Pain From A ‘Nurse’s Back’

Written By Drew Coverdale

Nurse’s back - A Case Study

Let's look at the story behind the low back pain in this 50-year-old nurse.

Here’s how she explained her situation.

‘I've got a spondylolisthesis. I've seen a  consultant, and he’s told me that it doesn't need surgery and I'll have to manage it. It’s a ‘Nurse’s Back’ from 30 years of work and all those Australian lifts. My weight doesn't help. I’d like to lose some of it and want to go swimming, but a friend of mine is a physio and said I shouldn't go swimming with my back as it is because it’ll make it worse. I don't know what else to do and am frightened that I’ll just have to live with it.’

Subjective Findings

The pain she complained about came on gradually about eighteen months ago, and there wasn’t any significant physical trauma that she recalls that precipitated the onset of the pain.

The pain in her lower back radiated into her left leg. It was a constant deep ache, and she also had intermittent numbness in the right buttock and thigh.

She had received X-rays and an MRI scan which outlined degenerative changes in her lumbar spine and spondylolisthesis at L5-S1. This is when there is a movement of one vertebra over another, and in this instance, the L5 indicates that the 5th lumbar vertebra had moved forward over the first sacral vertebra S1.

She had been assessed by a spinal consultant who said this was stable, and there was no indication that she required or would benefit from surgery. 

Spondylolisthesis can occur with trauma or repetitive events. Still, as there was no history of trauma with the onset of the pain, it was determined by the consultant that the changes were due to degeneration over time. The movement of one vertebra over another can narrow the space of the hole through which the sciatic nerve runs, giving rise to pain in the leg.

So this lady's symptoms were explainable from a biomedical point of view, but if these changes are likely to have been there for many years, why would they start at this particular time in her life, when before this, she had been entirely pain-free?

General Health and Medication

Her general health was good, and she did not take any medication other than the painkillers she had been using for the last year. These included paracetamol, ibuprofen, codeine and gabapentin. This mix of tablets covers the spectrum of analgesia for joint and muscle pain, inflammation and nerve pain symptoms. Despite all this medication, she had no significant change in her pain.

She had tried Osteopathy and Massage, which did not provide her with any long-term relief.

Social History

She worked full-time in a managerial role in a health care setting, so her daily manual tasks were office-based, and outside of her work hours, she could only manage short walks due to the pain. She liked swimming but feared doing this as the physio told her it could worsen things.

Objective Findings

On examination, she had pain at rest in sitting, and standing positions and her movement forwards and backwards were limited by both the pain in her back and left leg. Testing the sciatic nerve in her leg showed the reflexes to be brisk and sensitive to stretching manoeuvres. There was local tenderness over the lumbar spine paravertebral muscles, but all the other joints in the lower limbs were full and pain-free.

Clinical Reasoning

So the objective findings match the subjective results for a commonly seen phenomenon for those who may have spent many years repeating mechanical loading tasks on their lumbar spine.

The degeneration found on the scans and X-rays is common and often becomes part of the reason for the patient to become cautious about how they should move that part of their body in the future.

This is sensible once the awareness of those changes is apparent, but as there was no trauma precipitating the pain, and these changes were present for a long time before, could there be another explanation for pain with this patient?

A Sense of Caution

Could that new sense of caution become a driver for pain that is separate from the structural element for which, on this occasion, the consultant had highlighted as the primary contributor to the current pain?

This overweighting of the structural components of pain often comes from a biased biomedical view when a logical thought process contradicts such a hypothesis.

The physical area of the pain is relevant, and so are the degenerative findings that outline repetitive loading over time. They highlight the potential and the probable regions of historic episodic low back pain.

Pathways of Potential

These present neural pathways that the brain and body have used as part of the natural repair process throughout our lives. The development of these protective pathways, which correlate with signs of injury, load and recovery, can happen with an awareness of pain at that time or without conscious recollection of any symptoms.

They develop to help learn what creates potential overload and injury so we can avoid similar incidents in the future. For example, the aches and pains that may have appeared with the day-to-day circumstances in a nurse's career provide this information. In the same way, we recall things in our lives that may have felt hard or created moments of injury or overload.

This is represented by memories, movements, positions, sensations and pain, which all bring to our attention the current risk in what we may be doing.

Dormant For So Long

But what about these pathways that had remained dormant for so many years for this nurse?

Suppose these pathways were well established as drivers for the current pain. So why would they suddenly create such constant and ongoing pain, lasting over a year, without any precipitating physical change, which makes sense to a logical exploration of the reasons behind this patient’s pain?

Doesn’t Make Sense

It makes no sense to attribute this constant low back pain with radiation into the whole left leg to some ‘old’ findings that, although relevant, do not provide robust evidence for causing the pain when the onset is considered.

Even if the symptoms had been precipitated by physical trauma or an extraordinary overload level, the patient would easily recall this. However, within three months of such an incident, any new bodily injury would have passed the tissue healing phase.

So in the absence of a plausible history supporting a biomedical cause and a time-lapse of over eighteen months since that onset, there must be another explanation for the pain rather than a solely structural and degenerative nature.

The Wrong Filter

The filter of starting to look at structure is based on good intentions, and a search for any significant sinister of systemic pathology is always essential. But once excluded, hanging the structural hat for this lady's pain is the moment of mistake and where the biomedical approach stops and fails.

So what else could be the dominant driver of this patient’s pain?

It is only by exploring some of the other components in her life around the onset of that pain that the clues start to appear.

What Else?

When asked about what else was happening in her life when the pain started, she paused to consider and mentioned that her ex-partner had approached her children to re-establish contact after several years.

She continued to describe how this partner had been abusive during the marriage, and it had been a difficult one to manoeuvre due to his selfish and controlling behaviour. She couldn't stop the children from that current relationship but recognised what that situation brought back regarding emotional charges, memories and the associated fears attached to those thoughts.

Even though it had been many years since leaving that marriage, she understood the triggers that this reemergence of this person into her children’s life once more had brought.

Historic Patterns

Making her aware of the historic coping strategies that had helped her deal with him first brought a tipping point to see how the overuse of those elements could be a more understandable creator and driver of her recent painful experience.

When success in a career, business, finance or physical prowess comes from an innate desire to push through resistance, it is natural to use those mechanisms for moments of adversity and stress.

However, with the sense of threat that can suddenly appear in our life as it did with this patient, the additional demands on the system for someone already wired as a high performer can be the tipping point for the development of pain.

Why And Where?

There are various reasons why this patient may have complained of pain in her back. For example, if the neural pathways fired at a time of stress whilst being a nurse, they have an invisible connection with stress unknown to the patient.

That means that the same neural pathway has the potential to fire if a sufficient level of emotion is reached where the brain uses the physical element of pain to alert the person not to a new injury but to the presence of system stress that the organism finds challenging to balance.

Some suggest that pain appears as a metaphor for the circumstance creating the stress and our unconscious interpretation of where we feel that. For example, ‘He does my head in’, ‘I’ve got the world on my shoulders’ or ‘It's a burden on my back’.

Whatever the manifestation pathway, the constant focus on the threat, even when it isn't present in reality, drives the system's stress.

Constant Thoughts

These are the thoughts we may take to bed each night and wake up to.

The patient described these thoughts as precisely the kind that she was feeling. She felt that lack of control she had experienced all those years ago whilst in her previous marriage, and the sense of dread was palpable to her at that time.

She also recognised that during that time and beyond, she continued to present a front of calmness to others and took pleasure in the distraction of work and the blocking mechanism it offered her. She understood the perfectionist, people-pleasing and controlling traits that she had used to help many others when she was suffering her difficult situation.

Massive Shift

It is a massive shift for someone trained in the biomedical model to accept a different belief system when, for such a long time, her painful experience was based on fear of the structural elements where she felt that pain.

The words, diagnosis, X-rays, MRI, and imagery created despair that she could do nothing other than accept her fate of having to live with the circumstance that had befallen her.

The authority of the consultant in his explanation, the advice of her physio friend as well as the failed treatment of the Osteopath and Massage all add to the belief that she nor anyone else can do anything for her,

Open To Change

Fortunately, she was open to the idea that her pain was more due to the emotional charge and the shock it brought to her life rather than the pre-existing changes.

She could use that reframe to think, breathe, move and feel differently with all the currently linked related cues that triggered her pain.

And none of them now have any unpleasant effect on her at all.

She fully recovered from this pain she believed she was destined to live with for the rest of her life, and she lives happily ever after with her spondylolisthesis and the ‘Nurse’s Back’ that created it.

Your Story

  • How does this story relate to yours?

  • Is there anything that makes sense now that didn’t before reading this?

  • Are you curious about other factors which may influence pain?

That awareness or openness could provide a gateway to recovery for you, no matter what structural elements you may believe to be the only or primary source of your pain.

 

What’s next?
Take Your First Step to Recovery.

Drew Coverdale
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