"Can we review our status here, Sy," says Krantz, "let's look at these things from a... from a standpoint of status. What have we got on that spacecraft that's good?"
I just finished reading a really interesting book called Watch Your Back by Dr. Richard Deyo. It's an impeccably referenced and highly readable book, for both patients and health professionals, about the problem of chronic low back pain and the many ways that people try to treat it. One of the most salient points that Dr. Deyo makes is that few people make it through life without ever having back pain; it is one of the most common complaints brought up in primary care medical visits. Among US adults, 60-80% have back pain at least sometimes, and many have it often, with accompanying limitations. As do many academics, I "dance" with back pain a lot, so I very much appreciate Dr. Deyo's review of the evidence. He supports something that has always been a solution for me: to learn the right physical therapy exercises and do them, and to try to modify my cognitions to avoid hopelessness ("What's the point? It's too hard to exercise every day"), impulsive thinking ("I want it fixed now"), and catastrophic thinking ("If it hurts this much today, imagine how bad it will be in the future!"). Exercising and keeping a positive attitude sound cliché, but they actually work. When my attention is riveted on pain, and everything seems to be going wrong, I find that it is wise to pull together a status review: What have I got that is working? What have I got a handle on? What's good?
Dr. Deyo offers a great deal of evidence that exercise and cognitive-behavior therapy (CBT) together are highly effective treatments for chronic low back pain. CBT is a problem-focused and action-oriented psychological approach in which the individual learns to develop and reinforce target behaviors, such as appropriate pacing of activity and rest, that help the pain. In CBT, the individual also learns to control thoughts in order to stay positive and solution-focused. Exercise and CBT together surpass many medical and surgical interventions, hands down, in both their efficacy and their safety. They help people both feel better and function better; they give people with chronic low back pain a sense of control over their lives. Increased self-efficacy --the belief in one's own ability to reach one's goals --helps to avoid the anxiety and depression that can often accompany chronic low back pain and contribute to making it even worse.
Exercise and CBT do require commitment and effort, and while this effort does pay off, it must be maintained for a lifetime. Some people are happy to develop and maintain new habits, such as exercise and CBT, that will serve them lifelong. They understand that chronic low back pain is chronic, just like many other medical conditions such as diabetes, heart disease, COPD, asthma, HIV/AIDS, and even some cancers. By definition, chronic conditions persist over the lifetime; nearly one in two Americans has at least one chronic medical condition, and chronic disease care accounts for over 75% of healthcare spending in the US today. But with chronic low back pain, many people tend to hope for a cure. Data show, however, that surgical interventions and many pain medications can sometimes have poor outcomes and can cause a lot of problems (including increased pain, movement limitations, and pain medicine addiction). Bed rest has been shown, in much research, to be among the worst possible choices. Exercise, on the other hand, does work. It is important to get moving and keep moving in ways that include aerobic exercise, and strengthening, flexibility, and balance-type activities; it is critical to continue to stay positive and engaged in valued life activities.
But Americans don't move nearly enough. We spend up to 60% of our waking time (i.e., nine or more hours/day) sitting or lying still. According to the CDC, only about 20% of US adults 18 and older meet recommended minimum levels of aerobic activity and muscle strengthening guidelines; for middle aged and older adults, that drops to below 15%. For individuals with pain, that percentage is even lower. Mostly, we say we don't have time to exercise, or we don't like or cannot afford a gym, or the weather is too bad, or we are tired, and/or our backs hurt. But Americans watch television 5 hours per day on average, and the older we get, the more TV we watch. We spend several more hours each day on personal email and social media.... all sitting or lying down. In the realm of activity, a status review can focus on what we can do as opposed to what we cannot. We may not be able to join a gym, or run anymore; but walking in the neighborhood, or at the mall, can be great. Stretching and core strengthening exercises can be done while watching TV. Taking the stairs instead of the elevator, and parking farther from the building at work, may be possible most days. We have heard it all before, of course; moving is essential.
And sometimes, even after we have evidence that some activity makes us feel better, and stronger, and happier, we stop doing it. Studies even show that among the many patients who stop caring for their chronic conditions, 25% do so because they "feel better". The fact is, it's hard to continue to manage chronic conditions for the rest of one's life --taking medication, exercising every day, changing one's diet. We stop because we hope we are cured, a word that does not even belong in the vocabulary of chronic disease.
Every day, we need to assess what we can do to actively take control of our chronic conditions. We need to figure out what works and keep on dancing with our limitations, whatever they may be. Perfect health might not be achievable, but we may be able to live our lives doing things that we value. We might not be pain-free, but if we are honest with ourselves, we often find that we can do a lot of what we enjoy and also care for ourselves. In the realm of health, we can ask ourselves (and perhaps our health professionals can help us to ask): What do I have that works? What activities can I engage in to the fullest extent possible? What goals, that challenge and push me, are within reason? Will I commit myself to be actively involved in exercise and managing my thoughts pretty much every day, for the rest of my life? A status review of what is working can help us commit our thoughts and our activities to living our lives as fully as we can, and figuring out what we can accomplish. Often, it's a lot.