SIRPA Blog Chronic Severe Low Back Pain Attributed to Spinal Degeneration

Since the 1970’s MRI research has shown that spinal degeneration is just as common in people without pain. This case study demonstrates the truth in this.

A Case Study of Treatment by SIRPA Recovery Programme

ByGeorginaOldfield MCSP

Chartered Physiotherapist and Founder of SIRPA

David D. Clarke, MD

Clinical Assistant Professor Emeritus,OregonHealth & ScienceUniversity

Portland,Oregon,USA

Background

The enormous cost of chronic pain in the UK, both to health care and to business, is rising.1,2,3 Despite many forms of physical intervention and regulations to prevent injury, back pain, repetitive strain injury and whiplash continue to increase.4,5 Possible solutions lie in the development of more effective interventions for back pain.6,7 Even better, many studies are demonstrating the benefits of educational and psychologically focused approaches to managing chronic pain.8 – 14

For example, the pioneering SIRPA Recovery Programme (originally the TMS Recovery Programme) offers a cost-effective solution to chronic functional pain and other symptoms by using a mind-body approach to address the root causes of these conditions. This programme was originally based on the work of John Sarno MD, with numerous retrospective clinical audits, case studies, and more recently random controlled trials demonstrating the effectiveness of a psychophysiological approach.15,16,17,18 For example, several studies show that imaging evidence of spinal degeneration19,20,21,22,23,24 is equally common in subjects with and without symptoms. Therefore, “the discovery by MRI of disc bulges or protrusions in people with low back pain may frequently be coincidental”.24

Research is also demonstrating that stress and emotions affect persistent pain. This has led to most NHS Pain Clinics having Cognitive Behavioural Therapists within their Pain Management teams. Unfortunately, these teams don’t work on the premise that they can cure the pain, but merely teach patients how to manage or cope with it. In contrast, the SIRPA Recovery Programme is demonstrating how uncovering and treating the hidden stresses causing a condition can result in its complete reversal.

Research supports this concept. For example, the best predictor of persistent pain after injury is not the severity of the injury but rather such factors as cumulative traumatic events, high levels of depression and even belief that pain might be permanent.25 In another study of low back pain in student nurses, the key factor linking all the episodes of pain, other than a past history of low back pain, was psychological distress.8

The Concept of Stress Illness

The autonomic nervous system is strongly affected by emotions and causes a variety of responses throughout the body.26,27 The most common example is the body’s response when danger is perceived.

The symptoms of Stress Illness result from and provide a release for built-up emotions that have no other outlet. Emotions trigger the brain to activate the autonomic nervous system, causing a response in the body. The response is often quite specific for each individual, activating nerve pathways that then become sensitised, resulting in chronic pain. Fortunately, the symptoms of Stress Illness are reversible and full recovery is possible.

Treatment begins with an explanation of how and why symptoms are produced. Next is an effort to find the links to stress and specific triggers relating to an individual’s condition. Acknowledging the underlying emotions, past and present, starts the process of recovery. Learning self-care techniques, such as journaling and mindfulness, allows the patient to become empowered in their own health and well-being. Recognising the contribution of self-induced pressures and how they interact with external stress is another way for patients to make positive changes.

Case Study

Subject: 39 year old lady Paula (not her real name)

Presenting Condition: Early in 2009, Paula suffered a week-long severe exacerbation of chronic low back pain, with paresthesias down both legs.

Paula’s back pain episodes had begun 5-6 years ago and worsened in severity and frequency since then with a severe setback in 2007 that continued for six months despite conventional Physiotherapy. Despite limitations due to her back, she was able to continue working during this time. Towards the end of 2008 her back “went” again. She struggled on with medication. She then became ill with ‘flu which seemed to exacerbate her back pain until Paula was struggling to move. Tramadol prescribed by the Doctor caused severe side effects. When she became housebound early the next year, she called one of us (G.O.) to see her.

Subjective Examination:

Paula complained of constant “grinding pain” over her left Sacro-Iliac joint spreading around the hip area and up the left side of the lower spine. The pain was at a level of VAS 2-3 out of 10, which reached 10/10 due to severe spasms with any slight movement causing her to keep her back rigidly still. She was also complaining of constant altered sensation laterally down both legs from the hips to the ankles and with tingling in the soles of both feet. On the Measure Yourself Medical Outcome Profile (MYMOP), used as an outcome measure, she scored 5.75, where the maximum is 6.

Objective Examination:

The physical assessment was limited due to her severe pain. The spine was shifted to the right in standing and the only movement possible was some rotation to each side. Palpation of the spine was not possible due to pain, spasm and inability to lie down. Neurologically there was altered sensation down both legs crossing dermatomes L2 – S1 with no S1 reflexes bilaterally.

D.H.: Diclofenac prn

PMH: An accident to her back as a teenager. No treatment had been required, yet Paula had always believed this to be the root cause of her long-term back problems.

Test results: Lumbar x-rays in 2005 indicated some degenerative changes.

Lumbar MRI – Degenerative changes of the lumbar spine with bulges of the discs between L3/4, L4/5 and L5/S1

Treatment:

Paula was familiar with Stress Illness after observing two friends successfully treated for severe back pain with the SIRPA Recovery Programme. Despite this, Paula waited 18 months before seeking this approach for herself. This illustrates the common difficulty of accepting that significant physical symptoms can result from stress.

After ruling out other serious causes, such as cancer, infection, fracture and auto-immune disorders, the next step was to acquire an in-depth history of her psycho-social stresses. This included traumas and stresses from childhood through the present, her relationship with her parents and personality factors and learned behaviours that might cause self-induced pressure. A timeline was drawn up to look for chronological links between Stress Illness symptoms and difficult events in her life.

Causes of Paula’s Pain

When Paula was a young child, her mother was diagnosed with a degenerative disease and quickly became wheelchair bound. Paula became her mother’s carer, while also helping her ill grandmother and managing the household. She became skilled at looking after everyone but missed out on the innocence and frivolity of childhood and never learned the importance of self-care.

As an adult, Paula had her own family, doing everything for them and never allowing anyone to help her. She would go out of her way to help others and was constantly on the go, never sitting down for long because she feared she would end up in a wheelchair like her mother and grandmother. Paula also had a nearly fatal accident a few years previously and had been supporting two friends with major illnesses, not realising the burden this was for her. Her self-care skills were poor and she never did anything purely for herself, so all these together resulted in growing emotional turmoil for which the symptoms provided an outlet.

First Stage of Recovery

As the assessment progressed, Paula gained insight. Slowly, she began to recognise how much self-induced pressure resulted from her need to care for others and from being so conscientious and perfectionist. She began to relax in the chair and started feeling more comfortable. When the assessment ended, she was able to stand and move without severe spasms of pain.

Over the next few weeks, Paula spent at least 15 – 30 minutes daily learning more about Stress Illness from written educational material. She also made a list of stresses she had experienced and then used emotional journaling as a way to offload her feelings about them. This helped put her experience into perspective and enabled her to begin letting go of powerful emotional drives that were counter-productive. She began to focus more on her own needs.

Progress

Within a couple of days Paula was able to go outdoors and within a week was back at work. Paula continued to follow the full Recovery Programme with support and guidance from SIRPA and used a number of tools in the SIRPA Recovery Workbook to help resolve her pain and prevent recurrence. This included a number of life skills to modify the behaviours that caused self-induced pressure, plus tools to help her acknowledge emotions as they presented. Her pain resolved quickly, achieving complete relief after about 5 weeks. She regained full range of movement, normal sensation in her legs and normal spinal reflexes, indicating that this programme had not just resolved her pain, but her neurological signs too.

Life Changing Results

Over the past 2 years Paula has moved wardrobes, climbed trees and gone down zip wires, landing on her back without any problems. Increased stress sometimes brings back mild aching, but this resolves quickly once she recognises that inner turmoil was taking place.

She has also lost 3 stone and says, “I feel like I have my life back and I am doing all the things I’ve been unable to do for 20 years.” She now has the tools to cope with any stress in her life and prevent further stress-related symptoms, whether these are musculoskeletal, organic or mental health.

Discussion and Conclusions

It is likely that several million people in the UK suffer from Stress Illness with symptoms including but not limited to headache, tinnitus, fibromyalgia, globus, dysphonia, TMJ arthralgia, difficulty breathing, itching skin, irritable bowel syndrome, nausea and/or vomiting, paresthesias and, of course, pain which may develop nearly anywhere. It is a medical tragedy that more clinicians do not consider this possibility, particularly for those patients without a confirmed cause for their symptoms. As Paula’s example clearly shows, the potential for an excellent outcome is present even in seemingly hopeless situations.

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