Welcome back to the Spine IQ BackBlog! This week, we will be discussing the prevalence of stress and how to help your patients cope with stress. Numerous definitions have been given for stress, the most common being a physical, mental, or emotional strain as a reaction to a real or perceived threat.¹ Approximately 30% of people are feeling stress at any given moment.¹ Most (79%) people consider stress to be a common part of life.² Symptoms due to stress can vary widely between and within individuals, however, some of the common symptoms are exhaustion, depression, pain, and difficulty concentrating. Additionally, persistent stress has been associated with increased likelihood of mental health issues, diabetes, obesity, and persistent pain.³

People with low back pain are more likely to perceive stress compared to people without low back pain.² Persistent stress can decrease the likelihood of recovery from low back pain and increase the risk of chronicity. Therefore, stress can be an important thing to discuss and intervene on with your patients. Stress is a perceived state and research has demonstrated that the way in which stress is interpreted is a huge factor in how stress is coped with.  Clinicians can be very influential in how “stress” is internalized and perceived.

Suggestions for stress management

The key to interventions intended to decrease stress is the willingness and ability to listen to your patient and recognize the stress factors. For a long time, stress and other mental health issues have been seen as “all in your head”, malingering, or not “real.”^4,5 This has led to stigma around stress and mental health issues. As a clinician, people are seeking care from you at a vulnerable (possibly the most vulnerable) time in their life. It is important to go into every session with a willingness to listen carefully and empathetically. It is surprising how little time it takes to actively listen and connect with your patient versus simply following a script.

It is important to ask about stress in your patients personal or work life. After listening to their stress inducing situations, you can work with your patient through a shared decision making process to come up with a plan to overcome or cope with stress. Some common interventions that work for low back pain can also be helpful for stress reduction such as exercise, mindfulness, meditation, yoga, and psychological therapies (e.g., CBT).⁶

Some clinicians may want to get further training in mindfulness-based stress reduction therapy.⁷ This has been shown to reduce stress and low back pain. Additionally, it is recommended by clinical practice guidelines for low back pain.⁸ Mindfulness-based stress reduction consists of meditation with the goal of reinterpreting pain as a biopsychosocial event that does not necessarily mean tissue damage and focusing on pleasurable events instead of painful events.⁹ This can be done in group-sessions and be taught to patients so they can self-manage their stress and pain with as little as 15-minute sessions a day. There are even some recent apps that help guide you through mindfulness.  Stress has been studied for decades and has been understood to be an important factor in how it is managed.

Conclusion

Stress is a common part of life. Not all stress is necessarily detrimental, however, stress that people do not adapt too and continues to persist has numerous negative health effects. People with low back pain are more likely to perceive higher stress compared to people without low back pain. Clinicians must be prepared to ask about stress and listen with intention and empathy to their patients experiences with stress. Some common treatments for low back pain have also been shown to be helpful for stress reduction. Specifically, mindfulness-stress reduction is a guideline concordant treatment for both low back pain and stress that clinicians should consider.  Clinicians can alter patients reaction to stress and have a fundamental and lasting change in their health.

References

1. Salari N, Hosseinian-Far A, Jalali R, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Glob Health. 2020;16:57. doi:10.1186/s12992-020-00589-w
2. Vinstrup J, Jakobsen MD, Andersen LL. Perceived Stress and Low-Back Pain Among Healthcare Workers: A Multi-Center Prospective Cohort Study. Front Public Health. 2020;8:297. doi:10.3389/fpubh.2020.00297
3. Schneiderman N, Ironson G, Siegel SD. STRESS AND HEALTH: Psychological, Behavioral, and Biological Determinants. Annu Rev Clin Psychol. 2005;1:607-628. doi:10.1146/annurev.clinpsy.1.102803.144141
4. Burke MJ. “It’s All in Your Head”-Medicine’s Silent Epidemic. JAMA Neurol. 2019;76(12):1417-1418. doi:10.1001/jamaneurol.2019.3043
5. Mental health: it’s not all in your head. MEDICC Rev. 2013;15(4):3. doi:10.37757/MR2013V15.N4.1
6. Anheyer D, Haller H, Barth J, Lauche R, Dobos G, Cramer H. Mindfulness-Based Stress Reduction for Treating Low Back Pain: A Systematic Review and Meta-analysis. Ann Intern Med. 2017;166(11):799-807. doi:10.7326/M16-1997
7. Niazi AK, Niazi SK. Mindfulness-based stress reduction: a non-pharmacological approach for chronic illnesses. North Am J Med Sci. 2011;3(1):20-23. doi:10.4297/najms.2011.320
8. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
9. Garland EL, Hanley AW, Nakamura Y, et al. Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care: A Randomized Clinical Trial. JAMA Intern Med. 2022;182(4):407-417. doi:10.1001/jamainternmed.2022.0033