or some other non-specific back injury.

Yet even though back pain is incredibly common, not all people respond in the same way to this often-disabling condition. In fact, even if two people have the same level of pain, their responses to that pain can be very different. These differing responses are due in part to different people’s psychological attitudes and outlooks.

Even when you have low back pain that is being medically treated, it helps to understand the psychological factors that impact your pain — and your brain. It also helps to know what you can do about this.

Why chronic back pain is connected to “your head”

When your physical movement is limited, this can cause psychological distress, and the psychological distress can, in return, worsen the pain. Your personal health beliefs and coping strategies can influence both your level of distress and course of the pain. For instance, if you are anxiety-prone, expect the worst, and have catastrophic thinking, this can make the pain far worse. That’s because those psychological vulnerabilities can change your brain and intensify the pain.

Often, if you have these pre-existing psychological attitudes, you also have abnormalities in the regulation of your brain’s chemistry (particularly dopamine), and the usual brain functions in emotional control, anxiety, and attention are also disrupted. As a result, you can’t control your distress; your become anxious; you expect the worst; and you can’t focus on anything else. The pain becomes all-consuming.

But it’s not just pre-existing attitudes that worsen back pain. The pain itself can rewire your brain. When pain first occurs, it impacts your pain-sensitivity brain circuits. But when pain lasts, the related brain activity switches away from the “pain” circuits to circuits that process emotions. That’s why emotions like anxiety often take center stage in chronic back pain. And it’s why emotional control becomes that much more difficult.

What you can do to tame chronic back pain

Fortunately, some psychological therapies can be really helpful with back pain. They help lessen pre-existing psychological vulnerabilities, change how you perceive the pain, and also alleviate the psychological factors (such as anxiety and anticipation) that maintain your pain.

The treatment with the greatest supporting evidence (for all chronic pain syndromes, not just back pain) is mindfulness. A recent study demonstrated that a technique called mindfulness-based stress reduction (MBSR) can help to reduce back pain and also improve emotional control by increasing brain blood flow to the frontal lobe. A full eight-week course in this technique may even improve anxiety and depressive symptoms as well. Practicing mindfulness involves activating a brain relaxation pathway by deliberately ignoring mental “chatter” and focusing on your breathing. When you do this, an “unfocus” circuit, called the default mode network, is activated. However, in some chronic pain patients, this circuit is disrupted. In these cases, MBSR may not work.

There are other forms of psychological treatment that can be helpful as well. Cognitive behavioral therapy (CBT) can be especially helpful. You can attend group or individual sessions either in person or via computer. Even a single episode of back pain can benefit from psychological treatments. CBT can also prevent an acute injury from progressing to chronic back pain.

Hypnosis may help relieve the pain as well. CBT and hypnosis have weaker evidence to support their effectiveness for back pain than MBSR does, but they are worth trying if MBSR fails.

Depending on the cause, low back pain can be treated with progressive muscle relaxation too. This is a technique in which you learn how to decrease your anxiety by becoming more aware of how you can tense and then relax your body.

And there is also some evidence that combining psychiatric medication with psychotherapies may be more helpful than either treatment alone.

But it’s not simply “mind over matter”

So while it’s clear that low back pain can be “in your head,” that doesn’t mean that you have to trivialize it. In this day and age, “mind over matter” makes little sense. “Mind” includes “matter,” especially when you consider that the physical “matter” of the brain plays a major role in mindset changes. This is especially true when it comes to the brain-based changes related to low back pain. To that extent, changing your mindset and brain biology can help your brain — and lessen your pain.

Comments:

  1. Mary martin

    I’m surprised to see no mention of chiropractic here. I’ve suffered back pain for 25 years or more. The kind that I could work through and play through but would be almost paralyzed at times. Mostly lumbar and then lower back pain started 10 years ago. 20 years ago I started chiropractic to unstick three vertebra that had locked together. Went through three months of extensive treatment which removed most of the pain and restored mobility. I’Ve been going back to the same chiropractor once every six weeks or so for adjustments and have had no major problems. If I do something stupid I go right in and the doctor gives me three or four sessions to restore health. I am 73 and have much degenerative arthritis but this has really worked for me.

  2. Mary Belle

    My sister had severe back pain, especially down her leg — foot was often like a chunk of ice. She was very limited in sitting, standing and walking. Doctors couldn’t help and she tried many things to no avail.
    Finally she heard of Dr Sarno and read/studied his books. She was much better in a month. So was I and another sister and lots of our friends that were willing to accept the method. TMS is a hard concept for many to grasp. Some people would rather have the pain than accept it has an emotional base. It was liberating for us. Dr Sarno thinks much chronic pain, that doesn’t heal has an emotional base. The brain is very powerful. Highly recommend his books. There are 3 or 4. Hope this is helpful to someone.

  3. Emilio Ghergo

    I find this article unbearably banal, a rehash of countless speculations from immemorial times. Surprised that Harvard would stand behind such trivial exercise. Now, doctor, what about matter including mind?

    • Srini Pillay

      At the most fundamental level, most of clinical medicine is different degrees of speculation tested using statistical methods to assess the probability of truth. Nothing is absolute. To that extent, I think, especially in blog format, it is possible to assimilate evidence for or against arguments that is not comprehensive. That said, I think that research-based evidence offers a more comfortable rigor upon which to reflect. And most scientists would agree that the thing that most matters is if someone can achieve reliable help from a therapy based on speculation. If they can, then that matters most. My perspective is that these studies offer such hope at different levels of evidence. And I like the possibility of matter including mind. If you have a specific perspective, I am sure readers would benefit from reflection on this. Thank you.

  4. Karen O. For display (Karen Ostby)

    My severe chronic lower back pain is quite real (L4-5), the result of RA, spinal stenosis, scoliosis, osteoporosis. It required not only Fetanyl but a spinal stimulator to become bearable & manageable 8 yrs. Ago. It has nothing to do with how I perceive it, it’s not in my head. Along the way, I’ve had compression fractures, sciatica & probably a pinched nerve or two, real physical characteristics causing pain. PT helped sciatica about 15 yrs. Ago, stretching exercises help to quiet leg spasms at night.
    I know all of this is real as my back no longer supports me. I lean on something to prepare food, brush teeth, do most things. A cane or Walker support me walking. I’m 70, not 80 or 90 & distressed, finding it difficult to cope.

    • Marianne Pietersen

      I also have lower back pain, muscle spasms mostly at night, but also when sitting. Pain if I sit too long, stand too long or walk too long. Long is a matter of minutes. When I carry a bag I need a cane or walker. Standing I always lean on something. In airports I ask for wheelchairs.
      I fell with ice skating when 26, and probably dislocated a disc at that time. Injections with pethedine en cortisone and rest were treatment at that time. After 2 weeks I was back at work, but ever since have had problems with standing long. Walking and other problems only started in recent years. I’m 72 now. I had one disc removed L4-5, and have 2 more slipped discs, L3-4 and L5-S1. Doctors are not interested in more surgery, because….. as I only recently discovered, arthritis is in my spine from neck to bottom. I has caused scoliosis, stenosis and the rest. I go for regular neck massages and do lots of exercise to keep everything moving. I have discovered that taking anti-anxiety medicine (zoloft) helps with pain tolerance.
      I have Baclofen against the muscle spasms, and if I cannot sleep due to spasms, I can take a low grade valium.
      I find that panadol osteo, an occasional panadol-forte help, as well as a glass of wine. (not together). Frame of mind and attitude can help.

  5. Katharine Hill

    So glad to read the first comment. I discovered Dr. Sarno’s work many years ago and truly believe that much back pain is the result of emotions. Highly recommend reading his books. I find my back is much better when I dance vigorously!

    • Marianne Pietersen

      Yes, emotions do play a role. Positive outlook on life helps a lot. I still cannot do much of what I’d like to do, but work around it. And just concentrate on doing what I can do. I do use Swiss Ball a few times a week when I have pain and that helps too.
      I do realise that I most likely will live 10 years less than I would without this condition. But, I don’t dwell on that. I could develop something else that is worse. I could have been in a wheelchair from the day of the accident. Instead I had 30 good years with minor back aches, and 15 with pain and surgery, but still living a regular existence. I feel I am lucky to have reached 71 and hope for another 10 years of reasonable self management.
      I’ve had co-worker who needed an electric wheelchair, was quadriplegic since his early 20s. Now he had much less of a life, but still hangs on. That’s mind over matter.

  6. j tracy

    Dear Dr. Pillay,

    Your article is one of the best I’ve seen on back pain, but you mentioned nothing about TMS–Tension Myositis Syndrome–and the work of John E. Sarno MD. People need to know that so-called spinal “abnormalities” such as disc problems do NOT cause chronic pain. Studies proved this over 25 years ago, and yet surgeons still wrongly perform surgeries on discs even though the US Dept. of Health and Human Services reported that “surgery has been helpful in only 1 out of 100 cases of low back pain.” [HHS publication No. 95-0644, Dec. 1994 page 12].

    • J. Cro

      Thank you for mentioning SAINT Dr. John Sarno. The man is a true life-saver. I had disc surgery at 38 and thought my life of exercise was over, very depressed. Then someone told me about Dr. Sarno’s books and it completely gave me my freedom back! (pardon the pun)

      The man should be knighted and sainted when you factor in all of the people he has cured of debilitating pain over decades.

  7. skip bennett

    I experienced a nonfault car wreck last year. Was taken by ambulance to a local hospital, examined and released. My condition was diagnosed as follows: “mild grade one subluxation of L4 on L5. Degenerative facet disease in the lower lumbar spine. Mild endplate degenerative spurring at L4-5.” Was refereed to an orthopedic surgeon by my internist of over 15 yrs. This specialist “pinpointed my condition as “723.4 cervical radiculopathy, neuritis nos; 723.1 cervicalgia. Previous to my appointment with the ortho surgeon, my internist shared his evaluation that although he agreed that I had some degenerative back issues (my age is 70), his view was that the accident exacerbated my condition. Thus, I was now experiencing pain, most in my left that may not have occurred and if it did was now happening perhaps 5 years earlier. My arm pain occurs daily and the pain is annoying but bearable. It is greatest when I drive my automobile, which I can tolerate for long distances. My ortho surgeon has given my arm pain the label of “spondylosis.” I also have hip pain which has been labeled “spondylolisthesis” In addition, I have completed 6 months of physical therapy, which has helped me but my ortho surgeon has recommended a procedure called ACDF – anterial cervical distectomy fusion. Can you help shed some light on my situation. Thank you much.

    • Srini Pillay

      I’m so sorry that you had to go through this difficulty. I am unfortunately not able to respond to individual clinical scenarios, as some vital information may be missing. However, I would encourage you to discuss the psychological treatments described in this blog with your coordinating physician, and to see if any of the treatments mentioned might be worth trying to help with symptomatic relief. Some others here (in the comments section) have also mentioned techniques they have tried. I would encourage you to add this to your list of approaches to discuss.

    • Elizabeth Turner

      Important- grt at least 2 opinions from the abdolute best neurosurgeons in your area. If 2 of them agree you need cervical fusion, get it. I have had 2.iThe goal is to stabilize your spine. Might or might not help your pain. I have been totally disabled >20 years. Mindfulness meditation is an excellent coping mechanism. Will be your best tool in daeling with everything. Be sure to go to BEST hospital and BEST neurosurgeons. That is absolutely imperitive. Good luck!

    • Teresa

      You need to see a physiatrist before you do anything else. They are very good in treating these kinds of pains. Neurologists always want to operate and that may no t be the best solution, believe me I have been there and back.

      • dianrib

        Skill of the surgeon is Paramount.. Success rate for Back surgery is not that high. But if you must get the Best Surgeon – Best hospital . My son fell off a roof onto grass while working. . Broke his back ! Northwestern Hospital in Chicago performed surgery, inserted a 10 inch rod in his back This was in 1996. Northwestern is highly rated for back surgery. My son is doing well, walking, working …he is now 55 years old. Take care

    • Marianne

      Get 2nd and even 3rd opinion from neurosurgeons. They actually are less keen to co surgery than ortho surgeons. Neurosurgeons specialise on nerve damages, ortho surgeons focus on the bones. Some do backs, some don’t. My neuro surgeon figures that with all the arthritis in my spine removing another disc isn’t going to help much. He’s most likely correct.
      Surgery should be last resort, if your pain is unbearable and you cannot function. I was at that point when I had a disc removed 15 years ago. Couldn’t move, so it had to be done. Now I keep moving, thanks to Pilates, stretching, treadmill walking, and generally being as active as I can.
      Don’t forget that at 70 or over surgery has more risk than at 60 or 50. If you can manage the pain thru mindfulness, exercise and medication that is preferable over surgery. Also, there’s no guarantee that surgery will bring relief. After a fusion there is also loss of range of movements. So, be careful, think it over.

  8. Elise

    I’ve had sciatica, but, my little dogs take me walking thru it. (sometimes very slowly)
    In two weeks, I walked normally.
    Having worn a toolbelt for decades, you stand different. Chiropractor said we and Casino change people were his most patients. Haha. Thanks Doc.

  9. Rich

    Another thing one might want to consider is to “accept” the pain as an offering for past deeds needing forgiveness. I have found when i do this and accept the pain, it somehow seems to become less severe and more easily bearable.

    • Srini Pillay

      Thank you for this additional information. Back pain is clearly very debilitating, and the more ideas we have, the more we can consider.

  10. susan yount

    I have scoliosis and i do yoga and hang upside down and mindfulness meditation, and it all relieves pain for awhile. Having a positive attitude does help too.

  11. Karlene

    Thank you for this paragraph: “Often, if you have these pre-existing psychological attitudes, you also have abnormalities in the regulation of your brain’s chemistry (particularly dopamine), and the usual brain functions in emotional control, anxiety, and attention are also disrupted. As a result, you can’t control your distress; your become anxious; you expect the worst; and you can’t focus on anything else. The pain becomes all-consuming.’ I suppose it can apply to other ailment as well.

  12. Niall Kelly

    Thank you for airing this problem once again. The British Medical Journal has a very well researched trail showing how effective a psycho-physical approach as used by Alexander Technique teachers can be in resolving chronic back ache. http://www.bmj.com/content/337/bmj.a884. This may offer your readers a further option in dealing with this problem. Niall Kelly, certified Alexander Technique teacher.

  13. Carol Pozefsky

    One can comment only from one’s own experience.
    For years I suffered from episodes of severe lower back pain several times a year and was sent by my family physician to physical therapy.
    Although it was comforting to lie on a table on a heating pad with some electric stimulation, it afforded me no relief whatsoever.
    A physiatrist recommended a book called something like Healing Your Own Back by Robin McKenzie. The recommended exercises were so simple that I memorized them and gave the book away after several years.
    The principal exercise was to bend back from the waist as much as I was able and hold it there for 10 seconds or so. I did it once or twice a day . That was at least eight years ago and I have never suffered lower back pain again
    Now from time to time I lean back from the waist and hold it for several seconds just to reinforce the benefits.
    I am happy to share this simple tip and hope that at least it helps some people. I realize that others may have a different type of pain requiring different procedures.

    • Srini Pillay

      Awesome. As with all tips, including the one’s I offer, it’s best to discuss with your physician to see what best works for you and your situation. It’s really great that you can share this tip-Thank you.

    • joe 0'connell

      thanks for sharing that… you may never know how many you have helped with that

    • Richard Brennan

      I have quite a few clients whose back pain has become worse by bending back from the waist so this is not for everyone and you do need to be careful.

      Richard Brennan (Alexander Technique Teacher and author of ‘Back in Balance’)

    • Alexa

      I second the comments on the MacKenzie exercises. Twenty five years ago I experienced severe back pain related to a herniated L5/S1 disc. I was fortunate to be referred to an excellent physical therapist who prescribed MacKensie exercises, which I still use as needed. I am pain free and active at 67.

  14. Carter Newton MD

    Sorry to disagree with the author, but for real pain caused by a real mechanical abnormality in the spine or adjacent soft tissue issues, the brain has nothing to do with perception. Same thing applies to feeling cold when it is actually cold or perceiving an itch and trying to think the discomfort away. Sorry, this is a hefty dose of baloney.

    • Srini Pillay

      Thanks for sharing your perspective. In my clinical experience, I always take reports of pain as being “real” even when it is not clear what the source is. Even factitious symptoms indicate that there is a real underlying problem. As for your statement that “for real pain caused by a real mechanical abnormality in the spine or adjacent soft tissue issues, the brain has nothing to do with perception”, I would refer you to this article on spinal cord injury and psychological symptoms (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743728/) and basic studies such as this one (http://www.ncbi.nlm.nih.gov/pubmed/25122899). That said, there is always room for more and better controlled trials, and the samples included may not reflect the situations of individual patients. In that respect, many patients may not benefit from psychological interventions, but as you can see from the accompanying comments here, there are patients who can do better with psychological interventions.

    • Rami Randhawa

      I agree…sure, your attitude and pain threshold and personal circumstances can help you bear or not bear the pain…But it is there and it’s not all in your head !

  15. Ronni

    I stopped reading at “In fact, even if two people have the same level of pain…” There is no way to compare levels of pain in different individuals.

  16. Madonna Zellitti

    What about nerve compression in foot caused by bulging discs and stenosis? Can this be overcome by this method?

  17. Jack

    Pain is inevitable.
    Suffering is optional.

  18. stephen Gardner

    Thank you. Very well written and informative.

  19. yoginder malhotra

    a very good submission.