Study Finds Understanding their Pain May Help Lesson Fear in Patients

Lesson fear, catastrophising, anatomy, biomechanics

A 2015 study of 36 chronic pain patients sought to explore the causes of pain-related fear in the hopes of contributing to research that might help practitioners develop avoidance models in the future. The study found that the most common cause of pain-related fear is its inexplicability and unpredictability—because patients could not make any reasonable sense of when their pain would occur or how to control it, they experienced the potential of future pain as a threat and limited their physicality in response to their anxiety.

The authors of the study examined three sets of patients: those who were fearful due to diagnostic uncertainty; those who feared their pain symptoms were a sign of damage or impending damage to their bodies and who faced confusion as to how to ‘fix’ their problem and; those who reached out to healthcare providers due to the loss of function (ability to complete tasks) they had experienced because of their pain, but whose treatments had failed to restore their full functionality. These patients were therefore unable to make sensible decisions about how to function to avoid or lesson their pain.

 

The Study

Subjects involved in the study were adult general practitioner, chiropractor, physiotherapy, or pain clinic patients between the ages of 18-65 years. Each of the subjects had experienced intense lower back pain for a minimum of six months. Patients with spondylolisthesis, radicular pain caused by nerve compression, and pregnant women were excluded from the study. Those with particularly high pain-related fear, as determined by their scores on the administered TSK questionnaire, were included in the study. The average age of the study participants was 42 years, and the subjects were 69 percent female. The typical subject had been experiencing pain for around seven years and had high (47/68) TSK scores.

The patients conducted taped interviews in their homes or by telephone, which were immediately transcribed. The researchers sought to identify and understand the overarching theme common to most patients with pain-related fear. Using an agreed-upon system of inductive coding, the study researchers were able to determine a common theme in all three subtypes of pain-related fear subjects: the inability of understand or make sense of their own pain.

Across all three groups of the study’s participants, it was the unpredictability of lower back pain that created the most anxiety and affected the day-to-day physical and psychological existence of patients. Negative past experiences, the fear of suffering and a loss of functionality, and repeated failure of practitioners to control their pain all contributed to the patients’ inability to make sense of their pain, which increased their anxiety and fear. Not knowing when or how the pain might be triggered, how long it would last, what, exactly, was the cause of, or whether they would be able to find sufficient relief from their pain to function caused fear in pain patients and altered how they went about their daily lives. A poor understanding of diagnostic ‘jargon’ also contributed to the patients’ fear of injury and pain, in particular when they were diagnosed with a condition such as disc degeneration from which there was no ‘cure.’

Discussion & Implications

Because people with chronic pain they cannot understand may be more likely to catastrophize their symptoms, which can lead to increased pain-related fear and a possible increase in the pain itself, the study’s authors suggest it could be helpful for practitioners to improve methods of pain control and patient-education about the causes and possible consequences of their pain. Doing so could empower chronic pain-suffering patients by allowing them to better make sense of their pain.

Targeted interventions designed to help patients understand their pain could be effective in reducing pain-related fear. Improvement of pain control measures, a reduction in the pain’s intensity, and better methods of predicting pain could help reduce the vicious cycle of pain-related fear and fear-induced pain. Cognitive functional therapy could help control pain and lesson the anxiety associated with the unpredictability of pain.

The study’s authors suggest practitioners query their pain patients regarding the previous experience with pain to determine appropriate intervention strategies that will replace negative associations with more optimistic expectations regarding therapeutic outcomes.

‘Nocebo’ Response Should be Considered in Doctor-Patient Communication

Nocebo Response, nocebo, communication, patient

When it comes to pain medication, what you know might hurt you. Research on the nocebo effect 1 suggests that patients who are educated about the potential risks or non-efficacy of the pain drugs they take are at higher risk for developing negative symptoms and less satisfied with the outcome after taking the drug.

The nocebo effect, like the placebo effect, is the product of a patient’s suggestibility and expectation. Placebo effect studies have demonstrated that when a patient is conditioned to expect a positive outcome, he is more likely to experience a positive outcome. This is true of the nocebo effect, as well. A patient who is conditioned to anticipate a negative reaction to or inefficacy of pain medication is much more likely to experience the inefficacy or negative physical, physiological, behavioral, or functional response to medication. Patients conditioned to expect that their pain medication will not work receive less pain relief from their pain medications.

Three Types of Nocebo Effects:

  • The positive effects of the pain medication are reduced by the patient’s negative expectation.
  • Patients whose expectations are not met by pain treatment once may have lowered expectation when it comes to the medicine’s efficacy in future treatments and experience less pain relief as a result.
  • Patients whose expectations have been preconditioned and lowered by negative information as to a drug’s efficacy may lose the benefits of the placebo effect, which have been identified as a relevant component of medicinal relief. In other words, believing a medication or procedure is going to improve your pain is an important part of pain relief.

Clinical Trials

During randomized controlled clinical trials, patients were more likely to experience adverse events or pain after being informed of the potential they might occur. Patients who were told they might experience a negative drug effect were more likely to experience the effect, even when the effect was in opposition to the pharmacology of the drug. Disclosing potential serious illnesses—including cancer— associated with a drug was more likely to induce a negative prognosis.

Though the placebo response has been widely studied and verified, the nocebo response remains somewhat of a mystery. Studies of the neurobiology of drug action indicate a similar effect between the molecular changes involved in drug treatment and placebo responses. To date, no such effect has been studied in the case of nocebo effect.

Effects of Doctor-Patient Communication

A recent (2017) review seeks to identify doctor-patient communications that may trigger nocebo reactions and suggests clinicians avoid potential negative outcomes by down-playing negative information and emphasizing positive outcome expectations when counseling patients.

In one study, almost half of the 15 patients who were told their drug might produce headaches developed headaches during the trial. None of the 13 patients in a separate group that was not given the headache information developed headaches. Being told to expect a headache might have produced the headaches, so the authors of the study concluded it was best not to mention the possibility of headaches to patients being prescribed drugs with the potential side-effect.

In a randomized controlled study of epidural procedures, patients who were forewarned to expect a prick of pain were more likely to experience discomfort than patients who were told the medication would make them comfortable during labor. Researchers concluded that framing the experience in a more positive light was beneficial to the patients’ experience.

In another study, patients undergoing prostate surgery were more likely to develop negative side effects over time if they were told in advance they might occur. Roughly 43 percent of a group of patients who had been told about potential negative sexual side effects later developed those side effects, while only 15 percent of those in the group who were not informed of the side effects developed them.

The nocebo effect also discourages potential study subjects from participating in research. When the subjects were informed of the potential negative effects of participating in the study, they were more likely to drop out of the group. Study subjects who were informed about potential gastrointestinal consequences were more 6 times more likely to experience gastrointestinal side effects and drop out of the study prior to its conclusion.

Discussion

Practitioners and researchers should carefully weigh the benefits of informing patients of potential negative effects of medication or procedures against the possibility of inducing the nocebo effect, along with its potential harm. This may be particularly true in cases of pain treatment, as patients who suffer from long-term, chronic pain may be more susceptible to the negative events associated with the nocebo effect. Because the expectation of increased pain can trigger or increase extent anxiety or depression, which may then contribute to further algesia and hyperalgesia and inhibit or produce interactions within the neuropathways that lesson a medication’s effectiveness (or placebo benefits), the nocebo effect should be an important consideration prior to pain-medication counseling.

Concern should also be taken with patients whose health depends upon the medications being prescribed. In one study, breast cancer patients counseled as to the potential negative effects of adjuvant endocrine treatment were more likely to experience long-term side-effects and be less compliant in continuing their treatments.

Studies have shown that a positive doctor-patient experience is more conducive than a negative experience in producing positive long-term health results. The amount, delivery method, and attitude of doctor-patient communications can contribute to placebo or nocebo experiences in patients and should be carefully balanced to minimize negative suggestions and emphasize positive outcome expectations.

Biomechanics Dynamic Spine Model Basics

biomechanics, flexion, extension

Here are a series of labeled Professional LxH model pictures to help in the greater understanding of anatomical pain generators (and relievers) when exploring symptoms as they relate to spinal motion. At Dynamic Disc Designs Corp. we believe that careful evaluation of the quality of motion can help in the diagnosis and treatment of back and neck pain.

 

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Study Determines Running Improves IVD Health

Running and IVD health

A 2017 study 1 determined that fast-walking and slow running can strengthen the intervertebral disc. While it was previously assumed that the metabolism in intervertebral discs (IVD) was not responsive enough to make any substantial changes over the course of a human lifetime, the new study demonstrates that moderately-paced walking or running can improve IVD hydration, hypertrophy, and glycosaminoglycan content in the lower lumbar spine.

 

The Study

The study enlisted participants between the ages of 25 to 35 years old who had no history of significant spinal injury or surgery, scoliosis and were not experiencing current spinal pain. Smokers, pregnant or possibly pregnant women, and those with claustrophobia were also excluded from the study. The study participants were divided into three groups: long distance runners with a history of running at least 50 km per week for the past five years; joggers who ran 20 to 40 km per week for the past five years; and a “no-sports” group, who were minimally active, with less than 150 minutes of activity per week.

Scanning was performed on each of the participants—who refrained from exercise on the day of testing— during the afternoon, when IVD water content is most stable. The participants remained still for 20 minutes prior to the scan. While they were sitting, they filled out questionnaires regarding their vital statistics and sitting or exercise habits.  After their scans were completed, the participants were given a hip-mounted ActiGraph to wear during all activities for eight except swimming or bathing. The data collected from these devices was then uploaded into a digital software program for analysis.

 

Findings

Joggers and long-distance runners showed a significantly more positive anabolic response in their IVD than the “no-sports” participants. Their discs were better hydrated, and their glycosaminoglycan levels were roughly two times higher than the non-athletes.

Based upon this study, we can conclude that dynamic IVD loading of .2 to .8— with the subsequent intra-discal pressures of roughly .3 to 1.2 MPa—could be the best loading amount for the IVD. The in vivo disc pressure data suggests that most moderate walking and running—but not heavy lifting or lying down—occur within this range of loading pressure.

 

Implications

Most disc degeneration is attributed to lower lumbar IVDs, often in association with repetitive spinal loading. Though running does cause repetitive spinal loading, the study participants showed no ill effects in their lower lumbar segments. Instead, they exhibited positive changes, including better IVD hydration and glycosaminoglycan content than the subject group participants that were not active. In healthy individuals, running may benefit the lower lumbar IVDs. This information could lead to better prophylactic deterrents for disc herniation and degeneration—one of the most prevalent disabilities in our society and a leading cause of spinal pain.  

Review Concludes Facet Joint Osteoarthritis Likely Caused by Whole-Joint Failure

Facet Joint Osteoarthritis

A 2012 review 1 concerning facet joint osteoarthritis (FJ OA) explicates the current understanding of the ailment and concurs with the widely-held view that OA represents a failure of the entire facet joint, rather than only the facet joint cartilage.

 

About Osteoarthritis (OA)

Spinal OA occurs in the facet or zygapophyseal joints—paired joints at the back of the vertebral column— and is closely linked to degenerative disc disease. Though FJ OA has not been as widely studied as knee OA, the most recent view that knee OA is not caused by cartilage degeneration alone but involves a systemic imbalance that inhibits the repair of joint tissues and creates whole-joint failure may also be true of spinal FJ OA.  

 

Facet Joint Osteoarthritis (FJ OA)

FJ OA is the result of a failure in the synovial facet joints, including the surrounding cartilage, ligaments, subchondral bone, synovium, capsule, and periarticular paraspinal soft tissues and muscles. Because the FJ is part of a segmented intervertebral disc, there is an association between degenerative disc disease and FJ OA, which is most often found in the lumbar region of the spine.

Typical cross-sectional imaging (radiograph, CT, and MR) of patients with FJ OA demonstrate narrowing of the space between the facet joints, subarticular bone marrow lesions (BML), erosion, and cysts, enlargement of the articular tissues, formation of osteophytes, and disc degeneration.  

 

The Spine Sections’ Interdependence

Because the facet joint is part of a three-joint motion segment (one disc, two facet joints) of the spine, it is completely distinct from the intervertebral fibrocartilaginous disc articulation. The spine is made up of interconnected motion segments, and joint alignment and load distribution throughout the spinal column are considered integral in the progression of FJ OA.

The three joints in each segment are functionally interdependent. What affects one joint will ultimately affect the others. Injuries or diseases of the disc will cause biochemical or mechanical alterations in the facet joint, and any injury to the posterior structure will affect the disc. Facet joint problems usually start with disc injuries. The three-joint complex may fail due to insult to any of its parts. Because each three-joint segment is connected to another spinal segment, injury to any one section may lead to changes in the segments above or below the injured facet joint.

The discs are usually responsible for bearing loads, and in a healthy spine, the facet joints may carry up to 33 percent of the weight. In cases where the lumbar disc space is severely narrowed, the facet joints may bear up to 70 percent of a spinal load. The muscles around the spine help to stabilize the vertebral column and provide a sense of where the spine is positioned in space. These functions may significantly decrease with age, compromising the motion of the spinal segments and contributing to FJ OA, as well as adult degenerative scoliosis and spondylolisthesis.

 

Degeneration

Degeneration of the facet joints may begin during youth and progress over many years. Early disruption of the articular cartilage, capsule, and synovium can lead to subchondral bone and bony joint margins in later years. Thinning of the articular cartilage leads to narrowing of the space between the joints, and the cartridge can develop lesions, pitting, fissures, and flaking as it slowly erodes. The joint capsule may receive decreased blood and become fibrous and inflamed. In time, the entire posterior capsule becomes fibrous and inflamed.

 

Who is at Risk?

Age appears to be a strong correlate the development of FJ OA. Though women are more prone to a diagnosis of FJ OA based upon a lumbar CT, there is no statistically significant difference between genders when it comes to developing FJ OA. Weight—or a high BMI—plays a significant role in the progression of lumbar FJ OA, but it is only slightly relevant as a determinant in the development of cervical FJ OA. African-Americans are less likely than Caucasian Americans to develop FJ OA. Heavy lifting, carrying, or pulling objects has not been studied as a possible correlate, and other occupational motions are most likely not associated with cervical FJ OA. There is a significant correlation between disc-height narrowing and the development of FJ OA in patients of any age, weight, or sex. Patients with disc-height narrowing are twice as likely than disc-height unaffected patients to develop FJ OA. Smoking and other risky habits appear to have little bearing on the development of FJ OA, but there is an apparent correlation between lumbar FJ OA and abdominal aortic calcifications.

 

Symptoms of FJ OA

FJ OA—alone, or in combination with other disc-related ailments— may cause significant neck or lower back pain (LBP), especially in adults and older patients. This pain can be caused by nociceptors in the bone or surrounding joints. Mechanical pressures on the bone, distension of the surrounding capsules, small fractures, and synovial inflammation can contribute to muscular spasms that sensitize the nerves, creating a chronic cycle of spinal pain.

Diagnosis procedures may include lumbar hyperextension, flexion-straightening, and extension-rotation to determine whether the patient’s pain increases with these exercises. Other types of pain may also indicate FJ OA.

Fat-suppressed MRI spinal sequence studies have shown BML—a common cervical spine finding— in the lumbar FJ articular processes of up to 41 percent of back pain patients. This suggests a link between back pain and FJ BMLs. Many FJ features are easily detectable using fat-suppressed MRI’s. These include FJ effusions and periarticular and ligament edema, though these observations are currently not used to grade or evaluate FJ OA in patients.  The role of heredity in the development of FJ OA has not been adequately studied.

FJ OA can contribute to narrowing of the central spinal canal, intervertebral foramina, and the lateral recess, and spinal nerve roots in these areas may be pressed. This situation may be compounded by the development of synovial cysts.

 

Conclusions

Injury to any part of a spinal motion segment may contribute to whole-joint and/or segment failure, causing neck or back pain. Any change that affects the spinal segments, particularly disc degeneration and unbalanced joint alignment or muscle weakness, may contribute to the development of FJ OA. Aging appears to increase the risk of developing FJ OA.

Real-Time MR Imaging Shows Effects of Lumbar Traction on the Spine

Lumbar Traction on the Spine

Lumbar traction – alone, or in combination with physical therapy – has been employed for decades as a therapeutic measure in treating back pain. Numerous studies have shown that the procedure stretches muscles and ligaments, increases intervertebral space, and enlarges the foramina and apophyseal joints, but the effects of traction on herniated lumbar discs and the surrounding intervertebral areas have been difficult to study in “real time” with magnetic resonance imaging (MR) because traditional traction devices contain metal, which disrupts the magnets in MR machines.

A 2012 study 1 used a nonmagnetic traction device to study 48 patients—13 men and 35 women— with lumbar disc herniation. The purpose of the study was to determine if the effects of traction on herniated disc patients could be visualized as they were occurring.

 

The Study

Subjects in the study had all been previously diagnosed with lumbar disc herniations and were treated using 30 kg of sustained traction before MR and at 10 minute intervals for a half-hour during lumbar spine imaging. The axial and sagittal images were later reviewed to check for any significant changes that occurred during the procedure. Using the lumbar vertebral column elongation and disc reduction ration as measurements, researchers were able to identify quantitative changes caused by the traction procedure.

Applicants who were pregnant or had previously undergone back surgery, had hypertension, severe osteoporosis, cardiac pacemakers, intracranial clips, lumbar instability, disc inflammation or tumors, were excluded from this study.

 

The Results

Real-time effects of continuous traction are clearly visible when using MR imaging on patients. The study subjects demonstrated significant changes in disc shape, reductions within the openings of intervertebral discs and of herniated disc volumes, as well as widening of the facet joints and separation of the discs and their connected nerve roots, post-traction. The mean lumbar vertebral column length also increased in correspondence with the amount of time a patient underwent traction. The ability to visualize the effects of traction during real-time procedures could be a helpful treatment tool.

Back or Legs?—Load Position more Important than Technique in Reducing LBP

Reducing LBP with proper lifting.

Frequent heavy lifting can be a major contributing factor in lower back pain (LBP), but researchers disagree when it comes to the most effective lifting mechanism to reduce spinal loads and avoid injury. While the adage, “Lift from the legs, not from the back,” sounds like good advice, recent study findings 1 suggest the benefits of “squat” lifting over “stoop” lifting may have more to do with how the load is positioned than which muscles are engaged in picking it up. The results of the in vivo study indicate a need for further research on the topic, as LBP caused by heavy lifting is responsible for missed work and high disability rates—especially in the male population. Understanding the biochemical processes involved in the different lifting techniques and how to best position loads in preparation for lifting could help alleviate injuries that cause pain and represent a tremendous cost to society.

The Study

While numerous previous studies have compared stoop lifting (using the back, keeping knees straight) and squat lifting (bending the knees, keeping the back straight), with conflicting results, this study utilized a telemeterized vertebral body replacement (VBR) to acquire in vivo measurements of lumbar spinal compression and implant forces during different spinal loading scenarios, with several study subjects. The purpose of the study was to determine if the initial weight location of a load had a significant bearing upon the amount of lumbar compression and if lifting a weight from the side with one hand would result in a lighter implant force than lifting the same load from the front.

Four male patients with compression fractures of the lumbar vertebral body were informed prior to the study that they would receive modified VBRs. Three of the subjects received the VBR in the first lumbar vertebra (L1), and one of the subjects received his VBR in the third lumbar vertebra (L3). Over the course of two surgeries, their fractures were stabilized with a fixation device which, along with the fractured vertebral body and adjacent discs, was subsequently removed. The VBR devices were then implanted and bone material was used to assist in the fusion process.

The patients were instructed on the proper mechanics of both lifting techniques (stoop and squat) and were measured over the course of 17 sessions as they employed the two techniques a total of 104 times. The patients lifted a crate with two hands from a position in front of the body, and they lifted the identical crate from a lateral position, using one hand. The crate location measurements were compared over nine sessions. The data collected identified the resultant force – the sum of three measured force components—as the determinant mode acting upon the VBR during the experiments, in which stoop—and squat-lifting were performed equal or near-equal amounts of time.

Results

The results of the study suggest that lifting from the side with a single hand results in slightly less (14%) VBR force than lifting from the front, but there is no significant difference (4%) between stoop and squat lifting in the effects of spinal loading. The study’s authors point out that there was significant variance in each patient’s lifting execution, fitness level, coordination, and flexibility, and this and other differences in loading techniques might have influenced the study’s findings. Since load-lifting efficacy may be dependent on different spinal sections (lower or upper lumbar), the study’s authors point to the need for a broader and more detailed study to determine with more certainty the effects of various load-lifting techniques on the lumbar spine’s biochemical and structural forces. Nevertheless, results of the study suggest that lateral, single-handed lifting and –more significantly—reducing a weight’s distance in anterior-posterior lifting may help reduce the effects of spinal loading.