New research is showing that chronic pain, for example in the back, may be experienced in people with relatively minimal pathology. Often, the MRI will show only age related changes despite the patient experiencing severe symptoms. Sometimes, even if there is more than average pathology, their pain is disproportionately severe compared to the MRI.
We have come to learn that it may be the nervous system (nerves/spinal cord/brain) and not just the back that could be contributing to the pain. When pain becomes chronic, the nervous system seems to play an increasing role in their overall pain experience.
In some cases, once the pain begins, the area of the pain starts to spread as it becomes chronic. That is why back pain may start out localized to one small area but over time it begins to encompass a larger area. It is not that the whole back has become worse but the changes in the spinal cord are beginning to send pain signals from structures that are not causing pain. Therefore, it becomes difficult to identify the exact source of the pain when it becomes chronic. Furthermore, treating the original source does not necessarily eliminate the pain because the spinal cord continues to send the pain signals.
The causes are multifactorial with psychology and genetics playing a strong role.
First, lets differentiate pain from suffering. Imagine a football player is tackled by several players. He may be hit multiple times in multiple places of the body. Despite this, the player will often get up ‘shake it off’ and keep playing. These people are experiencing pain but not much suffering. Now imagine someone being injured in the same way but in the context of an abusive relationship, or as a result of a car accident from a drunk driver or from a work place injury. While they may experience the same forces of impact, these situations are more likely to lead to chronic pain. That is because they are not just experiencing pain from the physical trauma but there is the added layer of suffering because of the context of how the injury happened.
Even if there is no psychological trauma associated with an injury, if the person lives in stressful circumstances, they are more likely to go into chronic pain. Imagine experiencing back pain while living with an unsympathetic spouse/boss or dealing with financial uncertainty. The added layer of psychological stress will take the underlying pain trigger and add on a layer of suffering which makes it more likely to become chronic.
This is why it is important to manage psychology when managing chronic pain. Some patients have heard their doctor suggest that ‘it’s all in your head’. As if to imply that they are making up or exaggerating their pain. Even family members may begin to think this when the pain does not improve over time. It is important to know that while pain is never ‘all in your head’, managing your psychology can often help lessen the suffering. Many studies have shown that mindfulness, stress reduction and CBT counselling have all produced a measurable reduction in chronic pain. I like to tell people ‘While it is definitely not all in your head, your mind does have the power to influence your pain’. Studies have also shown that yoga and tai-chi have reduced chronic back pain due to its dual effect on the body as well as the mind. Here is an interesting article about how hypnosis has been shown to reduce pain even with surgery. This speaks to the power of the mind which can both increase and decrease the pain experience.
Sometimes, it is impossible to manage chronic pain if you have not addressed the psychological suffering that accompanies it. In addition to counselling, some people may benefit from anti-depressants.
This is because opioids not only help with the pain but they can also briefly relieve the patient of psychological suffering. If you find yourself taking an opioid during moments of stress, you are not treating pain but you are treating suffering. Sometimes it becomes difficult for patients to tease out what is pain and what is suffering.
The more you take an opioid to manage suffering, the more likely you are to get addicted.
The fact is that opioids would be a great drug if there was no tolerance. If you could get away with taking an opioid once a day to stay level and happy, then it is worth taking on a regular basis (much like an antidepressant). The problem is that once you start taking it regularly, you will need more and more drug to produce the same benefit.
After a while, you are not just taking it to relieve suffering but you are taking it to manage the mini withdrawal between pills. This is why almost every study has shown that opioids tend to worsen chronic pain and mood in the long run. Studies have shown that pain scores rarely change in chronic opioid users. At first, an opioid may take your pain from a 9 to a 5 but over time, it will only bring your pain from a 9 to an 8. You will need more opioid to bring it back down to a 5.
After each successive dose increase, patients will briefly notice pain improvement. However, over time, they migrate back to their original pain scores. Now they have 2 problems, addiction/tolerance and chronic pain. When we try to wean these patients off the opioids, the withdrawal alone can increase their chronic pain.
1) Manage stressors/psychology through CBT, counselling, progressive relaxation, mindfulness, etc
2) Manage the underlying pathology through stretching and strengthening exercises. Building muscle often helps offload joints. Exercise will bring blood supply to nourish damaged structures. Proper stretching will help off load abnormal stresses placed on muscles, tendons and ligaments.
3) Manage sleep. Sleep is restorative and aids in healing. Many patients often overlook the importance of sleep when they use screens at night or avoid a bedtime routine.
4) Manage diet/weight. Some diets can contribute to inflammation. There is a positive correlation between obesity and chronic pain. Here is a reference.
5) Quit smoking. Smoking, through its effect of clogging small vessels, can contribute to back pain. Here is a reference.
In our clinic, we manage chronic pain through a combination of medications and interventional treatment. 15 years of experience has taught me however, that pain is difficult to address unless the patient employs the self management strategies as outlined above.
Many patients have told me that they can’t exercise, sleep properly, lose weight or address their mood until their pain is relieved. I fully understand this.
It has been my experience that managing pain through drugs/injections can kick start the cycle of improving their lifestyle which improves their pain.
Here is a story that I have seen time and time again during my 15+ years of managing chronic pain:
John Smith is referred into our clinic for chronic back pain. He has tried physio, chiro, acupuncture, massage, and TENS but continues to suffer. Over the counter pain medications have been unhelpful. He is unable to exercise and puts on weight. He tends to eat comfort foods which are often inflammatory. His sleep is impaired. His relationships, both at work and at home suffer. He becomes depressed and feels hopeless. He is unable to work and ends up unemployed or on disability.
Through a combination of medications and injections we are able to get him to start exercising. Slowly at first, but with diligent goal setting, he gradually increases his walking distance. This allows him to build up his back muscles which helps offload the joints. Increased activity leads to increased blood supply, allowing for healing. He learns about making proper food choices and embarks on a plan of losing weight. He employs a proper sleep routine which gives him more energy during the day and improved mood. He finds strategies to manage his stress. Life seems less hopeless. He is able to work on his relationships. He begins to look for work. We gradually reduce our medications/injections as he learns of new strategies to manage his pain.
My goal in the pain clinic is to kick-start a healthy lifestyle so that you can manage your pain without relying on our treatments. This website was created to educate patients on how they can do this.