Chronic pain can have far-reaching effects on a person, deeply affecting their overall quality of life and general health.
Chronic pain may cause a person to limit their activities, avoid movement, and decrease their social interactions. Many people with chronic pain often experience disturbances in mood, sleep disorders, and inability to function at the level required by everyday responsibilities like performing their work, or caring for their children or other family members.
What is pain? How does it start? Why does it persist? Why is it so hard to “get better” sometimes?
Pain is a complex experience, and the answers to these questions vary depending on the individual experiencing the pain. Everything from your beliefs to tissue damage you may have experienced initially will impact how you experience pain.
Pain can also occur without tissue damage. For example, a person may continue to experience pain, even when the original tissue damage (such as a broken bone or ligament sprain) has healed. Conversely, tissue damage can occur without the perception of pain. Have you ever looked down and noticed a huge bruise on your shin, but you don’t even remember getting hurt? You did not perceive pain, yet the tissue is clearly “damaged.”
As one of my teachers, Dr. Jan Dommerholt (a renown expert in the physical therapy diagnosis and treatment of people with chronic pain) explains: “The pain is what the patient says it is, where they say it is, to the magnitude they say it is.”
The experience of pain is very real for a person going through it.
Your body constantly receives input from your nerves, sending messages up the spinal cord to the brain. The brain then makes decisions about whether it perceives a message as a threat. If it does, it can create a “danger” message (pain) to tell you to avoid that activity.
Professor Lorimer Moseley has an informative and engaging TEDx talk on this topic, and his book, Explain Pain (co-authored by Dr. David Butler, founder of the Neuro Orthopaedic Institute) can be very helpful for people experiencing pain, as well as for their loved ones.
Chronic pain is not prolonged acute pain. Chronic pain is typically defined as pain that lasts longer than three months, or past the time of normal tissue healing. Some of the most common chronic pain complaints include low back pain, arthritis pain, headaches, cancer pain, and nerve and muscle pain. Though not always the case, chronic pain could start with an injury or other specific cause, but lingers long after healing has occurred.
On the other hand, the onset of acute pain happens fairly quickly as the direct result of injury or trauma, disease, or inflammation, and is often accompanied by anxiety or emotional distress. This type of pain normally resolves when the cause is treated and healing takes place.1
Chances are that you or someone you love is living with chronic pain. In fact, it is estimated that in the United States, nearly half of all adults experience chronic pain.
Based on a survey conducted by the CDC between 2001 and 2003, the overall prevalence of common, predominantly musculoskeletal pain conditions (such as arthritis, rheumatism, chronic back or neck problems, and frequent severe headaches) was estimated at 43 percent among adults in the U.S. Findings from a 2012 National Health Interview Study showed that 11.2 percent of adults report having daily pain.2
As a physical therapist, I work with people in pain every day. A major component of my treatment involves educating people about their pain, and ways that they can influence their behaviors around pain including gentle movement and addressing their thoughts and beliefs about their pain.
I first learned about the concept of pain science in 2011 from Dr. Dommerholt. I had treated people in pain for 19 years at that point, and I lacked a paradigm for explaining why some people had pain that continued even in the absence of tissue damage. I completed over 100 hours of classroom and practical education with Dr. Dommerholt and Dr. Robert Gerwin in an effort to understand pain science and the role of a physical therapist in the treatment of chronic pain.
The effects of chronic pain can become extremely costly, both in terms of health care costs as well as the emotional and social impact that chronic pain has on a person’s life. Patients with chronic pain often find that they cannot continue to work the type of job they had before their pain began, and they may need to stop working. Many of my patients with chronic pain are on disability, and find that they can longer support their families. This leads to not only financial issues for the family, but also stress and discord, which in turn may increase the patient’s perception of their pain.
Historically, chronic pain has largely been treated with medication. However, in recent years, patient education has increasingly become a preferred approach to treatment by many medical professionals. In the last 10 years there has been increasing support for therapeutic neuroscience education from clinical trials, educational science, neuroscience, plain logic and the failure of drug therapy on chronic pain outcomes. Dr. David Butler said:
“It is no longer acceptable that pain be just managed. We must expect that it can be treated, and sufferers can alter it themselves through education.”
An estimated 20 percent of patients who go see a doctor about non-cancer pain symptoms or pain-related diagnoses (including acute and chronic pain) receive an opioid prescription. In 2012, health care providers wrote 259 million prescriptions for opioid pain medication—enough for every adult in the United States to have a bottle of pills! In 2013, based on diagnosis criteria outlined in the DSM-IV (fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, a handbook used by healthcare professionals in the United States and much of the world to diagnose mental disorders), the Centers for Disease Control and Prevention (CDC) estimated that 1.9 million persons in the United States abused or were dependent on prescription opioid pain medication.3
In March 2016, after conducting a systematic review of the available scientific evidence, the CDC published new guidelines regarding the use of opiates for chronic pain. Upon review, the CDC concluded that there is limited evidence available on long-term opioid therapy for chronic pain, outside of end-of-life care, and thus, not enough evidence to determine long-term benefits of opioid therapy compared to no opioid therapy. Their findings also suggest there is a dose-dependent risk for serious harm.3
In light of the new guidelines and the magnitude of the opioid epidemic in the U.S., the way we treat chronic pain must change. Evidence supports the use of education about pain science and the use of graded exposure to movement as part of the team approach to working with people experiencing chronic pain.
Treatment requires a team approach, and the person experiencing pain needs to be part of this team.
Treatment is generally most effective when it follows a biopsychosocial paradigm—this approach considers biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery.4 Because pain is the result of many factors, we cannot just address one factor in treatment. The experience of pain will vary from person to person, based on many factors such as the person’s thoughts, attitudes, and beliefs about pain, as well as tissue damage and healing process.
Pain science patient education aims to help patients significantly change their pain beliefs, attitudes, and physical performance. Dr. David Butler and Prof. Lorimer Moseley, leading researchers in the area of pain science, explain that pain is not necessarily a sign of damage, but more of an individual’s response to threat, real or perceived.5 Their research shows that when we teach a patient to understand their body and its signals, and to gain confidence in their movement, therapists help that patient reduce the stress responses that occur in their body when they think about experiencing pain.
One aspect of treatment that a physical therapist will utilize when working with a person in pain is graded exposure to movement. That is, gradual performance of tasks that previously set off alarm messages in the brain. Through a gradual progression of previously feared activities, a patient can increase their threshold of movement. For example, if a person experiences pain when bending forward, we gradually increase their tolerance of bending forward to achieve their goal of being able to tie their own shoes again.
Our beliefs about our injury and our pain are often incorrect. The authors of Explain Pain have devised an easy-to-understand way to talk about beliefs as they relate to pain. They refer to these beliefs as “thought viruses,” or “Danger in Me” messages, that become part of our belief system. The belief that “movement is dangerous” is an example of a thought virus, and this belief can cause a patient to begin to severely limit their activities. Lack of movement can lead to a host of other health issues over time. Knowledge, on the other hand, can be a “thought vaccine,” or a “Safety in Me” message.5 When we question the validity of our limiting beliefs about pain, we can begin to improve our quality of life and our function. This short video explains thought viruses in an easy-to-understand format.
The experience of pain is very real for the person going through it, and many factors, including their beliefs and their environment, can affect that experience.
Working with knowledgeable and compassionate medical professionals, and having the support and understanding of friends, family, and colleagues can make a great difference in their progress.
If you are living with chronic pain (or know someone who is), please take a look at all of the resources mentioned in this article, and find a physical therapist who will partner with you, empowering you to reach your goals for a more active life.
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