Chronic Pain Rehabilitation

A central tenet of chronic pain rehabilitation is that what initially caused your pain is often not now the only thing that is maintaining your pain on a chronic course. Let’s unpack this important statement.

It’s no accident that healthcare providers commonly refer to chronic pain syndromes as ‘complex chronic pain’ or ‘complicated chronic pain.’ It’s because pain, of course, typically starts with an acute injury or illness, but it isn’t typically maintained on a chronic course by the initial injury or illness. For after all, injuries and illnesses tend to heal. Rather, something else takes over to maintain pain long past the healing of the initial injury or illness that started it all. In most cases, this transition from pain of an acute injury or illness to chronic pain involves the development of central sensitization.

Central SensitizationCentral sensitization is a condition of the nervous system in which the nervous system becomes stuck in a heightened state of reactivity so that the threshold for stimuli to cause pain becomes lowered. As a result, light amounts of stimuli to the nerves, which typically aren’t painful, become painful. In normal circumstances, it takes a high level of stimuli – like a slug in the arm – to cause pain, but in chronic pain states any little thing might be enough to cause pain. Simple movements hurt, even such movements as sitting down or getting up from a chair or walking. The amount of stimuli to, say, the low back that is associated with these movements shouldn’t be painful, but they are because the nerves in the low back have become increasingly sensitive — so sensitive, in fact, that any amount of stimuli to them is enough to cause pain.

This condition of central sensitization explains why not only simple movements can hurt, but also why light amounts of tactile pressure can hurt. Patients with chronic pain often have had a healthcare provider ask them, “Does this hurt?” when lightly touching or pressing the painful area of their body during an examination. This light amount of pressure is often enough to send the patient through the roof. In other circumstances, you might notice that a hug or massage, which typically should feel good, is enough to cause pain. It’s all because the nerves in the painful area of the body have become so reactive that any little thing sets them off.

Other forms of stimuli, beyond that which is associated with movement and touch, can also become painful once the transition from acute pain to chronic pain occurs. As most anyone with chronic pain knows, stress can cause pain too. The stress of a bad night’s sleep or the stress of work or family problems shouldn’t typically cause pain, but it does once the nerves become stuck in the highly reactive state of central sensitization. It may also be why changes in weather can cause pain. Emotional stress or changes in temperature or barometric pressure shouldn’t typically be enough stimuli to cause pain but they do once pain occurs as a result of central sensitization.

Sensitive nerves are normal in acute injuries or illnesses

The sensitivity of the nervous system is normal in acute pain. Say, for example, you step on a nail. We often think that the resulting tissue damage from the injury (in this case the puncture wound from the nail) is the only thing that matters when it comes to pain. However, even in cases where there is demonstrable tissue damage, we also need a nervous system to have pain. Without nerves and a brain, we would never be able to feel the tissue damage associated with an injury.

In our example, the nerves in the foot detect the tissue damage and send messages along a highway of nerves from the foot, up the leg and to the spinal cord. From the spinal cord, the messages travel up to the brain, where the messages are processed by different parts of the brain. The result of this processing is the production of pain. In other words, the brain produces pain in the foot. The brain and spinal cord (i.e., the central nervous system) produces pain in response from messages sent from nerves in the foot (i.e., the peripheral nervous system).

In this process, the brain and the rest of the nervous system team up with the endocrine (hormonal) system and the immune system. With the help of hormones and neurotransmitters, the brain tells the immune system to flood the area around the injury with inflammation. Inflammation is white blood cells and certain chemicals that assist in fighting infection and repair of the tissue damage. While engaged in these activities, inflammation also makes the nerves in the area around the injury super sensitive, which, again, is why the area of the body around an injury becomes so painful to touch or pressure. In most cases, the injury heals and the brain tells the immune system that inflammation is no longer needed and so the inflammation subsides. As a result, the pain of the injury also subsides upon healing because without the inflammation the nerves return to their normal level of sensitivity. So, they stop sending messages to the brain when normal levels of stimuli to the foot occur, such as when walking on the foot.

However, sometimes, the nervous system remains stuck in a vicious cycle once the tissue damage associated with the acute injury heals. The brain, in a sense, continues to call for inflammation even after the tissue damage is repaired. With the continued presence of inflammation, the nerves in the area of the initial injury remain sensitive so that any stimuli to them, even if they wouldn’t typically be painful, continue to produce pain. The continued pain thereby keeps the brain calling for more inflammation, thus eliciting continued sensitivity of the nerves to normal stimuli and subsequently more pain.

When this process continues past the point of healing of the initial injury, it’s called central sensitization, as we’ve discussed.

Complex or complicated chronic pain

Once central sensitization occurs, any number of things can reinforce it. Just think of all the stressful problems that occur or can occur as a result of having chronic pain. Loss of work and subsequent disability can cause loss of income and significant financial hardship. The loss of work is often a blow to one’s sense of self-worth and self esteem. Chronic boredom or social isolation can also set in. Pain often produces insomnia, which further wears on the nerves. Because pain is also emotionally alarming, people with chronic pain also commonly become fear-avoidant of different activities that are associated with pain. Such distress lends itself to becoming persistently focused on pain so that life becomes predominated by pain and its associated difficulties. Anxiety and depression can secondarily occur.

All of these problems are stressful. The stress associated with these problems affects the nervous system. It makes an already reactive nervous system more reactive. The threshold that the nervous system has for producing pain becomes lower and lower. As a result, the pain of chronic pain tends to become worse and more widespread.

Notice, though, that the initial injury or illness associated with the onset of pain isn’t getting worse. It may not even be a factor at all anymore, for as we’ve discussed, most injuries and illnesses heal (e.g., lumbar strains). Sometimes, of course, the initial condition associated with onset of pain continues (e.g., rheumatoid arthritis). However, in either case, the nervous system is now also playing a role in the cause of pain. The nervous system is now maintaining pain on a chronic course. Any number of stressful problems that occur as a result of the pain can then play a further exacerbating role in the long-term maintenance of chronic pain.

So, a central tenet of chronic pain rehabilitation is that, in most typical situations, what initially caused your pain is not now the only thing that is maintaining your pain on a chronic course.

What to do about chronic pain?

The public and even some healthcare providers commonly don’t take into account the role that the nervous system plays in maintaining chronic pain. Instead, the focus of care tends to remain on looking for evidence of any lingering tissue damage or disease associated with the initial injury or illness, respectively. The presumption is that pain must be caused by either tissue damage or disease and so the initial condition that started the pain must remain unhealed. The possibility never gets considered that the nervous system has changed so that the threshold for stimuli to cause pain has lowered.

This type of thinking leads to a lot of repetitive interventional and surgical procedures. In a pain clinic, it is not uncommon to see patients who have had numerous epidural steroid injections, neuroablation procedures or spine surgeries, repeated at the same site of the initial injury. The presumption is that the tissue damage associated with the initial injury remains unhealed and so is therefore the “pain generator”. However, repetitive attempts to rectify the tissue damage associated with the initial injury often remain ineffective because the pain is no longer due (or predominantly due) to tissue damage associated with the initial injury. Rather, the pain has transitioned from acute pain to chronic pain and as such it is due to the nervous system having lowered its threshold for producing pain. Simple movements and light touch hurt – not because the tissue damage is so great – but because the central nervous system maintains the peripheral nerves in a highly sensitive state.

From here we can see why the afore-mentioned central tenet is so important to chronic pain rehabilitation. In contrast to the typical interventional and surgical forms of pain management, chronic pain rehabilitation focuses its interdisciplinary therapies on the nervous system. Chronic pain rehabilitation aims to down-regulate the nervous system so that the nervous system is not so reactive and more approximates a normal threshold for producing pain. In other words, the goal is to get to a state of the nervous system in which it again requires the force of a slug in the arm to cause pain, and not just a simple movement like walking or sitting or a light touch.

Chronic pain rehabilitation is an empirically effective form of pain management – meaning, numerous scientific studies over the last four decades have shown that interdisciplinary chronic pain rehabilitation helps people to reduce pain, get off narcotic pain medications, and return to work in some capacity.

The key components of interdisciplinary chronic pain rehabilitation are the following:

  • Cognitive-behavioral based pain coping skills training
  • Mild aerobic exercise
  • Use of antidepressants and anti-epileptics for pain
  • Relaxation therapies
  • Exposure-based milieu therapies

All of these therapies are pursued in a coordinated fashion on a daily basis over a number of weeks. Patients learn them and become adept at independently pursuing them. As a result, patients continue to engage in them on an independent basis over the lifetime.

The target of all these therapies is the nervous system, particularly the central nervous system (i.e., the brain and spinal cord). They improve the health of the nervous system and in doing so they reduce the sensitivity of the overall nervous system and thereby reduce pain. In other words, interdisciplinary chronic pain rehabilitation focuses care on what’s now maintaining your pain and not on what initially started it way back when.

Author: Murray J. McAllister, PsyD

Date of last modification: 2-14-2016

Stress, Inflammation and Chronic Pain

People with chronic pain know that they tend to have a pain flare when they are under stress. They are, however, sometimes sensitive to acknowledge it aloud for fear that others might think that their pain is all in the head. Nonetheless, the fact that stress makes pain worse is entirely normal and common. It is a natural product of how we are made.

In fact, stress has a much more significant role in the production of pain than simply making it worse. The development of pain itself, from acute injuries or illness to the long-term maintenance of chronic pain, incorporates what we call the stress response. In other words, were it not for our stress response, we would not have pain as we know it. To review the remarkable and significant role that the stress response has in pain, we would require much greater time and space than this blog post allows. [For a good review within the professional literature, please see Chapman, Tuckett, & Song (2008)].

Instead, in this post, let’s look at one way stress exacerbates pain and leads to what we typically call a ‘pain flare.’ We’ll focus our attention on a particular aspect of the stress response, which leads to increased pain: inflammation. Specifically, let’s review how stress triggers our normal and natural stress response, which subsequently produces inflammation that, in turn, makes pain worse.

The immune system

The immune system is our natural defense system. It works in conjunction with our nervous system and our endocrine (or hormone) system. Traditionally, we have always divided these systems up as if they are three separate systems, but we now know that they do not operate independently of each other. So, whenever we discuss the functioning of one system, as we are today discussing the immune system, we have to keep in mind that structures in the brain, the rest of the nervous system, neurotransmitters, and hormones are almost always also at play when the immune system functions as it does.

So what does the immune system do? Traditionally, we have understood the immune system to have a defensive role in response to injury or infection. When injury or infection occurs, the immune system produces inflammation. Inflammation is a catchall term used to describe a number of different types of chemical messengers and cells that fight off the infection or prepare for healing. For instance, it’s what makes us well when we are sick by fighting off viral or bacterial infections.

Many years of basic science in psychology and biology have allowed us to now know that inflammation also plays a role in changes in mood and behavior, both of which can also allow for fighting off infection or responding to injury with damage control (Sternberg, 2001). In more general terms, these psychological responses are also responses to danger. Indeed, we now think of the immune system, in conjunction with the nervous system and the endocrine system, as part of a three way response to danger, or what we call the stress response.

Stress response

The stress response is our natural cognitive, emotional, motivational, bodily, behavioral and social response to a danger, or what we might more generically call a ‘stressor.’ Take for example, thousands of years ago, we would have been likely living on the savannas of Africa and we would have faced various threats, such as the possibility of being attacked by lions.

In response to the stressor of a lion attack and its resultant injuries, we naturally and automatically react, without conscious awareness or intention, with our built-in stress response. A quick review of the multifaceted – or biopsychosocial – aspects of this stress response are the following:

  • Cognitive responses: Heightened focus on the danger, rapid learning about the danger and subsequent acute memory of the stressor, among others
  • Emotional responses: Heightened alarm, anger and/or fear, increased sense of social belonging, among others
  • Motivational response: Heightened drive to react, increased energy
  • Bodily responses: Among others, increased muscle tension, heart rate, blood pressure; increased glucose in bloodstream; increased immune response
  • Behavioral and social responses: fight-or-flight, and tend-and-befriend (i.e., some combination of taking on the danger or getting away from it and/or joining together, coming to the rescue, and protecting or caring for one another and wanting to be cared for) (Taylor, et al., 2000)

In later posts, we’ll discuss in more detail the various aspects of the stress response, but this quick overview is important for two reasons.

First, and foremost, we see clearly the larger context in which the immune system functions. Its defensive function is part of a greater whole and the whole is the protective, or defensive, function of the stress response. From here, we can also see how the stress response is a whole contingent of automatic responses, from the microscopic to the macroscopic, that occurs when we are threatened by danger. In other words, it is the stress that the human organism undergoes when threatened.

Second, we see that in our society we tend to categorize these microscopic to macroscopic responses under particular headings, such as those that are biological, those that are psychological, and those that are social. We subsequently tend to think that these categories represent actually different things and then begin to wonder how they are connected. However, these categories do not represent distinct kinds of things. They are heuristic categories that reflect different aspects of the same kind of thing, the human organism, or person. In this way, we no longer wonder how “the mind” is connected to “the body,” as if they are two separate kinds of things. No, the cognitive, emotional, motivational and social aspects of the stress response occur within the same kind of thing as the biological and behavioral aspects of the stress response do. That is to say, they occur within a person, not some separate entities called “a mind” or “a body.” As such, in science and healthcare, we typically no longer refer to this mental/physical or mind/body distinction, but rather refer to these aspects of a person with the term ‘biopsychosocial.’

Inflammation

So, the stress response involves many natural, automatic responses and one of them is the immune system kicking into high gear to produce inflammation (Kiecolt-Glaser, et al., 2002). This response clearly makes sense. If we go back to the example of a lion attack, we will have a greater chance of surviving if our immune system is functioning in high gear as it fights off any infections from the scratches or bites that we might get.

This peak performance is the product of the immune system working in conjunction with the sympathetic nervous system and the endocrine (or hormone) system. Specifically, different structures in the brain, associated with the fight-or-flight response, send messages via a highway of nerves to the pituitary and adrenal glands, which then produce hormones such as cortisol and adrenaline (also known as epinephrine). These are often called ‘stress hormones’ and they are responsible for getting us ramped up. For instance, cortisol prevents insulin (another hormone that’s produced in the pancreas) from working well and so glucose (i.e., sugar) increases in the bloodstream, giving us increased energy. Initially, these hormones also start the immune response in the form of white blood cells and what are called cytokines. We call this immune system response ‘inflammation.’

Inflammation is what occurs when, upon injury, the injured area becomes red, swollen, and sensitive to the touch. The redness and swelling is our immune system at work, the white blood cells and cytokines engaging in their protective function, engaged in damage control. The sensitivity comes because the immune response irritates the nerves in the area. At this stage, this irritation is good because it serves a protective function. If the injured area is sensitive to the touch, it is going to prevent us from using it or poking it too much or otherwise re-injuring it. Subsequently, we are motivated to protect or guard the area. We’ll come back to this point.

At this time, there are also cytokines in the brain too intermingling with its hormones and neurotransmitters. If the injury or infection is severe enough or widespread enough, this mix of chemicals in our nervous system, including the brain, further lead to a run down feeling, which we call ‘malaise.’ It’s the ‘blah’ feeling we have when sick: run down, achy, fatigued, and unmotivated to do anything but lay around and rest. We are also motivated at this stage to need others, associate with them, and depend on them for help. In other words, we feel upset, perhaps even a bit abandoned, when others ignore us when we are sick or injured. We’ll come back to this point too.

After some time, these processes unfold and the threat passes (for example, microscopically, the infection and injuries from the lion attack have been successfully warded off and subsequently healed, just as we might have banded together, at a macroscopic level, to fight off the actual attack in the first place). Subsequently, cortisol tells the brain to start turning off the stress response.

The whole process is remarkable, even amazing. At all the multifaceted levels, from the microscopic to the macroscopic, we are made to survive. The stress response is an almost beautiful, elegant way to optimize our chances of survival when threatened by danger.

We still respond to threats, or stress, with the stress response

Admittedly, lions don’t attack us much anymore. With some few exceptions (such as the occasional natural disaster or bad car accident, or the activities of soldiers and first responders), our life and limbs don’t get threatened very often in our present day and age. We still, however, face threats.

The threats that we most commonly face nowadays are psychological and social in nature. They are the death of a spouse or child or other family member or friend. They are the loss of a job and subsequent loss of income. They are the bankruptcies and home foreclosures. They are the overly critical bosses or the fights with a sister or brother or when best friends move away. They are a son or daughter joining the armed forces and going off to war. They are the occasions when a family member comes down with a serious illness, say, cancer. They are the times when we have to live with a chronic illness, such as chronic pain. These kinds of stressors are not threats to life or limb, on the order of a lion attack or combat, but nonetheless they are threats. They are threats to our livelihood and well-being.

As such, we are hard-wired to respond to such stressors with the stress response.

Moreover, we also have the ability to anticipate the above-noted psychological and social threats. That is to say, the kinds of threats listed above are not the only kinds of threats that we commonly face. We also face the threat of anticipating the potential for those kinds of stressors.

We call it anxiety. It is the worrying or ruminating or fretting about the possibility that we face any of those threats listed above – the loss of a job, the loss of an income, the home foreclosure, the overly critical boss, the well-being of our loved ones, the loss of our health, the living with pain and all the problems that occur as result.

Human beings have an amazing capacity to worry about everything that could go wrong. In a sense, it’s a form of the stress response, preparing us for danger. However, anxiety or worry is what happens when our stress response has become stuck in the ‘on’ position. When anxious, in other words, we continue to prepare for danger or threat even when there is no actual threat, just the possibility of one.

Either way – whether we are actually living through a stressor or worrying about the possibility of a stressor, we still automatically, and without much conscious intention, still respond to such threats with the stress response.

Stress and inflammation make pain worse

If you have a chronic pain condition, you know that stress makes it worse. From here, we can see why. When experiencing a stressful event like those listed above or when worrying about the possibility of such a stressful event, you automatically, and without conscious intention, react with the stress response. Your immune system, in conjunction with your nervous system and endocrine system, puts out inflammation in response to the real or perceived threat. This inflammation causes irritation to your nerves, including the nerves in the area of your chronic pain. As a result, the nerves become more sensitive, just as they are supposed to do when the immune system is engaged in the stress response. With the nerves more sensitive due to the increased inflammation, they subsequently require less stimuli to cause pain and you experience increased pain with your normal activities.

For instance, suppose that you have chronic low back pain and usually it doesn’t hurt to get out of a chair. However, when under stress, the stress response leads to higher levels of inflammation, which make the nerves in your low back more sensitive. As a result, the stimuli involved in the act of getting out of a chair makes your low back painful when ordinarily you can get out of a chair without pain at all. What you experience in such instances is the all-too-common exacerbation of pain due to stress.

Notice that your immune system is doing exactly what it is made to do when under threat. While problematic, it is normal and common.

It can become increasingly problematic when the stressor remains unresolved and subsequently goes on for some time. The threat is on-going and so the stress response continues unabated. The level of inflammation becomes higher and higher. The nervous system as a whole becomes more sensitized. As a result, widespread inflammation can lead to both increasing pain and more widespread pain, in the form of body aches.

Moreover, as we saw above, widespread inflammation can lead to malaise, an overall ‘blah’ feeling. You become fatigued and unmotivated to do anything but rest. In addition to higher levels of pain or possibly even more widespread pain, you are now not feeling well. You feel like you have the flu, but without the flu.

At the same time, your needs for others increase. It is the result of the tend-and-befriend aspect of the stress response. These needs are the needs for others to provide comfort and care. You don’t want to be left alone and, if you are, it’s like adding insult to injury.

Now, some people might not want to admit that such emotional and social needs arise when not feeling well. For after all, we have a sense from society that we are supposed to remain strong and independent. If we don’t, we have a good likelihood that we’ll face stigma.

It’s important to recognize, however, that such emotional and social needs are built right into us when the stress response kicks in and, particularly, when it goes on for some time. It’s important to understand that you are not just being weak. The stress response is doing exactly what it is supposed to do in response to a threat against your well-being.

It’s okay to acknowledge it. It is a common and natural consequence to stressors, or threats.

What you can do about chronic pain

With that said, however, it’s also important that you recognize that you are not helpless to it.

Chronic pain rehabilitation programs are a traditional form of chronic pain management that focuses on reducing the stress response in the presence of pain. Through multiple therapeutic modalities, they focus on reducing the reactivity of the nervous system and teaching you how to maintain this reduced reactivity of the nervous system, which, in turn, leads to less inflammation and less pain, greater energy and motivation, and greater abilities to independently do what you want to do. The Institute for Chronic Pain has a number of resources that provide information on chronic pain rehabilitation.

A brief list follows:

References

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: Reciprocal neural, endocrine and immune interactions. Journal of Pain, 9, 122-145.

Kiecolt-Glaser, J. K., McGuire, L., Robles, T. R., & Glaser, R. (2002). Emotions, morbidity, and mortality: New perspectives from psychoneuroimmunology. Annual Review of Psychology, 53, 83-107.

Sternberg, E. M. (2001). The balance within: Science connecting health and emotions. New York: W. W. Freeman.

Taylor, S. E., Klein, L. C., Lewis, B. P., Gruenewald, T. L., Gurung, R. A., & Updegraff, J. A. (2000). Biobehavioral response to females: Tend-and-befriend, not fight-or-flight. Psychological Bulletin, 107(3), 411-429.

Author: Murray J. McAllister, PsyD

Date of last modification: 11-24-2014

CBT and Central Sensitization

A study published this month in Pain produced what is likely some of the most important research findings this year for the field of chronic pain rehabilitation. The study demonstrated that basic CBT interventions can reduce central sensitization (Salomons, et al., 2014).

Countless studies in the past have shown that CBT and CBT-based chronic pain rehabilitation programs are effective in reducing self-reported pain in chronic pain patients. In these studies, we have had to infer that CBT reduces central sensitization: because CBT is effective at reducing chronic pain based on verbal self-report, and because central sensitization is a leading cause of chronic pain, we have inferred that CBT must reduce central sensitization. Now, we have a study that directly demonstrates it.

In their well-designed study, Salomons, et al., are the first to experimentally induce a form of central sensitization in a group of previously pain-free subjects, deliver a CBT intervention, and measure the reduction in central sensitization that results from the CBT intervention. As such, they are the first to demonstrate that CBT reduces central sensitization as measured in the laboratory and not simply rely on inferences based on self-reported pain levels.

The study design

The study consisted of 34 healthy women who did not have pain. Through a series of pain-provoking procedures, the researchers induced secondary hyperalgesia in these healthy women. Secondary hyperalgesia is a type of central sensitization. Central sensitization is largely considered a common, if not the most common, cause of chronic pain. In secondary hyperalgesia, the nerves in the general location of the pain become reactive in an increasingly wider area. As a consequence, it takes less and less stimuli to cause pain in this widening area around the site of the original pain.

Along side this series of pain-provoking procedures, the researchers provided half the group of healthy women with a few basic cognitive behavioral interventions for pain. The CBT intervention consisted of both providing the subjects with information about the sensory, cognitive, and affective aspects of pain and engaging them in cognitive restructuring in order to reduce the stress response that accompanies pain. Cognitive restructuring is an intervention that helps people to make sense of their pain differently, from understanding it as something that is alarming or frightening to understanding the pain as something that is more benign and not harmful or perhaps even beneficial. For the other half of women, they provided a psychotherapy focusing on becoming more assertive in interpersonal communication skills.

By comparing CBT for pain with a non-pain related psychotherapy, they attempted to determine the effectiveness of the CBT itself.

The provision of some form of psychotherapy to both groups is important because it controlled for the effectiveness of non-specific therapeutic factors of psychotherapy. Let me explain. To do so, we need to stray from our original topic a bit.

One of the most consistent findings in the last four decades of psychotherapy outcome research has been that a large percentage of what accounts for the effectiveness of psychotherapies are factors that are common to all psychotherapies. So, whether we are talking about cognitive behavioral therapy for pain or diabetes or depression, or psychodynamic therapy for dysfunctional relationship patterns, or family systems therapy for teenage behavior problems, they all tend to have some things in common, which contributes to what makes them effective. That is to say, despite having some obvious differences, they each share certain factors and these factors are in part what make them all effective.

These factors tend to be characteristics of the relationship between the provider and the patient. We tend to refer to these characteristics in general as the qualities of the ‘therapeutic relationship.’ For example, research consistently finds that, in whatever type of psychotherapy that one pursues, the development of a relationship with an expert provider who takes the time to listen to you and provide mutually respectful, caring, and honest feedback leads people to become motivated to make healthy behavior change – whether it is in learning how to manage pain or diabetes, overcome depression, develop healthy relationships, or change problematic teenage behaviors. In other words, the therapeutic relationship that you have with a healthcare provider is what leads, in part, to making healthy changes that can improve health.

So, in a study aiming to determine how CBT is effective for managing pain, Salomons, et al., needed to make sure that they were measuring what is unique to CBT for pain and not the general effectiveness that all the psychotherapies have in common. To do so, they compared CBT to a psychotherapy that was not for pain, but which would have the general therapeutic factors that are common to all therapies, including the CBT for pain. This study design thus allows the researchers to conclude that if CBT for pain is in fact more effective, then what’s making it more effective are those things that are unique to CBT. In other words, the therapeutic relationship might play a role in both psychotherapies equally, but if one is more effective, such as the CBT, then what’s pushing it over the top are those things that are unique to CBT.

So, let’s get back to what Salomons, et al., found.

Cognitive behavioral therapy and central sensitization

While both groups of study subjects reported less pain intensity, those who underwent CBT reported that the pain they had was less unpleasant and therefore more tolerable. These findings that CBT reduces pain and makes pain more tolerable are largely similar to most clinical trials of CBT for pain.

The more interesting and important finding was that the subjects who received CBT exhibited a 38% reduction in the area of secondary hyperalgesia. Recall that secondary hyperalgesia is a form of central sensitization in which the nerves around the site of pain become more reactive in a widening area. In this increasing area around the original site of pain, less and less stimuli are required to generate pain. Secondary hyperalgesia is thought to be one of the ways an acute injury can transition to chronic pain even after the acute injury has healed. In their study, Salomon, et al., experimentally induced secondary hyperalgesia and subsequently showed that CBT can reduce it.

To my knowledge, no previous study has directly demonstrated a reduction in a form of central sensitization with CBT interventions.

A possible explanation for this finding is that CBT reduces the stress response that occurs with pain. By coming to think about pain differently, the change in thinking corresponds to changes in the neural network of the brain. These changes in the brain might subsequently alter the hormonal and inflammatory responses of the stress response, which subsequently makes the nerves in the peripheral area around the site of the original pain less reactive. As such, the cognitive restructuring corresponds to changes in the brain that reduce the stress response, which lead to downstream reductions in nerve reactivity.

Whatever is the explanation, the findings of Salomons, et al., are important as they can lead us to greater confidence as to why CBT and CBT-based chronic pain rehabilitation programs are effective at reducing chronic pain.

References

Salomons, T. V., Moayedi, M., Erpelding, N., & Davis, K. D. (2014). A brief cognitive-behavioral intervention for pain reduces secondary hyperalgesia. Pain, 155, 1446-1452. doi: 10.1016/j.pain.2014.02.012

Author: Murray J. McAllister, Psy.D.

Date of last modification: 9-2-2014

Therapeutic Neuroscience Education: A New ICP Website Content Page

As an educational and public policy think tank, the Institute for Chronic Pain (ICP) brings together thought leaders from around the world to provide information about chronic pain and its treatments. We make every effort to provide academic quality information in ways that are also approachable to patients and their families. We also aim to bring this information to healthcare providers, third-party payers, and public policy analysts. We envision a day when all stakeholders in the field of chronic pain management have a scientifically accurate understanding of the nature of chronic pain and how best to treat it – a day when healthcare providers deliver and patients demand treatments that science has shown to be effective.

The information that we provide on our site meets various important criteria. These criteria are the following:

  • The information is of academic quality while at the same time being approachable by patients and their families.
  • The information is empirically (i.e. scientifically) supported by high quality research and appropriately referenced.
  • The information is unbiased by financial support from the pharmaceutical and medical technology industry.
  • The information is unbiased by any need to maintain discipline-specific traditions or positions of authority (i.e., no need to maintain a specific discipline’s “turf”).
  • The information is provided within a forum that allows for open, respectful dialogue and social connectedness.

By providing information that meets these criteria, we aim to provide accurate and trustworthy information about chronic pain and its management from an organization that is trustworthy, transparent and community-based.

In doing so, we hope to raise our cultural understanding of the nature of chronic pain to a level that is as accurate as the current state of science allows.

Our educational and public policy mission also has significant ethical implications. Care for chronic pain patients (or for patients with any health condition, for that matter) should be as effective as possible. When multiple treatment options exist for a particular condition, we maintain that treatment decisions should be guided by science – by the question of what’s most effective, regardless of other possible concerns, such as the profit-motive or tradition-bound practices. Similarly, patients and their families should educate themselves about the nature of pain and what treatments have been scientifically shown to be effective. However, patients and their healthcare providers have historically lacked a trustworthy and easily accessible source for such information. At the ICP, we aim to fill this gap and provide accessible information about the nature of chronic pain and how best to treat it. With such information, both healthcare providers and patients can improve their decision-making by relying on a scientifically accurate understanding of pain and its treatments. In these ways, we aim to raise the quality of care for chronic pain. It’s the right thing to do and, if successful, we might just change how we manage chronic pain for the better.

As stated, in pursuing these efforts, the Institute for Chronic Pain brings together thought leaders from around the world to provide this scientifically accurate and trustworthy information. Today, we announce a new content page to our website on Therapeutic Neuroscience Education, authored by Adriaan Louw, PT, PhD, CSMT. Adriaan is a leader in Therapeutic Neuroscience Education (TNE). A physical therapist by training, he is a frequent lecturer, a researcher, and an author of a number of patient-friendly books, such as Why Do I Hurt?, among others. He is also the CEO of the International Spine and Pain Institute, an educational seminar organization for healthcare professionals.

His piece on TNE fully meets our criteria for inclusion on the ICP website. It is scientifically accurate and yet accessible by patients, their families, their healthcare providers, and the third-party payers who pay for their care. Indeed, teaching people about pain — providing them with scientifically accurate yet easily understandable information about pain — lies at the heart of therapeutic neuroscience education.

Therapeutic Neuroscience Education is a relatively new therapeutic intervention therapeutic neuroscience educationthat aims to change patients’ perception of pain by providing them with a more accurate understanding of the nature of pain. Akin to a cognitive behavioral intervention, it employs verbal-based lessons along with visual illustrations and diagrams with the goal of changing how patients make sense of their pain. In other words, it helps patients to understand their pain in a more scientifically accurate and less threatening way. Once this more accurate understanding is achieved, patients are typically more willing to engage in therapies that have been shown to be effective.

Typically associated with physical therapy, TNE is actually an intervention that most any healthcare provider might pursue given sufficient training. With such an expertise, chronic pain management providers of all kinds might provide TNE while engaging in their own discipline-specific interventions. Thus, it might be considered a cognitive-based meta-therapy that can be provided at the same time as other therapies.

We appreciate Adriaan’s expertise and contribution to the ICP. Please read his important piece on the ICP website and talk to your healthcare providers about whether TNE might help you to manage chronic pain more effectively.

Author: Murray J. McAllister, PsyD

Date of last modification: 6-7-2014

Institute for Chronic Pain – One Year Anniversary

The Institute for Chronic Pain celebrates this month its one-year anniversary of going live with our website and blog.  The Institute for Chronic Pain is an educational and public policy ‘think tank’ devoted to changing the culture of how chronic pain is managed. We imagine a day when the management of chronic pain is guided by the principles of empirical-based healthcare (i.e., pursuing only those treatments that research has shown to be effective). Our public face is our website and blog, where we provide academic-quality information that is accessible to patients, their families, as well as providers and third-party payers.

In this last year, our main goal was to establish the website as a leading source of information on chronic pain and its treatments, particularly chronic pain rehabilitation.

In this next year, our main goal is to grow our stakeholder community. We want to be a trusted source of high quality information to patients and their families. We also want to increase our presence among the provider and third party payer communities. We expect to provide content by an increasing diversity of experts in healthcare and from academia. Outreach to third party payers will also be essential, providing information on empirically-based treatments for chronic pain.

To these ends, we ask you to become a stakeholder with us in the future of a more effective and cost-effective healthcare system for the management of chronic pain syndromes. Please like us or follow us on:

The more we learn together, the more effective our care will be as providers and consumers of chronic pain management.

In closing this celebration announcement, I’d like to re-post our first introductory blog post (in a slightly edited fashion). Originally published on October 7, 2012, it remains a fresh statement of our guiding vision. Thank you for being a stakeholder in this future.

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Welcome to the Institute for Chronic Pain blog. We appreciate your interest in our organization and issues related to chronic pain management.

 Changing the culture of how chronic pain is managed

Our hope with this blog is to create a community of stakeholders in the field of chronic pain management who participate in informed discussion on an array of issues related to the field. The stakeholders in this community are patients and their families, healthcare providers, third party payers, policy analysts, and society generally.

Our mission is to change the culture of how chronic pain is managed in the U. S. and other industrialized societies. Our specific goal is to make chronic pain management more effective and beneficial for the individual patient, their families and society.

It is no small task. The improvement of healthcare for chronic pain patients requires a change in the culture of how chronic pain is conceptualized and treated. Multiple, complex issues must be addressed and resolved.

  • As stakeholders, we need to acknowledge and accept that our healthcare system is expensive and largely ineffective in the treatment of chronic (non-cancer) pain.
  • As stakeholders, we need to recognize that the on-going cause of chronic pain is typically different than the acute pathology that was involved in the initial onset of pain.
  • We need to help stakeholders to understand that chronic pain syndromes are more accurately conceptualized in terms of nervous system dysregulation (e.g., central sensitization reinforced by secondary psychosocial stressors) than in terms of structural or orthopedic pathology.
  • As stakeholders, we need to recognize and accept that at present chronic pain syndromes are truly chronic and typically cannot be cured; we tend to recognize the chronicity of  other chronic conditions, such as diabetes or heart disease, but tend to forget it when it comes to chronic pain.
  • Once accepting the chronicity of chronic pain, we need to stop misleading ourselves (as both patients and providers) by thinking of pain-related interventional and surgical procedures as significantly helpful when in fact they are not.
  • As stakeholders, we need to accept that, on average, long-term opioid management for chronic pain syndromes fail to provide demonstrable reduction in pain or improvement in functioning.
  • As stakeholders, we need to accept that, even when effective for an individual case, long-term opioid management is typically not feasible to continue indefinitely, assuming a normal lifespan; so, unless terminal or elderly, most patients will have to learn how to self-manage pain at some point in their lives.
  • As stakeholders, we need to engage in a frank discussion of whether it is ethical to maintain patients on long-term opioids to the point of developing tolerance to high doses of medications, if the patients still have a long life expectancy ahead of them.
  • As stakeholders, we need to secure a change in reimbursement practices that at present privilege interventional pain management and spine surgery procedures, which are largely ineffective

The list is not exhaustive. However, it does demonstrate that the number of problems within the field of chronic pain management is expansive. It is for this reason that we use the word “culture” in the mission statement of the Institute for Chronic Pain.

To improve the health and well-being of patients with chronic pain syndromes, we need to change not just clinical practice patterns. We need to change the very culture of how we (as patients, providers and third party payers) conceptualize the nature of chronic pain and subsequently provide care for it.

In short, we need to change the paradigm that underlies chronic pain management.

Analogy to the change in our cultural understanding of cigarette smoking

Our current cultural understanding of chronic pain is like how we as a society thought of cigarette smoking forty years ago.  In the last forty years or so, cigarette smoking has undergone a paradigmatic change in its cultural understanding. At one point, it was a cool thing to do that had no adverse health consequences. Smoking in public spaces, like the work site or even your healthcare provider’s office, was the norm. Now, cigarette smoking is largely considered by society as a smelly habit that is one of the leading causes of death. It’s almost even hard to imagine now what it was like when people smoked at their desks at work or in the doctor’s office.

A number of factors brought about this change in our cultural understanding. Science identified the adverse health consequences of tobacco use. The science subsequently informed the clinical practice patterns of healthcare providers. Providers began and continued to make recommendations to their patients to stop smoking. Multiple methods to quit smoking were developed and proliferated. Insurance companies started to pay for them and they continue to do so to this day.

Factors outside of the traditional healthcare system had a role too. Educational campaigns and marketing campaigns helped to change how we thought about smoking. They changed our understanding of the facts, as well as our attitudes and values about the facts. Society changed the regulations that impacted both the tobacco industry and societal norms. These regulations changed who could smoke, what they smoked, and where they smoked. Educational, marketing, and regulatory campaigns have had a profound impact on the health of people through changing how we think about smoking.

It might even be reasonable to argue that educational, marketing and regulatory campaigns have had as much if not more impact than the afore-mentioned changes in the healthcare system regarding smoking.

On the one hand, the focus of the traditional healthcare system is on the individual and as such its impact on our cultural understanding of smoking is limited. The progress of health sciences is interesting to only a select few. Changes in clinical practices, such as what gets recommended by healthcare providers, have limited effectiveness. Patients commonly fail to get persuaded by recommendations that differ from what they know. Healthcare providers too commonly fail to adhere to guidelines for recommendations that differ from what they know or were taught in school. Insurance companies and policy analysts are often slow to change their bureaucracies.

On the other hand, educational campaigns, marketing campaigns, and regulatory campaigns reach large numbers of people. They have the capacity to change our cultural understanding of health-related facts and our attitudes about those facts in ways that the individual healthcare provider simply cannot. We see it every day in commercial marketing or public service announcements. They persuade us to buy one product over another or change our attitudes about drugs. When it comes to health-related issues, such campaigns can have a profound impact on our health – even though we don’t typically think of them as part of our healthcare system per se.

All these factors have had an impact in changing the culture of how we think about smoking and what we go on to do when helping people to stop smoking.  They have been largely effective in making a profound and beneficial impact on our health.

The time has come to do the same thing in chronic pain management. We need to change the paradigm of how we think about chronic pain and what we then go on to do when treating it.

It’s here where the Institute for Chronic Pain is going to come into play. We founded the Institute to be a leading voice and propagator of paradigmatic change in the field of chronic pain management.

The management of chronic pain syndromes needs to change. The above-noted bullet items describe a number of ways the field needs to change if it is to have a demonstrable beneficial impact on the health of patients with chronic pain syndromes. The list is not exhaustive. There are more issues than those cited above that highlight a need for change:

  • We need to develop a greater sense of conventional agreement among all stakeholders as to how to best treat chronic pain, as there is little to no such agreement currently, even for common chronic pain conditions, like chronic low back or neck pain, fibromyalgia, or chronic daily headaches.
  • Among all stakeholders, we need to develop conventional agreement in how to conceptualize the nature of chronic pain, as presently there is no such agreement.
  • Given this lack of agreement, the care that patients receive is based largely on the specialist to whom they get referred and as a result care tends to be a hodge-podge mix of different therapies, even across patients with the same condition.
  • We need to acknowledge that treatment recommendations, which patients receive, are largely based on tradition and not on a careful allegiance to what science tells us is most effective.
  • We need to acknowledge that, in addition to tradition, profit motive can affect treatment recommendations in ways that fail to adhere to what science tells us is the most effective.

The Institute for Chronic Pain was founded to help change the culture of how we think about chronic pain and how we deliver care to patients with chronic pain syndromes. In short, we developed the Institute to help change the culture of how chronic pain is managed. In the process, our aim is to develop consensus among the lay public, patients, providers, third party payers, and public policy analysts as to a) how to conceptualize chronic pain and b) how to most effectively treat it.

Goals of the Institute for Chronic Pain

The Institute has set out a number of methods for achieving the resolution of these goals.

  • We provide a free health information website that provides academic-quality information which is also approachable and understandable by the lay public, patients, third party payers, and policy analysts.
  • We provide this blog through our website.
  • We promote traditional media communications on the nature of chronic pain and its most effective treatments vis-à-vis conference presentations, video presentations, academic journals and newsletters, books, and white papers.
  • We promote traditional educational and marketing campaigns to change our cultural understanding of chronic pain and how to best treat it.
  • We provide fee-based education and consultation to the lay public, patient advocacy groups, healthcare provider groups, and third party payers.
  • We maintain financial independence from pharmaceutical and medical technology industries for the on-going operations of the Institute.
  • We rigorously adhere to the principles of empirical based healthcare (i.e., using science to inform us about what works and what doesn’t work in healthcare, and using this information to guide treatment decisions).
  • We rigorously adhere to the guiding values of integrity, transparency, excellence, concern for the health and welfare of patients, and social responsibility.

Through commitment to these methodologies, the Institute plans to change how the healthcare community and its patients conceptualize and treat chronic pain.

We hope that you will join us in this endeavor. Join our community and be part of this change.

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Author: Murray J. McAllister, PsyD

Date of last modification: 10/7/2013

Memory Problems and Chronic Pain

Half jokingly, patients with chronic pain can sometimes start to wonder whether they are coming down with Alzheimer’s. They don’t seem to remember anything anymore. Besides memory problems, it can be hard to concentrate, multi-task, and find the right word to use – that experience when the word you want to use is “on the tip of your tongue.” People with fibromyalgia have even given these problems a nickname – “fibro fog” – as in when your head is in the clouds.

More professionally, we might call these problems “mild cognitive problems” or “mild cognitive deficits.” The term “cognitive,” of course, comes from the noun “cognition,” which is a catchall term for types of thinking, such as concentration, memory, multi-tasking, use of language, etc. The use of the term “mild” is not meant to minimize the extent of these problems, as patients can report them to be quite problematic. Rather, the use of the term is common among healthcare providers because it contrasts the extent of these problems with people who typically have more severe cognitive deficits, such as those with traumatic brain injuries or dementia.

So are the memory problems that seem to go along with chronic pain real? What’s the connection between chronic pain and memory problems?

Is the connection real?

Over the years, healthcare providers have asked themselves this question and scientists have put it to the test. There’s a couple of ways of going about doing it. It takes a little bit of explaining first.

One way researchers determine whether the reports of memory problems are real is to use psychological tests of memory. They test a large group of patients with chronic pain and they test a large group of people without chronic pain. Next, they compare the average scores of both groups. If the average score of the chronic pain group is significantly different (and worse) then the average score of the group without chronic pain, then they conclude that the memory problems of the chronic pain patients are real.

Another way researchers can determine whether the memory problems of chronic pain patients are real is to take studies like those described above and combine them into one super large study. They find the studies published in professional journals. They do a systematic search for all such studies and then combine them. This type of study is called “a meta-analysis.” Meta-analyses are thought to be the most valid kind of study because it combines many studies, any one of which in isolation may have produced erroneous results. In other words, in science, large studies are better, because any potential errors that can occur along the way get watered down by the large number of studies and don’t throw off the main results.

A meta-analysis on the relationship between memory problems and chronic pain is what Berryman, et al. (2013), published in this month’s issue of Pain, a leading professional journal in the field of pain management. They combined 24 studies that tested the memory abilities of people with chronic pain and compared them to the memory abilities of people without chronic pain. They found a consistent, moderate deficit in what’s called ‘working memory’ for people with chronic pain.

Working memory is the ability to hold information in mind in order to do something. It involves short-term memory, attention, and information processing. You use working memory when deciding upon doing something and setting out to do it, such as when you decide to get something from the basement. You have to hold the thing in mind while walking down into the basement and remember what it is you are looking for when you get there. You use working memory when learning to do something. You have to hold the instructions in mind while you practice it. You also use working memory when multi-tasking. You have to hold information in mind while engaging in the different activities.

In sum, Berryman, et al., (2013) found that people with chronic pain had moderately lower scores on tests of working memory when compared to the scores of people without chronic pain on the same tests. This finding is consistent with the common complaints of memory problems by chronic pain patients.

What is the connection between chronic pain and memory problems?

To understand the connection between chronic pain and memory problems or other forms of cognitive problems, we have to review a known fact that is commonly overlooked. This fact is that the experience of pain occurs because of our brain and other parts of our nervous system. Whatever the initial cause of pain, once pain becomes chronic, it becomes a nervous system problem. Different areas of the nervous system, such as in the brain and spinal cord, go through changes and these changes are responsible for the development of chronic pain.

One area of the brain that appears to go through such changes is the hippocampus (Cardoso-Cruz, Lima, & Galhardo, 2013; Mutso, et al., 2013). The hippocampus is involved in the development of central sensitization (Lamtremoliere & Woolf, 2009), depression (Campbell & MacQueen, 2004), and memory (Squire, 1992). Pain can change the hippocampus. In turn, these changes to the hippocampus can create a cascading effect on the experience of pain, leading to central sensitization, depression, and memory problems.

Much is yet to be learned from the study of chronic pain and the nervous system. The hippocampus may not be only thing that is responsible for the development of memory problems in people with chronic pain. Indeed, in all likelihood, it is not the only thing that leads to such problems. At the very least, though, it is likely a part of the connection between chronic pain and memory problems.

References

Berryman, C., Stanton, T. R., Bowering, K. J., Tabor, A., McFarlan, A., Mosely, G. L. (2013). Evidence for working memory deficits in chronic pain: A systematic review and meta-analysis. Pain, 154, 8, 1181-1196.

Campbell, S. & MacQueen, G. (2004). The role of the hippocampus in the pathophysiology of major depression. Journal of Psychiatry & Neuroscience, 29, 6, 417-428.

Cardoso-Cruz, H., Lima, D., & Galhardo, V. (2013). Impaired spatial memory performance in a rat model of neuropathic pain associated with reduced hippocampus-prefrontal cortex connectivity. Journal of Neuroscience, 33, 6, 2465-2480.

Lamtremoliere, A. & Woolf, C. J. (2009). Central sensitization: A generator of pain hypersensitivity by central neural plasticity. Journal of Pain, 10, 9, 895-926.

Mutso, A. A., Radzicki, D., Baliki, M. N., Huang, L., Banisadr, G., Centeno. M. V., Radulovic, J., Martina, M., Miller, R. J., & Apkarian, A. V. (2012). Abnormalities in hippocampal functioning with persistent pain. Journal of Neuroscience, 32, 17, 5747-5766.

Squire, L. R. (1992). Memory and the hippocampus: A synthesis from findings with rats, monkeys, and humans. Psychological Review, 99, 2, 195-231.

Date of last modification: 8-12-2013

Author: Murray J. McAllister, PsyD

Why See a Psychologist for Pain? (Part 2)


In the last post, we addressed the question, “Why see a psychologist for pain?” The answer is that psychologists are the experts in teaching patients how to self-manage and cope with chronic pain. Patients who see psychologists for chronic pain can learn how to self-manage and cope with pain so well that they can largely come to live a normal life despite having chronic pain.

 

Another way to respond to the question of “Why see a psychologist for pain?” is to look at the role of the nervous system in chronic pain and how psychologists are experts in the treatment of health problems related to the nervous system. Let’s attempt to unpack this statement.

Nervous system & chronic pain

People commonly think of chronic pain as if it is a long-lasting symptom of an injury or illness that has failed to heal. This viewpoint is mistaken. Take, for example, the notion of degenerative disc disease. It is common to think that degenerative changes of the spine are the cause of chronic back pain. However, we know that degenerative changes of the spine are only minimally correlated with pain, which means that most of what makes up the experience of pain cannot be attributed to degenerative changes of the spine (Endean, Palmer, & Coggon, 2011). Such changes of the spine are a minor ingredient, if you will, in the pie that’s chronic pain.

A more accurate understanding of chronic pain is that it is a disorder of the nervous system called “central sensitization.” An orthopedic injury, for example, might have initially caused a case of back pain, but now, after many months or years, the whole nervous system is involved, including the brain and spinal cord. Changes to the whole nervous system have now made the nerves at the original site of the injury highly sensitive and reactive. They are stuck, as it were, in a “hair trigger” mode that makes any little movement painful.

In the notion of central sensitization, we also see one of the central tenets of chronic pain rehabilitation: that when it comes to chronic pain, what initially caused the pain is not now the only thing that maintains pain on a chronic course. The notion captures the complexity of causal factors in chronic pain, as opposed to acute pain, which may have one cause – an injury or illness. Biological, psychological, and environmental factors are known to influence the development of central sensitization (please see the Institute’s content page on central sensitization for more details). The notion of central sensitization also explains other psychosocial aspects of chronic pain – chronic fatigue, insomnia, limited cognitive deficits such as poor concentration and short-term memory, gastrointestinal upset, anxiety, and depression (Meeus & Nijs, 2007; Wieseler-Frank, Maier, & Watkins, 2005; Yunus, 2007)

For many years, psychologists have successfully treated patients with health conditions related to the nervous system: depression, the various anxiety disorders, insomnia, irritable bowel syndrome, as well as chronic pain.

Psychological therapies for chronic pain

The Society for Clinical Psychology, which is a division of the American Psychological Association, developed task forces to compile a list of treatments that have been determined to be effective for a variety of disorders. They defined “effectiveness” as having multiple clinical trials from different researchers showing the effectiveness of a specific treatment. Not surprisingly, they have identified as effective multiple psychological treatments for mental health disorders such as depression, post-traumatic stress disorder, panic disorder, obsessive compulsive disorder, and general anxiety. However, they have also identified as effective multiple psychological therapies for health conditions. There is strong empirical support for cognitive behavioral treatments for chronic low back pain, osteoarthritis, rheumatoid arthritis, fibromyalgia, headache, and chronic pain syndromes in general. They have also identified effective psychological therapies for primary insomnia and irritable bowel syndrome. You can find information on these treatments here and here.

These therapies are effective likely because of their impact on the nervous system. Just as cognitive behavioral therapies reduce the reactivity of the nervous system in persons with post-traumatic stress disorder or panic disorder, in terms of their heightened startle response or susceptibility to panic, respectively, cognitive behavioral therapies for chronic pain disorders are likely to reduce the reactivity of the nervous system. By reducing the reactivity of the nervous system, patients come to have less pain and increased abilities to cope with the pain that remains.

References

Endean, A., Palmer, K. T., & Coggon, D. (2011). Potential of MRI findings to refine case definition for mechanical low back pain in epidemiological studies: A systematic review. Spine, 36, 160-169.

Meeus M., & Nijs, J. (2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Journal of Rheumatology, 26, 465-473.

Wieseler-Frank, J., Maier, S. F., & Watkins, L. R. (2005). Immune-to-brain communication dynamically modulates pain: Physiological and pathological consequences. Brain, Behavior, & Immunity, 19, 104-111.

Yunus, M. B. (2007). The role of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain. Best Practice Research in Clinical Rheumatology, 21, 481-497.

Published date: 7-29-2013

Date of last modification: 7-29-2013

Author: Murray J. McAllister, PsyD

How People Cope with Pain Really Well: 2

In the last post, we started a discussion about how people cope with chronic pain really well. Specifically, we looked at five attributes and skills that people do when coping well with chronic pain. The point of the discussion was that it is a way to learn how to cope better. Coping with chronic pain is a set of skills like any other set of skills and you learn how to cope with pain just like you learn other skills – like learning how to knit or play the piano or play tennis. If you wanted to learn how to play the piano really well, you would do a number of things (such as take piano lessons), but one of the most important things is that you would study those who are better than you. You would play their recordings and listen and watch how they do it. You would then try to do what they do. The same can be true with learning how to better cope with pain. With this idea in mind, we looked at five attributes and skills that people do when they cope with pain really well.

These five things were the following:

  • Being open to change and learning from others
  • Accepting that chronic pain is chronic
  • Focusing on self-management
  • Engaging in a mild, low-impact aerobic exercise on a regular basis
  • Understanding the relationship between pain and stress, and managing stress well

These are things that people do when coping really well with chronic pain.

Lets look at five more attributes and skills that make for good coping. As we do, remember one more thing from the last post. It was the discussion about how there is no shame in acknowledging that you can learn to cope with pain better. All skills, including the skills of coping, can be seen as on a spectrum for which there is no point at which you are as good as you ever will get. Rather, if you take any skill imaginable, you can always get better at doing it no matter how good you are at it. Any guitar player can get better with learning and practice – even rock and roll superstars. Any tennis player can get better too – even the pros. Similarly, anyone with chronic pain can learn to cope better — no matter how good you are at it. So, there is no shame in acknowledging that you can learn a thing or two. You are in the same boat as everyone else. So, let’s look at five more ways to cope better with chronic pain.

1. People who cope really well don’t react to their chronic pain as if it is acute pain.

If you accidentally stepped into a hole and broke your ankle, the pain of the broken ankle would be considered acute pain. The normal reaction to such an injury would be to become alarmed, seek help, stop using the ankle, stay at home, and rest. With the pain of acute injuries, such as a broken ankle, this set of reactions would not only be normal but largely helpful. Generally, a broken ankle gets put into a brace or cast and we are told to stay off it. By doing these things, we allow the bone fracture to heal. Subsequently, the pain goes away. As such, this set of reactions to acute pain is a good thing.

However, what’s good for acute pain is not good for chronic pain. The normal sense of alarm that goes along with being in pain becomes problematic when occurring on a chronic basis. It can become any number of negative emotions, such as fear, anxiety, irritability, and even depression. The normal reaction of resting becomes problematic too when done on a chronic basis. While resting can help an acute injury, it can make chronic pain worse. Your body is made to move and if you don’t use it for too long you get stiff, achy, and sore. It’s not just you. It’s true for everyone of us. We also get out of shape and gain weight when we are inactive for too long. Becoming de-conditioned in these ways can make pain worse too. Staying home and resting for too long also leads to what healthcare providers call “fear-avoidance.” Fear-avoidance is the cycle of avoiding activities out of concern that the activities will increase pain. Any number of normal activities of daily life can increase pain and so it can become easy to stop doing them out of anticipation that they will cause pain. When done in response to acute pain, it might be helpful. When done on a chronic basis, it’s one of the ways pain can become disabling. Moreover, staying home and not doing your normal daily activities for too long can lead to becoming chronically bored or aimless or depressed. In all these ways, responding to chronic pain as if it is acute pain becomes problematic.

People who cope with pain really well make the transition in their understanding that their pain is no longer acute pain but chronic pain. They know what their chronic pain is and are no longer alarmed by it. They understand that chronic pain is a nervous system condition and not a long-lasting orthopedic injury. They understand that engaging in normal activities won’t make the nervous system condition worse, as it might if it was an acute orthopedic injury, like a bone fracture. Consequently, they no longer become alarmed that they will make the underlying condition worse when they do normal activities of life.

Now, of course, their pain might be worse when they do things, even if it doesn’t make the underlying nervous system condition worse. However, they recognize that not doing things makes their pain worse too. Staying home and resting doesn’t serve a useful purpose when done on a long-term basis. So, people who cope with pain well respond to their pain by saying, “I got to get up and do something!” or “I’ve got to get out of the house or else I’ll go stir-crazy!” That is to say, they react to their chronic pain in ways that are almost opposite to how you normally react to acute pain.

People who cope with pain well have gotten back into the normal activities of their lives despite the pain because the pay off is that it leads to improved coping. They are no longer bored or aimless or depressed. They are getting things done, checking things off their lists, and even having fun on occasion. Because they are doing these things, they feel productive. They feel like they are going somewhere and have a direction again to their life. Their self-esteem is on the rise. In all these ways, they are now coping better and their improved abilities to cope buffer the increased pain they may have from doing these activities.

2. People who cope with pain well pace their activities.

Having gotten back into the normal activities of life, people who cope with pain well are reasonable about how much they do. They do some things, but not everything. They break up a large activity or their entire ‘to do’ list into manageable size chunks. Referring to the story about the tortoise and hare, they might joke that their motto is “slow and steady wins the race.” That is to say, they have overcome any tendencies to engage in what psychologists call “all-or-nothing” approaches to life.

Additionally, they are reasonable about what they do, and not just how much they do. They might not expect to be able to water ski or dirt bike race. Nonetheless, they make it a point to still do a lot of fun things.

3. People who cope well with pain overcome any perfectionist or workaholic tendencies they may have had.

Perfectionists and workaholics get a lot of kudos in our society. They get a lot done and what they do they do very well. Employers love them and reward them for it. So, if you are a perfectionist or workaholic, it may have gotten you far before the onset of chronic pain. However, now that you have chronic pain, perfectionism and workaholism are problematic.

Perfectionism and workaholism are problematic in many ways. First, perfectionists and workaholics engage in “all-or-nothing” thinking and as such tend to struggle with pacing themselves. If they have a good day in terms of their pain level, they clean, not just the kitchen, but the entire house. As they do, they might say to themselves, ‘If you are going to do it, do it right or not at all.’ However, their strict adherence to perfectionistic standards leads to exacerbating their pain through over-activity. Second, their ‘do it right or not at all’ attitude lends itself to the ‘not at all’ side of the equation because they have chronic pain and the pain makes it difficult to ‘do it right.’ Not doing things leads to all the problems described above – getting out of shape, weight gain, aimlessness, and more pain. Third, once they have stopped doing things, they are prone to self-criticism. Their perfectionistic standards are hard taskmasters. When they don’t live up to their standards, they get down on themselves. No one is harder on him- or herself than the perfectionist or workaholic. Such persistent self-criticism can lead to poor self-worth and depression. Fourth, perfectionism and workaholism tend to make people inflexible and poor adapters. We reviewed in our last post that one attribute of a good coper is someone who is flexible and can adapt. The ‘all-or-nothing’ thinking of the perfectionist or workaholic makes it hard to adapt and be flexible. They have difficulty finding the middle ground between their ‘either-or’ thinking. In all these ways, perfectionism and workaholism do not lend themselves to coping well with pain.

People who cope with pain well tend to have worked through their perfectionist and workaholic tendencies. With persistent effort and time, they have broken themselves of the habit of holding themselves accountable to perfectionistic standards. They have come to see that even before the onset of their chronic pain they never really did achieve those standards. Whatever they did, they could always find some fault or room for improvement. There was always something more on the list to do. It never really was a very good recipe for happiness. By overcoming perfectionism, they came to see that what they thought was happiness was really just temporary satisfaction. The feeling associated with a job well done lasted only as long as it took to move on to the next thing on the ‘to do’ list. And there was always more to do on the ‘to do’ list. So, people who cope with pain well have worked through these issues and no longer hold themselves to perfectionistic and workaholic standards.

4. People who cope with pain well maintain a regularly structured day.

Everyone has a routine. We typically go to bed and get up at more or less the same time each day. We typically eat our first meal in the morning, our second meal in the early afternoon, and our third meal in the late afternoon or early evening. We typically shower or bathe shortly after awakening or shortly before bed. Our typical daily chores and activities also follow a routine. We all do better when, more or less, we follow a routine.

Sometimes, of course, it’s fun to break up the routine. When we are on vacation, we enjoy the break in the routine. Right after retirement or obtaining disability, it is nice to have a break in our usual routines and many people have some fun with it.

However, if the break in the usual routine never returns to the normal routine or is never supplanted by a new routine, a couple of problematic things happen that reduce our abilities to function well in life. First, we become aimless. After awhile, we don’t know what to do with ourselves if we don’t have a focus for the day. Without a focus for our concentration and efforts, our attention tends to focus in on the problems of life. For those with chronic pain, our attention gets focused on pain and all the stressful problems associated with living a life in chronic pain. Second, we tend to start napping. Now, an occasional nap is fine, but when it starts happening everyday, it become problematic. It disrupts our nightly bedtime routines. It’s hard to fall asleep because of the nap earlier in the day. Once we start falling asleep later in the evening, we tend to start sleeping in longer and longer in the morning. In turn, this shift pushes the naptime later into the afternoon, which subsequently pushes bedtime later and later. As a result, a shift occurs in your sleep-wake cycle, sleeping more and more into the day and awake more and more at night. Chronic disruption in your sleep-wake cycle is a common cause of social isolation, aimlessness, persistent fatigue, and depression.

I often tell patients that we all need a reason to get up in the morning. We need to have some idea of what we are going to do with ourselves throughout the day. When, on a chronic basis, we don’t have any plans or routine to guide us through the day, then every moment requires a decision – “What am I going to do?” The question can become surprisingly hard to answer! It’s like when you were a kid during the last few weeks of summer vacation and you and the neighborhood kids have done everything you wanted to do; you sit around the house or backyard, staring at each other, asking, “What do you want to do? Oh, I don’t care, what do you want to do?” Back and forth it goes and boredom and aimlessness are the result. Routines serve the function of allowing us not to think so hard. We just know what we are supposed to do from one thing to the next. They keep our minds focused on getting things done, rather than becoming aimless or, worse yet, becoming focused in on all the problems of life while awake in the middle of the night when every one else is sleeping. That’s not what good coping looks like.

5. People who cope with pain well engage in a daily relaxation exercise.

Like mild aerobic exercise, a regular relaxation exercise is an essential component of successful self-management. People who cope with pain really well engage in both on a regular basis.

People commonly misunderstand the role of relaxation in pain management. They tend to think of it as something you do when experiencing a lot of pain in order to get through it. When they try it, it doesn’t work real well and so give up.

While a relaxation exercise can be done in the midst of a pain flare (think, for example, the deep breathing women learn for childbirth), relaxation for this purpose is a very difficult skill to achieve and it takes a lot of practice – more than most people are initially willing to do.

The most important reason a relaxation exercise is an effective treatment for chronic pain is that it is an intervention that targets the nervous system and reduces its reactivity over time. It’s more of a prevention type treatment than something you do in the midst of a pain flare.

Chronic pain is the result of the nervous system being stuck in a persistent state of reactivity that makes nerves highly sensitive to pain. As you know, any normal movement can be painful. Mild pressure like massage or even touch in the painful area of the body can feel painful. Of course, normal movements and massage and touch shouldn’t be painful, but they are because the nerves and the rest of the nervous system are stuck in a persistent state of reactivity, making the nerves in the painful area sensitive. It’s called central sensitization.

A daily relaxation exercise is one of many treatments for this condition. A relaxation exercise targets the nervous and relaxes it for a short period of time. After awhile, the nervous system returns to its high level of reactivity. If you do it again everyday, however, the nervous system begins to return to lower and lower levels of reactivity. As a result, you have less and less pain over time.

You are also more grounded and less stressed. As a result, you also tend to cope better.

A daily relaxation exercise is a two-fer: less pain over time and improved coping over time.

There are literally countless ways to get better at coping with pain. In this post, we reviewed five of them. We reviewed a different five ways in the last post. I intend to periodically review more ways to cope with pain on this blog.

 

Author: Murray J. McAllister, PsyD

Date of last modification: 9-27-2013

From Degenerative Disc Disease to Central Sensitization: A Paradigm Shift

Thomas Kuhn, a historian of science, popularized the notion of a scientific paradigm in the second half of the 20th century and since then almost every significant change in a field of study gets characterized as a “paradigm shift.” So, it is a bit of a cliché to talk of the “paradigm shift” that is going on in the field of chronic pain management. Nonetheless, it is true.

We are actually witnessing it happening. The field of chronic pain management is undergoing a change in both how we understand the nature of chronic pain and how we subsequently treat it. While observable with any number of chronic pain conditions, this paradigmatic shift is most clear in the case of chronic back pain.

For the last twenty to thirty years, we have understood chronic back pain as a symptom of an underlying disease process of the spine called degenerative disc disease. This conceptualization has led to a common view of chronic back pain as a long-lasting orthopedic injury or condition. In the last ten years or so, a competing explanation for chronic back pain has begun to take hold. It is the notion that chronic pain is a nervous system condition, not an orthopedic condition. The condition is called “central sensitization.” It is the understanding that chronic pain results when the nervous system, including the brain, becomes stuck in a persistent state of reactivity, which leads the nervous system to become highly sensitive. The nervous system gets stuck, as it were, in a ‘hair trigger’ mode.

CNSThese competing ways of understanding the nature of chronic pain explains the occurrence of chronic back pain symptoms differently. Take, for example, symptoms of back pain that occur with normal movements, like walking, standing, leaning over, sitting down or getting up from a chair. Pain with simple movements such as these is often perplexing to the patient and their loved ones: these kinds of movements shouldn’t be painful, but they are to many patients with chronic back pain.

Those who uphold the view that chronic back pain is the result of degenerative disc disease would make sense of these symptoms by considering the normal movements as somehow aggravating the underlying degenerative changes of the spine. If the onset of these symptoms occurred slowly over time, they might posit that normal movements have become painful because the degenerative changes of the spines are progressively degenerating.

Those who uphold the view that chronic back pain is due to central sensitization would make sense of the symptom by understanding that the nervous system has become stuck in a persistent state of reactivity. This persistent reactivity has subsequently made the nervous system highly sensitive, so sensitive that even normal activities, such as those listed above, are painful. Indeed, the sensitivity can be so great that even simple pressure, such as touch and hugs, can increase pain and mild bumps to the painful area can send patients through the roof.

A number of factors are leading this change in our understanding of the nature of chronic back pain:

  • The proliferation of scientific studies and publications linking the brain and the rest of the nervous system to the onset and maintenance of chronic pain (see, for examples, Apkarian, Baliki, & Geha, 2009; Baliki, et al., 2006; Chapman, Tuckett, & Song, 2008; Curatolo, Arendt-Nielsen, & Petersen-Felix, 2006; Woolf, 2011).
  • The explanatory nature of central sensitization explains not only the chronicity of pain, but also its psychosocial aspects, such as excessive fatigue, insomnia, poor concentration and short-term memory, gastrointestinal upset, anxiety, and depression (Meeus & Nijs, 2007; Wieseler-Frank, Maier, & Watkins, 2005; Yunus, 2007).
  • Numerous studies show consistent findings that chronic pain rehabilitation, an interdisciplinary therapy that focuses on down-regulating the nervous system, is the most effective form of chronic pain management (see, for examples, Gatchel & Okifuji, 2006; Turk, 2002).
  • In contrast, the explanation that degenerative disc disease is the cause of chronic back pain leads patients into the mistaken belief that their spines are fragile and inevitably going to worsen. This set of beliefs further lead patients to respond with behaviors that are more appropriate to acute injuries — rest, inactivity, and extended use of narcotic pain relievers. When done over time, these behaviors can lead to fear-avoidance, de-conditioning, and disability (Leeuw, et al., 2007; Vlaeyen & Linton, 2000).
  • Numerous studies show consistent findings that surgical and interventional procedures are largely, though not wholly, ineffective (Gibson & Waddell, 2007; Leclaire, et al., 2001; Mirza & Deyo, 2007; van Tulder, et al., 2006; van Wijk, et al., 2005; Weinstein, et al., 2006; Weinstein, et al., 2008). These procedures presume chronic pain to be the result of an orthopedic condition, specifically degenerative disc disease.
  • While degenerative changes of the spine have some relation to pain, the correlation between such changes and pain is weak to modest, at best (Endean, Palmer, & Coggon, 2011). In the case of chronic back pain, these low correlations indicate that much is left unexplained when attributing the cause to degenerative changes of the spine.
  • Numerous studies show consistent findings that degenerative disc disease is neither inevitably degenerative nor a disease (see, for examples, Carragee, et al., 2006; Hutton, et al., 2011; Jarvik, et al., 2005; Jensen, et al., 1994; Matsubara, et al., 1995; Takatalo, et a., 2009).

Knowledge in science advances when both different investigators consistently come to similar findings and, subsequently, a shift occurs in how the community of stakeholders sees and understands a particular phenomenon. In chronic pain management, the sheer numbers of data are all pointing to the same conclusion: the notion of degenerative disc disease does not explain the majority of the variance of chronic back pain symptoms, but rather the notion of central sensitization does. In other words, chronic back pain is a nervous system condition, not an orthopedic condition. Presently, we are witnessing this shift in our paradigmatic understanding of chronic back pain.

 

References

Apkarian, A. V., Baliki, M. N., & Geha, P. Y. (2009). Towards a theory of chronic pain. Progress in Neurobiology, 87, (2), 81-97.

Baliki, M. N., Chialvo, D. R., Geha, P. Y., Levy, R. M., Harden, R. N., Parrish, T. B., & Apkarian, A. V. (2006). Chronic pain and the emotional brain: Specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. Journal of Neuroscience, 26, 12165-12173,

Carragee, E., Alamin, T., Cheng, I., Franklin, T., & Hurwitz, E. (2006). Does minor trauma cause serious low back illness? Spine, 31, 2942-2949.

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: Reciprocal neural, endocrine and immune interactions. Journal of Pain, 9, 122-145.

Curatolo, M., Arendt-Nielsen, L., & Petersen-Felix, S. (2006). Central hypersensitivity in chronic pain: Mechanisms and clinical implications. Physical Medicine and Rehabilitation Clinics of North America, 17, 287-302.

Endean, A., Palmer, K. T., & Coggon, D. (2011). Potential of MRI findings to refine case definition for mechanical low back pain in epidemiological studies: A systematic review. Spine, 36, 160-169.

Jarvik, J. G., Hollingworth, W., Heagerty, P. J., Haynor, D. R., Boyko, E. J., & Deyo, R. A. (2005) Three-year incidence of low back pain in an initially asymptomatic cohort. Spine, 30, 1541-1548.

Jensen, M. C., Brant-Zawadzki, M. N., Obuchowski, N., Modic, M. T., Malkasian, D., Ross, J. S. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331, 69-73.

Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved November 25, 2011, from The Cochrane Library, Wiley Interscience.

Hutton, M. J., Baker, J. H., & Powell, J. M. (2011). Modic vertebral body changes: The natural history as assessed by consecutive magnetic resonance imaging. Spine, 36, 2304-2307.

Leclaire, R., Fortin, L., Lambert. R., Bergeron, Y. M., & Rosignol, M. (2001). Radiofrequency facet joint denervation in the treatment of low back pain: A placebo-controlled clinical trial to assess efficacy. Spine, 26, 1411-1416.

Leeuw, M., Goossens, M. E., Linton, S. J., Crombez, G., Boersma, K., & Vlaeyen, J.W. (2007). The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence. Journal of Behavioral Medicine, 30, 77-94.

Matsubara, Y., Kato, F., Mimatsu, K., Kajino, G., Nakamura, S., & Nitta, H. (1995). Serial changes on MRI in lumbar disc herniations treated conservatively. Neuroradiology, 37, 378-383.

Meeus M., & Nijs, J. (2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Journal of Rheumatology, 26, 465-473.

Mirza, S. K., & Deyo, R. A. (2007). Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine, 32, 816-823.

Takatalo, J., Karppinen, J., Niinimaki, J., Taimela, S., Nayha, S., Jarvelin, M. R., Kyllonen, E., Tervonen, O. (2009). Prevalence of degenerative imaging findings in lumbar magnetic imaging among young adults. Spine, 34, 1716-1721.

Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344.

Vlaeyen, J. W. S. & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85, 317-322.

Wieseler-Frank, J., Maier, S. F., & Watkins, L. R. (2005). Immune-to-brain communication dynamically modulates pain: Physiological and pathological consequences. Brain, Behavior, & Immunity, 19, 104-111.

Weinstein, J. N., Tosteson, T. D., Lurie, J. D., et al. (2006). Surgical vs. nonoperative treatment for lumbar disk herniation: The spine patient outcomes research trial (SPORT). Journal of the American Medical Association, 296, 2441-2450.

Weinstein, J. N., Lurie, J. D., Tosteson, T. D., et al. (2008). Surgical vs. nonoperative treatment for lumbar disc herniation: Four-year results for the spine patient outcomes research trial (SPORT). Spine, 33, 2789-2800.

Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152 (3 Suppl), S2-15.

Yunus, M. B. (2007). The role of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain. Best Practice Research in Clinical Rheumatology, 21, 481-497.

Author: Murray J. McAllister, PsyD

Date of last modification: 4-29-13

Your Doctor Says That You Have Chronic Pain: What Does That Mean?

Your injury was many months ago. You initially saw your primary care provider who sent you to a pain clinic. The provider at the pain clinic who evaluated you may have been a surgeon who told you to come back after you have gone to the interventional pain provider and physical therapist. You subsequently underwent evaluations and started care with each of these providers. You had this procedure and that procedure. You went to physical therapy. You did it all in the hopes that they would find the source of the pain and fix it. None of it really worked, though. At best, some of them were helpful for a few days or weeks but pain seemed to always return to the level it was previously. So, you decided to go back to the surgeon. You underwent a surgery and followed it up with more physical therapy. Perhaps, you had to go through a revision of the surgery a few months later. Maybe the surgery or surgeries didn’t help. Maybe, your pain was worse afterwards. Or, maybe it helped for a few months, but again the pain returned. Then, you go to another pain clinic and the provider there tells you that you have chronic pain.

What does that mean?

Frequently, definitions of chronic pain characterize it as pain that lasts longer than three or six months and then leave it at that. While the timeframe is accurate, this definition leaves out a whole lot. There’s more to chronic pain than just the time frame. Let’s look at what more there is and come back to the timeframe in a bit.

The understanding that your pain is chronic signals a change in what your providers think is the primary cause of your pain. When pain is chronic, the source of your pain is no longer the initial injury that started the pain. Rather, if your pain is chronic, then the source of pain has become the nervous system. It’s no longer an orthopedic problem, but a nervous system problem.

What happens is that, once having an injury and coming to have pain, the nervous system can change. It can become stuck in a persistent state of reactivity. Over time, the nervous system becomes so sensitive that any little movement hurts. Leaning over hurts. Standing back up hurts. Sitting down and getting up from a chair hurt. Walking hurts and so on. These simple, everyday movements shouldn’t be painful; but they are. They are painful because the nervous system has become stuck in a persistent state of reactivity. This state of reactivity has led the nerves in the area of your initial injury and the corresponding nerves in the spinal cord and brain to become so sensitive that simple, everyday movements hurt.

Patients often come to think that these movements are painful because the initial orthopedic injury, such as to the spine, has made their spine permanently fragile. Along the way, they may have been told that they have degenerative disc disease. This way of making sense of the pain naturally leads you to think that you have a disease that is inevitably going to deteriorate your spine, making it more and more fragile. As such, it’s natural to think that simple, everyday movements hurt because the spine is so fragile.

Over the last several years, however, basic science has studied how commonly degenerative changes of the spine occur in people with chronic back and neck pain as well as how commonly degenerative changes occur in people without back or neck pain. It turns out that degenerative changes of the spine are as common, if not more common, in people without spine-related pain. Basic science has also tracked the natural outcomes of degenerative changes of the spine over many years. It turns out that most of the time degenerative changes get better. Sometimes, they stay the same, but they typically don’t get worse.

With such research, we now know that “degenerative disc disease” is a misnomer. That is to say, it is a misleading term. Degenerative changes of the spine are neither a disease nor are they inevitably going to get worse. Now, I’ll save the details and references for another post, because the issue of degenerative disc disease is such a big topic. For now, you can visit the content page on degenerative disc disease at the Institute’s web page.

Suffice it to say that it is not accurate to think of “chronic pain” as a long-lasting acute injury, such as an orthopedic condition of the spine. The initial injury that started the pain may have long since healed. Rather, chronic pain is a nervous system condition whereby the nervous system is stuck in a persistent state of reactivity that has made the nerves highly sensitive. As such, simple, everyday movements hurt.

Besides the term “chronic pain,” researchers and providers call this condition “central sensitization.” The nerves at the site of the injury, say, for example, your low back, are part of the peripheral nervous system. These nerves send chemical information, what we might call a ‘pain signal,’ to the spinal cord and from there the signal takes an elevator up to the brain, where there, it registers as pain in the low back. The spinal cord and brain make up the central nervous system. With chronic pain, the peripheral nerves at the site of your pain, for example, your low back, and the central nervous system have become stuck in a persistent state of reactivity that leads them to react like a ‘hair trigger.’ Any little movement can set them off.

Often, with chronic pain, the site of pain is also sensitive to touch or pressure. Pushing on the area causes pain. A simple bump is likely to cause more pain than it should, were it not for the nervous system’s reactivity and sensitivity. Sometimes, in more severe cases, simple touch can hurt.

Patients with chronic pain are not making this stuff up. It’s really happening and it is real pain. What’s happening is that the nervous system problem is maintaining the pain.

So, when your provider tells you that you have chronic pain, it means that he or she no longer sees your condition as primarily an orthopedic problem, but a nervous system problem. The timeframe of three to six months is important because the pain of most acute injuries subsides after this number of months. Sometimes, of course, pain continues and becomes chronic. In these cases, as described above, the nervous system reorganizes and becomes sensitized. In this way, the pain of an acute injury transitions to the pain of central sensitization, or chronic pain.

So, your provider tells you that you have chronic pain. Now what? Just as your pain has transitioned from acute pain to chronic pain, you must transition your treatment strategies. Under your provider’s direction, you will likely do two broad categories of things. First, you will likely stop undergoing orthopedic treatments, such as spinal injections, surgeries, and physical therapies that are geared towards resolving an injury. Second, you will start obtaining treatments for the nervous system problem that you now have. There are a number of them that are proven effective. What are these?

Before listing these treatments, a brief caveat is in order. A number of treatments are proven effective, but “effective” does not mean curative. We do not have any cures for chronic pain. This fact brings us to another important part of the definition of “chronic pain.” Chronic pain is chronic. The word “chronic” itself means that it will last indefinitely. It doesn’t mean terminal. You won’t die from it. Rather, what it means is that it is not fixable and it is something you will likely have for the rest of your natural life.

Nonetheless, there are a number of treatments that are effective in the sense that they have all been shown in research to either reduce pain or improve functioning or reduce the need for on-going healthcare services, including the use of opioid medications. The known effective treatments for chronic pain are the following:

  • Cognitive behavioral therapy
  • Relaxation exercises, including mindfulness-based therapies
  • Mild aerobic exercise, including pool therapy
  • Anti-epileptic medications
  • Antidepressant medications, particularly tricyclic antidepressants
  • When done altogether in a coordinated fashion, these therapies are called a chronic pain rehabilitation program

The common denominator of all these therapies is that they target the nervous system and reduce its reactivity over time. All of them have multiple clinical trials showing their effectiveness.

Recently, a few clinical trials of yoga and tai chi have been published showing that these too are effective. It seems reasonable given their quieting effect on the nervous system. However, because of the insufficient number of studies, I think it is too soon to draw firm conclusions. My guess, though, is that more studies will come in time and that these therapies will also some day firmly be established as effective. Many chronic pain rehabilitation programs already incorporate them.

Author: Murray J. McAllister, PsyD

Date of last modification: 3/18/2013