The Circles of Pain and Recovery: A Biopsychosocial Approach to MusculoskeletalPainBy Bruce I. Kadish, PT CertMDT

Muscles, bones and jointsdon't feel pain. People do. Howwe evaluate our musculoskeletalproblems (what we believe andfeel about them) can make a greatdifference in our ongoing experi­ence of pain, including how muchpain we feel, how distressed wefeel because of it, how disabledwe may become as a result, andwhat we do to get better. Thesemay all affect and be affected bythe social environment of family,work, health care practitionersand the larger society.

Recognizing this, many re­searchers show increasing interestin the role of psychosocial factorsin the origin, continuation andtreatment of back and other mus­culoskeletal disorders. In whathas been called the "biopsycho­social" approach by GordonWaddell, so-called physical (bio­logical and mechanical), psycho­logical and social factors worktogether to create or ameliorateproblems.'

If biological (including activ­ity-related), psychological andsocial factors always play interre­lated roles in musculoskeletalproblems, does it make sense totreat them as if they were entirelyseparate and isolated? Even whenwe focus on one particular aspectwe may be affecting other aspectsas well. Indeed, as practitioners ofMechanical Diagnosis and Ther­apy (MDT) know, adequate activ­ity-related assessment can revealpart of the biological aspect of aproblem in a way that can alsohelp build a positive psychosocialclimate for the person experienc­ing pain and disability.

This article presents a biopsy­chosocial approach to activity­related musculoskeletal pain. It

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fits together the various factorsmentioned above into a posture­movement model to explain howsuch pain gets started, perpetu­ated and then resolved.? Themodel shows how the variousfactors work together in interact­ing circles of negative feedbackIoops.> Understanding the circu­lar causation implied in thismodel has practical significanceand can enhance the problem­solving partnership of practitio­ners and their clients. To empha­size the personal and practical, Iwrite as much as possible, as apractitioner speaking to a patientin the second-person "you." In thefollowing discussion, I will focuson the example of back pain, eventhough the model relates to othermusculoskeletal problems aswell.

The Circle of Injury and Pain

Figure 1 shows the first half ofmy posture-movement model. Itshows important stages (italicizedin the text) in the process of ini­tially responding to injury andpain. The key below lists andbriefly defines these stages. Un­fortunately, the useful process ofinitial response to injury cansometimes lead to a self­perpetuating vicious circle of dis­use and pain, which I explain inthe section following this one.

An initial injun) occurs. As theresult of some visible trauma,bone, muscle, joint capsules,ligaments, discs, nerves and othertissues are affected. Forces strongenough to bruise, stretch, tear orcompress one or more of thesetissues of the spine may causeimmediate pain from the damag­ing stress.

Physiology texts traditionallyhave focused on the importance

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of a sudden reflex-like withdraw­ing from the source of damage atthe time of this senson) impact.This can be represented in thediagram by the arrow leadingfrom senson) impact to altered mo­bilih) and back to sensorq impact, arelatively simple lower-levelfeedback loop. However, painresearcher Patrick Wall considersthis kind of reaction trivial andrather over-emphasized in peo­ple's efforts to understand humanresponses to pain."

Following the immediatedamage, sensory nerves in thearea respond by releasing chemi­cals that dilate local blood vessels.These can also stimulate pain. Inaddition, products from the bro­ken cells of damaged tissues andthe enzymes that break downthese products both providechemical irritants that can triggeradditional pain. 6

Thus begins the process ofinflammation and its familiar signsof swelling, redness, heat andpain. In a peripheral injury, suchas a sprained wrist or ankle, wecan observe this more easily thanin a back injury. The swellingwalls off and isolates the area ofinjury as fluids from the dilatedblood vessels move into the tissuespaces. White blood cells alsomove into the area to clear up thedamaged tissue.

Inflammation provides the ba­sis for repair of damaged tissues.Cells called fibroblasts begin theprocess of forming new connec­tive tissue. New blood vesselsand nerve fibers may also grow.This process of healing creates ascar that knits together the brokenelements. Both the swelling andthe cellular cleanup and healingoperations may provide chemical

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•

"'--~

•

•

••

•

Environment

In~tial :> Sensory Impild

lftl, I

Inflammation

Figure 1- The Potentially Vicious Circle of Pain and Disuse

Key to Figure 1

Environment: As organisms-as-wholes-in-environments we transact with objects and processes suchas air, food, gravity, etc.; other organisms (microbes, cats, dogs, etc.); other people and the resultingsocial-cultural processes (language, beliefs, etc.). The environment of each individual's nervous sys­tem also includes what goes on inside and on the skin. "The animal does not merely adapt to the en­vironment, but also constantly adapts the environment to itself."4Initial Injun): Visible or microscopic disruption or damage to soft tissues of body (muscle, joint, disc,ligaments, etc.) through undue application of force.Inflammation: Sequel to injury characterized by swelling, redness, heat and pain. May also result frominfection and from certain inflammatory diseases.Sensory Impact: Immediate information (feedback) about internal and external environments.Non-Verbal Experience: Higher-level nervous system processes of which organism has awareness.Shared by humans and other animals. Involves 'thinking', 'feeling', perceiving without words.Attitudes, Beliefs, Expectations: 'Thinking', 'feeling', perceiving expressed and elaborated in words andother symbols. Through complex, circular feedback mechanisms, these are both influenced by and in­fluence ongoing Sensory Impacts and Non-Verbal Experiences.

• Altered Mobility: Efforts affected by and further affecting our experience of injury and/or pain. In­cludes withdrawal from external source of damage (considered trivial) and more important stage ofguarding (protective holding) of painful area.

• General Posture-Mooement Patterns: Global organism-as-a-whole changes of posture and movementrelated to Altered Mobilihj. Posture-movement patterns can develop as a response to local changes inmuscles and joints following injury, inflammation and healing. They may also be based on imitationof others, on emotional factors, e.g. slump of depression, and may become habitual.

• Local Soft Tissue Changes: Local tissue changes in joints, ligaments, discs, muscles, etc., related to Al­tered Mobilih) following injury, inflammation and healing of these tissues. May also occur as conse­quence of continuing guarding and immobility and as a result of poor General Posture-Movement Pat­terns.

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sources of inflammatory pain?

This inflammatory responsecan occur not only with injury butalso in cases of inflammatory ill­nesses, such as rheumatoid arthri­tis. Such illnesses involve the in­appropriate activation of an in­flammatory response due to somemalfunctioning of the immunesystem. The chemical by-productsproduced during such an episodecan also result in tissue destruc­tion. Posture-movement relatedproblems may exist once such anactive episode has passed.

The sensory impact of injuryand inflammation continues on­goingly. The upward-directedarrows from sensonJ impact to non­verbal experience to attitudes, beliefs,expectations represent various lev­els of the nervous system experi­ence of pain. The sensory impactand non-verbal experience stepscan be understood to representthe input side of a complex hier­archy of negative feedback con­trol.

A downwardly-directed arrowmoves from attitudes, beliefs, expec­tations towards altered mobilib],This arrow has breaks in it to in­dicate that the influence of thehigher level of beliefs, expecta­tions, etc., is not direct. Rather theoutputs of higher levels exerttheir influence on lower levels byproviding internal standards (ref­erence signals) which ultimatelyaffect the actions of the individ­ual.

The arrows pointing in to­wards and then out from lowerlevels indicate that beliefs, etc.,affect non-verbal experience; beliefsand non-verbal experience in turninfluence the level of sensory im­pact. The full extent of these influ­ences includes internal changes inthe nervous system (such as dis-

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cussed in the Gate theory of Mel­zack and Wall) and hormonal andimmune system changes, as wellas observable efforts that youmake if you feel pain. All of theseoccur within an environment, both'physical' and 'social', which in­fluences and in turn is influencedby what you do.

Your pain may tend to power­fully capture your attention; yetyour immediate environment,other concerns that you attend to,the meanings you give to thesituation, your beliefs and expec­tations (both personal and cultur­ally-derived) may all have veryreal effects on your ongoing ex­perience and on your physiology.This provides the basis for under­standing the beneficial (placebo)or harmful (nocebo) effects ofsuggestions and expectations."

Psychiatrist and neurobiolo­gist J. Allan Hobson writes:"...consciousness is causal, and ina very material way... sincesubjectivity is itself a brain[nervous system] function, it verynaturally can redirect its own en­ergy from one neural region toanother. "9

Let's return to what happensfollowing an injury. You can tracethe arrows directed out and to theside from non-verbal experienceand from sensonJ impact and fol­low their path to altered mobility.These arrows suggest the organ­ism-as-a-whole-in-an-environ­ment process related to postureand movement that takes placeonce damage has occurred andinflammation has set in.

The process of altered mobilityfollowing injury involves guard­ing, reducing the amount of localmovement in the damaged areato allow the repair process toadequately take place. As Wall

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describes it:

"All of us have minor acci­dents several times a year, oftenso minor that we may forgetthem, but, during the recoverytime, we guard the damaged area,protect it, and move it as little aspossible. That motor behavior,which is the opposite of thesudden brief withdrawal, is cru­cial for recovery because the areaof damage cannot complete theinflammatory and recovery proc­esses if it is moving and underpressure."lO

Guarding a damaged area af­ter an injury constitutes a healthyand necessary process. It com­pletes a negative feedback loopby providing the means for con­trolling the ongoing sensonJ im­pact and thus reducing the non­verbal experience of pain. It allowsthe process of recovery to proceedwithout further aggravation. Wallpoints out the disastrous conse­quences of minor injuries forthose people who have a rarecondition called congenital anal­gesia. These people do not ex­perience pain and subsequentlydo not guard their movements,thus continuing to damage theirjoints, increase inflammation, etc.11

Guarding actions involve theorganism-as-a-whole. To indicatethis, an arrow points down and tothe right from altered movementtowards general posture-movementpatterns. This outward-pointingarrow and the reverse arrow rep­resent global changes in postureand movement related to local­ized altered mobility followinginjury. Wall notes:

"Joints are splinted by thehighly unusual, steady, simulta­neous contractions of all of themuscles that can move the joint.

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Dogs are a wonderful example ofthe widespread readjustment ofmuscles produced by a small in­jury to one foot. They switch ef­fortlessly to a three-legged gaitwith one foot steadily flexed. Thisrequires an instant reorganizationof all the leg and body muscles.And so it does with US."12

Changes in general posture­movement patterns can occur bymeans of feedback loops of con­scious and unconscious behaviorthat control potentially painfulperceptions.

These posture-movement pat­terns are associated with otherorganism-as-a-whole changes in­volving the autonomic nervoussystem, which regulates the hor­mone-secreting glands, the heartmuscle and the smooth musclesof the blood vessels, gut andother internal organs. Under calmconditions, there exists a balancebetween the parasympathetic andthe sympathetic parts of this sys­tem. The parasympathetic systemgenerally slows heart rate, in­creases circulation to the limbsand surface of the body, and aidsthe digestion of food. The sympa­thetic system, the "fright, fight,flight" component, raises theheart rate, shifts circulation to themuscles and body core, and re­duces digestion and movementsin the gut. When you experiencepain, your autonomic balance willtip towards this sympathetic re­sponse of "fright and flight. "13

Another arrow from alteredmobility points up and to the righttowards local soft tissue changes.Here we change the scale of inter­est from general posture­movement patterns to a muchmore narrow focus on particularmuscle, joint, and other tissue

j changes. Various practitioners,

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following differing schools ofthought, have found it difficult toagree on the particular tissue(muscle, joint, disc, etc.) responsi­ble for common back pain. None­theless, injury and the processesof inflammation and healing (viascar tissue formation) undoubt­edly can occur in any of thesetissues. As MDT practitionersknow, testing movement patternsand pain responses can help todetermine what tissue might beaffected. More importantly, suchtesting can help determine theappropriateness of any particularposture-movement strategy tohelp restore normal function.

The Vicious Circle of Disuse andPain

Immediately after injury, in­flammation may predominate.You may feel pain all of the time.With inflammation pain, whatMcKenzie calls "chemical pain,"reducing your movement hassome usefulness.t- However, evenhere some ways of reducingmovement, i.e., staying as relaxedas possible while maintainingneutral postures, may be betterthan "a body fixed in an overallpain posture. "15

Once an injury has occurredand healing has taken place, painand altered mobility may con­tinue past the point where theyserve much useful purpose. Somepains may get incorrectly inter­preted as meaning further dam­age. This leads to continuedguarding of posture and move­ment to avoid the pains that getinterpreted as more damage andlead to more guarding, etc. Youcan trace the circle in Figure 1that goes around and around inthis way.

Wall describes this circle ofdisuse, pain and more disuse as

15

follows:

"Muscles are in steady con­traction and, as time goes by,some muscles grow while jointsand tendons deteriorate because[the] frozen posture sets off localchanges... the problem is to over­ride a natural defense mechanismthat has a protective role in briefemergencies but becomes mal­adaptive when prolonged...movement that produces paindoes not necessarily increase theinjury.. .lack of movement thatseems at first to prevent paineventually acts to prolong pain."16

Many practitioners in the pos­ture-movement field havepointed out that hurt does notnecessarily equal harm. The exis­tence of pain does not necessarilymean the existence of damage.Understanding the kinds of SoftTissue Changes that can occur afterinjury can help us understandand better deal with these notnecessarily harmful pains.

Soft Tissue Changes

Changes in the soft tissues,e.g., muscles, joints, etc., resultingin limited movement, have beencalled "contractures" by physicaltherapy researchers Cummings,Crutchfield and BamesP Theygroup soft tissue contractures intothree main categories:

1. The formation ofadhesions in the muscles, ten­dons, joint capsules, ligaments,etc., as a result of injury andscar tissue formation.l"

2. Adaptive shortening inuninjured muscles and skin thatoccurs as a result of alteredmobility and guarding;19

3. Joint displacements thatinvolve restriction of movement

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"due to malpositioning of thearticular surfaces of the joint. "20

Let's look first at how adhe­sions get formed. As healinghappens, connective tissue cellsbegin producing new fibers thatwill 'fill in' with new connectivetissue whatever tissue has beendamaged. This process, calledscarring, may begin several daysafter a back injury and can con­tinue for several weeks until thenew tissue gets layed down.While this happens, too muchmovement, especially vigorousend range movement in thewrong direction, may interferewith the process and interruptconnective tissue formation. Atsome point, however, scar tissuedoes get formed and will begin tomature. At this stage, inadequatemovement will result in an adhe­sion, a shortened, stiffened area,painful at its restricted end range.McKenzie calls this kind of condi­tion a "dysfunction syndrome."21Movement testing can help todetermine if this kind of situationexists.

Pain in this case is not some­thing to avoid. Restricted motionassociated with pain that you feelintermittently at end range andwhich doesn't worsen with repeti­tions means that tightened struc­tures are getting stretched. Nodamage occurs. In fact, you mustfeel that type of tolerable 'stretchpain' for the movement to do anygood. While a newly-formed scarmatures, one can apply enoughbeneficial stress to it throughmovement so that it will reformin a strong, lengthened, unre­stricted and painless way.

Such "dysfunctions" do not re­sult only from direct injury, sincea second type of contracture,"adaptive shortening," can affect

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even uninjured muscles and skin.These tissues can become adap­tively shortened over time if theydo not have adequate movement.Muscles, for example, can changetheir length, sometimes quitequickly, if they are constantlysplinting a painful joint or whenthey otherwise become over­worked by constant contractionand fatigue.F

A third kind of soft tissuechange or contracture, "joint dis­placement," can also contribute toa circle of disuse and pain. This isnot a dislocated joint. Rather, achange occurs in the relationshipbetween the articulating surfacesof a joint so that normal move­ment is restricted. This seemssimilar to what McKenzie callsthe "derangement syndrome."23

If you have this kind of prob­lem, you may feel constant pain.However, unlike the pain associ­ated with inflammation, symp­toms will vary with the time ofday and with different positionsand movements. You mayor maynot be fixed in a position ofdeformity. What is going on here?

According to Cummings, etal.:

fI ...at a normal joint...bone Bmoves around bone A. The ar­ticulating surfaces remain in con­tact and the looseness of the cap­sule and ligaments allow the ex­cursion [normal movement] totake place...[With a joint dis­placement] bone B for some rea­son is displaced on bone A in thestarting position. You will findthat it will not be possible forbone B to move all the wayaround bone A. The range-of­motion will be limited. This limi­tation may be caused by intrica­cies of the articulating surfacessuch as configurational

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mismatches, curves of the articu­lating surfaces, or bits of menis­cus [cartilage pads], which maycause the joint to lock. ..Anotherpossible cause of joint limitationby displacement is reflex inhibi­tion of muscle action. fl24

Following the work of ortho­pedic physician James Cyriax,McKenzie has argued that in theback this kind of problem mostoften results from changes withinan intervertebral disc. Accordingto this disc model of spinal joint"derangement," small reversibleshifts of material within the disccan occur that exert constant me­chanical stress upon pain­sensitive structures of the spine.

A disc consists of a fibrousouter wall and a gel-like innerportion. With normal aging, so­called "degenerative" changes,such as cracks and fissures, canoccur within the structure of thedisc. As the result of trauma or asa result of abnormal asymmetricalstresses - such as poor and pro­longed sitting and frequent andprolonged flexion of the spine ­displacement of material can oc­cur within the joint. 25

According to McKenzie's de­rangement model, when this oc­curs, something within the disc,perhaps some of the gel material,has moved from its normal posi­tion inside the joint. This dis­torted material may not thenchange position as quickly asnecessary when further move­ment requires such change. In­stead, pain and loss of movementoccurs as the joint and surround­ing tissues are placed under ab­normal stress. Severe changes ingeneral posture-movement patternsmay occur, visible as posturaldeformities, as part of a strategyto reduce the resulting pain.

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This process takes time to oc­cur as a result of undesirable re­peated movements or prolongedpositioning. It will usually taketime and the application of theproper repeated movements andsustained positions to makethings right again.

Surgeons and other physiciansare familiar with the extremestate of this disorder. With a her­niated disc, extruded materialpresses into the surrounding tis­sue spaces, causing nerve irrita­tion and injury.

Under these circumstances,especially when it first occurs,positions and movements willprobably not have much of aneffect in reducing symptoms.Time will be needed for the sur­rounding tissues to accommodateto the extruded material, whichmay also shrink over time.Surgery, however, sometimesmay be a good option here.

Short of this extreme, it oftenseems possible to treat such jointdisplacements and restore normalrelations within the spinal struc­tures non-surgically. Apparently,when this happens, therapy canchange the shape and location ofdisplaced material if the wall con­taining the gel contents of the discremains intact.

Movement testing can indicatewhich movements and positionswill reduce or abolish symptoms,or change where symptoms arefelt. With derangements, thischange in where symptoms arefelt seems especially notable.e

Clinicians have observed foryears that the pain resulting froma back injury often starts in ornear the middle of the back. As itworsens it can either spread outor shift away from the spine and

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into one or the other buttock orleg. McKenzie calls this"peripheralization," sincesymptoms have moved out to­wards the periphery of the body.

It has become more apparentin recent years that as symptomsimprove they may decrease at, ormove away from, the peripheryand move closer to the center ofthe spine. For example, pain feltgoing into the leg and calf mayreduce and/or disappear assymptoms improve and ability tomove increases. Concurrently,more symptoms may appear forawhile near the center of thespine. McKenzie uses the term"centralization" for this phe­nomenon of pain decreasing orshifting out of the periphery andmoving closer to the center.Centralization provides a consis­tently reliable guide for effectivetreatment.27

Peripheralization and centrali­zation may correspond respec­tively to increased and decreasedjoint displacement due to distor­tion and disruption within a disc.Many physical therapists, physi­cians and chiropractors still donot accept the model of disc de­rangement as explained above.Nonetheless, a significant amountof research provides evidence inits favor. Treatment based on thismodel works effectively much ofthe time.28

Posture-Movement Patterns &the Vicious Circle

General posture-movement pat­terns provide ways of dealingwith immediate injury and sub­sequent inflammation. As healingproceeds, contractures develop inmuscles and joints. As a result,posture-movement patterns alsodevelop as coping strategies fordealing with these soft tissue

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changes. These patterns can alsodevelop through imitation of oth­ers, through ongoing emotionalfactors, e.g., the slump of depres­sion, and also as default habitsdeveloped in the course of youractivities of daily living.

Cyriax's assumption that "allpain arises from a lesion" is notcorrect. Sometimes your posture­movement patterns may causepain in the absence of injury orany joint or muscle problems.McKenzie uses the example of the"bent finger.29 Take one of yourfingers and bend it backwardswith a finger of the other hand.Bend it back as far as you can.Make it hurt! Now relax your fin­ger.

Do you have somethingwrong with your finger? If youanswered no, that doesn't meanthat your pain is 'just in yourhead' (whatever that means!).When you bent your finger back,you didn't damage anything.However, the pain presumablyprovided some warning of im­pending damage that might occurif you continued to stress theligaments, joints, etc., of your fin­ger.

Some people experience backpain after long periods ofslumped sitting or standing.When tested, they appear pain­free and have full spinal mobility.McKenzie calls this kind of painthe "postural syndrome," becausea movement examination yieldsnormal results and symptomsonly appear with sustained badpostures.v In this case, back pain,just like the bent finger, doesn'tnecessarily indicate damage.Rather, the pain seems to providea warning signal. When an indi­vidual who has this kind of con­dition begins to guard and restrict

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movement because of the pain heexperiences, he does exactly theopposite of what he needs to do,which is to sit less and becomemore active. If poor posture­movement habits continue longenough, they may lead to softtissue contractures due to adap­tive shortening. Micro-traumaand inflammation also may be­come factors here.

Thinking in Other Categories

The pathways of circular cau­sation and the multiple soft tissuechanges that can happen togetherat one time guarantee that a vi­cious circle can sometimes seemlike a confusing maze. In additionto what I've already discussedhere, Laslett and van Wijmanhave listed a number of types ofdiagnoses that may also be in­volved in a circle of disuse andback pain: sacro-iliac joint prob­lems, mechanical instability, facetjoint problems, spinal stenosisand psychologically-based illnessbehavior.n

Whatever the problem, usu­ally more than one tissue getsaffected when someone developssoft tissue changes. Even thoseareas that did not get directly in­jured may feel tight and uncom­fortable. Very likely muscles,joints, discs, ligaments, etc., allneed to have normal movementrestored once an acute injury hasoccurred. Muscles will need torecover the strength and endur­ance through their full range thatthey may have lost when normalmovements could not occur.

Recovery of normal move­ment seems necessary becausecontinuing soft tissue changes'and their concurrent posture­movement patterns increase thelikelihood of future problems.Abnormally shortened scar tissue

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or adaptively shortened musclesdo not have the strength or resil­iency of normal tissues. They canmore easily get pulled, over­stretched, and reinjured duringnormal activities.

Other complicating factors ex­ist as well. For example, variouspain syndromes associated withnerve damage appear to have apart to play in the back-relatedpain problems experienced bysome people. Injury to a nervemay result in a vicious circle be­cause of an increase in sensitivityto normal stimulation after theinitial damage has resolved.

In the case of chronic backpain, chronic inflammation mayprovide another complicatingfactor. This may include origi­nally injured tissues and secon­dary areas affected by a circle ofpain and immobility.v

Psychogenic. Pain

One category noted above,"psychologically-based illnessbehavior," deserves further dis­cussion. If done at all, making thisdiagnosis requires extreme cau­tion since it often represents amistaken attempt to separate the'body' (bio) from the 'mind' (psy­chosocial).

In understanding the circle ofback pain and disuse, psychoso­cial factors always need to beconsidered. Nonetheless, proba­bly only a very few people havewhat could be called purely psy­chosocial 'back pain' and actuallyfake back problems (malinger). Inaddition, although some peoplewith back pain may dramatize ormagnify it in order to gain atten­tion, compensation, relief fromresponsibilities, etc., it is not clearthat this involves more than asmall number of individuals.

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Clinicians who apply the re­lated notion of pSljchogenic painmay consider most back pain tohave a primary psychological ori­gin. John Sarno, M.D., a physicalmedicine (rehabilitation) special­ist, advocates this view. Sarnocontends that internal conflicts,anxieties, etc., often get translateddirectly into muscle tension in theback which then causes pain. Hebelieves that this accounts for alarge proportion of back prob­Iems.v'

According to Sarno, the besttreatment for such a problem con­sists of convincing the patientthat his symptoms are due topsychological conflicts. Accept­ing this 'diagnosis' often seemssufficient to solve the problem,although he does recommendproviding some level of counsel­ing at times.

With this approach, physicaltherapy may serve as an adjunctto help promote general mobility.However, for the most part, pa­tients are advised to forget aboutspecial exercises, body mechanics,etc., to stop worrying about pain,and to simply return to normalactivity.

Sarno's view of psychogenicback pain has some merit in thatit points to the importance of atti­tudes, anxiety and guarding inperpetuating back problems.Quite likely, some of his successeshave occurred with individualswho had became so fearful aboutreinjuring themselves that theirself-imposed guarding became amajor part of their ongoing dis­ability. In some of these cases,anxiety reduction leading to nor­mal, unguarded movement mayhave sufficed to correct minorsoft tissue contractures.

However, sometimes a change

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.s.>:

in attitude, although necessary,may not in itself be sufficient toget better. I have worked with anumber of people who, prior toseeing me, attempted to exerttheir 'minds' over their back prob­lems. They felt like failures whenthey did not succeed in gettingrid of their 'psychologically­caused' pain. This obviously did­n't help their ability to cope.

Advocates of the psychogenicapproach to back pain have over­simplified the relations amongemotional factors, movement andpain. They also underestimate theimportance of the kinds of softtissue changes in the joints andmuscles that I've discussed so far.As you can see in the posture­movement model presented here,emotional factors, soft tissuechanges and postural factors allwork together to perpetuate acircle of pain and disuse.

Faulty Effort

A simple, linear relation be­tween so-called psychologicalfactors and pain does not exist.Neither does there exist a simplelinear relation between mechani­cal joint problems and pain. Ex­clusively psychological ap­proaches (as these are usuallyunderstood) or those that focusonly on joint and muscle mechan­ics cannot provide a comprehen­sive approach for dealing withback pain.

The circular causal, bio­psychosocial model presentedhere does provide the basis forsuch an approach. This model issupported by the work ofWhatmore and Kohli on faultyeffort, which they call "dyspone­sis",

""dys" meaning bad, faulty, orwrong, and "ponos" meaning

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effort, work, or energy. The term[dysponesis] thus identifies thebasic nature of the condition,namely, a physiopathologicalstate made up of errors in energyexpenditure within the nervoussystem. If a patient's symptomshave their origin in dysponesisbut he is treated only for struc­tural disease or only to resolvepsychological problems, resultswill be disappointing, fordysponesis is a neurophysiologi­cal response pattern that will sur­vive these forms of treatment."34

The initial guarding (whatWhatmore and Kohli call a"bracing effort") in the first stagesof musculoskeletal injury mayserve as an appropriate way fordealing with that situation. Whenbracing, associated with increasedsympathetic activation, becomesan ongoing response to any ex­perience of discomfort withmovement (even if such move­ment may ultimately prove bene­ficial) than the guarding has be­come inappropriate, a faulty ef­fort.

Faulty effort may also initiatea back problem in the absence ofany apparent injury. Bracing andalso the inappropriate body me­chanics involved in slumping andpoor posture (which can also beconsidered a form of faulty effort)may lead first to warning pains inmuscles and joints (McKenzie'sposture syndrome). Eventuallymicrotrauma and inflammationcan begin a circle of symptoms.Faulty effort will also add addi­tional stress to any already exist­ing problems in the muscles andjoints.

Whatmore and Kohli suggestthat faulty effort can be measuredthrough the use of biofeedbackmachines which show the electri-

19

cal activity associated with mus­cular effort. They suggest the useof biofeedback training to recog­nize, reduce and eliminate faultyefforts.

However, you don't necessar­ily need a machine to observe thesigns of what posture-movementeducator F. M. Alexander called"undue effort": held breath,clenched jaw, tensed muscles,dilated pupils, cold, sweatypalms and feet, etc. Many meth­ods exist that may help you re­duce faulty effort, includingstudy of the Alexander Tech­nique, other forms of posture­movement education, hypnosisand relaxation methods, amongothers.

Chronic Pain

If you have had chronic backpain, you have been loopingaround a circle of pain and disusefor months or years. You mayhave given up hope.

Depression, anger and fearcan act like lenses that magnifyand concentrate pain and guard­ing. You can deal with these emo­tions successfully with somecombination of medication andcounseling. In the next section, Iwill discuss more about the im­portance of your attitude in cop­ing with back pain.

The neurological processing ofpain can also sometimes get al­tered in chronic pain situations.Specific medications and othertreatments exist that work veryeffectively with specific types ofpain. There is a growing medicalspecialty of pain management. Ifyou have an ongoing pain prob­lem, you may do well to considergetting a referral to a medicaldoctor credentialed in this field.

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When more health care practi­tioners begin to use and not sim­ply talk about the biopsycho­social approach to back problems,it will be easier for people withchronic pain to receive a compre­hensive approach to their prob­lems that includes the best thateducation, medicine, physicaltherapy and psychology presentlyhave to offer.

The Vital Circle of Recovery

Figure 2 shows the stages in­volved in entering a vital circle ofpain control and recovery. Thediagram shows that getting out ofthe vicious circle of disuse maystart in a number of interrelatedways. Remember that as anorganism-as-a-whole-in-an­environment, you constitute acomplicated multi-dimensionalsystem. Even one small positivechange can begin to make a dif­ference to the whole system since"we can never do merely onething. "3

For example, if you have softtissue changes you may on yourown or with assistance begin toimprove joint and muscle func­tion with particular positions andmovements. You can begin todistinguish hurts that harm fromhurts that don't. Apart from spe­cific effects on soft tissues, gentlemovement also can have impor­tant pain-reducing effects, accord­ing to the Gate Theory.

Improving your posture­movement habits can also havean important effect in controllingpain by reducing faulty effort andsubsequent irritation and in­flammation in muscles and joints.

Although it can help a greatdeal, working on the mechanicalaspects of your problems may notbe sufficient to deal with your

The McKenzie Journal

negative beliefs and emotions. Ifyou have become overwhelmedby pain, anxiety, depression, etc.,there are medications that canhelp. Coaching, counseling orpsychotherapy may also havespecial importance in helping youmove out of the disabling circle ofpain, fear, posture-movementlimitations and more pain.

Ultimately, it's up to you. Per­haps the most important thingyou can do is to recognize thepossibility of doing better.Changing your attitude towardsyour back problem will makeother parts of the vital circle rollmore steadily towards recovery.When appropriate, I tell peopleabout the ABCs of emotional self­care developed by psychologistAlbert Ellis, the founder ofRational Emotive Behavior Ther­apy (REBT). I refer them to booksand, if needed, to a qualifiedREBT-trained coach, counselor ortherapist.

REBT is based, in part, on theancient wisdom of the Stoic phi­losopher Epictetus, who wrotethat "What disturbs people'sminds is not events but theirjudgments on events." Ellis hasbuilt upon this to describe theABCs of emotions. "A" stands foran Activating event, an occurenceor situation with which we deal."B" stands for Beliefs, the judg­ments that we make on eventsbased on our experiences, expec­tations, assumptions and atti­tudes. "C" refers to the emotionalConsequences which, Ellis posits,result from these beliefs.

The beliefs that often get usinto emotional trouble are thosethat involve absolutistic demandson the way circumstances, otherpeople and ourselves 'should' be.lt may be appropriate at times to

20

get mildly upset for more or lessbrief periods when things don'tgo as we prefer. However, thesevere and ongoing emotionaldistress that we feel, even underthe most dire circumstances,seems to result to a significantextent from our belief that thingsmust go the way we absolutisti­cally demand that they go.

Ellis suggests that you canlearn to dispute your irrationalbeliefs about how things 'should'be by turning these absolutisticdemands into liberating prefer­ences. How does this relate toyour back problem? lt is notunlikely that you have been mak­ing yourself unnecessarily miser­able about your problem. Sinceyou are your own most en­chanted listener, you can startnow by listening to your ownself-talk for absolutistic and unre­alistic "musts," "shoulds," "al­ways's," "nevers," "can'ts," etc.

As Ellis points out in his bookHow To Stubbornly Refuse To MakeYourself Miserable About Anything,Yes Anything!, it is important topractice:

"distinguishing between ap­propriate concern, caution, vigi­lance and inappropriate anxiety,nervousness, and panic. When­ever you have strong negativefeelings because unfortunatethings are actually happening toyou or you imagine that theymight occur, see whether thesefeelings appropriately followfrom your wishes and desires tohave better things occur. Or areyou creating them by going be­yond your preferences and in­venting powerful shoulds, oughts,musts, demands, commands, andnecessities? If so, you are turningconcern and caution into overcon­cern, severe anxiety, and panic.

Vol. 10, No.2

......_-- ReducedInflammation

Attitudes, BelieJs,Expeetatiollll

(Positive, ReAlistic BeliefsJ "

i ~\\N.~V·rl»fP~ \ ~J~i!.T~.~'

Reeoverv L SeRso11' Restored r.-1obilit:y& Maint.1in,ence 04,0;-------- I t ~

/..." - \i Improved

Posture-MovementPattvms

Figure 2 - The Vital Circle of Recovery

.:»

Observe the real difference inyour feelings!"36

Besides disputing your irra­tional demands about your prob­lem, you can also remember thatthere is life beyond your backpain. In the search for solutions,you may have become so over­focused on your problem thatback pain threatens to becomeyour career. There is no need towait until you're pain-free beforeyou shift your attention to widergoals and interests. Ellis advisesto "try to become involved in along-term purpose, goal, or inter­est in which you can remain trulyabsorbed. Make yourself a good,ha ppy life by giving yourselfsomething to live for. In that wayyou will distract yourself fromserious woes and will help pre­serve your mental health. "37

And while you are learning tostubbornly refuse to make your­self miserable about your backpain, cultivate your sense of hu­mor! Remember that "Laughter isa tranquilizer with no side

effects. "38

1. Waddell, pp. 225-228

2. I coined the term "posture-movement"as a synonym for "mechanical" or "activ­ity-related." Using this term may avoid themachine-like connotation that the term"mechanical" may have for some people. Italso seems more descriptive than "activ­ity-related." In addition, conjoining pos­ture and movement with a hyphen tomake a single term makes the interrelat­edness of posture and movement explicit.Talking about "posture-movement" maykeep one from the unconscious verbalseparating of so-called 'static' from dy­namic aspects of motor behavior whichremain, in fact, inseparable.

3. Previous circular models of pain reac­tions, common in the literature, e.g., Paris;Cummings, et al.; and Waddell, have notexplicitly traced feedback loops to theextent that this one does. Feedback control(where response controls stimulus ratherthan the other way around) is explained ingreater detail in Chapter 7 of Back PainSolutionand in Marken's Mind Readings.

4. Arthur Koestler, TIle Act of Creation,qtd. in Danysh, p. 79

5. Wall, Pain:TIle Science of Suffering, p. 48

6. Ibid, p. 34

7. Ibid, p. 36

8. Ibid, pp. 125-140

9. Consciousness, p. 235

10. Wall, p. 51

11. Ibid, pp. 49-51

12. Ibid, p. 52

13. Liebman, p. 38

14. McKenzie, The LumbarSpine, pp. 22-24

15. Wall, p.145

16. Ibid

17. See Cummings, Crutchfield and Barnes, Soft Tissue Changes in Coniractures,p.3.

18. Ibid, pp. 3-5

19. Ibid, pp. 86, 105

20. Ibid, p. 113

21. McKenzie, TIle LumbarSpine, pp. 11-12;Chapter 10, "The Dysfunction Syndrome," pp. 95-108

22 Cummings et al., pp. 72-110

23. TIle LumbarSpine, Chapter 11, "TheDerangement Syndrome"; TIle Ceniicaland Thoracic Spine,pp. 35-37

24. Cummings et al., pp. 113-114

25. See Kramer, pp. 28-29.

26. McKenzie, TIle Lumbar Spine, p. 22.Also see The Ceroical and Thoracic Spine,Chapter 7, "The Phenomenon of Pain Cen-

The McKenzie Journal 21 Vol. 10, No.2

tralisation. "

27. Research studies that explore the Cen­tralization Phenomenon include: Donel­son, Silva, and Murphy, "The Centraliza­tion Phenomenon: Its Usefulness inEvaluating and Treating Referred Pain";Audrey Long, "The Centralization Phe­nomenon: Its Usefulness as a Predictor ofOutcome in Conservative Treatment ofChronic Low Back Pain"; and Mark Wer­neke et al, "A Descriptive Study of theCentralization Phenomenon: a ProspectiveAnalysis;" among other studies.

28. See Dr. Stephen Kuslich et al., "TheTissue Origin of Low Back Pain and Sciat­ica: a Report of Pain Response to TissueStimulation During Operations on theLumbar Spine Using Local Anesthesia."

Also see Donelson, Aprill, Medcalf, andGrant, "A Prospective Study of Centraliza­tion of Lumbar and Referred Pain: A Pre­dictor of Symptomatic Discs and AnnularCompetence."

29. TIle Ceruical and Thoracic Spine, pp. 22­23

30. TIle LumbarSpine, Chapter 9, "The Pos­tural Syndrome" and TIle Cervical AndThoracic Spine, Chapter 13, "The CervicalPostural Syndrome," Chapter 14, "Treat­ment of the Cervical Postural Syndrome,"and the "Treatment" section of Chapter 25,"The Thoracic Spine"

31. See their article "Low Back and Re­ferred Pain: Diagnosis and A ProposedNew System of Oassification."

32. Cummings, et al., pp. 127-145

33. See Sarno, HealingBack Pain.

34. Whatmore and Kohli, pp. 102-103

35. Garrett Hardin, FiltersAgainst Folly, p.58

36. Ellis, pp. 19-20

37. Ellis, p. 144

38. Arnold GIasow qtd. by Laurence J.Peter in Peter'sQuotations

References

Cummings, Gordon S., Carolyn A. Crutch­field and Marylou R Barnes. 1983. Softtissue changes in coniractures. Orthopedic

Physical Therapu Series, Vol. I. Atlanta, GA:Stokesville Publishing Co.

Danysh, Joseph. 1974. Stop without quit­ting. San Francisco: International Societyfor General Semantics.

Donelson, R, C. Aprill, R Medcalf, andW. Grant. 1997. A prospective study ofcentralization of lumbar and referred pain:A predictor of symptomatic discs andannular competence. Spine 22 (10).

Donelson, Ronald, G. Silva, K. Murphy.1990. The centralization phenomenon: Itsusefulness in evaluating and treating re­ferred pain. Spine 15 (3).

Ellis, Albert. 1988. How to stubbornlyrefuseto makeyourselfmiserable aboutanything yesanything! Secaucus, NJ: Lyle Stuart Inc.

Hardin, Garrett. 1985. Filters againstfolly:How to suroioedespite economists, ecologists,and the merelyeloquent. New York: Viking.

Hobson, J. Allan. 1999. Consciousness. NewYork: Scientific American Library.

Kodish, Bruce 1. 2001. Backpainsolutions:How to helpyourselfwith posture-movementtherapyand education. Pasadena, CA: Ex­tensional Publishing.

Kramer, [urgen et al. Trans. K.H. Mueller,et al. 1990. Interuertebral disk disease: Causes,diagnosis, treatmentand prophylaxis. NewYork: Georg Thieme.Verlag Stuttgart.

Kuslich, S., C. L. Ulstrom and C. J. Mi­chael. 1991. The tissue origin oflow backpain and sciatica: A report of pain re­sponse to tissue stimulation during opera­tions on the lumbar spine using local anes­thesia. Oriho Clinicsof North America22(2):181-187.

Laslett, Mark and Paula van Wijman.1999. Low back and referred pain: Diag­nosis and a proposed new system of clas­sification New ZealandJournal ofPhysio­therapy27: 5-14.

Liebman, Michael. 1979. Neuroanatomymadeeasyand understandable. Baltimore:University Park Press.

Long, Audrey. 1995. The centralizationphenomenon: Its usefulness as a predictorof outcome in conservative treatment ofchronic low back pain (a pilot study).Spine 20 (23): 2513-2521.

Marken, Richard S. 1992. Mind readings:Experimental studiesof purpose. Chapel Hill,NC: Control Systems Group/New ViewPublications.

McKenzie, Robin. 1981. TIle lumbarspine:Mechanical diagnosis and tlleraptj. Waikanae,NZ: Spinal Publications.

- - -. 1990. The cervical and thoracicspine: Mechanical diagnosis and therapy.Waikanae, NZ: Spinal Publications.

Peter, Laurence J. 1977. Peter'squotations:Ideas for our time. New York: Quill, Wil­liam Morrow.

Sarno, John E. 1991. Healing backpain: TIlemind-bodyconnection. New York: WarnerBooks.

Waddell, Gordon. 1998. TIle back pain revo­lution. Edinburgh: Churchill Livingstone.

Wall, Patrick. 2000. Pain: TIle science ofsuffering. New York: Columbia UniversityPress.

Werneke, Mark, D. Hart and D. Cook.1999. A descriptive study of the centraliza­tion phenomenon: A prospective analysis.Spine24: 676-683.

Whatmore, George B. and Daniel R Kohli.1968. Dysponesis: A neurophysiologicalfactor in functional disorders. BehavioralScience 13(2).

©All Rights Reserved, Extensional Pub­lishing.

C Adapted from Bruce Kodish'smost recent book, Back Pain Solutions:How to Help Yourself with Posture­Movement Therapy and Education, Extensional Publishing, 2001. Reprintedwith permission of Extensional Pub­

lishing.

o Bruce I. Kodish, Ph.D., P.T.,

CertMDT practices physical therapy,and teaches the Alexander Techniquein Pasadena, California. A respectedteacher in the field of general seman­

tics (applied epistemology), he hasalso written Drive Yourself Sane: Usingthe Uncommon Sense ofGeneral Seman­tics, with his wife Susan PresbyKodish, Ph.D.

The McKenzie Journal 22 Vol. 10, No.2