Chronic Pain – what do we really know?

Chronic Pain, pain

Dr John Sarno, TMS, chronic painThis blog post is dedicated to Dr John Sarno 23/06/1923 - 22/06/2017 - the pioneer of mind-body medicine.

I, along with my fellow mind-body workers, will continue to strive to realise his vision of the acceptance of mind-body theories by mainstream medicine.

Everybody has experienced pain at some time or another.

Some have it only fleetingly as part of an injury. Others are unfortunate enough to have it constantly - day in, day out.

Most of us have been brought up with the understanding that all pain is caused by some kind of injury or damage to our bodies.

If you cut yourself - it hurts.

If you break a bone - it hurts.

If you have infected tissue - it hurts.

This is a logical explanation and makes perfect sense for acute, short-term episodes of pain.

Chronic Pain

However, there are many more conditions that are linked to pain.chronic pain, pain, migraine

Arthritic joints, slipped discs, C.R.P.S., sciatica, Repetitive Strain Injury, Tennis Elbow, Plantar Fasciitis, painful menstruation, Carpal Tunnel Syndrome, Irritable Bowel Syndrome, migraines - the list is endless.

I, like the majority of people, understood that pain in these conditions is also caused by structural damage to bones, tendons, nerves and tissue.

Imagine the shock and bewilderment when I discovered there is actually no evidence to support this whatsoever?

I repeat:

There is NO EVIDENCE to support that chronic pain is caused by structural damage or abnormalities.

Back Pain

back pain,chronic pain, slipped disc, herniated disc, stenosis, spinal degenerationAs back pain is one of the biggest causes of ill health in the UK [1], there has been lots of research done into it so is a useful source of information.

Whilst the personal cost is huge to people whose lives are impacted by back pain, the cost to the nation through lost work days, medical treatment and social support is also significant.

Back pain continues to increase despite stringent Moving and Handling regulations. Specialist lifting equipment is common-place and we all know the mantra "bent knees, straight back" as we look after our 'delicate' backs.

Trapped nerves, slipped discs and spinal degeneration are all identified as major players in back pain.

The usual explanations I hear from physiotherapists and Doctors alike are:

You slept in an awkward position

The mattress isn’t right

He did hard manual labour all his life so has worn his back out

Your core strength is weak

The ergonomics of your work area are wrong

Sound familiar?

But what does the research say?

    • MRI, cervical spine"On MRI examination of the lumbar spine, many people without back pain have disc bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with LBP may frequently be coincidental” [2]

    • “MRI showed degenerative changes [including protrusions, compressions and stenosis] in both the lumbar and cervical spine in 78.7% of the [asymptomatic] volunteers [mean age 48]” [3]

    • “Lumbar MRI of asymptomatic volunteers (age 14 to 82, mean age 46) showed 60% had bulges, 45% had protrusions, 31% had extrusions, 76% had annular fissures, 76% had nuclear degeneration.” [4]

    •  “No correlation was found between symptoms and the degree of disc displacement, nerve root enhancement or nerve compression in 160 patients with unilateral sciatica.” [5]

    •  “Degenerative disc disease, as seen on imaging, is not a painful condition” [6]

    • “Findings on magnetic resonance scans were not predictive of the development or duration of Low Back Pain (LBP). Individuals with the longest duration of LBP did not have the greatest degree of anatomical abnormality on the original (1989) scans." [7]

      Studies have shown conclusively that back pain has NO CORRELATION with spinal abnormalities such as worn vertebrae and slipped discs.

      Osteopath, Eyal Lederman, explored studies carried out over the last 20 years in relation to low back pain – looking in particular at posture, structure and biomechanics (PSB) [8]. He found that:

      • back pain, posture, biomechanics, structure, core strengthAsymmetries and imperfections in posture, structure and bio-mechanics are normal variations seen in most people, with or without back pain.

      • Variations in muscle strength and motor control are also normal.

      • The body is able to tolerate such variations without any loss of normal function or the development of symptomatic conditions.

      • There is no relationship between pre-existing PSB factors and back pain.

      In summary, it doesn't matter how we hold ourselves, how strong our muscles are, how crooked or worn our spines are – these have no effect on pain.

    •  

      Although this research is focussed on back pain, these findings apply equally to all chronic joint pain and the majority of other chronic pain conditions.

      So, if the state of our bones, our posture and muscle strength don't cause pain  - what does?

Modern Pain Science

We now understand pain to be a complex mix of physical, emotional, psychosocial and cognitive factors.pain, chronic pain, pain bucket

It has long been accepted that our emotions impact our health. If we are more stressed we are more likely to come down with a cold or have a headache. Research is showing this also applies to chronic pain.

Numerous studies have found the most reliable predictors of chronic pain are a person's stress levels and their personality traits:

  • A&E nurses have increased musculoskeletal disorders in proportion to their increasing job demands. [9]

  • A study following student nurses through their training and for 6 months after found the onset of Low Back Pain (LBP) had no connection to doing any particular activity but that psychological distress was key. [10]

  • LBP in the workplace is correlated with perceived lack of control and lack of empowering and fair leadership. [11]whip lash, chronic pain

  • Psychological profiles predicted whiplash pain from a placebo crash with 92% accuracy. [12]

  • In the same study, those who experienced persistent pain had the highest stress levels and emotional distress in their lives at the time of the experiment. [12]

  • Cumulative trauma, high levels of depression and a belief that the pain is permanent have been found to result in increased likelihood of chronic pain and disability. [13]

Studies also show that it's not just the stress that we're dealing with in the present day that affects pain. Upsets and traumas from our past also play their part.

  • childhood trauma, past stress,People who experienced distressing events as a child were found to experience more headaches as adults. [14]

  • Child traumatic events are significantly related to chronic pain. [15]

  • Adults who experienced hospitalisation from a car accident, institutional care, maternal death or financial hardship at the age of 7 are more likely to suffer chronic widespread pain. [16]

  • People suffering fibromyalgia are more likely to have experienced physical abuse and emotional neglect and abuse. [17]

Dr John Sarno found the key underlying causes of chronic pain were anger, fear, guilt, shame and sadness. [18] Once these issues were addressed, pain resolved in most people. [19]

How is Pain Created?

A very simplified explanation is that:

Brain, neural pathways, neuroplasticityNerves send signals from the body to the brain.

The brain interprets the signals as dangerous or not.

If perceived as dangerous, the brain sends pain signals back to the body.

Chronic pain results from nerves between the brain and the body becoming overly sensitive.

This means that, all pain is actually created by the brain, not by the body [20]

An example where this is strickingly obvious is with phantom limb pain: a painful limb is amputated but the person continues to feel pain in the place where the arm or leg used to be. Obviously there is nothing wrong with the limb to cause the pain - and as it isn't even there, the pain cannot be created by the limb. However, the brain continues to use the over-sensitive nerve pathways to send faulty pain signals. [21]

The more a pain signal is sent, the more sensitive the nerves become. The pain pathway is reinforced and the signals can be sent even more efficiently.


The Pain Cycle

Once pain starts, it's easy to get caught in a vicious cycle with lots of elements feeding into it.

Emotions - Our emotions play a key role in the initiation and perpetuation of pain. Once pain has started, most people feel fear, anxiety, frustration and worries. These emotions trigger a stress response which then amplifies the pain [22, 23, 24]emotions, fear, anger, stress, guilt, sadness, shame

Behaviours - Our behavious often change as we stop doing activities that we fear will cause us pain. We restrict our movements and avoid certain 'triggers' that we feel make our pain worse such as certain chairs, foods or lights. This serves to reinforce the fear of the activity or 'trigger'. The connections between these and your pain become stronger over time. Just as Pavlov's dogs salivated at the ring of a bell, our pain becomes a conditioned response to the trigger.

thoughts, beliefs, health, pain Biology - As we are holding ourselves in such a tense, protective manner in order to avoid pain, our blood flow to tissues can be altered which can result in more pain and stiffness. Our hormone levels also change with the stress that can be caused by chronic pain. This effects our mood, our sensitivity to pain, our ability to cope and to sleep which have a knock-on effect on our pain.

Thoughts - our beliefs around our pain can affect how we experience pain.[23] If we perceive it to be dangerous and permanent we are more likely to feel fear, restrict our movements and for our pain to be perpetuated. Numerous studies have shown how our thoughts and beliefs have a huge impact on how our bodies work.

Effective Chronic Pain Treatments

drugs, medication, pharmacology, pain treatments, opioidsChronic pain is at epidemic proportions in the UK. Opioid use has increased by 400% in the last decade [25] despite serious side effects such as increased pain, immunosuppression, hormone dysfunction and dependency.

Current treatments offered by the NHS seem to make little or no lasting difference:

A review of back pain treatments found that surgery, injections and narcotic pain medications have shown to be ineffective. [27]

Very few people recover from fibromyalgia using standard medical treatments. [28]

Why is this?

Current treatment options are still using the out-dated pain model that looks for structural, pathological causes for the pain.

We now know there is much more to pain than this.

In order to treat chronic pain effectively it is necessary to address all aspects that initiate and perpetuate the pain:

  • Emotions

  • Stress

  • Behaviours

  • Thoughts

Only once these have been identified and dealt with can we move towards being in control of our pain rather than our pain controlling us.balance, recovery, healing, calm

Chiron Fatigue Treatment

Connecting Mind and Body for Health

References

[2] Jensen MC, Magnetic Resonance Imaging of the lumbar spine in people without back pain. New England Journal of Medicine. 1994, 69 - 73

[3] Matsumoto M, Tandem age related lumbar and cervical intervertebral disc changes in asymptomatic subjects. European Spine Journal. 2013, 708 - 713

[4] Kim SJ, Prevalence of disc degeneration in asymptomatic Korean subjects. Part 1: lumbar spine. Journal of the Korean Neurosurgical Society. 2013, 31 - 38

[5] Karppinen N, Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients. Spine. 2001, 149 - 54

[6] Centeno CJ, Degenerative disc disease and pre-existing spinal pain. Annals of the Rheumatic Diseases. 2003, 62: 371 – 372

[7] Borenstein DG et al, The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study. The Journal of Bone and Joint Surgery. 2001, 83: 1306 – 1311

[8] Lederman E, The fall of the postural-structural-biomechanicalmodel in mnaual and physical therapies: Exemplified by lower back pain. CPDO Online Journal. 2010, March: 1-14 www.cpdo.net

[9] Sorour AS, Relationship between musculoskeletal disorders, job demands and burnout among emergency nurses. AdvancedEmergecy Nursing Journal. 2012, 34(3): 272-82

[10] Feyer AM, The Role of physical and psychological factors in occupational low back pain: a prospective cohort study. Occupational and Environmental Medicine. 2000, 116-20

[11] Christensen JO, Work and back apin: a prospective study of psychological, scial and mehanical predictors of back pain severity. European Journal of Pain. 2012, 921-33

[12] Castro WH, No stress - no whiplash? Prevalene of "whiplash" symptoms following exposure to a placebo rear-end collision. International Journal of Legal Medicine. 2001, 316-22

[13] Young Casey C, Transition from acute to chronic pain and disability: a model including cognitive, affective and trauma factors. Pain. 2008, 134(1-2):69 – 79

[14] Anda R, Adverse childhood expeiences and frequent headaches in adults. Headache. 2010, 50(9): 1473-81

[15] Goldberg RT, Relationship between traumatic events in childhood and chronic pain. Disability and Rehabilitation. 1999, 21(1): 23-30

[16] Jones GT, Adverse eventsin childhood and chronic widespread pain in adult life: Results from 1958 British Birth Cohort Study. Pain. 2009, 92-6

[17] Van Houdenhove B, Victimisation in chronic fatigue syndrome and fibromyalgia in tertiary care: a controlled study on prevalence and characteristics. Psychosomatics. 2001, 42(1): 21-8

[18] Sarno J E, The Divided Mind. Duckworth Overlook, 2006

[20] Schubiner H, Unlearn Your Pain: a 28 day process to reprogram your brain. Mind Body Publishing, 2012

[21] Flor H, Elbert T, Knecht S, Weinbruch C, Pantev C, Birbaumer N, Larbig W, Taub E, Pantom limb pain as a perceptual correlate of cortical reorganistion following arm amputation. Nature. 1995, 375: a2338

[22] Klossika I, Flor H, Kamping S et al, Emotional modulation of pain: A clinical perspective. Pain. 2006, 124: 264-268

[23] Leiberman MD, Jarcho JM, Berman S, Naliboff BD, Suyenobu BY, Mandelkern M, Mayer EA, The neural correlates of placebo effects: a disruption account. NeuroImage. 2004, 22: 447-455

[24] Lumley MA, Cohen JL, Borszcz GS, Cano A, Radcliffe AM, POrter LS, Schubiner H, Keele FJ, Pain and emotion: a biopsychosocial review of recent research. Journal of Clinical Psychology. 2011, 67: 942-68

[27] Deyo RA, Mirza SK, Turner JA, Martin BI, Overtreating chronic back pain: time to back off? Journal of the American Board of Family Medicine. 2009, 22: 62-8

[28] Walitt B, Fitzcharles MA, Hassett AL, Katz RS, Hauser W, Wolfe F, The longitudinal outcome of fibromyalgia: a study of 1555 patients. Journal of Rheumatology. 2011, 38: 2238-46

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