Chronic Back Pain: Psychological Factors
Chronic (long-term) back pain can be difficult to treat as the problem is a psychosomatic “mind-body” condition. The problem and the pain source are real, but mental processes make the pain better or worse, depending on the person. Traditionally pain was understood as a signal transmitted from the brain, for instance, when you touch a hot item your body reacts from your brain’s response. This concept works well for acute pain but is more of a problem for chronic pain.
Nerves coming from the brain regulate the sensitivity of the spinal cord and therefore determine how we perceive pain. These nerves can increase, decrease or even fully block pain. This phenomenon explains how injured people can walks miles to a phone to call for help. Equally, how reports of soldiers carrying out remarkable activities, and only after some time realize that they’ve been injured. Attention and distraction account for much of the psychological modulation of pain. Mood equally has a profound effect on the perception of pain.
Research has shown that pain can change the way the central nervous system reacts to pain. Even after an injury is long gone, sensitisation of the previously affected body part can continue. These findings help to explain why people with normal-looking feet can still have constant burning pain, why perfectly healthy people have headaches and why the majority of people with chronic back pain, have no findings on examination or imaging to account for it.
Other factors such as catastrophising, which is the tendency to assume that the worst that can happen is true, has been shown to promote pain and dysfunction. In the case of back pain, a person who thinks, “this is awful, I’m never going to get better, I can’t cope, I must have something seriously wrong,” will likely suffer more.
Individuals who take control of their pain, realise that “hurt doesn’t equal harm”, gently exercise and move through the discomfort, take the task in hand and work at the problem to reduce the discomfort, generally do much better than those that don’t. These people return to work and social activities faster and return to their normal enjoyable life and sports sooner.
One of the most important factors in reducing pain and increasing function, is maintaining physical fitness. It clearly improves not only pain but the anxiety and depression that often accompany it. In the initial phase, it will be uncomfortable and stretching or exercising will not be a sudden fix. People with back pain are generally scared to move, but if you think about a wrist that has been in a plaster cast for 6 weeks, what is it like once you take the cast off? Lost muscle tone, weak, limp, and initially stiff when you try to move it again. Why do the same to your spine?
The number of times I hear patients say after a week, “I’ve done my exercises and I don’t feel any better”, is incredible. If you went to a gym for a week and lifted heavy weights would you expect your biceps or 6-pack to suddenly come rippling out beneath your t-shirt? Of course not, so why are gentle movement exercises going to work any faster?
Slow progression and positive actions! Relaxation training and yoga, along with Cognitive Behavioural Therapy can all help manage your perceived pain levels. Especially if your beliefs about life, yourself, other people, or your health situation have become liabilities.
On initial presentation to my clinic, it has always been the protocol to complete a Bournemouth Questionaire (BQ) and a STarT Back questionnaire. The BQ Questionnaire looks at seven core items, which are: pain intensity, function in activities of daily living, function in social activities, anxiety, depression levels, fear avoidance behaviour and locus of control behaviour.
Whilst, The Keele STarT Back Screening Tool (SBST) is a simple prognostic questionnaire that helps clinicians identify modifiable risk factors (biomedical, psychological and social) for back pain disability, the resulting score stratifies patients into low, medium or high-risk categories.
The recent courses I have undertaken have helped me to understand the reasoning and the thought processes that patients have about their back pain. I can now better utilize the results from these questionnaires and really delve into the psych-social aspects of the persons’ pain. This can help modify thoughts and beliefs about pain, fear avoidance and the resulting increase or decrease in physical actions such as exercise.
British Chiropractic Association (BCA) discovers half of people in the South East of England fail to prevent or manage back pain.
This Chiropractic Awareness Week (8th – 14th April) the BCA is encouraging people in the South-east of England to keeping moving, after finding that 25% of people in this region don’t take any steps to look after their back health.
The findings come from a survey conducted by the BCA, which unearthed that 25% of people in the south-east don’t take any action when they experience back or neck pain and 13% wouldn’t seek help from a health professional if they were experiencing these issues.
Chiropractic Awareness Week aims to educate people about the easy ways they can avoid or alleviate back pain, which on average 80% of the nation has experienced. Regularly changing posture and remaining seated for no longer than 30 minutes at a time are just a couple of the simple ways to prevent or reduce pressure on the back.
According to the BCA’s survey, when it comes to back and neck pain, they found that people in the south-east:
– 42% don’t take any steps to look after their back health
– Only 58% have taken preventative steps to protect themselves from developing back or neck pain
– 82% have experienced back or neck pain
– 13% wouldn’t seek help from a health professional for back pain and, 31% would wait a month or longer
– Only 13% would make changes to their daily routine if experiencing back or neck pain
– 18% choose their mattresses based on price, rather than comfort
Local chiropractor, Kelvin Storey from Joint Sense Sports Performance in Alton, commented on the findings:
“There are so many people in the South-East of England living with neck or back pain because they don’t know what preventative steps they can take, so we want to shine a light on the simple changes which can help. Chiropractic Awareness Week is designed to educate everyone on the best ways to prevent and tackle back or neck pain, from changing up your posture when sat at a desk, to sleeping on the right mattress.”
“Easy changes to your day-to-day life can make a significant difference, but if your pain doesn’t reduce or is prolonged, you should always see a health professional for further guidance.”
The BCA’s Kelvin Storey’s top tips for keeping on top of neck and back pain include:
• Keep on moving: Physical activity can be beneficial for managing back pain, however, it’s important that if this is of a moderate to high intensity that you warm up and down properly to get your body ready to move! If a previous injury is causing you pain, adapt your exercise or seek some advice. Activities such as swimming, walking or yoga can be less demanding on your body while keeping you mobile!
• Take a break: When sitting for long periods of time, ensure you stand up and move around every 30 minutes. When at work, also make sure your desk is set up to support a comfortable position. This is different for everyone so if you don’t feel comfortable in your current set up, try altering the height of your chair or screen.
Other things which people can bear in mind include:
• Lifting and carrying: Remember to bend from the knees, not the waist when lifting heavy items. Face in the direction of movement and take your time. Hold the object as close to your body as possible, and where you can avoid carrying objects which are too heavy to manage alone, ask for help or use the necessary equipment.
• Sleep comfortably: The Sleep Council recommends buying a new mattress at least every 7 years. Mattresses lose their support over time, so if you can feel the springs through your mattress, or the mattress is no longer level, your mattress is no longer providing the support you need. Everyone has different support requirements, so when purchasing your mattress ensure it is supportive for you. If you share a bed and require different mattress types, consider two single mattresses which are designed to be joined together, to ensure you both get the support you need.
• Straighten Up!: The BCA has created a programme of three-minute exercises, Straighten Up UK, which can be slotted into your daily schedule to help prevent back pain by promoting movement, balance, strength and flexibility in the spine.
1. The general consensus for effective running is based around an 80/20 training methodology. That is 80% of your training sessions should be based around what is considered below a Zone 2 pace, and around 20% in the higher paced zones. The science into the training efforts have been long studied by the physiologist Stephen Seiler and much written about by Matt Fitzgerald. The basis of the training is around energy expenditure and recovery, so in essence, keep your slow runs slow and your fast runs fast. Don’t plod around in no-mans land doing the same pace every time you go out.
2. The lowest and slowest end of pacing is generally for recovery runs. Slightly faster to where you can complete sentences and still run is considered for endurance or base training to build a good cardiovascular system. Next up, you move into the world of interval training where the intensity gets harder but you get rest periods in between the harder sessions. Tempo runs and fartlek training are common terms for such intervals. Rest periods are generally about 1/3 the duration of the high-intensity part, but of course recovery can be manipulated to increase fitness, along with the volume, duration and distance.
3. If you wish to get better at running, the simplest method is to run more. Add another training session in each week, but stick with the 80/20 principle and don’t increase any of the training factors by more than 10% or injury will likely come your way. If your main strength is already running and you run more than you cycle, drop a run session.
4. When you think about it, nobody really gets shown how to run. At infant and junior school you are told to run but not shown how. For that reason, running style is individualised and generally works for most people as the body is good at adapting. The downside of this adaptation is the body can learn bad habits after injury and your brain creates new compensatory movement patterns leading you down the pathway to another injury. Having your technique analysed early into your running can help prevent a whole world of pain and problems.
5. As mentioned in the last paragraph – most people will find a running style that is individual to them and many people will run without injury for many years. It is however very likely that as long as humans run we will get an injury at some point due to all the variables that occur with it. Most people land heel to toe when running and a smaller factor land mid-foot to toe. There are lots of theories on how best to run but it seems mid-foot/toe is most efficient as it allows the natural locking mechanism of the foot to work efficiently. Running heel-toe acts as a brake and creates more ground reaction forces through the foot, slows you down and it seems is more likely to cause injury.
6. Increasing your cadence will generally lead to a shorter stride. Combining this with thinking about moving the legs in a cyclic manner will also help. Most people find when trialling this, they not only become faster but they naturally land more towards the mid and forefoot. If you are not used to running this way, experiment with short intervals of normal technique and new technique. Even changing these little aspects can lead to aches in places you wouldn’t normally get them.
7. How many people run with their arms? Running with your arms moving from your hip pocket to chin and not crossing the midline has a major impact on your running. In running – your left arm affects you right leg, and vice-versa. Get one aspect of your arms wrong and your opposite leg will likely counteract wrong also.
8. Try and remain upright with good posture. There are varying theories that suggest running in certain ways such as running as if you feel you are falling forwards. The more you lean forward the more you are likely to heel strike, overstride, impact the ground harder and become injured. Ignore trends and go with what makes most sense.
9. It seems that after years of human evolution from running barefoot to running in sandals to running in the most advanced trainers. All the same injuries still persist. I can vouch for this personally through 20 years of musculo-skeletal clinic.
10. Evidence for barefoot running suggests no injury benefit to that of running shoe. There appears to be an equally big debate in research with regard to benefit to running in neutral, stability or motion control shoes. There are so many factors involved that you should go for an assessment with an experienced analyst at a reputable running shop. They should take into consideration your biomechanics, arches and gait. Shoe orthotics are not required unless you have pain so don’t buy into them.
11. Shoe thickness seems to be another myth when it comes to injury. Whether you run in vivobarefoot, zerodrop or the thickest Hoka one one’s it doesn’t matter. What feels most comfortable for you on the surfaces you run is what is important. Again, don’t go with fads or trends, go with what feels right!
12. Warming-up is essential to prepare your body for the work it is about to do. Gone are the days of static stretching hamstrings on the back of a park bench on a cold morning. Static stretching from cold just exerts unnecessary force on tendons and boney insertion points. Dynamic movement stretching prepares your body for increased ranges of motion and when done in combination with strides, you have a very effective warm-up. Strides are small accelerations of speed for anything up to 30 seconds with walking rest in between. Strides help with running form as well as preparation for exercise. They shouldn’t be all out sprints and you should be able to relax whilst doing them and not feel tense.
11. Do you pace your training with Jack Daniels? No, I haven’t lost the plot! Look up Coach Jack Daniels VDOT value based off a 5km run test. This will accurately determine your predicted times and pace values for 10km, half marathon and marathon. You can then use these factors to train effectively.
12. Use a recording device such as a Garmin or a Sunnto (other brands are available). If you can program the device in advance to map out your warm-up, intervals & rests and cool-down it is so much easier than having to look at the watch and manual stop starting. Use strava and analyse your intervals. Look for progression and manipulate your intensities.
13. Practice Brick sessions (bike-to-run). For anyone that hasn’t tried this, getting off a bike and trying to run can be a bit of a shock. It needs practice and lots of it. When you have been practicing it a while, practice it from different bike distances and different intensities. Riding at a slow level and starting to run is very different from race pace. Practice it!
14. Weightlifting, plyometrics and mobility – do them! Regularly! (too much to cover here)
15. Most Triathletes try not to eat on the run as most of this is best on the bike. That said it doesn’t hurt to learn as an ironman marathon can take considerably longer. As with everything else eating and running should be practiced. Your favourite foods don’t necessarily sit well when sloshing around and sitting in your stomach longer, due to blood working more favourably in your legs and heart and other areas. Gels are evil! Only use if you are really desperate or you know you can stomach them. Always go solid food if you can and drink water. Electrolytes in water are useful for longer or hot runs and again sit better in your stomach than high sugar energy drinks. Caffeine is legal and definitely a booster. Do not over stimulate yourself as it can have a negative effect too. Best used when you are nearer the latter part of a long run and need a boost.
16. Run trails. Trail running has so many benefits to running road: less impact, varying terrain, improved balance and preconception, better air quality, less boring, more fun, and better scenery.
17. Two final things to practice: if you are short on time and can’t do anything else – run hill repeats. Running hills is similar to sprinting, so the strength you build will improve your speed, strength and mental toughness. You should run hills regularly, so if you don’t normally, start doing them. Start gradually if you haven’t done them before! Finally – practice finishing fast on some of your longer runs. As you get to the end of your long run – speed up. This is good practice for running when fatigued.
Triathlon transition like a ninja – The A to Z
AGGRESION: Triathlon is a welcoming and accommodating sport. Running through transition with or without your bike, screaming at people to get out of your way is not good etiquette. The elite athletes don’t behave like this, so everybody knows you’re not one of them and you will just look like a self-important idiot – so don’t do it! An “excuse me” is fine! Equally, be polite to other competitors and say thank you to the marshals’ who are helping you in their free and unpaid time.
BELT: Remember to wear your number belt facing the correct way. Facing the back for the bike leg and the front for the run. It is commonly forgotten to turn this coming out of T2.
CHIP TIMING: All the big races have chip timing. Remember to wear it on your ankle and under your wetsuit, not over it.
DRINK: Remember to load up and fill-up your drink bottles for your bike cage. It’s not uncommon to load your bottles in your bike cage or in a crate but then not fill them.
ELASTIC BANDS: Experimenting with these attached to your shoes is highly recommended. The wrong thickness bands can lead to all kinds of problems on a flying mount.
FLYING MOUNT: The super-stylish transition technique of crossing the mount-line, jumping on your bike and slipping your feet into your already attached shoes. Practice, practice, practice or don’t do it.
GEARING: Check your bike gearing before racking. It’s not easy to pull away with your chain on the big chain ring at the front and the little sprocket on the back. It’s very amusing for those watching though!
HELMET: If your bike is out of the rack your helmet should be on your head and fastened. Put your helmet on before un-racking your bike and only take it off after racking your bike. Simple safety concept.
INTERNALIZE – Think about your race and your goals. You will be in transition prior to your race for some time, so relax and think things through. Put headphones on if need, block out your surroundings and calm your nerves, breathe and think things through.
JUST PRACTICE: Practice every aspect of your transition time. Know what you need, where it will be placed, and practice getting it on, off, in or out.
KNOW YOUR WAY AROUND: Walk around transition and check everything. Know where you swim in, bike out, run in, run out and where the entrances and exits are. If you have bag pegs such as in Ironman races locate and visualise where it is and make a plan for easily locating it. Same with your bike. Find something that corresponds with your line of bikes – a banner, a light post, a marquee, a tree.
LOCK LACES: There are plenty of different triathlon shoe laces available to help speed up your T2 experience. These laces help set your shoe fit pressure perfectly and enable you to just slip your shoes on with no lacing up. A cheap and time saving essential.
MOUNTING & DISMOUNTING: Check for the bike mount and dismount lines. Learn where they are on tour transition walk around.
NUTRITION: Most nutrition is taken in on the bike leg of Triathlon. Make sure you have your bike nutrition bags on your bike or tape energy bars or gels to your bike or tri bars. On rough surface courses make sure your bike cage bottles are secured as the behind the seat bottles are known to pop out over bumps.
OVER-INFLATION OF TYRES: If your bike is left in transition overnight it is good to lower your tyre pressures quite a bit. It is not uncommon for changes in temperature from night to day, especially in warm climates, to drastically change psi tyre pressure and in many an early transition you will hear tyres popping as people over-inflate them.
PUMP: Bring your own track pump. Don’t annoy other people for their ones. They have their own race and are trying to sort their own kit and get in their own zone. When you’re the 4th person to ask for their pump it gets annoying.
QUEING FOR THE LOO: Unless you’re the first in transition you will soon queue. Leave enough time for your morning needs and bring loo roll just in case!
RACKING: Unless told you can rack anywhere by marshals’, put your bike and kit with your corresponding race number. The ground underneath is not a camping area. Keep your kit close and tidy and think about the small space your neighbours have also. Don’t be selfish with space. Don’t invent space between numbers that isn’t there. Find another space on the rack, don’t push other peoples stuff out the way. If you want a specific place on a non-numbered rack – get there early enough!
SUNCREAM: Put it on early at your hotel when you get dressed. If you put it on after numbering you will have black smudges all over you. But importantly – wear it!
TRANSITION BAG: Can be a bag or a crate. Read the race instructions to see what you can leave in transition. Think about what you can carry easily whilst pushing a bike also.
UNDIVIDED ATTENTION: Focus on what is going on in transition. Listen out to announcements for countdowns to race start and be aware of who or what is going on around you during the race itself.
VASELINE OR LUBE: Rubbing the areas of resistance around your neck helps prevent wetsuit burn. Lube around your lower shins/ankles helps remove your wetsuit easier coming into T1. Remember the quicker you get your wetsuit off as you come out the water the easier it is to remove. So start undoing it the second your upper body is out of the water and you are standing up. Equally, a little talc in your bike shoes goes a long way to help with wet or damp feet as many triathletes ride without socks.
WETSUIT – Learn how to put on your wetsuit correctly. It should take quite a while to put on your wetsuit properly and is a 2 person job. Use plastic carrier bags over your feet to help slide them in the lower half and get help pulling it up and also zipping it up.
XTRA TIME – Plan what you intend to do in transition and practice it. On the morning set-up arrive early and give yourself extra time for the unexpected outcomes. Would you have enough time to change a tube if needed or would you be in a mad panic?
YOU: Have time for yourself, you will spend much longer in transition than you think, both before, during and after the race. Think about all aspects before, after and during. Where your keys, phone, wallet, change of clothes will be if not by your bike. Make a plan.
ZEALOUS: Be enthusiastic, eager and excited, be polite and most of all enjoy. Don’t be like A!