One of my favorite patients (seen 8 years ago) was a lady who was in her mid 60s who came to see me for a vestibular dysfunction. While going through my systematic exam and asking her to squat, I heard probably the most unsettling noises come from her knees as she bent down. Her knees sounded like door hinges that had not been opened in 100 years and in serious need of WD40. I asked her about her knee pain and she exclaimed “what knee pain!?! I don’t have knee pain and never have had knee pain”. I was shocked! What do you mean you have never had knee pain? If there ever was a definition of “bone on bone”, it was this woman, yet there was no pain and her knees moved well (albeit like rusty door hinges). This patient encounter was the beginning of my quest to better understand why people hurt. How can a 40 yo man with “mild” arthritis of the knee have more pain, disuse and disability than this lady? Can pathology really explain pain? What does age have to do with pain?
There is a large difference in the definitions of age and “being old”. Age describes the length of time that a person has lived (biological), whereas “being old” is a mindset and is relative to a comparison. Despite this difference, these terms are often used interchangeably to describe a person’s “experience in life”. There is no better example of this than the question of “how old are you?” versus “what is your age?”. These questions are used interchangeably, however, have very different implications.
Societal and medical influences, also help to shape this idea that we all “get old” and that aging leads to “wear and tear” on our bodies. “Wear and tear” is then associated with more pain, less activity and eventual “slowing down” until we find ourselves 6 feet under the ground. These comments are based on societal age stereotypes, which are driven largely by media and our medical system. Now, don’t hear me wrong, we all age and our bodies go through changes as we age, we may slow down a bit, but do we really have to “grow old” or is this more of a mindset we take on?
The root of the age versus “old” problem lies in the faulty beliefs of in how pain works, which is largely driven by medicine. Most people believe that pain = tissue injury and tissue damage = pain.1 The more tissue damage you have the more pain you will experience. The longer you live the more tissue damage you accumulate, and therefore, the more pain you will experience. Hence, old age = pain. Unfortunately, people also believe “if it hurts, don’t do it”. Johan Vlaeyen and Steve Linton showed us this with the fear avoidance model, where hypervigilance and avoidance behaviors leads to disuse, depression and disability.
Medicine plays a tremendous role in influencing these beliefs. I want to share with you a story about Aboriginal Australians from a 2013 publication in the British Medical Journal2. In the early 1990’s Aboriginal Australian’s were uniquely identified as protected from the disabling effects of chronic low back pain because of cultural beliefs and limited access to healthcare. While there was a reported high prevalence of chronic low back pain in these communities, the impact was small as few pain behaviors were observed and people did not seek healthcare. Aboriginal people did not view back pain as a health issue, but rather a normal part of life, and therefore did not seek healthcare. Fast forward to the year 2007-2010, when researchers went back to these remote communities to study contemporary beliefs to chronic low back pain. Thirty-eight Aboriginal Australians were interviewed. All but one had been to a medical professional to seek help for back pain. The majority of these participants believed their pain was due to damage of the disc or wear and tear of the spine.
“Well I got told by [medical specialist] that it might be a trapped nerve or, that was before I had my first MRI, and then they said no you’ve got lower lumbar … and as I said it’s just bone crunchin’ on bone” (42-year-old Aboriginal Australian man with highly disabling CLBP)
The key messages of the study were:
- Contrary to previous research negative beliefs, including an anatomical/structural cause of pain and pessimistic future outlook, were common.
- Negative beliefs originated from interactions with healthcare practitioners suggesting disabling LBP may be partly iatrogenic.
- Biomedical-orientated management approaches to LBP are far reaching, highlighting the need for healthcare practitioners to positively influence beliefs as part of LBP care in all settings.
The negative affectivity and threatening information provided from these medical providers likely led to more fear, disuse and disability.
If pain = damage, then all people with pathology should hurt and the more pathology you have the more pain you will experience.
This is an image that was shown to me by Dr. Adriaan Louw, which uses data from the Brinjink et. al. article published in 20153. It is a graph of facet arthritis vs the incidence of low back pain based on age. Help me find the correlation, because I have yet to figure this one out!
This image is now an integral part of the “pathoanatomical” education I deliver within the clinic, which focuses on the concept of pain ≠ pathology and “tissues heal”. It is also clearly displayed on my wall right above the drinking fountain for all to see.
What about the neck? In 2015 Nakashima4 demonstrated that in 1211 asymptomatic subjects, 87.6% of participants age 20-80 had cervical disc bulging! Additionally, five-percent of participants also had spinal cord compression and two-percent had increased signal intensities of their spinal cord.
I recently came across this figure that is published on BMUS: The Burden of Musculoskeletal Diseases in the United States (http://www.boneandjointburden.org).
This figure shows the percent of the US population with arthritis and joint pain compiled from reported conditions. In 2011, there were 60.8 million persons with arthritis and joint pain. What I find interesting from this “grossly underpowered study” (sarcasm) is that arthritis and joint pain takes on the shape of a bell shaped curve, with the highest percentage of middle age Americans reporting arthritis and pain (45%) compared to only 32% of Americans over the age of 65. In other words, those with more pathology actually experience less pain. Perhaps we need to remind middle age adults about “growing pains” and that “grey hairs on the inside” (Tim Flynn) are normal?
Perhaps it is not our age that makes us old but our attitudes, beliefs and life choices of inactivity, all of which are largely influenced by societal standards, media and medicine.
As healthcare providers we are in a tremendous position of power and influence on the beliefs about pain within society. Creating large shifts in beliefs will not be something that happens overnight, nor will it be easy, but I truly believe that it is our responsibility to influence one life at a time. The challenge is to look yourself in the mirror and be critical of yourself in attempt to remove words that create threatening illness information. The goal is to communicate with your patient in a way that builds a positive belief about their pain/condition and its future consequences, enhancing resiliency to disability. Lastly, encourage movement! Aerobic exercise has been shown to have effects on pain sleep, depression, anxiety and quality of life. Movement is the largest pain killer on the planet and it is SOOOOO underutilized! We have an incredible opportunity here as a profession and it will be up to each one of us to help this shift in beliefs happen.
- Puentedura EJ, Louw A. A neuroscience approach to managing athletes with low back pain. Physical Therapy in Sport. December 2011:1-11. doi:10.1016/j.ptsp.2011.12.001.
- Lin IB, O’Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open. 2013;3(4):e002654-e002659. doi:10.1136/bmjopen-2013-002654.
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.
- Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine. 2015;40(6):392-398. doi:10.1097/BRS.0000000000000775.