Avoidable fear & its undesirable impact on spinal disorders.

undesirable-impact-on-spinal-disorder

One of the most striking features I see everyday in my clinical practice dealing with spinal problems is the fear factor that comes along with them.
fear of backpain

Fear affects multiple aspects of spine health and treatment:

Fear that the pain may be due to a serious or debilitating disease or fear about the treatment options; especially surgical treatment, fear of side effects or complications of treatment, fear about recovery, fear of loosing livelihood or of becoming dependent on others etc.

Almost all the patients with symptoms related to spinal problems have a significant component of fear response. Although some amount of associated fear is considered normal with pain or other symptoms like numbness, weakness of limbs, loss of balance, loss of bladder control etc, an unusual amount of fear and anxiety amplifies the suffering.

The mechanism: 

Pain is a signal that draws your attention to a problem in the body. Pain is a sense that is always associated with some amount of fear naturally. Pain threshold, perception and the response to pain differs from person to person. Our body responds to the painful stimulus by generating natural opioids called endorphins that tend to mitigate the effect of pain. Fear is an emotional response to pain and it elicits an increase in steroid hormone secretion (cortisols) in the body. Corticosteroids, secreted when one encounters stressful situations, inhibit the production of endorphins thereby enhancing the pain perception. Therefore, fear can amplify the effect of pain and also influence the decisions one makes in that situation.

Fear and response:

  • Fear of serious disease or a disabling disorder is a common emotion associated with back pain. Not understanding the cause of pain leads to worry sometimes can lead to severe anxiety and catastrophising behavior. There are several factors that could enhance this kind of fear.

For example, knowledge of a family member or friend being diagnosed with a serious condition like a tumor or infection could lead one to think that he/she is also having a similar disease causing the pain. back pain tension

I often see young and healthy patients with usual mechanical back pain are severely anxious, depressed, with sweaty palms and trembling, some with panic attacks mostly because they have googled their symptoms and self diagnosed themselves with some dreadful disease and think that this is going to cause paralysis or that it is the end of their normal life.

Another important causative factor for unnecessary anxiety is reading your own spine MRI scan report that usually mentions words like a disc bulge or degeneration etc.; terms that represent changes related to natural ageing and exist almost universally in any MRI of an adult spine.

This kind of suffering is totally avoidable.

  • Selective Abstraction: Fear also affects the decisions regarding treatment options. One is overwhelmed with the amount of information and misinformation that is easily available nowadays on different media, which plays a major role in aggravating their fears. There is so much emphasis and attention on the negative aspects of treatment that the real benefits and the positive aspects are ignored or forgotten or viewed with an element of suspicion.

For example, there was a 60 years old lady with back pain and she was diagnosed to have a disease called multiple myeloma, which is a cancer arising in the bone marrow. Appropriate medical treatment can control multiple myeloma and prevent many harmful effects of the disease for many years. But her fear about the side effects of treatment was so great that she opted to take some native therapies. Within a couple of months she developed paralysis due to spinal cord compression and became bedridden. This outcome could have been prevented for many more years if she had taken the right treatment.

Fear avoidance beliefs

  • Past experience of pain due to injury or any activity can lead to anxiety of recurrence of same pain when similar circumstances are encountered. Usually most of us overcome the fear and recover. But in some, the fear of pain leads to avoidance of activity. The threshold for the perception of pain is lowered by the fear of pain and eventually even a light touch may elicit severe painful response at those points. Fear avoidance beliefs lead to an increased avoidance behaviour and it tends to get stronger with time. These individuals tend to develop chronic muscular pains or fibromyalgia, without any real pathology.
  • Avoidance of activity and limitation of movement leads to loss of muscle strength and de-conditioning of the body, disability and depression further increasing the risk of pain at much lesser strain or persistence of pain. The fear avoidance beliefs are a common cause for chronic back pain and also are known to be a cause for loss ofwork.backpain fear avoidance model

 

Every once in a while I see a young patient wanting to quit his/her job due to chronic recurrent back pain, which would actually improve with proper diagnosis, treatment including posture education, appropriate physiotherapy and exercises.

How to deal with it?

Fear is often due to inadequate understanding of the primary cause for the pain. The fear could sometimes prevent the patients from seeking medical advise and lead to aggravation of the problem. 

Educating the patients and family about the nature of problem causing the symptoms is an essential component of treatment which should not be ignored. Once the patients and their families are reassured and all their doubts and concerns are patiently answered, their suffering is greatly mitigated and further treatment becomes easier. Explaining the pros and cons of each treatment option in detail is also essential in helping them in making an objective decision.

Most of the patients who need a spine surgery are initially scared and anxious about the prospect of surgical treatment but explaining the details of the disease and the surgical procedure and explaining about the safety, recovery and probability of complications and their impact helps them in making the right choice without fear.

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Follow these general principles to prevent an excessive fear response to back or neck pain or any other spine related symptoms:

  1. Know that most common cause of the back pain is NOT a serious disease like tumour or infection etc. 
  2. Know that the diseases causing severe or prolonged disability or paralysis are generally rare, especially in younger age group. Visiting a spine specialist will help ensure that you are not dealing with something sinister and guide you in the right direction in dealing with the problem.
  3. Majority of terms in your spine MRI report represent natural age related changes that everyone undergoes; some earlier than others and may not even be the cause for your pain or other symptoms. So, discuss with your doctor before you start worrying about those findings.
  4. More than 80 to 90% of patients visiting the spine surgeon are treated without surgery.
  5. Majority of spine surgery procedures are very safe, with extremely low chances of any major complications. Your spine surgeon will explain the procedure and all the risks involved in detail.
  6. Even if there is a serious disease like an infection or tumour in the spine, appropriate treatment can relieve the symptoms and restore function in majority of the cases, especially if diagnosed in an early stage.

Know all the details and make an informed decision. Do not let the fear determine your spine health!.

About the author

Dr Phani Kiran Surapuraju is a practicing Spine Surgeon in Chennai, India. Trained in one of the top three Medical colleges (Maulana Azad Medical College) in the country. National Board of Examination certified Spine Surgeon. 12 years of Post-MS experience in Orthopaedic Surgery, with 9 years of exclusive experience in Spine Surgery. Special interest in spinal deformity correction and Minimally Invasive Spine Surgery. Fellowships in Spine surgery, including management of complex spinal disorders. (FNB, Univ Of Hong Kong and Univ of Bonn, Germany. )

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