Vital New Information If You Have Long Term Pain
New treatment information for chronic pain treatment
by Jeff Williams, DC, FIANM
When we think of chronic pain, we think about having pain beyond the point it should have disappeared. The fact is, it is so much more than that. Chronic pain is a beast and taming it is a process and a journey. Did you realize that chronic pain costs us more than cancer, diabetes, and heart disease globally? In case you didn’t catch that, it costs us all more than those huge, very serious conditions COMBINED.
Indeed, you might say that chronic pain is a problem. It is important to understand that nerves come from the arms and legs and everywhere else and connect directly to our central nervous system. The central nervous system is made up of the brain and the spinal cord. When information comes in from the arms, legs, or anywhere else, the brain must make decisions about how important those signals really are and then deal with those signals appropriately. Will the brain squash the information as meaningless? Or will it allow the signals to trigger pain and a reaction to the pain? Depending on all of this, the brain determines whether or not to make it hurt and, if so, how badly it should hurt.
Knowing this is very important: The brain is what decides whether something makes you hurt. Your brain is what makes up your ongoing pain experience.
The ‘Pain Experience’ is a protection mechanism and this process is only a small part of the overall ‘Pain Experience’.
Chronic pain is due to several things and, as just mentioned, the brain plays a BIG part. In fact, previous injuries suffered are imprinted in the brain and the brain uses that information when making future decisions about the stimuli that it continually receives. It uses that information when deciding if, or how much, one will hurt on a day-to-day basis.
The brain is the one that tries to predict the future likelihood of experiencing pain and sets the level of sensitivity in order to minimize our risks based on what the brain thinks is likely to happen. For example, the expectation of something being painful changes the way a person moves.
Another vital concept is that of ‘Neuroplasticity’.
Without getting too difficult, the term simply means that our nervous system can change in structure and function as it encodes new experiences. This means that not only can injury cause pain but that changes in the central nervous system also play an active part in maintaining the chronic pain experience.
That also means that treatment targetting the central nervous system has the potential to decrease pain and improve function.
So my pain is in my head?
When we discuss these points with patients, they sometimes think we’re telling them that their pain is all in their head. That is not the case. What it means is that our perception of ourselves and our capabilities combine with our past pain experiences. Past pain experiences could include injury and/or surgery. That information combines with what we have been told by doctors about ourselves. For example, “You have the back of an 80 yr old.” Or “your back is fragile and you’re going to have to protect it going forward.”’ “Or, you have this messed up, out of alignment, straight neck and we really need to work on this over the years to make sure you don’t wind up crippled in 40 years.” Another common one I hear from my patients is “My doctor told me that it’s not a question of if I’m having surgery eventually. It’s just a question of when, and he said to just call him when it’s time.” Wow. What can we do to get surgeons to stop using that script?
THEN you have to factor in your beliefs about yourself, your condition, your life with pain, and your likely chances of being able to recover.
So again, some of the factors contributing to your pain experience are the actual pain at the point of injury, past pain experiences, communication from previous healthcare practitioners or other outside sources, and your own self-limiting beliefs and fears. That’s just to name a few.
These factors can all pile up to produce what is termed an ‘up-regulated’ central nervous system. Some call it a ‘sensitized’ central nervous system. Your brain used all of these factors and takes them all into consideration to create your ongoing pain experience and when it is sensitized, the pain experience gets amplified.
This does NOT mean it is all in a person’s head. Far from it in fact. What it means is that your very real pain can be (and most likely is) made worse by your own central nervous system. The central nervous system that is in place to protect you.
To demonstrate the fact that pain can exist in your brain as well as at the source like a wrist or an elbow or a low back…..let’s briefly mention phantom limb pain. In case you are not familiar with the term phantom limb pain, it is when a person has pain and issues in a limb. So, the limb is amputated. Cut right off. Yet some of these folks still experience pain. In a limb that has been cut off and no longer is attached to their body. It not longer exists. But it still hurts as if it were still there and still attached. That is because the pain was handled at the source. But it wasn’t treated from the cognitive aspect.
Thanks to Dr. Anthony Nicholson and Dr. Matthew Long with Clinical Development International online continuing education, we can put this idea on paper. The title image to this article represents a simplification of the patient pain experience.
The arcs represent your body’s total ability. The bold red line is the point of tissue damage. Meaning that you can operate normally until you reach the tissue damage line. If you reach that line or go beyond it, you are likely to tear ligaments, muscles, etc.
The red dotted line represents the point of pain. We reach the point of pain just before we reach the point of tissue damage. Again, this is our body using pain as a protection mechanism.
If you notice, there is a little bit of space where the arc extends above the tissue damage line. That is the point where you can operate pain-free but you are damaging tissue. This is the space one operates in when they are picking a car up off of a child or performing some superhuman feat.
For most of us mere mortals, we are able to operate normally without a lot of pain as ‘A’ demonstrates. We have an expansive range wherein we are able to live, work, and play without hurting. If we get too close to tissue damage, we hurt enough to back us off and then we continue to live, work, and play pain-free again.
When we enter the realm of chronic pain syndrome, through all sorts of different influences that I mentioned, our pain point (our red dotted line) is moved down. We may have been told we will eventually need surgery no matter what we do to avoid it. We may have seen our parents deal with awful back pain and have a perception that we will suffer the same malady. Maybe we have had past pain experiences like some sort of prior surgery or an injury from years ago that we still have in our minds.
In this sort of scenario, your central nervous system moves that red-dotted line down to protect you. It moves it down because you have subconsciously told your body that you need to be protected. Now, as ‘B’ represents, you have much less space in which you can live, work, and play before you start hurting.
As mentioned before, this is a ‘sensitized’ nervous system. Also known as an ‘up-regulated’ nervous system. This is when more and more things that do not trigger pain pass through to the central nervous system and start causing a pain response.
Now, describing this to patients that are hurting can elicit a couple of big responses.
One response is that of relief. There is the relief that we have helped put a name on what is going on. Relief that we have provided a path that just might lead out of it someday.
The other main response is that of anger. Anger because they believe that we are suggesting their pain is purely in their head. If it’s all in their head, then how could they hurt so badly? They also think we are suggesting they’re somehow crazy.
That could not be further from the truth. There is almost always a real reason for the onset of pain. Some common reasons are arthritis that consistently irritates and inflames. Loose joint that tend to move around more than average and cause constant irritation with certain movements. There are very real reasons for pain at the actual source. But, the longer that pain sticks around, the more of it SIMULTANEOUSLY begins to also live within the brain and within the overall pain experience. That is exactly what chronic pain is. We can throw all of the stuff we do at the pain, chiropractic, surgery, acupuncture, physical therapy, and massage. But if it is not also, at the same time, being treated from a cognitive aspect, the outcome may remain disappointing.
There are all kinds of ideas on how to treat centralized chronic pain. One physician with some great research and ideas in his arsenal is Dr. David Hanscom, MD. Dr. Hanscom is a spinal surgeon from Washington State. A medical doctor. He has authored a book called ‘Back In Control’. Dr. Hanscom is actually a spinal surgeon who just happens to be on the warpath against spinal surgery. To be more specific, he is against surgery for the wrong candidate.
Dr. Hanscom is very clear that too many back surgeries are happening. He states that so many of them are failures because the patient was not a good candidate for the surgery in the first place.
He shares a shocking statistic as an example. He cites research showing that, when a chronic pain sufferer undergoes surgery and EVERYTHING goes beautifully, the patient will STILL experience chronic pain at the new site of surgery in 60% of the cases.
That’s a 60% failure rate for successful surgeries! THAT’S a sensitized central nervous system!
He also has a website we recommend often at www.backincontrol.com. This is where he provides more clarification and therapy ideas. Some ideas are as simple as getting adequate sleep, creative writing, or what he has termed ‘active meditation.’
In addition to Dr. Hanscom’s book we typically recommend the patient undergo a broad treatment management strategy. This broad management strategy typically includes spinal manipulative therapy. Broad management could also include targeted exercise regimens. Regimens urging the patient to move in ways they have not moved in some time. As they build confidence in these new movements, their pain point (red dotted line) begins to rise back up and the patient begins to have more confidence. That gives them more space to live, work, and play before feeling pain.
Hurt vs. Harm
It is always important for the patient to remember the difference between ‘hurt’ and ‘harm’.
If an exercise or activity hurts, yet clearly shows improvement, it is likely worth continuing. If an exercise or activity is harmful, it should either be modified or avoided completely. Not understanding the concept of hurt vs. harm leads to fear avoidance. That is when we back away from activities that we love. Activities that feed our lives and our hearts. Then we begin physically de-condition in as little as only 7 days. While it takes much longer than that to re-condition. It's completely unfair but, nonetheless, true.
When we are working through the pain understanding that it hurts but it is OK for it to hurt, we aren't slipping into fear avoidance and are continuing to move the needle forward while moving our pain point line further and further up.
Broad management may also include
- Medical treatment
- proprioceptive rehab,
- balance rehab, as well as
- cognitive-behavioral therapy.
Chronic pain syndrome is a beast and the pathways in the nervous system laid down are permanent. That means there will always be work to do in order to stay above the pain and keep the red-dotted line as high as possible. But, with a toolbox of techniques to help, there is hope and there is a way to begin climbing back out of the hole.
We are helping people in our area like never before. We are getting them closer to a pain-free life and we are getting them on the road to avoiding surgery, getting off of pain medication, getting better sleep, and taking control of their own lives without the need for a bunch of healthcare practitioners.
It can be done and the right practitioners that understand chronic pain can help you get there.
Dr. Jeff Williams, DC, FIANM is a Fellowship-trained Neuromusculoskeletal specialist, Orthopedic specialist, and chiropractor in Amarillo, TX. As an Amarillo chiropractor, Dr. Williams treats chronic pain, disc pain, low back pain, neck pain, whiplash injuries, and more. Dr. Williams is also the host of The Chiropractic Forward Podcast (https://www.chiropracticforward.com). Through the podcast, Dr. Williams teaches fellow chiropractors and advocates weekly for evidence-based, patient-centered practice through current and relevant research. If you have any questions for Dr. Williams, feel free to email at [email protected] Learn more about Dr. Williams and his practice at https://www.amarillochiropractor.com.
Dr. Williams was voted Best Chiropractor In Amarillo in the Best of Amarillo 2020. Dr. Williams's full-time Amarillo chiropractic practice is Creek Stone Integrated Care at 3501 SW 45th St., Ste. T, Amarillo, TX 79109. If you are searching for a chiropractor near me, Dr. Williams is your Amarillo Chiropractor.