Kinesiophobia state of mind

Kinesiophobia State of Mind.

Once yes. Phobia. Fear of movement. Chronic fear of movement. I've always had it. From what memory I have.

Kinesiophobia is defined as excessive, irrational and debilitating fear of physical movement and activity, resulting from a feeling of vulnerability due to a painful injury or repeated injuries. Here it is. I have always had motor difficulties (the nuns did not help in kindergarten), who have done nothing but get worse at school, where my efforts did not matter to anyone, in fact: I found myself overwhelmed by a flow of kids, whose skills motor skills were certainly superior to mine and I was asked to adapt to their standard, without having the means, with catastrophic results. So for me, moving and hurting myself was the norm. I started having the fear of physical education classes, during which, in junior high, I remedied the whiplash injury that caused the lesion that causes the occipital neuralgia, I broke a couple of flexor tendons of the fingers and other various figures of 💩 that I'm not telling (not to mention the apocalyptic fall that paved the way for persistent pain, but that was accidental).

I believe there is little wonder that it has become kinesiophobic. Somehow, my body has always been a traitor. It was normal for me to choose the brain. It was certainly more reliable.

Obviously, over the years, my kinesiophobia has nurtured and made strong of "don't move", which the various health professionals have offered me. I was happy that I was told not to move. The fact is that kinesiophobia is related to chronic pain. Understanding this relationship can be difficult, but it is important to address the "dysfunctions" that can "cause the pain cycle". To sum up, the belief that something is wrong with our body, and the belief that avoiding exercise will prevent an increase in pain, lead to a vicious circle that involves an avoidance of movement or any activity that could (could, in theory, according to us) cause pain or injury. Over time, the inactivity that results from this fear leads to psychophysical consequences such as muscle atrophy, loss of mobility and an altered response to painful stimuli and behavioral changes, which can contribute to perpetuate pain. In short, a mess: we trap ourselves (unknowingly) even better in the problem.

Immersed in my kinesiophobia, when Luca showed up saying that I had to move to manage the pain, I thought he was crazy (sorry). Because it would have hurt, because I was not able. And it didn't happen that way. What happened was that in my journey I had people who welcomed me. They listened to my fears and, one kg after another, they helped me make it.

So when I mirror myself, with a barbell on my shoulders, and I see all the intelligence of my body, which just needed its time, not to be overwhelmed by the flow of "others", I don't feel simply freed from pain, but also from fear and insecurity. And I firmly believe that the bit of self-esteem I managed to recover has passed and I pass through the instrument that I felt least congenial: my body.

My body, which I look more and more astonished.

Sources:
Butler DS, Moseley GL. Explain pain. Adelaide: Noigroup Publications; 2015
Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999; 80 (1): 329 – 339. doi: 10.1016 / 0304-s3959 (98) 00229-2.
Lethem J, Slade P, Troup J, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception — I. Behavior Research and Therapy 1983; 21 (4): 401 – 408. doi: 10.1016 / 0005-7967 (83) 90009-8.
Neblett R, Hartzell M, Mayer T, Bradford E, Gatchel R. Establishing clinically meaningful levels for the Tampa Scale for Kinesiophobia (TSK-13). Eur J Pain European Journal of Pain 2015; 20 (5): 1 – 10. doi: 10.1002 / ejp.795.

In search of the lost symptom

"The drug removes the symptom, but it does not help to deal with what has led to being sick. Psychotherapy removes the symptom and allows us to face the difficulties that led to the development of the symptom ".

Mh.

Calm. Let's keep our heads. As a basic assumption, it can work.

Psychotherapy has led to a demand for renewal in relation to a tendentially mechanistic vision, in some way functionalistic, of the human being. However, we cannot consider psychotherapy a panacea for all ills or, at least, not in the case of persistent pain. If psychotherapy has changed the view of the human being, which therefore is not a machine, it seems to have jammed on one of its fundamental premises. Pain is considered as an expression of dissociation from emotional trauma: it seems to be an axiom. But is it really an axiom? Persistent pain challenges it, in a scientific way.

Although there are predictive psychosocial factors (emotional trauma, adverse socio-family conditions ...), these are not a sufficient condition for the development of persistent pain (not all those who have persistent pain, have experienced such conditions): pain necessarily has a demonstrable and verifiable biological basis (including nociplastic pain, for which structural and functional cortical changes are appreciable - the famous pain "which is nowhere to be seen").

If pain is a problem on an organic basis, it is not human to think of treating it with exhausting psychotherapy sessions in search of lost trauma, which may not exist (and often does not exist). Rather, it would be useful to renounce the premise pain = dissociation and stop considering people with persistent pain as sick people: they have a disease, they are not their disease, provided that persistent pain is a disease, rather than a (psycho) physical condition.

Scientifically, neurosciences question the premises of psychotherapy. A person with persistent pain is not a sick person, he is a person who lives a (psycho) physical condition, but he is not to be identified with his problem, with his difficulty, with his painful condition, he is a person who needs to be treated, but not in medical terms: he needs to be accepted, tout court. The aim of “cure medically intended” is to lead to the condition prior to that of the disease: it is often not possible. Psychotherapy, accepted all these assumptions, should be genuinely open to these new demands.

The Science of Pain, is a new science, which looks at an ancient problem with new eyes. It is not possible to think of finding innovative solutions while remaining anchored to old prejudices. Psychotherapy, which at the dawn of the twentieth century became the bearer of a revolution, has the possibility of renewing itself by playing a new and very important role, giving people with persistent pain different looks and alternative tools to deal with their own experiences in a constructive and effective way , detaching itself from the old vision of which we have spoken that, in this case, demonstrates its ineffectiveness.

In the case of persistent pain, intervention on the symptom is not useful, because we act with the idea that it is the manifestation of something, of the famous "repressed trauma", while pain is not the symptom, but the manifestation: if we enter this perspective we can try to understand how it affects the life of those who live with it constantly and therefore it becomes possible to work at different levels on pain and its manifestations, disrupting the idea that there is something to cure, to try rather to understand how it is possible to increase self-efficacy and live well with pain.

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(We chose to talk about psychotherapy, not psychology, because it intervenes directly on the epistemological constructs of the personality and on the functioning of the persons themselves).

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Article written with Andrea Ghirelli, trusted friend, educator, family mediator, systemic relational counselor.

Sources:

Chronic pain epidemiology - where do lifestyle factors fit in? by Oliver van Hecke, corresponding author Nicola Torrance, and Blair H Smith Br J Pain. 2013 Nov; 7 (4): 209 – 217. PMC4590163

A Broad Consideration of Risk Factors in Pediatric Chronic Pain: Where to Go from Here? by Hannah N. McKillop, and Gerard A. Banez2 Children (Basel). 2016 Dec; 3 (4): 38. Published online 2016 Nov 30. doi: 10.3390 / children3040038 PMC5184813

Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and Their Efficiency by Kai McGreevy, MD, Michael M. Bottros, MD, and Srinivasa N. Raja, MD Eur J Pain Suppl. 2011 Nov 11; 5 (2): 365 – 372. PMC3217302

New concepts of pain, by Anne-PriscilleTrouvina SergePerrota on Best Practice & Research Clinical Rheumatology

Bardolino Chiaretto Bentegodi, 2018

Just a (wrong) word

I can seem a cold person, lonely, indifferent and devoid of feelings. Not so: I had to build an armor. Because surviving physical pain has been complicated. So complicated, that sometimes I don't know where I ended up.

It was even more complicated to survive the sense of inadequacy that caused me to fail to heal, despite all my efforts.

Up to about twenty-two, I don't think I was fully aware of the pain. There was, but it wasn't scary. It has started to be so since the summer of 2003, due to the combination of a number of factors, which I can now clearly identify (psychological, social, environmental, biological), but which at that moment completely eluded me.

In that summer, the pain, and a series of absurd symptoms, began to eat everything. I am no longer just talking about musculoskeletal pain and allodynia, but rigidity, sleep disturbances, stubborn headaches, tinnitus, irritable bowel, alterations in the perception of body temperature, tachycardia, allergic symptoms, dizziness, confused head. I felt like a crazy fly in an upside down glass. At that point I, already a loyal customer of countless physiotherapists, started my tours with doctors, who invariably resolved themselves in trips from shrinks or in bankruptcy treatment and consequent iatrogenic damage.

My pain and my "related" symptoms did not go away as planned, not as I expected, and not even as doctors, physiotherapists, osteopaths, chiropractors and shrinks were expecting.

So, at some point, I became the problem. The problem was not the pain, or my symptoms, or the tremendous situation I was in, or the treatments that didn't work. It was not those who treated me that he had insufficient knowledge about the mechanisms of persistent pain. No. I was the problem. And I was told in the face. As if I were hostile to healing.

As human beings, we generally like to think we are prepared and empathetic, but I wonder if we ever really think about the power of words. Because words build worlds. And the ones I heard from health professionals, have shaped my world and my personality.

Looking back, it is no wonder that I was so ashamed of having persistent pain. No wonder I felt guilty. Because it was really done everything possible to make me feel inadequate, not so much incapable of facing the situation as directly responsible for its maintenance. I do not say it was done deliberately, with the intent to harm, but the result is this.

It makes no sense to deny the complexity of pain by offending the patient, yet it is what happened to me. We are people with persistent pain, not bad people, lying, fragile, incapable, uncooperative, irretrievable, condemned to pain "because of us"; we live in terrible situations, we are forced to adapt to a "standard" with which, frankly, no human being would like to confront: I know that I often say, that I am repetitive, it is just that I want to enter into your head well. Living with chronic pain is not normal.

Considering how important language is for those suffering from pain, any health professional should be prohibited from using inappropriate terms, those that end up making us feel weak, guilty (you'll end up in a wheelchair, just learn to live with it, it's the worst that I've ever seen, you only have Lourdes left) or ineffective (the pain doesn't go away because you don't want it to pass, you're like this because of yourself), crazy (you're doing it too big, you can't see anything from exams). The collection can easily be expanded. These words take us away from healing, first of all. Secondly, they are inhuman. And, in our heads of people with persistent pain, they consolidate a world of ineptitude and guilt.

A fundamental task in the psychology of pain is to help people learn to reformulate their inner monologue so that it becomes more realistic and supportive. Being able to grasp and recognize unnecessary or unrealistic impulses is not easy, but this skill is the basis of many successful adaptations to persistent pain. This insight forms the basis of cognitive behavioral therapy (a form of psychotherapy that aims to change useless thinking behaviors), which plays an important role in helping people live with persistent pain. Living with persistent pain, living well with pain, is a fully achievable goal, I know from personal experience. I would add that it is fully achievable in a context where the patient is not regularly skewed by health professionals, which is often the case.

If the patient is to be guided towards a greater awareness, the same must happen for those who take care of him: health professionals should motivate people with persistent pain, offering a language that must be carefully chosen in order to take more care of the patient, not to rub against him.

When a treatment doesn't work, it's human to find someone to blame. I would avoid accusing the patient, I've already said. I would also avoid blaming the clinician (although in this case, I admit, it takes an effort of mercy, I'm biased). Moreover, by accusing each other, we do not have much to gain. Surely a motivated patient is a step closer to success, and a health professional who is aware of his or her limits will know how to motivate a person, respect it, pass on the right information, when to stop and pass the baton, or choose to inquire.

I do not believe that health professionals are evil by nature. I believe that once we assume that the "old way of proceeding" to which we are accustomed is detrimental, just as we seek new ways for patients to help them reformulate their thoughts in order to live well with pain, it must be given greater emphasis on the importance of "communicating well" pain on the part of health care professionals.

If patients wish to be helped, I assume that health care professionals want to help, so if we interpret the patient / health professional relationship as a dialectic and not as a match between opposing teams, we could achieve something good for both categories.

There is hope for everyone.

When chronic pain kills

One of the "interesting" things that happened to me since I began to leave chronic pain behind, was that people started to recognize my illness. People who had denied it for years, when they saw me go to the gym twice a week, run, treat me with "never heard" medicines and literally become another, they started thinking (mostly to understand) that I was "Really sick".

At that point, even the most unexpected, not only began to ask me for information for the friend who suffers or (even) for himself, but also to tell me about those of their acquaintances who, for years, sought help because they suffered from terrible pains and that, in the end, unable to find him anywhere, they decided they had had enough.

I had always thought that chronic pain could ruin a life to the point of suicide. I myself had thought about it, for about thirty seconds, in the summer of 2003, looking at the pavement from the second floor of the house. Now I had some more empirical data, which was not just about me.

Surely it is not pleasant to talk about suicide. It's not a topic to talk to. But generally, problems are not solved by ignoring them.

We, of chronic pain, kill each other. I don't feel like turning a blind eye.

In fact, unless specific underlying pathological conditions exist, chronic pain "in and of itself" does not die. It is possible to develop a predisposition to cardiovascular diseases, probably caused by prolonged anxiety and stress to which those suffering from persistent pain are exposed, but this is a condition that can be managed with appropriate strategies.

Other factors related to increased cardiovascular risk, cancer and lung disease, often also affecting those suffering from chronic pain, are too high a BMI, inactivity, poor nutrition, but they are all factors related to lifestyle, which is affected negative of a series of prejudices on chronic pain (in particular the need to reduce movement, which is deleterious), not to chronic pain in itself: by improving one's lifestyle, one returns to “normal” ranges.

In short, I don't think I have to explain here what it means to live with persistent pain but, to summarize, it means carrying a load of pain that, in the long term, physically and psychologically is simply devastating. First the body is stolen, then the psyche, sometimes the whole. If he eats it. It takes life. Point. And you can get to contemplate suicide.

Suicide rates are more common among people with persistent pain. Generally the risk factors in this population can be conceptualized in terms of two categories. The first includes factors that are not limited to patients with pain, but are associated with suicidal tendencies in general. The second category groups specific risk factors for people with pain. Some of these are difficult or impossible to change, such as the duration of pain, or affected body sites. Others, such as the intensity of pain, the tendency to catastrophism, functional interference, poor self-efficacy, can be improved with appropriate interventions (and this could be considered good news).

Although rarely discussed, suicide in people with chronic pain often occurs. There is no concrete data on how many people with chronic pain die by suicide every year. But there are some assumptions. It is believed that on about 40.000 people who succeed in their suicide attempts every year in the United States, at least from the 10 to the 15% are people suffering from chronic pain. The truth, of course, is diabolically difficult to understand with certainty (I do not want to dwell on dissertations on the subject, but we do not have the data of people who do not leave letters explaining their motivations and it is often not possible to frame opiate overdoses such as intentional acts, etc.).

Because individuals with chronic pain are at least twice as likely to report suicidal behavior or suicide, it is of the utmost importance to identify which risk factors contribute most to increased suicide risk. There is solid evidence that chronic pain itself, regardless of type, is an important independent risk factor for suicide. The only sociodemographic factor found associated with suicide in individuals with chronic pain is related to unemployment and disability. Depressive symptoms, anger problems, harmful habits (such as smoking, alcohol abuse, illicit drugs), adversity in childhood or adulthood and family history of depression or suicidal tendencies have all been identified as general risk factors.

Regarding pain factors, sleep problems, low mood, the concomitant conditions of chronic pain and the most frequent episodes of intermittent pain, they have all been considered predictive factors of suicide. Unexpectedly, the characteristics of pain (eg type, duration, intensity, severity) and physical state do not seem to be related to suicide risk. Psychosocial factors (for example the sense of mental defeat, the tendency to catastrophism, despair) are more significant, associated with suicidal outcomes.

A large number of these factors are susceptible to change through targeted intervention, emphasizing the importance of thoroughly assessing patients with chronic pain at risk of suicide, also incorporating a suicide prevention component in chronic pain management programs.

The sad situation of patients with chronic pain, and their potential link with suicide, will hardly improve until the chronic pain epidemic is really taken seriously, acting really effective strategies that are not based on the prehistoric treatment of the problem .

People living with chronic pain are the reason why increased care funding is needed to manage chronic pain, at all levels, starting with the training of health personnel (and others). The weight of pain often exceeds the human will to live, too often not because research is lacking, but because of a dramatic lack of skills on the part of those who should take charge of the health of patients, who are left to themselves, lives without lives, in which the pain leads to a disintegration of the lived, of the relationships, of the personality, with very serious repercussions, which should no longer be ignored.

Sources:

When pain kills - chronic pain and chronic diseases by Chris Williams on Body in Mind read it here

The Painful Truth, by Lynn Webster

A Nation in Pain. Chronic Pain and the Risk of Suicide by Judy Foreman on Psychology Today

Chronic pain and suicide risk: A comprehensive review, by Melanie Racine Neuro-Psychopharmacology and Biological Psychiatry PubMed # 28847525

Testing the Interpersonal Theory of Suicide in Chronic Pain by Wilson KG, Heenan A, Kowal J, Henderson PR, McWilliams LA, Castillo D on Clinical Journal of Pain PubMed #27768608

Remission From suicidal Ideation Among Those in Chronic Pain: What Factors Are Associated With Resilience? by Fuller-Thomson E, Kotchapaw LD on The Journal of Pain PubMed # 30979638

Chronic pain does not exist

We constantly hear about cancer, diabetes and heart disease. I think it's good. Not that you love hearing about diseases, of course, but if something is talked about, it means that you are not sweeping it under the rug pretending that it does not exist. Talking about it probably also means more prevention, more research.

Obviously, the perception that results is that cancer, diabetes and heart disease are the great evils of our time. What if I told you that things are not exactly like that? It is estimated that around 1,5 billion people worldwide suffer from chronic pain. It is a huge number, higher than that of cancer, diabetes and heart disease put together. This data is obviously a projection made in the light of some surveys conducted in Europe, the USA and Australia and Asia. It affects at least one adult in five, leaving out children and adolescents. Studies conducted at European level confirm that persistent pain has a significant impact on daily life, sociality and the quality of life of those affected.

Between the middle and the 2 / 3 of those who live with persistent pain, sees their ability to rest normally, move, participate in social activities, drive a car, have a normal sex life diminished. Not to mention that one in four people say that relationships with friends or family members have become less frequent or interrupted. One in three is less able, or completely incapable, to maintain an independent lifestyle. One in five is depressed because of pain. The 17% suffers so much at times that it would like to die. Some really kill themselves, but the study doesn't say how many. The 39% of respondents feel that their pain is not properly managed and that doctors do not consider pain a problem. Chronic pain, not wanting to consider the psychosocial aspect, because for now we assume that we are heartless and the suffering of others does not care about a tube, it has a tremendous economic impact.

Let us reason as if we were Ebeneezer Scrooge: lumbar pain alone is one of the most impactful economic burdens in developed countries. In fact it implies costs for care, for welfare, but also for the absence from work and the drop in performance of those who have to take on the tasks of absent colleagues, loss of earnings for companies and for the patient, decrease in earnings and, therefore, the possibility of spending for those who eventually find themselves in the position of having to support the family forced into inactivity because of chronic pain. Research also shows that those suffering from persistent pain are more at risk of losing their jobs and often cannot work outside the home. In short: we are talking about an apocalyptic problem, with tremendous social and economic implications.

So I think the legitimate question, without using bad words, is: "Why is the global pathological burden of chronic pain underestimated?" I searched for some answers. The answers that are there, when they are found, make one shudder. In this regard, I found a simple but rather interesting document for my hands. A "Fact Sheet", entitled "Unrelieved Pain is a Major Global Healthcare Problem". Persistent pain is not diagnosed and is not treated because it is considered "psychosomatic", fruit of depression (I have already become a pressure cooker) that often afflicts those who suffer from chronic pain, therefore lacking a real organic cause. It is not diagnosed because treatments are considered futile. It is not diagnosed because pain is inevitable. It is not diagnosed because patients are old and have little to live, or are they too small and some still believe that children do not feel pain, or that third-degree burns are pain-free. Primarily, there is still unacceptable ignorance about the subject. And I'm not saying it. The World Health Organization says so. Including the reasons why chronic pain is underestimated, that are fundamentally determined by a series of goat biases (forgive me, I have been kind to this), What are the obstacles to the evaluation and treatment of chronic pain? I have a suspicion, but let's see what the "Fact Sheet" that I have on hand tells us.

The first culprit is, ladies and gentlemen, ignorance above. Lack of knowledge or awareness. This problem does not only concern the poor patient or his family, who may be florists and would have the right not to know a damned persistent pain, but also health professionals, so those who should treat him, the poor patient and who , supposedly, I add, they should at least know more about him. Moreover, we consider that in Europe, one in four patients with moderate or severe pain reports that the attending physician never asked questions about the pain, did not think that he had problems with pain and, in any case, even if he asked for information, he paused briefly and failed to provide a solution. That good news. Although the availability of opioid analgesics to relieve cancer pain has increased even in developing countries, thanks to the efforts of the World Health Organization, cancer pain is not the only severe persistent pain that exists and opiates do not they are the only drugs needed to treat it, so most people with persistent pain remain without adequate drugs worldwide.

And what do you do to change this state of affairs? We educate ourselves. You study, you learn. Such as? Changing university programs, for example. Reading scientific magazines. Going to training courses. Stopping to consider yourself intellectually and morally superior to your patients, because a degree in a medical health profession does not ennoble man.

It's a big problem, I'd say. And it does not seem to me that the World Health Organization and the International Association for the Study of Pain have been very successful.

The Fact Sheet I'm reading is from the 2004. It was carried out on the occasion of the First Global Day Against Pain by the International Association for the Study of Pain - IASP and by the European Federation of Chapters IASP - EFIC, with the co-sponsorship of the World Health Organization. Old news? In terms of time for sure. If we rely on the results, frankly the contents seem to me to be valid.

Something is moving, it's true. But there is still a tremendous disconnect between clinical practice and scientific research. And it is not admissible. We must continue to talk about pain. There is nothing ignoble or whining about it. It would be like not talking about cancer, because it is not dignified or gives us sadness or is not "virile". To me it would seem simply incredibly stupid.

Sources:

www.science.org.au

www.reasearchamerica.org

Unrelieved Pain is a Major Global Healthcare Problem, Fact Sheet, IASP - EFIC

The beginning of (my) history

I state, in my defense, that I love my mother madly. She is a brilliant woman, a cross between Alice in Wonderland and Piperita Patty. My mother is an artist. Which means that it has a very refined taste when it comes to flower compositions and watercolor painting or furnishing, but everything that is not figurative art is beyond its interest: the wardrobe, for example. As long as it's your own, there are no particular problems, as far as I'm concerned. But when it comes to my well, it was hard to be twelve and put her into a counterculture militant. When my companions were hiding in bomber of Energie, flared jeans and Kikers, I was condemned to clothes like an intellectual in the grass. They made fun of me for my milk-white skin, they called me "the dullness". No, I don't tan. Never. It is not a quirk. I'm like that. It's called the 1 phototype. If we add to this the wardrobe, we understand how my desire to disappear increases, but becomes more and more an unrealizable desire. I had the gene for being upstream in me, but at twelve I didn't know what to do with it. It was Saturday. I think it was spring. When they left school they started making fun of my skin color. The oversize sweater didn't help me have courage. I had black leggings. Black ballerinas. I don't know what exactly happened. I know that the bully-boss has froze me in front of me, then I fell. The backpack, full of books, with its exorbitant weight, dragged me backwards, and I stayed there, so, on the ground, in the middle of the road, for a time that I can't define, I presume fainted. I don't know what exactly the phrase "see the stars" derives from, which is used to describe being struck by a strong and sudden pain: the fact is that I saw the stars or rather the stars (here they are!). And it wasn't a bright flicker in front of my eyes: I took a walk right in the middle of it, in a dark blue tunnel. And from that day my long and very complicated love story began with chronic pain. Why do I call it love story? Because our relationship has been a long life, mine, and it has been difficult, made of very long moments of mutual misunderstanding, then in some way it has blossomed, when I found the way to speak its language: it may seem delusional, but it's not too much. You will understand by reading. After all, I can't say I hate my past life: it was my life.

When I woke up, after my astral walk (it is the case to say it), there was no one around me anymore: I was alone, lying in the middle of the road and I was suffocating. I remember lifting myself off the ground by pulling my arms out of the rucksack straps, abandoning it there, and walking rattlingly into the arms of a perfect stranger who, somehow, rubbing my back and hugging me, managed to bring me back to life. I did not feel the victim of an act of bullying, in the '92 I had not even heard of it, but only a perfect idiot: a simple, further, living confirmation of my clumsiness.

Here, to me the chronic pain touches from that epic fall, of which, essentially, it has not imported a pipe to anyone. I had fallen. Everyone falls. I played with Barbie and I had atrocious back pain, but they told me they were the pains of growing up. It didn't seem to me that none of my classmates suffered like this, moreover in an area hit by a crazy blow, but I took the explanation for good. In short, it seemed to me that it was my grandmother who had back pain and I certainly didn't have my grandmother's age, but I made the interpretation go well.