One of the more daunting challenges that may occupy us as we grow old is cultivating an ongoing relationship with pain. I’m not talking about acute discomforts, like the current throbbing in my swollen cheek following a recent bout of oral surgery; I’m talking about becoming acquainted — and reasonably comfortable — with the chronic pain that tends to plague so many of us. And there may be no better example of this curse than the betrayal of the lower back.
A 2021 report from the Centers for Disease Control and Prevention noted that nearly half of all U.S. seniors suffer from some degree of back pain. And those who are forced to deal with it on a regular basis will tell you that they feel its effects both physically and psychologically. As it limits mobility, for instance, that aching back may also increase anxiety, encourage social isolation, and invite depression.
Conventional treatment approaches — surgery, physical therapy, injections, muscle relaxants — can help relieve the pain, but a couple of recent studies suggest that the most promising solution requires that we simply get better acquainted with it.
Researchers from the University of Pittsburgh and the University of Minnesota recruited 1,000 participants with acute or subacute low-back pain who, when screened, were found to be at a moderate or high risk of developing chronic pain there. They were randomly assigned to one of four groups for up to eight weeks of treatment. The groups included:
- a supported self-management (SSM) group, where a physical therapist or chiropractor offered exercises, relaxation techniques, pain education, and strategies for reframing psychological perceptions about pain;
- a group focused on spinal manipulation therapy (SMT), where participants learned manual therapy techniques, such as soft tissue mobilization and lumbar neural mobilization;
- a group that combined SSM and SMT;
- and a group offering conventional medical care from physicians using anti-inflammatory medications and muscle relaxants.
Measuring levels of pain 10 to 12 months later, researchers found that participants assigned to the self-management group fared much better than those in any of the other three groups. Their pain levels were significantly lower when compared with those who received conventional medical care or practiced spinal manipulation. And, they noted, adding spinal manipulation to the self-management approach did not result in any additional benefit.
But these results might be explained less by the exercises or even the relaxation techniques, according to the researchers, than by the psychological shifts participants in that group were able to put into practice. The results, published in JAMA Internal Medicine, show that less-negative thought patterns about pain and a reduced fear of movement were responsible for 76 percent of the SSM treatment’s effect.
That’s not to say that spinal manipulation can’t be an effective approach, notes the study’s co-principal investigator, Michael Schneider, DC, PhD, a professor in the University of Pittsburgh’s School of Health and Rehabilitation Sciences. “The dramatic responders to manipulation are people with acute pain who aren’t afraid of their pain. They tend to get better quickly,” he explains. “But people with fear of movement and higher psychological risk — you can’t just manipulate their spine and expect them to get better without addressing their fear of pain and movement. For those patients, supported self-management can be the winning strategy.”
In a sense, Schneider is saying that we need to get to know our pain and get comfortable with the discomfort it causes in order to manage it effectively. Or, as Jon Kabat-Zinn, PhD, puts it in his book Mindfulness Meditation for Pain Relief, “Pain may be unavoidable at times, but suffering — in other words, how we relate to the pain — is optional.”
Kabat-Zinn is perhaps best known for developing the Mindfulness-Based Stress Reduction (MBSR) program that has expanded since its introduction in 1979 as a somewhat exotic public health initiative to become a popular offering at more than 720 medical centers and clinics around the globe. Most recently, researchers at Boston Medical Center (BMC) utilized it to learn whether mindfulness meditation can help people with chronic low-back problems reframe their response to pain and improve their quality of life.
“What our program does is give people real, repeatable skills for how to respond to pain differently,” explains lead study author Natalia Morone, MD, a BMC primary care and internal medicine physician. “Once patients have those skills, they also seem to carry them forward and we see improvements lasting beyond the program.”
A version of MBSR is designed to treat the anxiety that pain can trigger, and that’s what Morone and her team used to help 451 study participants shift their thinking about their chronic low-back issues. Researchers randomly placed about half of the participants in the MBSR group and the others in a control group that received conventional medical care. All participants reported “moderate pain interference” at the beginning of the study period.
A mindfulness instructor and a primary care physician conducted the online MBSR sessions, which included stretching exercises and mindfulness activities, over an eight-week period — all designed to help participants work with, rather than against, their pain. Researchers subsequently tested participants from both groups to determine their perception of pain six, eight, and 12 months later. At each juncture, the MBSR group had a “statistically significant improvement” in their quality of life when compared with the control group. The results were published last week in JAMA Internal Medicine.
“We have evidence-based guidelines, but the challenge has been getting those approaches to more people,” Morone says. “If we can bring evidence-based treatment into primary care and build a model the healthcare system can sustain, we have a real opportunity to help far more people. That’s what drives this research — getting effective care to the people who need it most.”
Thankfully, I’m not one of those people, though there are times when the arthritis in my neck makes me think I should draw upon my 30-odd years of meditation practice to focus on getting to know that pain a little better. The throbbing I’m currently enduring in my swollen cheek, on the other hand, does not seem to be particularly amenable to any sort of relationship. That’s why there’s ibuprofen.
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