What Is Chronic Pain: What, Why, & How To Treat It

Tuesday, June 18th, 2019

The topic of pain is vast and varied. It is so incredibly complicated. In fact, some cannot agree on the exact mechanisms at play from person to person. What we can all agree on, however, is that it hurts, we do not like it, and we want it to stop!

 

Chronic pain is bigger than a direct causative factor, meaning that it is more than, “This was pushing on that and it made something hurt. If we could cut out the something pushing on something else, the pain will be gone.” It does not work that way.

Chronic pain is multifactorial. That means that several things come together to create the ‘pain experience’. Our body uses pain as a protection mechanism. Our body and/or brain can convince itself that we need protection. As a result, it goes to work changing our ‘pain experience’ to fit the level of protection we perceive that we need. What I mean is that, if we perceive the need to be careful, our body uses pain to make sure that we are being careful.

When I tell patients this, they think I’m 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.” These factors can pile up to produce what is termed an ‘up-regulated’ central nervous system. Some call it a ‘sensitized’ central nervous system.

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.

Pain is not originally felt at the site of pain. As complicated as that sounds, let me try to explain using a simple burn for an example. What happens is that a burn sends a signal to the brain for processing and decision-making. That signal is processed and then the brain itself formulates a response that it feels is appropriate.

This happens in a millisecond! Which is absolutely incredible.

When it comes to a burn, the response is to hurt is immediate and to jump back quickly removing the cause of the pain.

What if it is something that is not so sharp as a burn and tends to linger and bother? It may be a pain that has been allowed to hang around nagging here and there. Eventually, new nerve pathways are laid down that keep that pain around. Pathways that keep the pain permanent. Even when there is no identifiable pain generator that should be causing the pain.

Thanks to Dr. Anthony Nicholson and Dr. Matthew Long with Clinical Development International online continuing education, we can put this idea on paper. The image below 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 with pain-free gain.

When we enter the realm of chronic pain syndrome, through all sorts of different influences, 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 mind.

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 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. But, the long-term maintenance of that pain is typically more centralized in the nervous system. That is exactly what chronic pain is. Chronic pain should be treated with methods that address centralized pain. Not with methods that treat pain in the arm or leg.

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. 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 where he provides more clarification and therapy ideas. Some ideas are as simple as creative writing or what he has termed ‘active meditation.’

In addition to Dr. Hanscom’s book we typically recommend the patient undergo a broad management strategy.

This management strategy typically includes very 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.

It is always important for the patient to remember the difference in ‘hurt’ vs. ‘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.

Broad management may also include acupuncture, massage, 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.