This is the second part of a blog about back pain. This blog deals with the MBS approach to understanding back pain. How can back pain occur in the absence of something wrong with the back? There is a way to explain this based on new research into how the brain changes over time (neuroplasticity). One way is to consider what happens in phantom limb syndrome. In this situation, there is pain in the area of the body that is missing; that has been amputated. Clearly, there is nothing wrong with the area where the pain is felt, yet there can be severe pain. In this case, the pain appears to be due to sensitization of nerve fibers that go back to the brain, amplification of pain in the brain and a conditioned response of nerve fibers going back to the body. The brain and body have in essence learned to have this pain. The nerve connections have gotten fired after the amputation, but then have gotten “wired” and keep sending pain signals, which are felt to be in the amputated limb. It is likely that back pain (and other pain syndromes, including headaches, abdominal and pelvic pain, whiplash, fibromyalgia and TMJ pain) is caused in many people by similar nerve pathways. What triggers this type of back pain to start and become chronic? The answer is surprising and even offensive to some people and that is stress and emotional reactions to stressful events. A classic study showed the Boeing employees over four years and found that psychological stress predicted back pain much more than any other variable, including how much they used their back on their job. Other studies in Sweden, Holland, and England showed similar findings. In fact, job satisfaction is the most important factor that appears to determine if someone will develop chronic back pain or return to work after back surgery. How can stress cause back pain? Simply put, the brain and the body are one; they are intimately connected and it is impossible to have anything occur to one that won't affect the other. If you stub your toe, the nerves send signals to the brain, which are interpreted in the brain as pain. If you get embarrassed, your brain sends signals to your face to cause blushing. The fascinating thing about the relationship between the mind and the body is that it is not a one way street, it is a broad highway of nerve signals that go in both directions at the same time and any changes in the body will affect the brain and any changes in the brain will affect the body. Most people would consider that we are aware of our emotions and that these emotions can cause reactions in the body, such as the stomach tightness that occurs with a sudden stressful event. However, we now realize that emotions cause reactions in the body before we can become aware of even having that emotion. This occurs because we need to survive and the best way to survive is to react before thinking. William James, the great psychologist, explained that it is not correct that we “see the bear, get afraid, and then run” but rather that we “see the bear, run, and then feel afraid.” When stressful events occur, it is known that the muscles of the body can tense up. In fact, the body is capable of tensing very specific muscles during a stressful event. It is not necessary to be aware of any emotions at all. The body may react to stressful events while we may not be aware that we are troubled by something. This occurs because the centers in the brain that cause reactions in the body are in the sub-conscious part of the brain, particularly the hypothalamus, which controls the fight, flight or freeze reactions. There are two typical ways that back pain can start. One is with an accident, an injury, or with back movement. In this case, there is usually some degree to tissue damage due to the injury. The pain associated with the injury will usually decrease over time and go away once the injury has healed. If there is no serious medical damage, such as a fracture or an injury that damages the spinal column or nerves (doctors can diagnose these conditions with X-rays, MRI's and by a neurologic exam, of course recognizing what we discussed above that an MRI abnormality is often not diagnostic of a medical condition if the neurologic exam is normal), then the pain should improve within a few days or weeks. However, the pain signals that start in the back and go to the brain can get “learned” as mentioned above and a vicious cycle can get started. Who is more likely to have this vicious cycle begin? The development of chronic pain is most likely in those who are the most stressed or distressed at the time of the accident. The brain has an area called the anterior cingulated cortex (ACC). This part of the brain amplifies pain signals and is activated by stress and emotions. Therefore, once the vicious cycle gets learned by the nerves, and this signal gets amplified in the brain and then muscle spasm and tension increases which increases pain. Back pain can also start without any injury or accident. In this case, the muscle tension is started by the nerves coming from the brain in response to emotions (whether these emotions are recognized or not) and pain ensues. Once the pain occurs, the vicious cycle can become learned just as in the example above. Over time, if the back pain doesn't go away, the individual is likely to become less active and begin to worry and develop fear. These things exacerbate the pain by causing more muscle tension. The longer the pain lasts, the more likely that the individual will develop frustration, exhaustion and depression. The patients that I see in the Mind Body program are usually desperate and view this program as their last chance because they have tried everything else and nothing has helped. The only way to cure most people with back pain, i.e. those people who do not have cancer, a fracture, or an infection causing the pain, is to get to the underlying cause of it. An MRI will not give accurate information on the cause of the pain. If the neurologic exam is normal, the pain is most likely coming from the Mind Body syndrome, i.e. this vicious cycle of nerve connections that can create and perpetuate pain despite the absence of a serious medical tissue disorder. The purpose of the Mind Body educational program is to identify the causes of the vicious cycle and to interrupt these connections. That is the best way to eliminate the pain. In addition, people who take this program learn to understand themselves better and gain more control over their lives. To your health, Howard Schubiner, MD Disclaimer: It is important to recognize that the information contained in this blog, whether posted by me or anyone else, cannot be considered to be specific medical diagnoses, medical treatment, or medical advice. General information about MBS/TMS will be posted in response to questions, but you will need to decide if this information is relevant to your situation and, as always, you should consult with your physicians and counselors regarding new symptoms and any changes that you might make in medications or activities.