Irritable Bowel Syndrome: A New ICP Content Page

The Institute for Chronic Pain (ICP) is an educational and public policy think tank that brings together thought leaders from around the world to provide scientifically accurate information about chronic pain and its most effective treatments. We endeavor to provide academic-quality information that is easy to read and as such we serve as a scientifically accurate resource to patients and their families, generalist healthcare providers, third-party payers, and public policy analysts.

Our aim is to change the culture of how pain is managed — to foster a culture in which the field of pain management more readily provides treatments with demonstrated effectiveness. We imagine a day in which healthcare providers deliver and patients regularly demand empirically-supported therapies for chronic pain. To bring this goal to fruition, stakeholders in the field must have a scientifically accurate source of information on the nature of pain and what most effectively treats it.

What drives pain management today?

Patients and their families are often surprised to learn that not everything that healthcare providers do is effective. Antibiotics for earache and arthroscopic knee surgery are two commonly cited examples of treatments that are routinely provided, but are no better than placebo (which is a common measure of effectiveness). Despite their demonstrated ineffectiveness, these kinds of procedures and therapies continue to be commonly delivered by healthcare providers and demanded by the public for a complex array of reasons.

  • Discipline-specific practice: Most healthcare providers do not practice within interdisciplinary teams and so become ignorant of advances made by other disciplines.
  • Tradition-bound practice: Healthcare providers tend to practice as they were taught, even if it has been many years since their initial education; keeping up with advances in the field is solely the responsibility of the individual provider and fulfilling this responsibility competes with many other demands on the time of the provider.
  • There are few sources of objectively neutral continuing education: Presently, continuing education is predominantly provided by pharmaceutical and medical technology companies, both of which have vested interests in teaching advances that only relate to the sale of their products.
  • The profit-motive: In the U.S., the healthcare system is capitalistic and so relies on providers selling a service, under the auspices of making treatment recommendations, and many ineffective procedures and therapies are highly profitable.
  • The predominance of the use of placebo-controlled trials of new medications: To come to market, new medications do not have to be more effective than already existing medications for a given condition, but only better than a placebo; as such, with the right marketing strategy, a new medication for a given condition can become a top selling blockbuster, and supplant the use of an already existing medication that happens to be more effective; in other words, the new, but less effective, medication can become more widely prescribed than a more effective older medication that lacks a good marketing strategy.
  • A common understanding of a condition that was initially developed based on common-sense considerations can easily remain as a widely-held understanding in society even though empirical research has shown the understanding to be wrong; the reason is that there is no entity responsible for making the more scientifically accurate understanding of the condition more widely known in society.

For any and all these reasons, the healthcare system can continue to provide care that is ineffective or less effective than other therapies and more effective therapies can come to be less commonly used.

Mission of the ICP

Many of the above-noted problems occur because there is no entity that assumes responsibility for both providing up-to-date, scientifically accurate information about health conditions and proliferating this education on a wide scale basis. The goals of the ICP are to engage in these endeavors for issues related to chronic pain. Without any vested professional or financial self-interest, we seek to educate the public and healthcare professionals alike on a) scientifically accurate conceptualizations of the nature of chronic pain conditions and b) how to most effectively treat these conditions.

Irritable Bowel Syndrome

To this end, we announce the publication of a new content page on our website. Written by Jessica Del Pozo, PhD, it provides approachable, yet scientifically accurate, information on irritable bowel syndrome (IBS). IBS is a particularly good example of a condition that society, including many healthcare providers, often misunderstands. Specifically, the commonly held understanding of IBS as a digestive condition isn’t accurate to what we know from science; as a result, in our society, we do not tend to treat it as effectively as we could.

irritable bowel syndromeAs Dr. Del Pozo indicates, IBS is not primarily a gastrointestinal condition, but rather primarily a nervous system condition. Nonetheless, treatment recommendations are commonly based on the inaccurate understanding of the condition as a gastrointestinal condition. These recommendations fail to be effective and yet they are more commonly pursued. They are even more commonly pursued than therapies focused on the nervous system, which science tells us are more effective.

Our hope is that Dr. Del Pozo’s piece on IBS can be one way for society to have access to approachable, yet scientifically accurate, information on the condition. Through this site and our social media, we’ll try to proliferate this information.

Your help in this regard would also be greatly appreciated. If IBS is important to you, please link to it on your site or post a link to it through your social media.

Dr. Del Pozo is an expert in the field of chronic pain rehabilitation and in the treatment of IBS in particular. She is the co-author of The Gut Solution, a book for families with IBS utilizing a biopsychosocial approach (www.thegutsolution.com).

Dr. Del Pozo is also the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). In addition, for the last six years, she has been involved in an interdisciplinary chronic pain rehabilitation program at Kaiser Permanente, where she helps people with chronic pain learn to manage their pain without the use of opioid medications.

We appreciate Dr. Del Pozo’s expertise and contribution to the ICP. Please read her important piece on irritable bowel syndrome on the ICP website.

Author: Murray J. McAllister, PsyD

Date of last modification: May 5, 2016

The ICP Supports the Make Your Day Harder Campaign

Recent data in the Lancet show that as societies become increasingly industrialized around the world, rates of low back pain, migraine, depression, obesity and type 2 diabetes increase (among other conditions). It’s an interesting commentary on the social determinants of health.

Why the increase?

modernityIt’s not that as societies industrialize they become awash in contagious viruses or bacteria that make people have these conditions. In fact, as societies industrialize, rates of infectious illness tend to drop and death rates overall drop. And, at any rate, viral and bacterial infections don’t cause the above conditions.

It’s also not that as societies industrialize the people who make up these societies develop genetic mutations that lead to the increasing rates of conditions such as low back pain, migraines, depression, obesity and type 2 diabetes. No, our genetic constitution doesn’t change that fast – at least not over the 50 to 100 years it takes for societies to industrialize.

So, what produces this rise in such conditions? General consensus is that it’s the psychosocial changes that come with industrialization: particularly, the increasingly sedentary lifestyle; the increasing consumption of cheap, processed foods (and the corresponding decrease in consuming traditional, whole food diets); and increases in chronic, non-life threatening, stress.

Sometimes, people get upset when healthcare providers talk like this. But, let’s explain.

The biopsychosocial nature of chronic health conditions

The afore-mentioned conditions are considered biopsychosocial in nature. That is to say, they are caused by a combination of multiple factors, some of which are biological, some of which are psychological, and some of which are social in nature. So, across the population as a whole, and even within any one individual, there are various combinations of these three factors that go into causing conditions, such as low back pain, migraine, depression, obesity, and type 2 diabetes, among others.

Now, with the advent of industrialization, it’s not the biological factors in the mix that seem to be increasing, but rather the psychological and social factors. It’s the increases of certain behavioral lifestyles and stressors, which seem to be accounting for the increases in these conditions. Meanwhile, the biological factors seem to be remaining largely constant.

So, what do we do about it? We educate ourselves. We practice tolerating what we learn and reflecting on it. We then slowly and incrementally begin to incorporate these lessons into our life by taking ownership of our health and begin to make small healthy changes in how we live. Slowly and incrementally, we continue and add to these changes. Over time, we become healthier and come to feel better, physically and emotionally.

The Make Your Day Harder Campaign

To this end, the folks at Dr. Mike Evan’s Health Lab developed an ingenious idea. They call it the Make Your Day Harder campaign. It’s provocative title challenges us to reflect on ways to make small changes in our daily life and get off our seats more. And then do it.

The idea, as Dr. Mike says, isn’t to take on a grand exercise routine. Rather, it is the idea to make small intentional decisions to use technology less. So, for example, walk upstairs to get your daughter from her room rather than texting her from the kitchen that it’s time for dinner; get up and turn the volume down on your stereo rather than using the remote control; walk over to your neighbor’s house to actually talk to him about borrowing some tool you need rather than calling him on your cell phone; use a rake rather than a leaf blower; take the stairs rather than an elevator; intentionally don’t take the closest parking space; and so on.

Now, of course, doing any one of these things once or twice won’t do much for you. However, if you cultivated an attitude of willingness to do them in which you were open to opportunities as they arose through the course of your day, these slow, incremental changes over time would help.

You might slowly become more physically fit. You might come to have a little more energy. You might not gain weight or as much weight over time. You might find that your life slows down a little bit and as a result you feel just a little less hectic and a little less stressed.

As Doc Mike points out in his 4 minute video, the goal, as funny as it might sound at first, is to live just a little bit more like how our parents or grandparents or even great-grandparents lived – for they had less chronic health problems and in some respects were healthier than we are today.

To be sure, these previous generations might have had higher death rates from infectious illness or injuries, but assuming they escaped these fates, they were leaner, more fit, and less chronically ill; which is to say, they were in some ways healthier. Now, as we said, in our current industrialized societies, the death rates from infectious illnesses and injuries have been considerably reduced. However, we suffer now from considerably more chronic health problems. So, maybe, we should get off our seats more and do things the old fashioned way: let’s use our bodies more and our technologies less.

So, Make Your Day Harder. Please pass it on through your social media.

Author: Murray J. McAllister, PsyD

Date of last modification: June 12, 2015

The Biopsychosocial Nature of Pain

Contexts matter. The same joke might go over in very different ways, depending on whether it’s told by a comedian in front of an audience at a comedy club or told by an applicant in the middle of a job interview. An action done over and over again might be considered in one context an admirable example of perseverance in the face of adversity, whereas in another context it might be considered an exercise in futility.

Contexts matter in health too. The onset of a health condition might have two very different trajectories based on the contexts in which its onset occurs. Take, for example, a flu infection. It might be a nuisance for someone who is otherwise healthy, whereas the same infection might be disastrous for an elderly person or for a person whose immune system has been compromised due to undergoing chemotherapy. The overall presentation of flu in these cases is different because of the context. They each share a common precipitating cause – the influenza virus, but their illness is manifested differently due to the contexts that they don’t share.

In this light, we have to acknowledge the importance of context as a cause of health problems. In the common influenza examples described above, the context plays just as an important causal role as the influenza virus itself. Indeed, it’s the context that determines whether the flu will be either a nuisance or life threatening. In other words, the particularities of the person who has the health condition – the host, if you will — have a causal influence on the overall ways that the condition presents.

Moreover, it’s hard to imagine a health condition that occurs in isolation of the person who has it. As such, we must acknowledge that health conditions almost always have multiple causes – the precipitating event and how it interacts with the particularities of the person who has it and experiences it.

The common reductionistic view of health conditions

In our society, we tend to forget this simple fact about health. We tend to equate a health condition with a single precipitating cause and explain the differences across people who have the same condition by asserting differences in the severity of the precipitating cause. So, in the influenza example above, we tend to explain differences in severity of illness by asserting that one person’s influenza infection (i.e., the precipitating cause) must be due to a more virulent strain than another person’s flu infection.

As a society, we take this stance all the time in chronic pain management. We assume that people with high levels of pain and disability always must have had more severe precipitating injuries than those who have less pain and disability. Of course, sometimes it is true. Someone who breaks her neck in a motor vehicle accident may result in a high level of pain and disability.

Reductionism leads to stigma

Yet, not everyone with pain, perhaps not even a majority, fit neatly into this simple equation that differences in pain and disability are always explainable by differences in the precipitating event or cause.

It’s not uncommon for people to have excruciating pain and severe disability from moderate injuries, such as a fall from a ladder or stairs, or mild injuries such as a muscle strain from lifting something or simply bending over to pick something light off the floor. It’s even common for people to have severe pain and impairment without a precipitating injury or illness at all.

These people don’t fit into our common assumption that severity of pain and disability must always correspond with severity of precipitating injury or illness. Unfortunately, what happens to these people is that they get stigmatized. Others invalidate them by doubting the legitimacy of their pain and disability. “All you did was to bend over and pick up your hammer off the ground,” they might say, “How can you have so much pain that you can’t work?”

But what if there is a rational explanation for their pain and disability?

Chronic pain is multifactorial

We need to recognize that pain is more complicated than we tend to think it is. There is always more than one factor that initially causes pain and always more than one factor that maintains pain on a chronic course. A good place to start to recognize these facts are in the context in which precipitating causes occur.

In healthcare, we tend to categorize the contexts in which health conditions occur in three ways. They are biological, psychological and social contexts.

The ‘bio-‘ in the biopsychosocial

The biological contexts are the health of the person in terms of his or her bodily systems – the nervous system, the endocrine or immune systems, for instance. In the cases above, we described two people with the same precipitating event, an influenza infection, and saw how in one person the flu was a minor illness and in another it became a life-threatening illness because of differences in their immune systems. Whether healthy or compromised, the immune systems of each have an influence on the overall presentation of the illness. Indeed, in the case of the person with the compromised immune system, it is equal in importance to the precipitating cause of the influenza infection itself: it’s what makes the infection life threatening.

Similarly, the health of a person plays a role in the onset and chronic maintenance of pain. We know, for instance, that certain conditions make the onset of pain more likely or the transition from acute pain to chronic pain more likely. Obesity is an example. Those who are obese are more likely to develop low back pain (Shiri, et al., 2009), hip and knee pain (Andersen, et al., 2003). Oftentimes, the cause of their low back, hip or knee pain gets attributed to osteoarthritis, but osteoarthritis isn’t necessarily a discrete illness. It’s typically considered overall wear and tear that comes with age, or in the case of those who are obese, the extra weight that those joints must bear. Thus, obesity can be a cause of a new episode of pain.

The overall health of the nervous system also plays a role in the development of chronic pain. We know that people who have been subjected to prolonged stress are more likely to develop a new episode of pain and develop chronic pain once pain occurs. Examples are people who have experienced trauma or who are depressed or anxious or experiencing other life stressors (Croft, et al., 1995; Linton & Bergbom, 2011; McBeth, et al., 2007; Pincus, et al., 2002; Raphael & Widom, 2011). It’s not because they are any more accident-prone or illness-prone. Injury or illness, we might say, is an equal opportunity event. Rather, it’s that nervous systems under prolonged stress tend to have lower thresholds for stimuli to provoke pain and tend to become increasingly sensitive once a new episode of pain occurs.

Obviously, there are countless facets about the overall health of people that can play causal roles in either the development of pain or in the transition from acute to chronic pain. These biological factors provide a context in which a precipitating event, such as a painful injury or illness, occurs and they influence how the pain of the precipitating event is manifested.

The ‘psycho-‘ in the biopsychosocial

The psychological contexts are the psychological conditions and stressors that impact the nervous system, as well as health beliefs and behaviors that might impact the experience of pain and how people react to pain once becoming injured or ill. As suggested above, those who have struggled with trauma, anxiety or depression are at greater risk for developing pain and especially transitioning from acute to chronic pain once having an acute injury or illness. In other words, the state of the nervous system at the time of the acute injury or illness, especially when it’s under prolonged stress, can have a causal role in the development of subsequent chronic pain. In this way, we can rightly say that anxiety and depression can be one of the many multifactorial causes of chronic pain.

Indeed, in people who subsequently develop chronic pain, it’s actually quite common to have experienced trauma, anxiety and/or depression prior to the acute onset of pain (Knaster, et al., 2012; Magni, et al., 1994) and these emotional disorders interact synergistically with biological causes of pain to heighten the overall experience of pain (Domnick, Blyth, & Nicholas, 2012). These factors can tip the scale, as it were, to transition acute pain into chronic pain, following a precipitating painful injury or illness.

Other psychological factors, besides emotions, can exercise a causal role in the development of pain and chronic pain. Beliefs about pain and prior learning about pain can influence how pain is experienced and what we go on to do about it once having it (Arnstein, et al., 1999; Edwards, et al., 2011; Linton, Buer, Vlaeyen, & Hellsing, 2000; Nahit, et al., 2003). Some beliefs about pain and what we are supposed to do about it are helpful. They can reduce the intensity of pain or promote healing or recovery in the case of acute pain. They can also promote coping well with pain and remaining active in the case of chronic pain. Some beliefs, however, are not so helpful and can lead people to inadvertently experience more pain or do things that don’t promote recovery or good coping. Examples are catastrophizing, fear-avoidance beliefs, and engaging in illness behaviors (e.g., persistent resting and activity avoidance).

There are countless more psychological factors that can influence how pain and disability are manifested. Nonetheless, the point here is to recognize that the context in which pain occurs has an influence. It has a causal role – even if it’s not the initial or precipitating cause – in how we experience pain and what we go on to do about it once becoming injured or ill.

The ‘social’ in the biopsychosocial

The social contexts are those social conditions and stressors that can impact the nervous system or otherwise affect the trajectory of people’s health. These aspects widen the context further, beyond the biological and psychological make-up of the individual. They involve the make-up of the individual’s surroundings in terms of their relationships and social resources. We know that these factors too have a causal influence on health, pain included.

To illustrate the point, let’s take an all-too-common example that occurs within our field of chronic pain management. Suppose you see a woman who has chronic daily headache. Outside your clinic, she’s been treated for many years with medications and interventional pain procedures. She tells you that she’s been told she has cervicogenic headache, which means that her headache is thought to be due to structural problems in the cervical spine (i.e., neck). On MRI, she does in fact have modest degenerative changes, but these findings are common in people of her age. As such, we might consider this way of understanding her pain as a biomedical conceptualization. You, however, are a provider who understands chronic pain from a biopsychosocial conceptualization and so you ask, in your initial evaluation, about her psychological health as well as about her relationships, home life, financial stressors, and about where she lives in the community. At first, she’s a little taken aback. No one, she tells you, has asked about such things, at least not in the depth that you go into. She also doesn’t understand, she says, what all of this has to do with her pain. With budding trust, however, she begins to tell you that she has been involved in a domestically violent relationship for many years.

Might it not be reasonable to suppose that the persistent stress of physical, emotional and sexual violence plays a causal role in her headache pain? How could it not? Such prolonged stress would have to adversely affect her nervous system and thereby exacerbate her chronic pain. Even if, as has happened to her, we adequately treated any ‘cervicogenic’ aspects of her pain, wouldn’t it be insufficient to adequately manage her pain? We have to address the social causes of her pain condition as well.

Domestically abusive relationships are not the only type of persistently stressful relationship that can affect the trajectory of chronic pain. Care-taking relationships are also chronically stressful: care-taking an elderly parent with dementia, care-taking a spouse with cancer or a spouse disabled by a stroke, care-taking a child with special needs. Chronic marital conflict, short of domestic abuse, might be another. The absence of relationships can also be a chronic stressor in the form of loneliness that can influence the development of pain (Jaremka, et al., 2013).

These chronic social stressors affect the nervous system, likely making it more sensitive to stimuli, and thereby exacerbating pain, as well as sapping the ability of such people to cope with the pain that they experience. As such, social stressors have a causal influence on pain, even if they are not the initial precipitating cause.

We also know that poverty and living in dangerous neighborhoods can affect overall health as well the onset of pain and its chronicity (Gooseby, 2013; Ulirsch, et al., 2014). These social-based stressors adversely affect the nervous system and thereby adversely affect pain levels as well.

We know too that lack of access to adequate healthcare affects the trajectory of pain once having an acute injury or illness. Lack of insurance or being underinsured can often lead to emergency room based care or other stop-gap measures that are poorly suited for chronic conditions. Lack of availability of effective chronic pain management, even for those with adequate insurance coverage, can also play a role (Prunuske, et al., 2014). For example, the most effective form of chronic pain management, interdisciplinary chronic pain rehabilitation programs, is not widely available in the United States (Schatman, 2012). As such, many people with chronic pain simply do not have ready access to them and so must rely on less effective means to manage their pain. These social factors thus influence the pain levels of an individual’s condition.

Conclusion

Like all health conditions, pain is multifactorial. Meaning, multiple factors go into causing pain and maintaining it on a chronic basis. In our society and healthcare system, we tend towards understanding pain in reductionistic terms – understanding pain as solely the result of the event that precipitated it – an injury or illness. This reductionistic understanding leads to the belief that severity of pain and disability is solely the result of the precipitating event. So, if pain and disability are severe, there must have been a severe injury or illness. Most people’s pain or chronic pain, though, simply don’t fit neatly into this reductionistic model. They can have high levels of pain and disability in the absence of severe injuries or illnesses. As a result, they often get stigmatized: others doubt the legitimacy of their pain and disability. However, there is a rational explanation for these people’s pain and disability. Their pain, as with all people’s pain, is not solely caused by the precipitating event that started it all. Pain is multifactorial: there are multiple causal influences to pain in terms of the overall contexts in which injuries and illnesses occur. The biological, psychological, and social health of these contexts play a part in the onset and chronic maintenance of pain. These causes provide a rational, accurate and legitimate explanation for how pain and chronic pain become manifested in individuals.

(For more advanced study of the biopsychosocial nature of chronic pain, please see Gatchel, et al., (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581-624. doi: 10/1037/0033-2909.133.4.581)

References

Andersen, R. E., Crespo, C. J., Bartlett, S. J., Barthon, J. M., & Fontaine, K. R. (2003). Relationship between body weight gain and significant knee, hip and back pain in older Americans. Obesity Research, 11(10), 1159-1162.

Arnstein, P., Caudill, M., Mandle, C. L., Norris, A., & Beasley, R. (1999). Self-efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain, 80(3), 483-491.

Croft, P. R., Papageorgiou, A. C., Ferry, S., Thomas, E., Jayson, M. I., & Silman, A. J. (1995). Psychologic distress and low back pain: Evidence from a prospective study in the general population. Spine, 20(24), 2731-2737.

Domnick, C. H., Blyth, F. M., & Nicholas, M. K. (2012). Unpacking the burden: Understanding the relationships between chronic pain and comorbidity in the general population. Pain, 153, 293-304.

Edwards, R. R., Cahalan, C., Mensing, G., Smith, M., & Haythornwaite, J. A. (2011). Pain, catastrophizing, and depression in rheumatic diseases. Nature Reviews Rheumatology, 7, 216-224. doi: 10.1038/nrrheum.2011.2

Gooseby, B. J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Heath and Social Behavior, 54(1), 75-91.

Jaremka, L. M., Fagundes, C. P., Glaser, R., Bennett, J. M., Malarkey, W. B., & Kiecolt-Glaser, J. K. (2013). Loneliness predicts pain, depression, and fatigue: Understanding the role of immune dysregulation. Psychoneuroimmunology, 38(8), 1310-1317.

Knaster, P., Karlsson, H., Estlander, A., & Kalso, E. (2012). Psychiatric disorders as assessed with SCID in chronic pain: The anxiety disorders precede the onset of pain. General Hospital Psychiatry, 34(1), 46-52.

Linton, S. J & Bergbom, S. (2011). Understanding the link between depression and pain. Scandinavian Journal of Pain, 2(2), 47-54.

Linton, S. J., Buer, N., Vlaeyen, J., & Hellsing, A. (2000). Are fear-avoidance beliefs related to inception of an episode of back pain? A prospective study. Psychology & Health, 14(6), 1051-1059.

Magni, C., Moreschi, C., Rigatti-Luchini, S., & Merskey, H. (1994). Prospective study on the relationship between depressive symptoms and chronic musculoskeletal pain. Pain, 56(3), 289-297.

McBeth, J., Silman, A. J., Gupta, A., Chiu, Y. H., Morriss, R., Dickens, C., King, Y., & Macfarlane, G. J. (2007). Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain: Findings of a population-based prospective cohort study. Arthritis & Rheumatism, 56, 360-371.

Nahit, E. S., Hunt, I. M., Lunt, M., Dunn, G., Silman, A. J., & Macfarlane, G. J. (2003). Effects of psychosocial and individual psychological factors on the onset of musculoskeletal pain: Common and site-specific effects. Annals of Rheumatic Disease, 62, 755-760.

Pincus, T., Burton, A. K., Vogel, S. , & Field, A. P. (2002). A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine, 27(5), E109-E120.

Prunuske, J. P., St. Hill, C. A., Hager, K. D., Lemieux, A. M., Swanoski, M. T., Anderson, G. T., & Lutfiyya, M. N. (2014). Opioid prescribing patterns for non-malignant chronic pain for rural versus non-rural US adults: A population-based study using 2010 NAMCS data. BMC, 14, 563.

Raphael, K. G. & Widom, C. S. (2011). Post-traumatic stress disorder moderates the relation between childhood victimization and pain 30 years later. Pain, 152(1), 163-169. Doi: 10.1016/j.pain.2010.10.014

Schatman, M. E. (2012). Interdisciplinary chronic pain management: International perspectives. IASP Pain Clinical Update, 20(7).

Shiri, R., Karppinen, J., Leino-Arjas, P., Soloviev, S., & Viikari-Juntura, E. (2009). The association between obesity and low back pain: A meta-analysis. American Journal of Epidemiology, 171(2), 135-154. doi: 10-1093/aje/kwp356

Ulirsch, J.C., Weaver, M. A., Bortsov, A. V… & Mclean, S. A. (2014). No man is an island: Living in a disadvantaged neighborhood influences chronic pain development after motor vehicle collision. Pain, 155(10), 2116-2123. Doi: 10.1016/j.pain.2014.07.025

Author: Murray J. McAllister, PsyD, LP

Date of last modification: 5-3-2015

A Webpage Worth the Read

Those of you who are connected to one of our social media sites know that we tend to post daily on the latest news and research in the field of chronic pain management. We recently came across a description of cognitive behavioral therapy for chronic pain on the web, which we initially thought we’d send out on one of our daily posts. After finding myself reading it for a second time, however, I thought that it was too good to simply send out on social media without more comment than the usual line or two of introduction that we tend to provide.

The webpage is Dr. Christopher Pither’s piece ‘Cognitive Behavioural Approaches to Chronic Pain.’ It’s part of the Wellcome Trust’s website on pain that originally accompanied an exhibition at the Science Museum in London, entitled ‘Pain: Passion, Compassion and Sensibility.’ The website overall is also well worth reviewing, containing webpages on an eclectic range of topics, including scientific research on pain, therapies for pain, the history of how we have conceptualized and treated pain in the past, and cultural issues surrounding pain. All of it is thought provoking as well as useful information to know.

As indicated, Dr. Pither’s article itself is entitled ‘Cognitive Behavioural Approaches to Chronic Pain.’ It is simply the best and most concise description of cognitive behavioral therapy for chronic pain that I have so far come across on the web.

He opens the piece with a compassionate, yet scientifically accurate, description of how chronic pain develops. He reviews the many and complex variables involved. I especially appreciate how he sticks to what the scientific data tell us while at the same time remaining empathic and non-stigmatizing. The importance of this approach to his writing lies in the scientific data: while painful acute injuries and illnesses occur to all of us, likely at a roughly equal rate across all people, what predicts the transition from acute pain to chronic pain are psychosocial factors. To put it another way, those who are at most risk of developing chronic pain once an acute accident or illness occurs are those whose central nervous systems have been previously up-regulated for psychosocial reasons. Now, of course, these consistent scientific findings do not mean that people with chronic pain are to be blamed for their condition. It is simply to assert a common truth that we all know, if we consider it for a bit, which is that the overall context in which an acute injury or illness occurs matters. If an upper respiratory infection occurs in a person whose immune system is already compromised, then that upper respiratory infection will likely take a much different course than if the same infection occurred in someone whose immune system is not already compromised. Similarly, if an acute painful injury or illness occurs in someone whose nervous system is already up-regulated, then the pain is likely to take a different course then if it occurred in someone whose nervous system is not up-regulated. Namely, the pain has a higher likelihood of continuing past the normal healing process of the original acute injury or illness, thus becoming chronic pain. Dr. Pither acknowledges such a scientific based understanding of the development of chronic pain, but does so with compassion and empathy. For after all, that is what people with chronic pain deserve.

All the stakeholders in the field of chronic pain management needs more of this kind of discussion. Whether we are provider, patient, family member, or policy analyst, we have yet to figure out a way to consistently be able to talk about the real psychosocial aspects of chronic pain without raising the specter of stigma. Indeed, all too often, we try to get rid of stigma by denying all the inherent psychosocial aspects of chronic pain. We do so, though, at our own peril. When we deny a major aspect of a health problem in order to resolve a social problem, like stigma, we are bound to have poor outcomes in the management of that health condition. Imagine the cardiovascular field attempting to successfully manage heart disease if its psychosocial components were off limits to discuss and in fact were denied as unrelated. Whether as patient or provider, the management of heart disease would fail if we couldn’t discuss the role of smoking, lack of exercise, obesity, poor nutrition, depression, and stress. Similarly, in chronic pain management, we are bound to have poor outcomes if we cannot discuss the role of the psychosocial aspects of chronic pain. But, of course, we need to be able to have this discussion without stigmatizing the patient. Typically, in our field, we don’t do a good enough job of walking this fine line. Dr. Pither, however, seems to be able to do it. We should learn from his example.

Dr. Pither also astutely describes the common trajectory of care that patients go through on their way to ending up in a cognitive behavioral based chronic pain rehabilitation program. Because chronic pain is truly a ‘biopsychosocial condition’ that doesn’t fit well into the acute medical model of care, providers tend to refer patients back and forth between the medical side of the healthcare system to the mental health side of the healthcare system with neither being able to help very much. All too often this back and forth care goes on too long. Eventually, as Dr. Pither notes, someone refers patients with chronic pain to a cognitive behavioral based chronic pain rehabilitation program where they begin to get the care that most accurately addresses the true biopsychosocial condition that they have.

While rightly claiming that cognitive behavioral based chronic pain rehabilitation programs are the most effective therapy for chronic pain, Dr. Pither’s writing exhibits the scientific values of humility and constraint (i.e., good science tends to provide conservative interpretations of the data, never making greater claims than what the data reveal). I appreciate such humility and constraint. I think that all too often in healthcare, and in the field of chronic pain management in particular, providers tend to promise more than they can deliver. Don’t get me wrong. I don’t think that the multitudes of well-trained professionals in the field are equivalent to the snake oil salespeople of yester year, intentionally making pitches that they know aren’t true. No, what I am saying is that I think there is a pervasive lack of understanding among the stakeholders in the field of what science tells us are the most effective ways to manage chronic pain. Without such knowledge, providers and the public tend to believe that everything we do — any chronic pain treatment that is commonly provided – is effective. Unintentionally, then, providers of various treatments for pain can tend to go beyond the data and promise substantial pain reduction, if not a cure, when discussing with patients what can reasonably be expected. The sentiment in Dr. Pither’s piece does no such thing. He rightly acknowledges that cognitive behavioral based chronic pain rehabilitation is the most effective treatment, but states, with humility and constraint, that what constitutes the greatest effectiveness in the field of chronic pain management is helping patients to live well despite having chronic pain. We simply do not have cures for chronic pain. Nonetheless, there is hope. People with chronic pain can live well. They just have to learn how and they learn how to do it in cognitive behavioral based chronic pain rehabilitation programs.

Charles Pither, MBBS, FRCA, is a physician and consultant in pain medicine. He practices at RealHealth, London, England.

Please read his piece entitled, ‘Cognitive Behavioural Approaches to Chronic Pain.’ You can find the link to the webpage here.

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Author: Murray J. McAllister, PsyD

Date of last modification: 10-4-2014