Article by Simon Bell (osteopath)
Not all movements are created equal with regards to back pain. It is my experience as an esteopath that patients often find their pain is eased by one movement yet aggravated by another. For example, twisting or leaning backwards might feel fine but putting shoes on or getting in and out of a car might be a nightmare. Even more interesting are cases where patients find performing the same biomechanical movement, like lumbar flexion, more or less painful depending on the context. Ity means a person could find squatting or bending their knees to their chest easy but touching their toes unbearable.
How It Works
This is all common stuff in practice, but what is it all about? As with most aspects of osteopathy, there is no concrete answer. However, there is an increasing body of evidence to suggest the fear avoidance mechanism (FAM) is a part of it. FAM concerns the body's perception of pain in relation to specific movements and, as is theorised, may cause sufferers to start avoiding activities in an effort to avoid pain As leading pain scientist Lorimer Moseley points out, in extreme cases this can even lead to depression and disability.
When you develop back pain, the body undergoes a protective response to a perceived threat. This could be something as simple as tying your shoes or bending forward or something more complex like cycling or hitting a golf ball. When this process occurs, the body may produce a heightened or disproportionate pain response (i.e. certain movements become a lot more painful than others). This leads to a number of changes:
Pavlov's Dogs and Conditioned Response
Perhaps the most interesting part of FAM is that it's what's termed a 'conditioned' response. The musculoskeletal therapist Ben Cormack likens this to the famous Pavlov's Dogs experiment. In case you need a reminder:
Pavlov found that dogs salivate when presented with food, a completely unconscious or unconditioned response...nothing unusual there! Our bodies behave much the same way. When we are in pain, things are more painful to do and we naturally become scared and apprehensive of movement. However, Pavlov found that getting the dogs to associate a neutral stimulus (in his case, ringing a bell) with feeding caused them to salivate irrespective of whether the food was present or not! This was a good demonstration that the dog's behaviour had become what we'd call 'conditioned.'
And guess what? This is exactly the same for us too. If bending forward becomes painful, our bodies can become conditioned to associate bending forward with pain even when there aren't any actual pain (noxious) signals present! This can cause us to become fearful of moving, feel stiff or have a protective response in the back tissues.
Changes in the Brain
Just as amazing is the effect all this has on your brain. The changes pain makes to neural tissue are well documented (see the work of Diesch and Moseley for a deeper analysis). However, current evidence has led researchers to acknowledge the presence of neurosignatures. Basically, this is the imprint left on your brain after experiencing a meaningful event. The presence of these memories leads us to another potential explanation for long term pain and FAM.
In addition, there also exists the concepts of 'imprecise coding' and 'cortical smudging' which plunge us deeper down the rabbit hole of understanding low back pain. Simplified, the former refers to the tendency of back pain sufferer's brains to present the conditioned pain response we looked at earlier to more generalised tasks/movements as opposed to very specific ones. For example, pain on bending forward can, in the long term, start to trigger even when the patient is doing something that only vaguely mimics bending! The latter relates to the overlapping of nerve signals to the brain that aren't present in people with no pain symptoms. This may give rise to the development of dysfunctional ways of moving in people with back pain and help explain the lack of muscle control some patients demonstrate. Both papers are included as part of recommended reading below.
How We Can Help
Here at Easy Physio, we know how important selecting the right movements are for helping you avoid long term pain and prevent fear avoidance behaviours. Our system devises a programme that is tailored to your level of back pain and provides you with the support and expert knowledge you need to get back to pain free movement and take back control of your condition in every step of your recovery.
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