The Social Aspects of Low Back Pain: A Personal Frustration
Being a clinician for nearly 30 years, I have seen many changes in rehab. Some have significantly, and abruptly, changed the way I assess and treat my patients. Others have been more gradual. Finally, even others have fallen by the wayside. In this post I want to share a personal experience of back pain, as well as my reflections in dealing with it.
Sorry, But This is About Me
In this picture, one of us had surgery, the other hurt themselves carrying this family member up and down the stairs. These positions adopted by the both of us are the only positions of comfort.
I suspect the strong majority reading this are, like my family, most interested in the one who underwent surgery. Well, sorry, this is about me. I think it will be informative so please don’t leave. My family is doting over the surgery family member. I need some attention.
Lola, our beloved 4-year-old German Shepherd, had a right hip replacement. She really is the story here. I will devote more attention to her in future posts.
I have become fascinated with my own story in this current situation though. The pain, disability, emotions, etc. of my current situation have been fascinating upon reflection.
Briefly, I noticed a gradual onset of right low back and buttock/lateral hip pain after carrying Lola a few times up and down the stairs. I woke up with a strong, distinct grabbing pain in my entire low back, right posterior-lateral hip and heaviness in both my low back and down my legs (right leg to the foot, left to the knee). It was constant at an 8/10, down to 6/10 in the above position. I would get (and still do) sharp, stabbing pain in the right SI joint and right lower back. I have a painful arc of movement and have trouble pushing through it. When I do, my legs feel like they are going to give out. They feel heavy, cold and tingle. I have a Gower’s sign.
I could not stand upright (lack about 10 degrees) and had a right lateral shift. I do have a 30-year history of low back pain, but only one episode comes close in comparison to this one. That episode, about 15 years ago caused me to miss 1.5 weeks of work, get on muscle relaxers and opioids and feel ‘out of it’ the whole time. I was destined to avoid all of this.
I stopped carrying Lola (which put significant strain on other family members), avoided any meds and was constantly doing ‘movement snacks’ as Ben Cormack would call them. The movement snacks were helpful, but short lasting. It was also exhausting. The more I did the more heaviness I felt about 20 minutes later, but they did give relief. When I went for a walk, I noticed increasing effort to advance my right leg forward. It felt weak, tight, heavy and like it was dragging. It eventually felt like it was burning. My foot felt cold. By the end of a 20 minute walk my leg was so heavy and weak I could not swing it through past mid swing.
If I was not a PT and was describing such a presentation to a PT, I suspect some red flag concerns may come up. Surprisingly, I was not at all concerned. I was (& still am) mostly frustrated with the exhaustion of the pain. It is unrelenting. The only times it feels good is in full child’s pose as above and some type of unloading (e.g. leaning on a counter). No other position is comfortable and gets much worse after about 5 minutes. I would get (and to a lesser extent now) sharp stabbing pain with all transitional movements. Again, it is mentally and physically exhausting…and, at this point it has only been 6 days.
I am mostly though frustrated with the load it has put on my family. My current condition increases some of their medical issues (will keep this out of the story, but these issues are much more significant than mine).
You Better Check Yourself!
I decided to test myself. I took the full version of the OSPRO. I scored positive for fear avoidance and self-efficacy for rehabilitation. What?? Fascinating! I simply do not agree. The question of “I can’t seem to keep it out of my mind” scored infavorably. Well, of course…it is a frickin constant 6/10 and affects everything I do. I am not fearful of it. Also, don’t start with me on whether or not I’m suppressing, etc. It HURTS!!! The question“My work is too heavy for me.” was relevant. Yes, remember, lifting Lola was painful. Apparently, my current tolerance is below Lola’s weight. I know my situation is normal. I don’t have sensation loss, the heaviness is not myotome weakness, reflexes are normal (the benefits of having a daughter in PT school). Yet OSPRO is trying to convince me otherwise. I am sure other scales would do similar.
I was going to take other PROM’s (e.g. PROMIS) but didn’t want to catastrophize myself further. It hurts. It affects everything I do. I have had it before. I do not have red flags. The concerning symptoms are reasonably explained. I just want it to stop. Simple as that! Sometimes it is relatively normal MSK related pain that wears on you mentally because it keeps you from doing what you want and need to do…stressing the rest of your environment. I don’t need to talk about it, I simply need it to go away.
On that front. I broke down and started taking Ibuprofen interspersed with Tylenol. Each day has been better. Placebo or real? My pain is now 6/10 at worst and 2/10 at best. I can sit for 20-30 minutes. I feel like I could now lift Lola. I feel like I could go hiking again. I feel like I could ride my stationary bike again. But I will progress my walking speed and duration first. I will progress my sitting and working at my desk first. I will continue to avoid washing dishes…after all, that was painful every time (there may be psychological undertones on this one I must admit).
Not to ignore psychological, but I will let my ability to perform functional tasks be my measuring stick. Yes, of course, the social demands, frustration and physical manifestations could affect my psychological outlook of the situation. But, honestly, I am simply frustrated. That is all! Why make it more than what I, the patient, make it out to be?
As I reflect on all of this, I wonder how many times I may have “yellow flagged” someone based on PROMs, etc.. I know I have “bio’d” many individuals. Have I always dug deep into how their situation is truly influencing them? Not psychologically, but socially? Perhaps the weight of their situation is bigger than either bio- or psychologically-related? Perhaps it is the sole issue in their mind?
The timing of this quote “The narrow focus on biological factors and cognitive behavioural change is inadequate to address the complexities of LBP” from a recent paper1 eloquently expresses my current situational frustration.
How does my back pain and current ability make me feel? Frustrated. I don’t need compassion or empathy. I don’t want to talk to you about it. Tell me what to do to make it go away! My dog needs me!
-Hip replacements in a 4 year old, majestic pup suck!
-Do you ever wonder what an animal is thinking when they are injured? This has been a big portion of my recent reflections.
-Low back pain is not fun.
-Consider all portions of your examination with necessary caution.
-Sometimes trunk flexion, both loaded and unloaded, can be pain relieving.
-Sometimes pain medication helps…for whatever reason.
-Sometimes people simply are frustrated with their pain and how it limits their social function.
-Social is a big part of our model and approach (as is psychological).
-We have increased our emphasis on psychological.
-I am not convinced we do a good job of truly measuring the social impact of an injury/pain/disability. I know I will once again change a portion of how I practice.
-I have to finish this off. I need to walk my dog down a ramp so she can do her business outside. I am also having numbness in my right foot, which I have had prior and I know will go away.
Frustrated bio-social patient
- Mescouto K, Olson RE, Hodges PW, Setchell J. A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disabil Rehabil. 2020 Dec 7:1-15. doi: 10.1080/09638288.2020.1851783. Epub ahead of print. PMID: 33284644.