Psychological Factors in Chronic Back Pain
George E. Becker, M.D. and Randall Smith, Ph. D
Published in Managing Back Pain, by Kirkaldy-Willis
Churchill Livingston, 1999.
Page 112, section entitled Somatization.

Somatization is experiencing and expressing emotion in physical terms.  Lipowski suggests a comprehensive, albeit succinct, definition: “ A tendency to experience and communicate somatic distress and somatic symptoms, driven by emotional and psychological factors, unaccounted for by relevant pathologic findings, to attribute them to physical illness and to seek medical help for them”. 

The depressive and anxiety disorders account for the majority of cases of somatization in practice today.  At least 80% of patients suffering from depression are initially seen and evaluated by primary care physicians.  Most of these patients have physical complaints, such as chronic back pain.  As a group, they tend to minimize, if they recognize at all, the psychological determinants of their symptoms. They are characteristically very resistant to understanding the emotional and psychological conflict that fuel their symptoms.  This makes treating them difficult and challenging although not always impossible. 

It is important to remember that somatization and organic pathologic states can and usual do coexist.  The somatizing back pain patient usually has experienced some sort of physical injury.  The injury in many cases is assessed as trivial, and prompt return to normal function is anticipated by the examining physician.  It is only when the patient does not enjoy the anticipated timely recovery that the first clues to the somatization diagnosis are evident.  At this point in the patient’s course, it may be noted that there are few if any objective findings to subjective complaints on an organic basis.  Meanwhile, the list of complaints lengthens.  In some cases, symptoms proliferation may come to involve the whole body.  Somatizing patients characteristically get worse rather than better with the passage of time.  They are refractory to virtually all treatment modalities, particularly those requiring active participation.  They frequently experience and report undesirable side effects associated with medications, and they are particularly prone to iatrogenic prescription narcotic dependance.  They may be seen as over-reactors in having motivation problems.  Above all, they are a source of frustration to the physicians trying to help them back to healthy as it seems, but no matter what approach is tried it always fails. 

Patients invariably repeat as a litany how independent they have always been, how they hate being unable to work and support their families, how they hate being taken care of and how intensely they want to return to work.  The only problem they relate is to get rid of the pain for them and they will go back to work.

Editorial Comment:  This is one of the most pertinent and relevant passages from any scientific paper or referenced text in the context of spinal care and for the back care community at large.  For those healthcare providers that see accident or injury related claims, and particularly those that are involved in litigation and/or with Workers Compensation Claims, these are very important guidelines to bear in mind when evaluating the patient.  Many patients do not present with somatization disorders, however, there are a sufficient number who do that make it necessary for the practitioner to be aware of these observations.

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Clinical Anatomy of the Lumbar Spine (2d)

Bogduk & Twomey,
published by Churchill Livingstone, 1991, page 158. 

Pattern of lumbar pain. It might be expected that different causes of lumbar pain should be distinguishable from one another on the basis of differences in the distribution and behavior of symptoms.  Frustratingly, however, this is not so. Because different structures in the lumbar spine share a similar segmental nerve supply, and because different disorders share similar mechanisms, no single disorder has a characteristic distribution of locally referred pain. 

A. Zygapophyseal pain. With respect to zygapophyseal joint disorders, experimental studies have shown that local and referred pain patterns at different levels vary considerably in different individuals and even in a given individual they overlap greatly.  Furthermore, the incidence of other clinical features in zygapophyseal syndrome include various aggravating factors and is insufficiently different from their incidence of other syndromes. Fairbank, et. al, performed diagnostic joint blocks in patients presenting with back pain and referred pain and analyzed the differences between those who responded and those who did not. Although certain features did occur more commonly in responders, they also occurred so frequently in non-responders that no clinical features could be identified that could be held to be indicative of pathopneumonic and zygapophyseal joint pain. 

B. Radicular pain. Although the quality of radicular pain is distinctive, its distribution is not. Radicular pain from a particular nerve root does not follow a constant distribution.  In general, L5 radicular pain radiates to the dorsum of the foot and hallux, while S1 pain radiates to the heel or lateral border of the foot. However, radicular pain does not always extend into the foot, and in the leg it is usually possible to extinguish between L5 and S1 pain.  L5 and S1 radicular pain can be felt in the back of the leg, and the pattern can vary with the intensity with which the root is stimulated.

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High Quality Control Trials on Preventing Episodes of Back Problems: Systematic Literature Review in Working – Age Adults. 
Stanley J. Bigos, M.D., John Holland, M.D., NPH et al
Department of Orthopedic Surgery
University of Washington, Seattle WA.
The Spine Journal 9 (2009 147-168)

The authors reported 20 high quality controlled trials which found strong, consistent evidence to guide prevention of back pain episodes in working-age adults.  Trials found exercise interventions effective and other interventions not effective, including stress management, shoe inserts, back supports, ergonomic/back education, and reduced lifting programs.  The varied successful exercise approaches suggest possible benefits beyond their intended physiologic goals. 

The authors state that the reasons for success of only exercise approaches are unclear.  The effectiveness of varied exercise approaches suggests that there may be general health benefits to exercise beyond the specific physiologic goal of increased strength, endurance or flexibility.  Perhaps, participants also feel more confident and less fearful when exercising and actively working to improve their health.