Murray J. McAllister, PsyD
Murray J. McAllister, PsyD, is a pain psychologist and consults to health systems on improving pain. He is the editor and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. In its mission is to lead the field in making pain management more empirically supported, the ICP provides academic quality information on chronic pain that is approachable to patients and their families.
The International Association for the Study of Pain (IASP), which is the world’s largest pain-related professional organization, revised their official definition of pain last year. It reads: “Pain is a sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” It was a revision of their earlier version from 1979, which also contained the phrase defining pain as a “sensory and emotional experience.”
This definition of pain is arguably accepted worldwide by clinicians, researchers, and policy-makers.
It is also commonly surprising to patients. For who thinks of pain as even in part emotional?
After all, pain is a sensation, not an emotion. Pain is like itches, tickles, numbness and tingling. All these experiences are sensations. They are associated with our tactile sense of perception. We do not see, hear or taste pain and itches and the like, but rather we tactilely feel them. Emotions are experiences such as being happy or mad or sad or joyful. These experiences are rightly not considered sensations.
There is, however, cross over between the experiences of sensations and emotions. It is readily apparent with emotions, which commonly involves also having sensations. Excitement and fear, for instance, are palpable. We can sometimes almost burst with tingling energy when excited. Grade school children have tummy aches the night before the first day of school. Less readily acknowledged is that sensations also have emotional aspects to them.
Itches are aggravating, especially when they don’t easily go away, and scratching them is relieving. Tickles make us giggle, and we squirm in their playfulness.
Pain is alarming. We wince, guard and protect. We cry tears and we cry out verbally. We look to others for help, and others react accordingly. Pain is a sensation that alerts us to something that is going wrong. It puts us on notice.
In this way, pain is like a fire alarm in a building. Fire alarms alert us to something that is going wrong in the building and we reflexively react with avoidance behaviors — we get out of the building. In a word, fire alarms are alarming. They are an auditory perception that is inherently alarming.
Pain is a similarly alarming perception. Of course, we do not hear pain, but feel it. We perceive it through our tactile sense, but it involves a similarly alerting and cautionary experience to which we reflexively react with avoidant behaviors (e.g., reflexively pulling away our hand from flame).
We thus might capture the definition of pain as “a sensory and emotional experience” with a quasi-equation: pain = sensation + alarm.
Mapping Pain onto the Brain
Pain as a sensory and emotional experience maps onto the brain. Suppose you broke your ankle, or stepped on a nail, or some other typically painful injury, and further suppose you were put into an MRI for a brain scan. Different parts of the brain that roughly correspond to both the felt sensation and alarm would light up in the scan (Da Silva & Seminowicz, 2019; Sperry et al., 2017).
First, the somatosensory cortex of the brain would show up as active. This area of the brain corresponds to the sensation that would be felt. It is largely responsible for the type of sensation (whether it would be a dull ache, a sharp piercing sensation, an electrical sensation, or what have you) and where in the body it will be felt (the left ankle that has the fracture or the right foot with the nail sticking in it). Second, in addition to the somatosensory cortex, the scan would reveal activity in the limbic system and prefrontal cortex. These areas are responsible for a great many things, but one of which is our danger response, commonly known as “fight-or-flight” or “fight, flight, or freeze.” It is our innate alarm system — something that gets activated in response to threat.
It makes sense that we’d be built this way — that our danger response would go off when having a certain sensation that we call pain. It is signaling danger in the sense of harm. We accidentally touch flame with our hand or we break our ankle or step on a nail. Something is going wrong and as a result we experience pain.
Pain is the only sensation that puts us on notice in this way. It alerts us and we reflexively guard, protect, pull away and seek help. No other sensation, such as tickles or itches or numbness, typically puts us into a state of alarm. In this way, pain is an inherently alarming sensation.
In our effort to clarify the IASP definition of pain as a ‘sensory and emotional experience… associated with… tissue damage,” we can thus be even more specific: pain is a sensation with an innate sense of alarm, or a sensory and alarming experience.
For more information, please see these related topics: the neuromatrix of pain, central sensitization, cognitive-behavioral therapy, and the mission of the Institute for Chronic Pain to educate the public about empirical-based conceptualizations of pain and its treatments.
Da Silva, J. T. & Seminowicz, D. A. (2019). Neuroimaging of pain in animal models: A review of recent literature. Pain, 4(4), e732. doi: 10.1097/PR9.0000000000000732
Sperry, M. M., Kandel, B. M., Wehrli, S., Bass, K. N., Das, S. R., Dhillion, P. S., Gee, J. C., & Bar, G. A. (2017). Mapping of pain circuitry in early post-natal development using manganese-enhanced MRI in rats. Neuroscience, 352, 180-189. doi: 10.1016/j.neuroscience.2017.03.052
Date of initital publication: October 11, 2021
Date of last modification: October 11, 2021
Every year, a “dead zone” appears in the Gulf of Mexico due to a gigantically large algae bloom. This summer, the National Oceanic and Atmospheric Administration predicted the dead zone to be the size of both Delaware and Connecticut combined.
The origins of the dead zone are traceable to over a thousand miles away from the farms of the upper Midwest, and all points further south. The origin, in other words, is farm run-off of nutrients from manure and chemical fertilizers.
Farmers in these states have animals that produce manure. They also use fertilizers on their fields. With time and rainfall, nutrients from these sources seep into the Mississippi and any of its countless tributaries. Making their way eventually to the Gulf of Mexico, these nutrients in the manure and fertilizers combine with the heat of the Gulf to spawn catastrophically large algal blooms that kill everything in its wake.
Well-meaning farmers of the Dakotas, say, or Minnesota, or Wisconsin, may never know of the distant consequences of their actions. As such, it’s nearly impossible, and perhaps even unfair, to hold any one person responsible. How would you ever know, for instance, that this farmer’s fertilizer applications, as opposed to that farmer’s application, led in part to the dead zone that occurs so far downstream in space and time? In general, we can rightly say that farm manure and the application of chemical fertilizer and its subsequent nutrient-rich run-off cause of the dead zone in the Gulf, but for any one particular farmer it is much harder to make a causal attribution.
The Gulf of Mexico dead zone, along with its distant causes, is a perfect analogy to the use of prescription opioids and the resultant opioid epidemic of addiction and overdose.
Cognitive behavioral therapy is a traditional form of therapy that is used for a great many types of health conditions. Historically beginning in the 1970’s, it was first used as treatments for chronic pain and depression,1, 2 but later applied to all forms of anxiety disorders and other mental health disorders, as well as other health disorders, such as diabetes3 and heart disease.4
This article explains the application of cognitive behavioral therapy to the management of pain. In it, we’ll discuss what cognitive behavioral therapy is and how it is used in pain management.
What is Cognitive Behavioral Therapy?
Cognitive behavioral therapy (CBT) is a type of psychotherapy. Psychotherapy itself is a therapeutic process in which the aim is for patients to learn to engage in healthy changes within a supportive, coaching relationship with a healthcare provider. In psychotherapy, patients learn to make health-related changes to how they are living their life, and over time these changes positively affect their health. This process of learning involves supportive counseling, education and feedback from the healthcare provider, and an openness to learning and practicing health-related changes on the part of the patient. Notice that in psychotherapy the aim of getting healthier occurs mostly by patients themselves engaging in healthy changes in living, rather than by the healthcare provider doing something to the patient, such as providing a medication or procedure. It’s patients themselves, in other words, who bring about improved health, rather than the provider delivering improved health to patients. There are many types of psychotherapy, and, as mentioned above, CBT is one type.
CBT is a model of psychotherapy that involves patients making two broad categories of health-related changes: changes that fall under either cognitive changes or behavioral changes. The term cognitive refers to the learning of increased knowledge and skills and the term behavioral refers to the health-related lifestyle changes.
While it is an incomplete list, some examples of the cognitive learning involved in CBT are the following knowledge and skill sets:
- Improved knowledge of the health condition that you have and are attempting to change
- Improved understanding of what you can do to become healthier
- Increased motivation to make healthy changes and the empowerment to bring them about
- Increased abilities to perceive multiple perspectives on the things you want to change
- Increased abilities to make intentional decisions with regard to the things you want to change, as opposed to merely automatically reacting to them as you go about life
- Increased abilities to tolerate distress, stress or pain
- Increased abilities to be happier even if you can’t entirely get rid of the problem(s) that you are trying to change
While again an incomplete list, some examples of the behavioral changes involved in CBT are the following healthy lifestyle changes:
- Improved nutritional choices and/or achieving a healthy weight
- Smoking cessation
- Reducing caffeine or other substance use
- Improving your sleep
- Intentionally engaging in activities that are fun or make you happy or align with your values
By learning and doing these things, and doing them over time, you have a positive impact on your health and well-being.
Let’s take a quick example. Suppose you have uncontrolled type 2 diabetes. Your blood sugars tend to run too high. So, in addition to working with your internal medicine provider, you also see someone for CBT. In the supportive coaching relationship that you develop with your CBT provider, you learn about type 2 diabetes, and its relationship to weight and food choices. You also learn how blood sugars respond to stress and exercise. You also set out to become more aware of how you eat — that you sometimes eat when you are bored or stressed. You come to realize that you tend to eat food as a way to have fun. As a result of these new perspectives, you come to practice making more intentional decisions about when, what and how you eat. All of this learning falls into the category of cognitive learning. These cognitive skill sets come to lend themselves to behavioral changes you subsequently make. For instance, with supportive instruction and feedback from your CBT provider, you come to check your blood sugars and take your medications on a more regular basis. You come to eat on a more regular basis and you switch out your dinner plates for smaller sandwich plates, as a means to reduce portion sizes. You start to cook from scratch more often, rather than eat processed meals you had been heating up in the microwave. You intentionally engage in other pleasurable activities, rather than eating, in order to have fun. You also intentionally respond to boredom or stress with other behaviors besides eating comfort foods. You also start to walk for twenty minutes three times per week. Throughout this process, you are checking in with your therapist, getting supportive feedback and pointers. As a result of all these cognitive and behavioral changes, your blood sugars start to fall into the normal range. You also slowly lose weight. You have a little more energy. You also find this whole process rewarding, empowering, and motivating so you keep all these changes going. These changes, in other words, come to be your new normal and your type 2 diabetes goes from uncontrolled to controlled.
Notice what happens. With openness to learning and feedback, and with a willingness to practice behavioral changes over time, you come to have a positive affect on the physiological basis of the health condition for which you sought care — in this case, diabetes.
CBT is thus an established method for fostering therapeutic changes over time to improve health and well-being.
How does CBT treat pain?
CBT for pain follows the same cognitive and behavioral model as described above — learning about pain and what you can do about it, and engaging in healthy lifestyle changes that can reduce pain and its impact on you. Let’s follow this model while explaining how it works.
To fully understand how CBT is used to treat pain, it is necessary to understand how pain occurs in the body. We often think of pain as the result of an injury or illness, but it is more complicated than a simple understanding of injury/illness = pain. To have pain, we may have an injury or illness, but we also require a nervous system. So, in cases where we have an injury or illness, we also have nerves which sense the injury or illness and these nerves send signals to the brain, which puts it all together to produce pain. No matter what the injury or illness we may have, pain is always produced in the brain in response to the sensory input from the nerves in the area of the body that involves the injury or illness. In this way, pain is like the alarm of a fire alarm system: smoke detectors in the area of the fire send signals through wires to a computer that sounds an alarm when it recognizes certain signals as threatening. Pain is a tactile alarm produced by our nervous system (which includes nerves in the body, our spinal cord and brain) that alerts us to something being wrong. We might thus understand that pain is more complicated than merely injury/illness = pain, and recognize the more accurate depiction of injury/illness + a nervous system = pain.
CBT is a method for targeting and changing one of the variables in this equation. It is not a method to heal injuries or illness, but rather is a method for training the nervous system to produce less pain. To understand how this aim can be achieved, it is necessary to further know how the nervous system produces pain. Specifically, we need to understand how different parts of the brain work together with the nerves in the body to produce the experience of pain.
We rightly consider pain a sensation. It is not an emotion, like being sad, mad or glad, but rather a sensation, like numbness, tickles and itches. Roughly speaking, sensations are produced in an area of the brain called the somatosensory cortex. The experience of pain, however, also involves another area of the brain, called the limbic system. Sometimes called the pain-pleasure area of the brain, the limbic system is home to the fight-or-flight response. It’s what makes the sensation of pain unpleasant or distressing. Unlike tickles that might make us giggle or itches that aggravate us, the sensation of pain is inherently alarming. It makes us gasp and become guarded, tense and vigilant. We go into, in other words, fight-or-flight when in pain, which is why we can be irritable (fight) or fearful (flight) when experiencing pain. What we are describing is what it is like when our somatosensory cortex teams up with our limbic system to produce an alarming sensation that we call pain.
It makes sense that the sensation of pain puts us into fight-or-flight. Fight-or-flight is our danger response and pain alarms and alerts us to danger with regard to our bodily integrity. We need to be alerted to injury or illness.
In this process, another area of our brain becomes involved as well. It is our frontal lobe and it does a number of things one of which is higher level learning. We only need to burn our hand on the stove one time and we learn to be careful around stoves on future occasions. As we grow and develop, we come to learn about pain. We learn, for instance, what is no big deal and can ‘rub it off’ or ‘walk it off’ versus what is a big deal for which we should rest, stay home or seek healthcare. This learning involves the degree of threat that we experience when having an alarming sensation called pain. In other words, when we experience pain as no big deal and so keep living life, we aren't very threatened by it, whereas when we do experience as a big deal and so stop, rest and seek healthcare, we do experience it as more threatening. This degree of threat is thus correlated with the degree to which we can tolerate pain. When we experience an alarming sensation of pain and have been told it might be cancer, but later receive a more reassuring diagnosis that it is not cancer and will be temporary, we come to more readily tolerate the pain. Similarly, acute pain, which we know is temporary, is often more tolerable than chronic pain. The tolerability of pain is thus related to the degree of threat that we experience when in pain. It’s what leads us to either keep living our lives when in pain versus responding with vigilance, avoidance of activities, staying home, resting, and seeking help.
Roughly speaking, these lived experiences of pain are produced in the different parts of the brain:
Sensation + Alarm + Perceived Threat + Behavioral Avoidance = Pain
Somatosensory Cortex + Limbic System + Frontal Lobe = Pain
This understanding of how the brain and the rest of the nervous system produces pain is referred to as the neuromatrix model of pain. It literally has about four decades of basic pain science demonstrating its accuracy.
From this more accurate and sophisticated understanding of the neuromatrix of pain, we can come to see how we might intervene to change the levels of pain that we experience. We might, for instance, set out to retrain this usually automatic response by intentionally practicing having the sensation while reducing its related degree of alarm, threat and behavioral avoidance. In doing so, we could alter the overall experience of pain. In CBT for pain management, there is actually a whole host of cognitive interventions that are taught and practiced by the patient to bring about this aim of retraining the nervous system and how it produces pain.
Before we describe how to achieve this aim, we need to cover one more topic related to how pain is produced in the nervous system. It’s called central sensitization.
When the limbic system goes into fight-or-flight when having the sensation of pain, multiple things happen. One of these things is that the limbic system tells certain glands in the body to produce hormones, which in turn tell the immune system to produce an inflammatory response. In turn, inflammation irritates nerves, lowering the threshold for what will lead the nervous system to produce pain. In this process, stimuli that normally do not lead the nervous system to produce pain come to in fact produce pain. When you have the flu and are achy all over, a massage, which normally would feel good, feels awful. When you bring your broken, swollen ankle to a healthcare provider and the provider lightly touches it while examining it, the light touch hurts. These are examples of inflammation irritating nerves to the point that the nervous system is producing pain in response to stimuli that typically are not associated with pain.
This process starts in the brain. The somatosensory cortex produces a sensation and the limbic system goes into fight-or-flight, while the frontal lobe understands it as a threat. In this process, inflammation is produced in the body that irritates the nerves, lowering the threshold for what will lead to pain. The brain, in other words, is centrally sensitizing the peripheral nerves in the body.
Central sensitization is normal in acute injuries and illnesses. It can, however, remain past the point of healing and become the cause of chronic pain. It can also occur secondarily to other causes of chronic pain, such as rheumatoid arthritis. We sometimes refer to central sensitization as the result of a persistently up-regulated nervous system. From the brain to the nerves in the body and back again, the nervous system is stuck in a chronically reactive state, producing an alarming and threatening sensation, that over time, once having become chronic, becomes physically and emotionally exhausting.
Let’s now review how CBT can be used to alter how the nervous system produces pain. As expected, there are both cognitive and behavioral ways of changing the nervous system and how it produces pain.
In CBT and CBT-informed therapies, such as chronic pain rehabilitation programs, patients initially learn about pain and how it is produced in the nervous system. This learning occurs much like we just described above. Once having this understanding of pain and how it is produced, the aim of the therapy changes to developing a cognitive-based skill set, which could be described in the following manner: In the knowledge that it is safe to remain active with reasonable life activities, we are going to practice remaining grounded in the presence of a sensation that you otherwise normally experience as alarming and threatening. There are countless ways to practice and develop this skill set. Any list would be incomplete, but some of these ways are the following:
- Learning to use diaphragmatic breathing to relax in the presence of pain and/or slow down your typical automatic responses to pain
- Increase awareness of your typical automatic reactions to pain — what you think, feel and do when having pain
- Learning that there are multiple perspectives for how you might react to pain
- Learning to make intentional decisions as to how you respond to pain, as opposed to your typical automatic (i.e., unchosen) reactions to pain
- Understanding that centrally sensitized chronic pain is pain that is being produced in the absence of an injury, so as a result you know that it is safe to remain active with reasonable life activities when having pain (i.e., ‘hurt doesn’t equal harm’)
- Intentionally engage in meaningful or pleasurable activities when having pain in order to distract yourself from it
- Practice accepting that the sensation can be there without it being a constant source of distress; you don’t have to constantly try to get rid of it and fail in your persistent attempts; instead, consider it like a box fan that remains on in the room — it captures your attention when the fan is first turned on, but you can come to ignore it by focusing on other things
In these and many other ways, you change the neuromatrix that makes up the experience of pain by repetitively practicing skills to remain grounded in the presence of a sensation. Recall our equation that makes up pain: sensation + alarm + perceived threat + behavioral avoidance = pain. Oftentimes, we try to reduce or avoid the sensation in an attempt to change pain, but we could go after the other variables in the equation and try to change them in order to reduce pain. We could stop avoiding the sensation and get distracted with other things, while reducing its perceived threat and sense of alarm by practicing remaining grounded. By repetitively practicing these skill sets, we would get better at it and with time what was once an intolerable sensation would become increasingly tolerable. In other words, we would start to rate pain as less severe.
By developing these skills, you retrain how your nervous system produces pain. As with any set of skills, the more you practice this set of cognitive-based skills the better you get at them. Initially, you need coaching and feedback from your CBT provider and it requires a lot of attention and energy to do them. With practice, though, they get easier and require less time, attention and energy. Over time, they become like second-nature. As a result, your nervous system is in a less reactive, inflammatory state.
In CBT for pain, you’ll also be encouraged to engage in certain healthy lifestyle changes that down-regulate the nervous system in more overt ways. Some of them are essential for successful management of pain, while others may or may not be necessary, depending on the individual.
One essential health behavior change is to start a routine of engaging in a contemplative practice. Examples of a contemplative practice are mindful meditation, tai chi or yoga. These therapies are traditional ways to target the nervous system and train it to be less reactive.
We don’t typically think of our nervous system as being under voluntary control. Despite the common admonition to “Relax!” from a friend or loved one when we are upset, we usually cannot relax our nervous system on command. However, humans have developed ways to practice gaining incremental control of the nervous system in order to relax it. They are the three mentioned above.
More often than not, a CBT therapist will start with teaching you how to diaphragmatically breathe. This is a form of deep breathing and it is a way to tap into your nervous system and relax it. However, when you do it for a minute or two, you find that it is actually really hard to do. You’ll notice that your thoughts and attention are repetitively distractible. You set out to simply breathe quietly and relax, and you find yourself lost in thoughts about things completely unrelated. Before you know it, you subsequently stop breathing from your diaphragm.
From here, the CBT therapist might introduce mindfulness as a form of meditation. While engaged in diaphragmatic breathing, you practice being aware of your thoughts and distractions, and without self-criticism you continuously redirect your attention back to your breathing. You might be encouraged to do a few minutes of mindful meditation each day and then gradually extend the length of time that you do it.
In developing this practice, you are doing two things. One, you are developing a skill to relax your nervous system. Once done, your nervous system tends to return to its typical reactive state. However, when doing it repetitively each day (or most days) over time, your nervous system returns to a less reactive state. As a result, your average level of reactivity starts to come down. We call it down-regulating your nervous system. Second, in practicing the skills of self-awareness and redirecting your attention, you are practicing one of the cognitive skills mentioned above — intentionally choosing your responses to the stimuli of life, rather than simply automatically reacting to them.
While less commonly taught in CBT, tai chi and yoga bring about similar results. If you already do tai chi or yoga when coming to CBT, your therapist is apt to have you continue them with the same goal in mind.
Another essential lifestyle intervention for pain is engaging in a mild aerobic exercise. Examples of a mild aerobic exercise are walking, stationary bike, or pool exercises. These forms of exercise are not super rigorous and they are not jarring on joints. They do, however, modestly get your heart rate up for a period of time. What happens after your heart rate is elevated for 20 or 30 minutes is that your brain produces feel-good chemicals that relax the nerve system. You may have noticed that feeling of calmness that follows aerobic exercise, if in the past you ever were an exerciser.
Like with meditation, this feeling of calm doesn’t last forever and so it goes away and your nervous system returns to its higher reactive state. However, if over time you repetitively engage in a form of mild aerobic exercise, 3 or 4 times per week, your nervous system begins to return to a less reactive state. In other words, it is another way to down-regulate your nervous system.
Both a contemplative practice and a mild aerobic exercise have been shown to reduce pain levels. It’s not dramatically effective and it does not happen over night, but you can bring your average pain levels to a more manageable level.
A third essential behavior change is committing to some form of gradually increasing exposure to pain or activities that you have historically tended to avoid because of pain. Now, I know, this prospect sounds terrible! But before you stop reading, hear me out. Maybe you have a goal of using less opioid pain medications or you have a goal of returning to work or regularly doing some other family or social activities. You discuss it with your CBT provider and other healthcare providers involved in your care. Maybe you also discuss it with your loved ones. It is important that the decision comes from you and that it is thoughtful. It’s also important to have a plan and commit to it.
Suppose that your goal is to use less opioid pain medications. In your discussions with your healthcare providers, you develop a slow and gradual taper plan. Suppose your goal is to return to work. So, in discussion with your providers, you participate in a CBT-informed chronic pain rehabilitation program that shows you how to return to work. Or suppose you commit to volunteering a few hours per week as a gradual step towards returning to work.
These plans involve risk — the risk of having more pain. You have historically avoided pain by taking opioids or not working. But you also want more out of life. You see the value of not being dependent on an addictive medication or you see the value of working. You don’t want to be so controlled by pain that you end up compromising these values. So, you make the decision to try and take back that control.
As a result, while practicing your cognitive and behavioral skill sets, you commit to gradually exposing yourself to what you have historically tended to avoid -- pain and activities associated with pain -- with the goal of taking back control.
The importance of this exposure-based aspect of CBT for pain is that you have real life things on which to practice your developing pain management skills. Oftentimes, patients want to learn how to successfully self-manage pain and then taper from opioids or return to work. Now, of course, you can achieve modest progress in developing these skills prior to ever reducing opioid medications or returning to some meaningful life activity, such as work. However, as long as you continue to buy pain relief through avoidance of it by taking opioids or not working or engaging in other meaningful life activities, you’ll never know if and how you could learn to self-manage pain while also achieving these important life goals.
It would be like learning all about bike riding, but never actually getting on the bike.
The goal of successful pain management the world over could be summed up as managing pain well while being able to engage in meaningful life activities and to do so as independently of the healthcare system as possible. In other words, to acquire the abilities to self-manage pain well, you must at some point face the decision to expose yourself to the risks inherent to reducing your dependency on opioids and the healthcare system that prescribes them, and increasing your activities. For these reasons, exposure is an essential aspect of CBT.
These risks are normally threatening. No one embraces them with enthusiasm and joy. However, you do it because it is your decision and you were involved in the planning of it. You do it because the plan is to proceed slowly and gradually, in incremental steps. You do it because you get supportive coaching along the way from your CBT provider. But, most of all, you do it because you want to take back control of your life. Pain has for too long controlled you and dictated what you do or don’t do. You want more out of life and you want to feel good about yourself and the life you live.
The exposure elements of CBT are the confidence building part of CBT. Much of CBT for pain is about learning knowledge and skills that retrain the nervous system to reduce pain and its impact on you. It’s a know-how. It’s about the development of abilities. With the development of any abilities, though, there is also a coming to know that you can do it. If developing skills is the know-how, developing confidence is the knowing that you can do it. You don’t know that you can ride a bike until you take the risk and get on the bike and learn how to ride. Similarly, knowing how to successfully manage pain is one thing, but learning that you really can successfully manage pain s another thing.
You will never know that you can successfully manage pain until you start doing it on less and less opioid medications or until you do it while returning to the activities that you used to do. The exposure aspect of CBT for pain is the means to regain your confidence that you really can live life in the ways you want to do.
In most any CBT for pain, patients will be encouraged to learn and practice cognitive skill as described above, engage in some type of contemplative practice and mild aerobic exercise on a regular basis, and incorporate some form of exposure to achieve their goals of successful pain management.
Depending on the individual needs of the patient, there may be other skills and goals to pursue. These could include CBT for insomnia; reducing caffeine, nicotine or other stimulants which activate the nervous system; eating an anti-inflammatory diet; CBT for a co-occurring anxiety or depression; or weight loss. CBT can be used for the management of these conditions too. They’d involve the development of different skill sets, but the emphasis would be on ways that the patient can bring about improvement in their health. If these apply to you, you might be encouraged to pursue them.
CBT for pain is a traditional form of pain management. It involves an established method of coaching people with pain what they can do to effectively and successfully self-manage pain. This coaching occurs within a supportive and instructive relationship with a healthcare provider. The instruction falls into two categories of skill sets, cognitive and behavioral skills. These skill sets aim to retrain how the nervous system produces pain. In so doing, you learn not only how to manage pain successfully, but you regain the confidence that you really can do it.
For more information, please see: Why See a Psychologist for Pain? and Is It Possible to Manage Pain Well without Opioids?
1. Turk, D. C., Meichenbaum, D, & Genest, M. (1983). Pain and behavioral medicine: A cognitive behavioral perspective. New York: Guilford Press.
2. Beck, A. T., Rush, A.J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.
3. Uchendu, C. & Blake, H. (2006). Effectiveness of cognitive-behavioral therapy for glyceamic control and psychological outcomes in adults with diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials. Diabetic Medicine, 34(3), 328-339.
4. Gullicksson, M., Burrell, G., Vessby, B., et al. (2011). Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary prevention in Uppsala Primary Health Care Project. Archives of Internal Medicine, 171(2), 134-140. doi: 10.1001/achinternmed.2010.510
Date of publication: 3-26-2021
Date of last modification: 6-15-2022
Commonly, patients and providers assume that pain is the result of an injury or illness, or at least some type of condition in the body. So, for example, when pain in the low back occurs, it’s common to think of it as the result of some type of tweak or mild injury that must have occurred. When it goes on for some time, it’s also is common to want an MRI scan to see “what’s going on” in the back. Such scans often reveal some type of degenerative condition of the spine, which is subsequently considered the cause of the back pain.
As a result, people with pain tend to seek therapies that target the condition in the body by means of physical therapy that strengthens the core, or undergo steroid injections, or even surgery.
The same would be true if the onset of pain occurred in the shoulder or knee or hip. We’d tend to think of the pain as a sign that something is wrong in these joints, something orthopedic in nature, such as arthritis or a problem with a ligament or muscle. We’d tend to seek a scan to help in diagnosis followed by physical therapy, an injection or surgery,
The purpose of these types of assessment and therapies would be to treat the condition that is assumed to be the cause of pain. While doing so, we might take pain medications that act on the brain.
People are sometimes surprised that there are psychologists who are not mental health providers. It’s also true for people with persistent pain who might wonder why their physician referred them to a psychologist for the management of pain. ‘I’m not depressed’, they might think. The implication is that you’d only see a psychologist if you have a mental health condition, such as depression, anxiety or insomnia. It can therefore be puzzling when referring providers continue to insist on the recommendation of seeing a psychologist for pain, even when yo don’t have mental health problems.
A little known, yet similarly surprising fact about pain management is that some of the historical founders of modern pain management were psychologists. Ron Melzack, a psychologist, along with Patrick Wall, a physician, developed the first modern theory of how pain is produced in the body, highlighting the central role of the nervous system. Five decades of subsequent research coming from their theory now informs our current day understanding of pain and how to treat it. Bill Fordyce, a psychologist, along with John Bonica, a physician, are largely credited with creating the first team-based, interdisciplinary pain clinic, which continues to this day to be the gold standard for pain management.
Psychologists have thus been integral to pain management since its inception as a field within healthcare, and yet their role in pain management remains puzzling to most people with persistent pain, and even to most in society itself.
What is a Pain Psychologist?
Pain psychologists are psychologists who assess and treat pain of all kinds, including post-surgical pain, cancer pain, and chronic pain. Pain psychologists are doctoral-level healthcare providers who have had training and experience typically in health psychology and then went on to specialize in pain management. To best understand how pain psychologists help to reduce pain, let’s first discuss what a health psychologist is, and then apply this understanding to pain psychology.
Health psychology is a type of psychology that centers on the assessment and treatment of health conditions, such as pain, diabetes, heart disease, obesity, among others. One common factor that underlies all these conditions is that their effective management requires more than simply relying on medical treatments alone. To best manage them, these conditions also require patients to make healthy lifestyle changes. So, for example, people with type 2 diabetes may rely on certain medications to manage their condition, but to best manage their diabetes they also need to know something about nutrition and make healthy food choices, achieve a healthy weight, get regular exercise, and manage their stress well. All of these latter changes are what we tend to call lifestyle change or health behavior change. When done over time, health behavior changes can positively affect the biological basis of these conditions and reduce the impact that these conditions have on the patient.
Here is where the role of the health psychologists, including the subtype of pain psychologists, come into play on the healthcare team. Predominantly, physicians have expertise in medications and procedures that can positively affect conditions such as pain, diabetes, heart disease or obesity, but tend to have less expertise in coaching and motivating patients to engage in health behavior changes that also must be pursued if these conditions are to be successfully managed. In contrast, health psychologists are doctoral level healthcare providers whose expertise lies solely in helping patients to take ownership of their health, educating them on how to best manage their health condition, motivate them to start and maintain health behavior changes, and supportively coach them along the way.
Now, pain psychologists are health psychologists who have a further specialization in the management of pain. They assess pain and its many contributing causes. They also assess how the patient is responding to pain, or, in other words, the degree to which the patient is responding to the pain effectively or not. From this assessment, pain psychologist determine a treatment plan to engage the patient in making health behavior changes, which, when done over time, positively affect the physiological basis of pain and thereby reduces pain. They also show patients how to respond more effectively to pain and in so doing patients also reduce the negative impact that pain has on their life.
The therapies that pain psychologists pursue are empirically-supported. Empirically-supported therapies are therapies that scientific research shows are effective. Pain psychology therapies have been shown to reduce pain, increase quality of life, and reduce the use of opioid medications.
How do pain psychology therapies work?
Pain psychologists have a sophisticated, scientifically-informed understanding of the nature of pain. To understand how pain psychology therapies are effective, it is necessary to understand how pain is produced in the body.
Many people naturally assume that pain requires an injury or an illness to occur. This assumption is apt to come from the many times we injured ourselves or became ill and had pain. We step on a nail, for instance, and the puncture wound usually hurts. We thus come to associate pain with injury or illness. So, whenever we have pain we look for some type of bodily injury or illness that causes the pain. To treat the pain, we subsequently try to treat the injury or illness associated with the pain.
From this way of understanding pain, it’s hard to see why you’d ever want to see a pain psychologist. What role, if any, could a psychologist ever play in treating a bodily injury or illness?
This understanding isn’t necessarily wrong, but it is incomplete. We know from five decades of scientific and clinical research (beginning with Melzack, the psychologist, and Wall, the physician, mentioned above!) that the occurrence of pain also requires a nervous system.
The nervous system consists of nerves in the body, sometimes called peripheral nerves, and the spinal cord and brain. The peripheral nerves are connected to the spinal cord and brain. Many of the peripheral nerves in the body are sensory nerves, which means that they sense things. You can feel a smooth table top because you have sensory nerves in your finger tips, which are connected to nerves in your arm, spinal cord and brain. When you touch the table top, the sensory nerves send an electro-chemical signal up the nerves to your spinal cord and brain. Your brain processes this electro-chemical signal and produces a sensation of smoothness in your finger tips.
The same would be true if you injure yourself by, say, hitting your thumb with a hammer. Your sensory nerves in your thumb send electro-chemical signals to your brain via your spinal cord. Your brain processes this information as threatening and produces a sensory alarm that you feel as pain in your thumb that you hit with the hammer.
We might therefore use an analogy of a building’s fire alarm system when understanding how pain works in the body. Just as there are smoke detectors located throughout a building, we have sensory nerves throughout the body. In the case of a fire alarm system in a building, smoke detectors persistently send signals to a computer on the state of the rooms in which they are located and when the computer recognizes the signal that corresponds to smoke, it sounds an auditory alarm. Similarly, sensory nerves are persistently sending signals to the brain on the state of the body — its position, what is being touched, the temperature, etc. When the brain recognizes a signal as threatening, such as when the body is injured or ill, the brain produces a sensory alarm, which we call pain. We don’t hear pain, like we hear a fire alarm, but pain functions in the same way. In other words, we don’t have an auditory alarm, but rather a tactile alarm. Despite this difference, the alarms function similarly in that they tell us that there is something wrong in the building/body. Just as an auditory alarm is produced by a fire alarm system in response to fire, our sensory alarm, or pain, is produced by the nervous system in response to something going wrong in the body.
Now, there are two things when an alarm goes off. In the case of the fire alarm, there is the fire and there is the auditory alarm produced by the fire alarm system. Similarly, with pain, or at least as we commonly think of pain, there is an injury or illness, and there is the sensory alarm, called pain, that is produced by the nervous system.
Now here’s the important part. Fire alarm systems are set at a certain level of sensitivity. We want it to sound the alarm when there is a fire, but not when we light a candle. We could imagine a fire alarm system that is set at a sensitivity that only goes off when there is a raging fire, but not a small fire. It wouldn’t be very useful. We want it set at just the right level. It shouldn’t go off in response to a candle, but it should go off with any fire bigger than a candle. The reverse settings would be equally problematic. Imagine a fire alarm system that sounds the alarm in response to a candle, or someone smoking a cigarette. Imagine further if the fire alarm system in your building was so sensitive that it went off if someone was smoking just outside the front door or on the front sidewalk. Imagine your building’s fire alarm was set at such a sensitive level that it went off with barometric changes that occur when a weather-related cold front comes through.
In such cases, we’d want to ensure that there is no fire, of course, but we’d also want someone to reset the fire alarm system to a normal level of sensitivity, so it would only go off when there is fire.
Here is where the role of the pain psychologist comes into play. Psychologists in general are experts in helping people change their nervous systems. Usually, as we mentioned in the beginning of this essay, we think of psychologists helping people change their nervous systems to reduce things like anxiety, depression, insomnia, trauma, and addictions. But pain psychologists, with their expert understanding of how pain is produced by the nervous system, can help people with pain change how their nervous systems are producing pain — regardless of the initial cause of the pain.
While it might be a bit overly simplistic, we might say of the two variables involved in the production of pain — injury/illness and a nervous system — that physicians tend to target the former to reduce pain while pain psychologists target the latter to reduce pain.
There are pain psychology therapies that reduce pain by reducing the reactivity of the nervous system that produces pain, whether it is the pain that follows surgery, the pain of childbirth, the pain of cancer, or chronic pain. By reducing the sensitivity of the nervous system, you reduce pain.
What does a pain psychologist do?
All pain psychology therapies target the nervous system and reduce its sensitivity to producing pain. Some therapies target how the brain processes the signals that are sent to it by the peripheral nerves in the body. These therapies help patients take a different perspective and change how they experience pain. Some other therapies target the peripheral nerves in the body and reduce their reactivity. These therapies help patients to learn how to calm the body’s peripheral nerves to change the set point of their nervous system. By doing so, their nervous systems do not react so easily and as a result their nervous system doesn’t produce pain so readily.
The former type of therapies are more cognitive in nature, meaning that they focus on changing how the brain processes the information that is sent to it by the peripheral sensory nerves. They involve helping patients learn about their pain, understand it better, and take the sense of fear or alarm out of pain. Patients come to learn that pain is unpleasant, but that it can be increasingly tolerated. Indeed, these therapies can show people how to increasingly stay grounded in the presence of the sensation of pain, and thereby learn to distract themselves from pain in the knowledge that the sensation itself is not harmful. By repetitively practicing this skill set, patients change how their brain processes the information that is sent to it by the peripheral sensory nerves.
The latter type of therapies are more behavioral in nature, which involve reseting the sensitivity of the overall nervous system, including the peripheral nerves. Reseting the nervous system is sometimes referred to as down-regulating the nervous system. As human beings, we don’t typically have voluntary control over our nervous systems. We typically can’t, for instance, simply calm down and relax despite the common admonishment from a loved one to do so when we are upset. However, pain psychologists can coach you on ways to target your nervous system and repetitively calm it down. When done over time, it tends to reset the set point for when it produces pain. So, for example, pain psychologists can coach patient in diaphragmatic breathing practices and forms of meditation that when practiced repetitively over time down-regulates the nervous system and thereby reduces average levels of pain. Pain psychologists might also recommend engaging in a mild aerobic exercise, such as walking or walking in a warm water pool or riding a stationary bike. When done on a repetitive basis, mild aerobic exercise can also down-regulate the nervous system and thereby reduce pain. There are a number of such health behavior changes that pain psychologists can coach their patients to do in a supportive manner.
In general, the overall goal of pain psychology therapies is to reduce pain and reduce the negative impact that pain has on patients. These therapies focus on what the patient can do to achieve these goals, rather than on what the healthcare system can do to achieve these goals. In this way, pain psychology therapies involve a focus on self-management. Self-management is a catchall phrase that captures the healthy lifestyle changes that patients pursue to positively affect their health.
Some of the most important things that we can do to achieve health involves things that we do, not what our healthcare providers do. In the case of pain management, some of the most effective things that can be done to manage pain are things that the patient does by targeting the nervous system. This emphasis on self-management further helps patients with chronic pain become as independent of the healthcare system as possible, such acquiring the abilities to self-manage pain successfully without the use of opioid medications.
Assessments and therapies that pain psychologists perform
Pain psychologists perform a variety of assessments and therapies. The following is a brief list of the most common types of assessments and therapies.
- Pre-surgical psychological evaluations for spine surgery, spinal cord stimulator implants, and intrathecal drug delivery devices (aka ‘pain pumps’)
- Evaluations for participation in a chronic pain rehabilitation program (sometimes referred to as functional restoration programs)
- Psychological evaluations related to the use of opioid medications
Research over many decades has shown these therapies to be empirically-supported, or scientifically proven to be effective. Indeed, when it comes to chronic pain management, these therapies are some of the few empirically-supported therapies that the field of pain management has.
Healthcare providers commonly refer patients with pain to pain psychologists because they know that what pain psychologists do is effective and important in the overall management of pain. However, it’s equally as common for people with pain to be confused by the referral, as they often do not know what it is that pain psychologists do and why it is helpful. To resolve this lack of understanding, it’s necessary to know how pain is produced in the body. Pain requires more than an injury or illness to be produced. For pain to occur, it also requires a nervous system. Both an injury/illness and the nervous system contribute to the production of pain. While some healthcare providers target their interventions at treating the initial injury or illness to reduce pain, pain psychologists target their interventions at the nervous system to reduce pain. The assessments and therapies that pain psychologists perform aim to show patients how to change the ways their nervous systems contribute to the production of pain. These therapies are empirically-supported in that they have been shown to be effective. They can reduce pain, reduce the negative impact that pain has, and can help people with pain become independent of the healthcare system in the management of their pain (e.g., help people to successfully self-manage pain without opioids). Thus, seeing a pain psychologist can be an important and helpful recommendation in the overall management of pain.
For more information, please see Cognitive-Behavioral Therapy for Pain & Tapering Opioids as an Exposure-based Therapy for Chronic Pain.
Date of initital publication: 2-14-2021
Date of last modification: 6-23-2022
The single most important concern in public policy debates related to the use of opioids for persistent, or chronic, pain is what happens to people with persistent pain when they reduce or taper the use of opioids.
It is often helpful to use analogies and metaphors when explaining complex health topics to patients and their families. This statement is no less true when explaining the complexities of successful pain management. There are many helpful metaphors and analogies, and we have discussed a number of them previously in this blog, such as in the different ways to relate to pain or even experience pain. Another helpful analogy to explain the nature and goals of successful pain management is with the analogy to successful weight management.
It is helpful to liken pain management to weight management because weight management is often better understood by patients and their families. So, let’s review and learn about what it takes to successfully self-manage pain by looking at how it’s similar to successful weight management.
You’d think that we’d all agree on what back pain is. Pain in the low back is almost as common as days of the week. Most everyone has had or will have back pain in the course of their lives and it is one of the most frequent reasons for seeking healthcare.1 Despite this common, everyday experience, we continue to be vexed by competing understandings of the nature of back pain.2
To be sure, our understanding of the cause of common back pain has changed over the last fifty some odd years. However, it’s questionable whether these changes mark true advances in knowledge.
A Brief History: Backache or Back Pain?
At one time, we tended to refer to back pain as backache. The term implied similarity to neck ache and headache. Today, when aches of the head and neck occur without any overt injury or illness, we tend to associate them with over-exertion, working too much, tension, and unresolved conflict, among others. We allow, in other words, for the occasions when problems or people are literally “such a headache” or “a pain in the neck.” Still other times, especially when people are prone to neck ache or headache, we tend to perceive such aches and pains as a barometer for when we need to take better care of ourselves because life has become too busy or problematic in some manner.
In the past, backache was considered similarly. The gradual appearance of low back pain, without injury or illness, was readily taken as a sign that life and/or relationships were getting out of sync: backache could be due to working too much, leading to the subsequent need for more rest and relaxation in life; or it was due to the persistent inactivity of a desk job and the habit of watching night-time TV, resulting in an unmet need for more exercise; or it could be due to the persistent unresolved conflict with, say, a boss at work and the mounting pressure that it entailed over time.
Suffering from backache (or neck ache or headache), people tended to prescribe a return to healthier ways of living – resolutions to get more rest and relaxation, work less, seek the solace of the country or outdoors, or bathe in warm springs or spa.
Today, we might understand this conceptualization of back pain with the concept of stress. We use the term stress to refer to the hectic and chaotic nature of modern life. We work too much. We are our chronically over-stimulated from information, messaging, and screens. We persistently juggle between work, children and their activities, and the management of elderly parents. Despite the apparent promise of connection through social media, urban and rural loneliness are all too common. When such imbalances persist for too long, we experience them in any number of emotional and bodily ways, some of which are headache, neck ache and backache.
We all recognize the grain of truth in this way of understanding the occurrence of low back pain, especially when it comes on gradually and without warning. We used to call this type of pain backache.
Injury/Spinal degeneration model of back pain
A competing conceptualization of backache, however, has coexisted alongside this understanding of backache as a malady of the stress of modernity. It is backache as the result of a condition of the spine brought about by injury or degeneration. Allan and Waddell3 have a rich history of the first published medical papers beginning in the late 19th century hypothesizing backache as emanating from problems associated with the spine and subsequent reports of acute back pain due to railway injuries. By the first half of the 20th century, the intervertebral disc had sunsequently come to be understood as a source of backache. With the advent of CT scans in the 1970’s and MRI scans in the 1980’s, this conceptualization eclipsed all other ways of understanding backache, as so much of the spine had become visible. Having become observable, abnormalities of the spine were readily identified as the source of pain in the back. As a result, it is now commonplace to consider pain in the back as due to injury to the disc or degenerative changes to the spine. Indeed, this view of backache has so taken hold that we no longer readily use the term backache in preference for back pain.
There is, of course, a grain of truth in this way of understanding back pain too. Like any other part of the body, we can injure our low back. We are involved in motorcycle accidents, sports injuries, slips on the ice, and falls from ladders, and countless other ways we can injure ourselves. Sometimes, these accidents cause significant enough injuries that they can be seen on scans.
Indeed, beginning in the 1980’s, but really taking off in the 1990’s and early 2000’s, the use of CT and MRI scans became widespread for all instances of back pain. It seemed to open up a whole new world in our understanding of back pain. Specifically, we made the leap from initially holding that back pain is due to spinal abnormalities from injuries on some occasions to holding that back pain is due to spinal abnormalities on all (or most all) occasions.
The primacy of what we might call the injury model for understanding back pain is evident even in those instances in which there is no overt injury associated with the onset of back pain. In response to the gradual appearance of back pain, we tend to look to what we might think of as micro-injuries: “I must have slept wrong,” “I must have tweaked my back,” or “I twisted the wrong way.” Conceptualizing it as an injury, we subsequently seek medical evaluation and oftentimes want a scan to see what’s going on with the spine. Indeed, both the general population and healthcare professionals now seem to simply assume the association of common back pain with spinal abnormalities. Subsequently, it’s now commonplace to want to look first to the vertebrae, discs and ligaments when seeking an explanation of common back pain.
The term for what’s wrong in many of these instances has tended to be spinal- or disc degeneration. It’s a way to refer to the medical equivalent of what we might think of as micro-injuries. Degenerative changes to the spine are the result of slow, wear and tear.
Moreover, such degenerative changes can and have been, of course, the object of medical and surgical intervention. Physical therapists, physiatrists, interventional pain physicians, orthopedic and spine surgeons – all are experts in the evaluation and delivery of interventions aimed at degenerative conditions of the spine.
Having reached its apex in the early 2000’s, this way of conceptualizing back pain as the result of overt or subtle injury, defined by abnormality of the spinal structures, keeps back pain squarely within the realm of healthcare, rather than lifestyle. People have come to look, not to what they can do to alleviate backache, but to healthcare providers with an expertise in the evaluation and treatment of abnormalities of the vertebrae, disc and ligaments. In this way, people with back pain must become patients, it seems, because they have little control over the abnormalities of their vertebrae, discs, and ligaments once they have them. The implication is that people with back pain went from having a problem that they resolved themselves to patients with a medical condition, akin to an injury, that healthcare providers treat.
During this period of shifting emphasis towards spinal abnormalities as the explanation of back pain, the period of the 1990’s to the 2010’s saw the use of scans, interventional procedures, and surgeries grow at exponential rates.4
2010’s: Cracks in the Injury/Spinal Degeneration Model
Looking back, we might question the logic of what happened. Just because some instances of common back pain are due to injury doesn’t mean that all instances of common back pain are the result of injury. In logic, this type of error is called affirming the consequent and it’s considered a fallacy. It is, however, exactly what happened in our understanding of pain in the back.
We were captivated by a model for understanding a particular set of a phenomenon, through which we came to see all instances of the given phenomenon.5 We sometimes think that science and knowledge comes from empirical observation, which then lead us to developing models for understanding those observations. Of course, it can happen this way, but the reverse can also be true. Sometimes, our models determine what empirical observations we make. Science and knowledge can be a reciprocal process in this regard. It’s the latter that occurred from the 1990’s to at least the early 2010’s, but even to some extent to this day. Our injury model of back pain has determined how we perceive the empirical data of back pain.
Our captivation to this model was aided, of course, by the development of high-powered abilities to perceive spinal structures – the CT and MRI machines in the 1970’s and 1980’s, respectively. With them, we could find abnormalities of the spine even when the onset of back pain occurred without any overt precipitating injury – we could still find micro-injuries, if you will, in the form of degenerative changes of the spine. Thus, the injury model of back pain could still explain back pain even when there was no demonstrable outward injury. In other words, we could see the apparent spinal correlates to those instances when we explain to ourselves that we “must have” have injured our backs with a tweak or a wrong twist, even though we hadn't previously observed such a tweak or twist when the pain had come on subtly and progressively.
Despite the power of explanatory models determining what we see, empirical data can still break through in the form of counter-factuals to the model and lead to a change in the conceptual model itself. It takes, however, time, sometimes on the order of years, and it can be aided by changes in society.6
One early instance of counter-factual data, aided by events in society, was that despite the exponential growth of scans and treatments for spinal degeneration, disability claims for back pain grew at a corresponding exponential rate.7
How could this be? If common back pain is due to injury and we have the capabilities to both accurately assess these injuries with the use of scans and treat them with, say, the use of physical therapy and spinal interventions and surgeries, people with back pain should be get better and go back to work at high rates. It’s not what happened, though. With the practice of scanning and treating spinal abnormalities, people have been becoming more disabled. It is hard to escape the possibility that, in at least some instances of common back pain, we have been assessing and treating the wrong things – things that in fact were not the cause of these instances of back pain.
Another set of empirical data that arose in the 1990’s to challenge the injury model of back pain was the discovery that spinal abnormalities are common even among people without back pain. The use of scans, when turned on people without back pain, find the very same things that are found in people with back pain, and which are used to explain back pain.8, 9 As it turns out, disc herniations and degenerative changes are common in people, with or without back pain. Jarvik, et al.,10 and Borenstein, et al.,11 subsequently followed their subjects without back pain over a period of three and seven years, respectively, to see if the presence of such degenerative changes predict later onset of back pain. The progression of degenerative changes over time had no statistical correlation with who later developed back pain.
To place the importance of these findings in perspective, we might use an analogy of the brown-haired bank robber. Suppose that a bank was being robbed one morning and the police had received a tip that the bank robber had brown hair. They surrounded the bank and out came a young man with brown hair. They promptly arrested him and placed him in the back of a squad car, confident that they had found the robber. Upon entering the bank to tell the customers and staff that they were now safe, the police came to realize that many people in the bank had brown hair. Had they found the culprit? They’d have to admit that their confidence could no longer be so certain.
Similarly, having become able to find spinal abnormalities with the occurrence of back pain, we had become confident that back was due to these spinal abnormalities. However, once we came to recognize that we find such abnormalities commonly in people without back pain, we can't and shouldn't so certain that we have found the culprit of back pain.
At the time of the publication of these findings in the 1990’s and early 2000’s, these findings were indeed puzzling, and made a splash among healthcare providers. Nonetheless, they weren’t sufficient to alter the model through which we had come to understand and perceive back pain. We continued, as we still do today, to understand back pain as the result of injury or degeneration of the spine.
I recall occasions in the 2000’s when patients reported to me, “I never knew how much pain I was in until my surgeon read me my MRI results.” Still, to this day, I have patients who report to me that their interventional pain physician or surgeon, when reading their MRI results, exclaim in wonder as to how they can even walk with a spine like they have. Rather than privileging the facts, in this case that the patient doesn’t report much pain or can readily walk, and thus interpret the scans as not representative of their pain and abilities, they privileged the findings of the scans and then told the patients that they are actually worse than they are. Such is the power of the injury model to captivate and determine our understanding of the phenomenon in front of us.
If, however, we are able to step out of the injury model for understanding back pain, we might not wonder such things. We would understand better why people don’t have a lot of pain or difficulty walking, even when finding the presence of spinal abnormalities on scans. CT and MRI scans commonly reveal such findings in people with or without back pain.
Moreover, we might come to understand that these findings have little or no relationship to pain levels or functional abilities. We might, in other words, realize that we are pointing to the wrong things when attempting to explain many instances of common back pain.
This conclusion bears out in large-scale studies that fail to find either statistical or clinically meaningful relationships between back pain and spinal degenerative changes.12, 13 It’s hard to make a case that we have found the cause of back pain when the purported cause doesn’t even correlate, or correlates poorly, with back pain. The most charitable thing we can say is that the lion’s share of what accounts for back pain isn’t captured by scans. Back pain is likely due to many different things that when put together adds up to pain in a person’s back and that what’s found on a scan is just one small factor that accounts for any given person’s back pain.
Modern lifestyle or injury and degeneration?
While we can, of course, injure our back, as we can any other location of our body, should we then infer that all back pain is due to injury? When we so commonly find spinal abnormalities upon scanning the backs of people who report an injury, it is tempting to think that spinal abnormalities are the objective correlate to the reported injury. Similarly, it is tempting to think that such spinal abnormalities are the cause of back pain when it occurs gradually, without a precipitating injury, as we can find spinal abnormalities in these cases too. Thus, it can come to seem that all back pain is the result of spinal abnormalities, whether as the result of injury or more subtle degeneration of the spine.
This explanation of back pain can seem so compelling until, at least, we come to find similar levels of spinal abnormalities in people without back pain. We now have about three decades of repetitive studies coming to the same finding. Most of these studies find no statistically significant relationship between back pain and spinal abnormalities. Even in the minority of studies that do show statistical significance, the relationship is poor and of questionable clinical significance. At best, spinal abnormalities play only a minor role in the cause of back pain.
This fact might shed some light on why spine surgery, despite its widespread use, has failed to produce any conclusive empirical studies showing its effectiveness. The largest and longest study to date, the SPORT trial for lumbar disc herniation, has shown no considerable difference between those who have surgery for disc herniation and those who do not.14, 15, 16
This study was originally designed as a longitudinal, clinical trial, meaning that subjects, who all had disc herniations in their low back, were randomly assigned to either receive surgery or conservative care without surgery (the clinical trial aspect of the study) and then followed to obtain data on their status over the course of 1, 2, 4, and 8 years (the longitudinal aspect). When the data was compared for the two groups, strictly defined by those who remained in their randomized groupings over the course of the study (which is how a clinical trials are run, for instance, for testing the effectiveness of a medication), outcomes were no different between those who received surgery and those who did not receive surgery, at any of the follow-up periods from 1 to 8 years.
If this clinical trial tested the effectiveness of a medication, or of a psychological treatment, no one would question the conclusion that the treatment failed to work. It was no more effective than usual care, which is to say that adding surgery to the overall treatment provided no value. Surgery for disc herniation is no more effective than not having surgery.
However, a funny thing happens when we are captured by an explanatory model of a particular phenomenon and are then met with counterfactual data. Counterfactual data are hard to believe. It’s no truer when it comes to the specific situation of a widespread treatment for spinal abnormalities like surgery. We all collectively might want to ask: how can this be that surgery for disc herniation doesn’t work? Surely, it can’t be true.
As it turns out, the study had some problems, which ironically leads to a reframing of the data towards an alignment with the explanatory model that back pain is due to spinal abnormalities. Specifically, the study suffered from a lot of crossover of randomized subjects. Crossover occurs when subjects of a clinical trial fail to stay in their randomized groupings and so don’t end up getting the treatment to which they were randomized to get. So, in the instance of the SPORT trial, some subjects randomized to get surgery subsequently decided against getting surgery after all; and some of the subjects randomized to conservative care without surgery eventually decided to get surgery anyway. The investigators did the best they could given this circumstance and compiled the data in accordance to the re-assorted groupings and compared those who received surgery against those who did not receive surgery.
Because the subjects in these newly sorted groupings were not fully randomized anymore, this lack of randomization introduces additional variables that might influence the effectiveness of the procedure, outside of the actual procedure itself. There might be something unique to the individuals who decide for or against a certain treatment that in turn influences the effectiveness of the treatment, something that might have been more evenly distributed and therefore washed out, if they had stuck to the initial randomization of who got which treatment. We know, for instance, that motivation and belief in the effectiveness or lack of effectiveness of a treatment can influence the effectiveness of a treatment. It's feasible that such motivation and belief may have played a role in the degree of crossover from one randomized treatment to another, and, as such, they may have also played a role in the degree of effectiveness that those treatments exhibited in the study.
Nonetheless, the data derived from the re-sorting of the groupings might shed some light on the effectiveness of the procedure, even if it is not as rigorous of a study as a clinical trial. The name for this type of study that the investigator’s secondarily pursued, given the circumstances, is called an observational study. The results of an observational study are not considered as conclusive as the results of a clinical trial.
What they found was that, at the 4-year and 8-year follow-up periods, both the group that received surgery and the group that did not receive the surgery improved, but that there was a statistically significant difference in favor of the surgery. In other words, those who had received the surgery improved a little bit more than those who id not receive surgery. This small improvement amounted to about a 13% greater reduction in pain for those who received surgery, which is roughly the equivalent of a one-point greater reduction on the commonly used 0 to 10 scale. There was no difference in the rate of returning to work between those who received surgery and those who didn’t.
The most charitable interpretation of these longitudinal findings of both the randomized clinical trial aspects of the study and the observational aspects of the study are that surgery for a herniated disc might show a small reduction in pain four years and eight years down the road, when compared to not getting surgery. Again, both the surgery group and the non-surgery group showed improvements, but the surgery group improved just a little more than those who did not receive surgery.
Nonetheless, this small improvement is of questionable clinical significance – is the difference, say, of having a pain level of a 7 rather than an 8, four to eight years down the road, enough of a difference to really make a difference in the actual experiences of one’s life?
Thus, the SPORT Trial, which is the best study to date of surgery for disc herniation is far from conclusive. It points to the conclusion that surgery for disc herniation might produce a small improvement in pain level over time.
This small effect for pain reduction but not work status improvement falls in line with what we have been discussing – spinal abnormalities might play a causal role in back pain, but if they do, it is a small role, and so targeting them surgically produces only small improvement. Again, all of this is to suggest that the lion’s share of what causes common back pain lies outside of what scans can identify and what therapies targeting such abnormalities can effectively treat.
Despite decades of data pointing to a cause of common back pain as more complex than simply the presence of spinal abnormalities, a large portion of society continue to have a default understanding that back pain is due to an injury for which spinal degenerative changes are its correlate.17, 18 This default understanding involves, of course, a subsequent default implication that first-line treatments of back pain should target these degenerative changes.
We continue this default understanding because we are captured by an explanatory model that back pain is due to injury, and spinal degenerative changes are the correlate to injury. We continue to do so at the peril of persistent pain, disability and cost.
What, then, of our alternative understanding of back pain – that of back pain as backache, similar to a headache?
With each time we develop a headache, we don’t automatically think that we must have injured our head, and subsequently seek medical evaluation and a scan to determine the specific nature of the injury that we figure we must have had. We also don’t automatically think that we must seek out therapies that target the presumed injury. Rather, we tend to naturally think of it as due to tension and stress, or working too much, or not getting enough sleep, or just the hectic pace of our modern lifestyle. We subsequently think that we need to take better care of ourselves and engage in some healthy changes to the life we live.
Maybe, it’s time to return to a similar understanding of back pain. We could start by going back to referring to back pain as backache.
For more information, see also:
1. St. Sauver, J. L, Warner, D. O., Yawn, B. P., Jacobson, D. J., McGree, M. E., Pankratz, J. J., Melton, L. J., Roger, V. L., Ebbert, J. O., & Rocca, W. A. (2013). Why do patients visit their doctors? Assessing the most prevalent conditions in a defined US population. Mayo Clinic Proceedings, 88(1), 56-67. doi: 10.1016/j.mayocp.2012.08.020
2. Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L… Lancet Low Back Pain Series Working Group. (2018). What low back pain is and why we need to pay attention. Lancet, 391(10137), 2356-2367. doi: 10.1016/S0140-6736(18)30480-X
3. Allan, D. B., & Waddell, G. (1989). An historical perspective on low back pain and disability. Acta Orthopaedica Scandinavica, 60(suppl. 234), 1-23. doi: 10.3109/7453678909153916
4. Brooks, M. I., Deyo, R. A., Mirza, S. K., Turner, J. A., Comstock, B. A., Hollingworth, W., & Sullivan S. D. (2008). Expenditures and health status among adults with back and neck problems. Journal of the American Medical Association, 299, 656-664.
5. Wittgenstein, L. (1953). Philosophical Investigations. New York: Macmillan.
6. Kuhn, T. S. (1996). The Structure of Scientific Revolutions (3rd Edition). Chicago: University of Chicago Press.
7. Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102
8. Boden, S. D., Davis, D. O., Dina, T. S., Patronas, N. J., & Wiesel, S. W. (1990). Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation. Journal of Bone and Joint Surgery: American Volume, 72(3), 403-408.
9. Jensen, M. C., Brant-Zawadzki, M. C., Obuchowski, N., Modic, M. T., Malkasian, D., & Ross, J. S. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331, 69-72. doi:10.1056/NEJm199407143310201
10. Jarvik, J. G., Hollingworth, W., Heagerty, P. J., Haynor, D. R., Boyko, E. J., & Deyo, R. A. (2005) Three-year incidence of low back pain in an initially asymptomatic cohort. Spine, 30, 1541-1548.
11. Borenstein, D. G., O’Mara, J. W., Boden, S. D., Lauerman, W. C., Jacobson, A., Platenberg, C., Schellinger, D., & Wiesel, S. W. (2001). The value of magnetic-resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: A seven-year follow-up study. Journal of Bone and Joint Surgery: American Volume, 83(9), 1306-1311. doi: 10/2106/00004623-200109000-00002
12. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnehan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Alvins, A. L., James. K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2016). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.
13. Corniola, M. V., Stienen, M. N., Joswig, H., Smoll, N. R., Schaller, K., Hildebrandt, G., & Gautschi, O. P. (2016). Correlation of pain, functional impairment, and health-related quality of life with radiological grading scales of lumber degenerative disc disease. Acta Neurochirurgica, 158(3), 499-505.
14. Weinstein, J. N., Tosteson, T. D., Lurie, J. D., Tosteson, A. N., Hanscom, B., Sinner, J. S., Abdu, W. A., Hilibrand, A. S., Boden, S. D., & Deyo, R. A. (2006). Surgical vs. nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial. JAMA, 296(20), 2441-2450. doi: 10.1001/jama.296.20.2441
15. Weinstein, J. N., Lurie, J. D., Tosteson, T. D., Tosteson, A. N., Blood, E., Abdu, W. A., Herkowitz, H., Hilibrand, A. S., Albert, T., & Fischgrung, J. (2008). Surgical versus non-operative treatment for lumbar disk herniation: Four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine, 33(25), 2789-2800. doi: 10.1097/BRS.0b013e318ed8f4
16. Lurie, J. D., Tosteson, T. D., Tosteson, A. N., Zhao, W., Morgan, T. S., Abdu, W. A., Herkowitz, H. & Weinstein, J. N. (2014). Surgical versus nonoperative treatment for lumbar disk herniation: Eight-year results for the spine patient outcomes research trial. Spine, 39(1), 3-16. doi: 10.1097/BRS.0000000000000088
17. Weber, C., Behbahani, M., Baardsen, R., Lehmberg, J., Meyer, B., & Shiban, E. (2107). Patients’ beliefs about diagnosis and treatment of cervical spondylosis with radiculopathy. Acta Neurochirurgica, 159(12), 2379-2384. doi: 10.1007/s00701-017-3356-0
18. Franz, E. W., Bentley, J. N., Yee, P. S., Chang, K. W., Kendall-Thomas, J., Park, P., & Yang, L. J. Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. Journal of Neurosurgery, Spine, 22(5), 496-502. doi: 10.3171/2014.10.SPINE14537
Date of initital publication: 12-6-2021
Date of last modification: 1-3-2021
Just this morning, a primary care provider came to consult with me, looking for pain rehabilitation options for her patient with a complex set of needs. Emphasizing the legitimacy of the patient’s pain complaints, the provider detailed a long history of an active substance use disorder. The patient has had multiple urine drug screens positive for both opioids, which weren’t prescribed to the patient, and illegal substances. The provider recounts that the patient has been asked to leave multiple pain clinics for similar aberrant prescription drug use behaviors, all of which are indicative of an inability to control the use of opioids. Given the patient's history, she is at high risk of further exacerbating her addiction and/or death, if opioids continue to be prescribed. Nevertheless, the provider feels as if she has to prescribe opioids to the patient because, "she has legitimate medical conditions with real pain."
Living among the COVID-19 pandemic, with its loss of life and livelihood, and our need to maintain physical distancing to protect ourselves and our communities, we face the dual burdens of stress and boredom. It’s a difficult combination because persistent stress leads to lack of focus and feeling scattered. This distractibility leads to aimlessness and inactivity, which further leads to boredom. In boredom, we have nothing to distract attention away from all the stressors in our lives. Thus, stress can lead to boredom and boredom leads back to stress.