Back pain is an epidemic in major industrial nations across the globe. It is estimated that up 80 percent of all adults will suffer back pain at some point in time during their life. This problem can take its toll on individuals, but it can also affect the health of a nation’s workforce and put the economic strain on its healthcare system. In the United States alone, it is estimated that healthcare costs to treat chronic LBP may be as high as $100 billion per year. Therefore, finding cheap and quick ways of treating back pain not only benefits the individuals suffering from the condition but is a benefit to the society in which they live as well.
However, back pain in the sacral region, also known as LBP, is not an easily identifiable condition that one can simply diagnose and treat. This region of the body is complex with numerous possible reasons that back pain can occur. It helps if you first understand the anatomy of the lower back if you want to be able to effectively diagnose and treat chronic LBP. Still, it is not as simple as the soft-tissues located in the lower back, because the pain in this region can either be referred from or caused by issues in ancillary regions of the body—especially in the pelvic region, the upper legs, and the mid-back.
Regardless, when examining the lower back, the first muscle groups to check should be the extensor muscle group, the flexor muscle group, and the obliques which are better understood as the lateral muscles of the stomach. Moreover, various muscle groups in the hip region may also contribute to lower back pain including the psoas muscles, the adductor group, and the piriformis. The bones associated with these issues can include a wide range from lower thoracic vertebrae to the proximal femur, though of special concern are the lumbar and sacral vertebrae as well as the ilium. Nerves to pay attention to include the lumbar and sacral plexus as well as their primary branches—especially the sciatic and femoral nerves.
However, pain in the lower back region can also be distinguished by duration, either acute or chronic. The latter of which may be designated differently from condition to condition, but chronic conditions can loosely be understood as those lasting longer than 3 months. Roughly categorized, there are generally 3 contributing factors that can lead acute LBP into a chronic condition; they are: neurophysiological mechanisms, physiological mechanisms, and barriers to recovery. Within the first group, an examiner would be looking for nerve impingement of the peripheral nervous system (PNS), though certain unrelated conditions can cause the central nervous system (CNS) to affect the PNS and contribute to pain in the region.
Outside of neurophysiological causes, the next route of diagnosis would be to examine the patient’s psychological state. There is more and more evidence that suggests the health of the body may be directly influenced by the psychological state of the patient. In this case, a patient with psychological conditions may find them expressed or exacerbated via physiological conditions. Within the psychological category, contributing factors can further be broken down into behavioral mechanisms which can include a lack of activity, both vocal and non-vocal expressions of pain, and movements or actions which seek to protect the patient from further injury.
The next subsection of psychological factors revolves around cognitive-affective influences. Depression is a primary concern here as depression can both cause pain or be caused by pain, and furthermore, can turn an acute injury into a chronic one of one or both are left untreated. The final subsection of the psychological influences relies on psychophysiological factors. This is a broad subcategory which can include a diverse range of influences from something relatively common as fatigue or prolonged muscle use to more psychological influences such as emotional stress. This last factor may trigger a secondary action via norepinephrine—a stress hormone which can antagonize the sympathetic nervous system and cause undue pain.
Barriers to recovery are generally understood as pre-existing conditions which prevent or delay the patient from returning to homeostasis. These factors can also be grouped into three subcategories. The first of these three are premorbid conditions. These influences are often psychological in nature and can include diverse affectations as depression—mentioned earlier—to childhood abuse. However, this subsection also includes a bevy of other conditions like psychosis, drug abuse, or various personality disorders.
The second of the subsections in this group fall into the traumatic designation. These are not acute trauma like massive injury but instead are also psychological in nature ranging from anxiety to an abnormal relationship of dependence. Within this subsection, other factors can include fear and potentially a total loss of control on behalf of the patient. The final subsection is the largest and is defined as posttraumatic conditions. However, this final subsection may include conditions from the previous two subsections as well as general anger, posttraumatic stress disorder, and somatoform pain disorder.
Both psychological and psychophysiological conditions may make treating LBP difficult whether because the patient is simply unable to engage in the treatment or because the patient personally refuses to engage in the treatment. On occasion lower back pain can in and of itself be a coping mechanism for individuals suffering from some other psychologically based condition. For instance, borderline personality disorder can be noted by a sense of absence or emptiness of being. In some circumstances, people suffering from BPD have been known to foster pain as a way of providing meaning to their life. Likewise, patients who exhibit strong personality traits along the narcissistic spectrum may find a sense of self-satisfaction in the attention they receive for suffering under pain.
Antisocial, or non-violent psychopaths, may also present challenges for clinicians as they are apt to manipulate those around them and excel at playing a role for personal motivations. Of course, one of the more common psychological barriers to treatment remains hypochondria. Hypochondriacs will provide headaches two-fold: first, they will present with symptoms that may not be real. This can make both diagnosis and prognosis exceedingly difficult as the clinician will have to disentangle real symptoms from those that merely psychological. Second, hypochondriacs may also stall or prevent their treatment from achieving the desired results by simply not engaging with the prognosis. This may be due in part to the fact that the hypochondriac believes the symptom to be a result of a different and often more serious condition—generally organic in nature.
The psychological factors when treating LBP can become further compounded based on the patient’s worldview devel oped by authority figures or guardians when they were a child. For example, is a male patient was raised in an environment where masculinity was defined, in part, as the ability to deal with pain without treatment or in some other way shape or form respond to pain in a stoic manner, the patient may reject treatment or simply not engage with prognosis as detailed. Conversely, though for different reasons, a patient who was raised to believe that he or she was frail and incapable of withstanding the general physical ailments incurred over the course of one’s life may find the treatment as pointless and give in to a fatalistic sense of futility.
Psychosocial factors may also come into play and impede a patient’s recovery. For instance, if the patient is engaged in a lawsuit or seeking a settlement for damages received, there can be an economic motivation for the patient to either delay recovery or present as much. This influence can further be strengthened by family members or attorneys who wish their relative or client to receive the largest payout or possibly have a case for further litigation. Furthermore, social conflict may also exacerbate or prolong patients with a chronic LBP condition either due to influence from their social network or caused by the stress such interaction facilitate.
Regardless, it is the clinicians job and duty to treat patients with lower back pain and chronic LBP, but this task may be influenced by numerous factors which are not strictly physiological in nature. It is at this point that the clinician must seek to understand the patient as a holistic presentation—if they have not already—and consider the possibility that the mind-body system is exerting somatic symptoms from a psychological cause. Without doing so, many patients may simply go untreated or make no headway in their treatment.
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