• Nigel Peek MSc (chiro) PGDip (pain) PGCert (acu)

The "Social" in Back Pain


In a previous blog I discussed the psychology of back pain (see here), in keeping with contemporary understandings of the human experience of pain I have touched on the bio-psycho-social model (see here). Current evidence informs us that pain is a multidimensional experience and that these dimensions are inextricable/inseparable and person and context dependent (unique).


Back pain is a common life symptom, for most this experience is self-limiting and resolves spontaneously; however, for some this may become an ongoing, recurrent, and disabling condition. The epidemic of back pain continues to escalate, despite continued efforts to find better solutions. This in part may be due to the continued pursuit of a unidimensional, mechanistic approach to solving this issue. Back pain, like all pain should be addressed with the individual at centre (not just the symptom).


Central and hardwired into our evolutionary adaptability is our “social being” – that part of us that is fundamentally tied to “the tribe.” In a modern day (western) context we are often adrift from this basic tenet; however, our “animal self” remains necessarily contingent on our social world. Humans are social creatures, and we are hard wired to exist within a group, tribe, or culture.


Our social being is embedded in who we are, not a consequence of what we are


I recently read somewhere that we are so dependent on this vital aspect of our make up that our social being is placed ahead of our physical (including our individual physical protection). This makes sense, to be ostracised from the tribe or group would likely lead to death or exposure to the elements. We have evolved to exist within a social structure - it is central to our existence.


Social and Pain?


If we recall from a previous post (see here), pain is an output of the central nervous system principally designed to protect us from danger or harm (remember the experience is not determined solely by damage). In the social context, an individual’s need for protection must also be integrated into the fabric of the tribe. Hence, it is fundamental and necessary that our relationship with the collective is inextricably integrated into our wellbeing. Social determinants dictate how we think, feel and sense and they also predict how we behave and share our experience.


In our present-day form, our social is more complex, we have different “tribes” and groups including family, work, gender, culture, race, sexuality, and socioeconomic status. These are all social groups or collectives within our society. Our social whole is also made up of variations in income or wealth, education, employment, community, healthcare accessibility, neighbourhood etc.


Back pain – a social phenomenon?


How does our society view back pain? – I have alluded to this in another piece (see here), culturally we have a general tendency to “catastrophise the meaning of back pain”, our social subtext imposes a narrative that tends to imply that back pain is serious, age-related, untreatable. We also have strong social cues that are reinforced by large public health campaigns about “safe lifting” and “postural correctness”, these explicit narratives may have a strong influence on our experience of back pain. Fortunately, research is beginning to challenge and debunk these so called truths (see here).


How we relate to back pain may be strongly determined by our prior experiences. For example, if we grew up in a household with a parent who suffered from chronic disabling back pain, our own experience and the beliefs and behaviours we hold and express when confronted with an episode of back pain are likely contrasting to someone who does not have this prior conditioning. Therefore, our meaning of back pain is different and therefore our behaviour, outlook and expression is unique.


Despite our strong bias toward back pain being predominantly a physical/mechanical issue, research tells us that people who develop persistent back pain may have certain socially determined characteristics. Some of these include educational status (low), relationship status (being single), socioeconomic status (being poor), and workplace factors (low support, high demands, lack of autonomy, poor job satisfaction) (1, 2).


How we respond and relate to others in pain matters!


The way we communicate our experience of distress also matters, and may strongly influence our recovery. Grimacing, limping, and yelping are all communicative gestures that elicit attention from others in the group. This recruitment of the collective helps draw assistance, empathy and support – all necessary ingredients to bolster protection and nurturing.


Social behaviours such as empathetic touch have strong physiological effects that also help to dampen the intensity of the pain experience. Our brain is wired to respond to communicative behaviours from others in order to regulate and bring the system back to equilibrium or safety. These are primary and necessary components of our individual and collective wellbeing.


The social in healthcare settings


I think we can all relate to an encounter with a health professional when we have felt dismissed, or "not heard". These social encounters are pivotal when relaying our concerns to others. Being understood, empathised with, and collectively engaged in a solution is central to the treatment process.


Professional ideologies and biases are abundant in the back pain world, these often generate dissonances that confuse patients and compound their distress. Just think of the last time you had a conversation about who you should see for your back pain. It is likely you were given a highly charged and opinionated stance about whether you should see a physiotherapist, osteopath or chiropractor.


Unfortunately strong mechanical biases predominate and persist in the management of back pain. Patients are often left with an incomplete pain schema that often over-simplify and contradict the current evidence.


Humans are not machines, we are multiplex interactive systems in constant interplay with our internal and external experiential environment.


We cannot solely be defined by our physical parts, this is not what makes us human

and it surely isn't what defines the experience of pain.


We know that social isolation leads to premature death. In fact, loneliness is akin to smoking and obesity as a driver of poor health and premature death (4. 5).


Do you think it makes sense that the experience of pain is fundamentally embedded in our social being? - I sure do!



References

1. Karran EL, Grant AR, Moseley GL. Low back pain and the social determinants of health: a systematic review and narrative synthesis. Pain. 2020;161(11).

2. Thiese MS, Lu ML, Merryweather A, Tang R, Ferguson SA, Malloy EJ, et al. Psychosocial Factors and Low Back Pain Outcomes in a Pooled Analysis of Low Back Pain Studies. Journal of occupational and environmental medicine. 2020;62(10).

3. Van Griensven H, Strong J, Unruh AM. Pain : a textbook for health professionals. Second edition. ed: Oxford : Churchill Livingstone Elsevier; 2014.

4. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS medicine. 2010;7(7).

5. Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspectives on psychological science : a journal of the Association for Psychological Science. 2015;10(2).

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