Chronic Pain Revolution

Chronic back pain has become another epidemic condition in the Western world with around 80% of people suffering from back pain at least once in their life. It is also very common for a back injury to cause intermittent symptoms for over a year after the injury, 80% of cases to be exact. Around 20% of people never fully recover from a back injury.

There is currently a revolution in the understanding of what drives these types of chronic pain. One that not many people are aware of - that pain is perceptual. The new evidence-base is suggesting a bio-psycho-social approach to chronic pain, and that treating pain as only physical ("bio") is missing the role the mind has to play.

The emerging biopsychosocial model of chronic pain is this - The normal tissue healing time after an injury is around 3-4 months, and in this time it is perfectly normal to experience pain and associated symptoms of inflammation during this time. Any injury that lasts longer than this time is classified as "chronic pain".

With chronic pain the pain is almost an entity in itself, and the tissue damage and inflammation can become only one part of the factors driving the pain. The pain or "alarm" signal being sent from the physical site of the inflammation to your brain is interpreted and moderated by your brain. How your brain interprets this pain in a large extent controls how much pain you experience, and how severe that pain is.

To give you an example of why the thinking around chronic pain is changing, is that back pain is so difficult to diagnose when searching for only physical factors. Strangely enough, if you take ten people off the street with no back pain and scan their lower back, half of them may have herniated discs but no pain. How can this be?

The physical "alarm" sent by your injured tissue can be amplified by your perceptions of pain and injury. For example, if you catastrophise and fear that the back pain associated with a herniated disc could become more severe and need surgery, or land you in a wheelchair, your brain will amplify the pain. In other words, anything that creates a high level of fear about your injury and makes you think that you are fragile, is going to amplify the pain or "alarm" felt. This can then lead to avoiding any physical tasks to wait until the pain goes away, leading to weakening of your core musculature and increasing the mechanical stresses that may be driving your pain, further increasing your pain.

Chronic stress and constant hyper-arousal of your nervous system also amplify the pain and "alarm". Studies on the predictors of back pain actually found that emotional stress is a more significant predictor of back pain than whether or not you have a herniated disc. When interviewing patients about the history of their back pain it is not uncommon for them to remember some low-level discomfort that wasn't much of an issue early on, which blew up into severe chronic pain around the same time as a severely stressful life event, and persisted for a long time afterward once the chronic pain cycle had started.

Psychological studies on hope and optimism found that people who score more highly in hope and optimism tend to have higher pain tolerances, and that undergoing a treatment to improve peoples hope and optimism also increases their pain tolerance.

Chronic neck and shoulder pain is often closely related to stress, the primitive response to fear being to raise your shoulders towards your ears to guard yourself. This tense "guarding" in addition to poor movement patterns with your head and arms can overwork your neck and shoulder muscles leading to pain and discomfort after time. Amplify that with stress, avoid activity due to fear, get a scan which shows (normal) age related degeneration in your neck, catastrophise that you'll never be able to play tennis again and need neck surgery, and you have started a chronic pain cycle.

Another common pitfall is not differentiating between a good and perfectly normal pain associated with using your body or resuming physical activity, and a bad pain that is a sign of aggravation of inflammation. Not understanding the difference between these two types of pain often leads people to avoid any physical activity if even the slightest bit of pain is experienced, further worsening the mechanical contributors to their pain, and becoming dependent on passive modalities. This might include an over reliance on pain killers, massage, acupuncture, etc.

It is interesting that in patients with chronic pain, education about this self-feeding paradigm of chronic pain can be enough for their pain to improve on some level.

A large focus of the exercise therapy for chronic pain is to help people to have confidence in their bodies again, to understand what both normal pain and a "bad" pain feel like, to realise that they can exercise safely and keep themselves fit and strong despite experiencing some normal pain, and how to safely get back into previous activities that they used to enjoy. Purely providing an exercise program is just one very small part of what is important.



Practical Tip:

What to do if you or someone you know are suffering from chronic joint or muscular pain?

- If it is still under 3-4 months from the onset of the injury, go and see your GP for advice and request a referral to a good physiotherapist.

- If the pain has lasted longer than this time (4 months +, even a year or more), you can assume that a combination of tissue injury, mechanical stresses, poor coping responses and negative beliefs about your injury are driving your chronic pain cycle. Once again see your GP for advice to rule out other causes, and request a referral to a good exercise physiologist.


The bottom line is - Don't let the pain become you.