Chronic Pain Explained

Chronic pain is often misunderstood and contributes to frustration, feelings of guilt, decrease in mood, and hopelessness. Chronic pain is often invisible without any outward signs of the condition and this contributes to the lack of understanding. But chronic pain is real and can be effectively treated.

In this video, Dr Christopher Sletten explains the concept of central sensitization and validates the myriad of symptoms that can be experienced by individuals with chronic pain. This provides a context for you to be able to share with your patients. If YOU are the individual with chronic pain, it provides a valid framework from which you understand pain and can set the stage for you leading your best life despite the presence of chronic pain.

Pain rehabilitation programs, or comprehensive pain programs, are commonly attended by those individuals with chronic abdominal pain, headaches, fibromyalgia, neuropathic pain who have difficulty living the lives they desire in a typical, age-appropriate manner. They may find it difficult to attend school, maintain gainful employment, or care for their families, often missing out on the enjoyable activities of life. This can lead to loneliness, mood disorders, and worsened health conditions. Pain can be experienced constantly and accompanied by other bothersome side effects, leading to a decrease in the quality of life for those individuals as well as their families.

Pain rehabilitation programs have a long history with excellent outcomes. But aside from the more commonly known indications for attendance, other conditions such as Ehlers Danlos syndrome, autonomic dysfunction, and post-Covid syndrome are amenable to treatment through strategies learned in a comprehensive pain program.

To begin the discussion about the benefits of pain rehabilitation programs, it is important to discuss the differences between acute and chronic pain.

It is important to understand the treatment principles for acute and chronic pain. Given their differences, it is imperative to address them in differing ways.

With acute pain, your pain signals that you should rest to minimize worsening of tissue damage, for example with the pain you might feel in your ankle when tripping off a sidewalk. The pain could signal that structures may be at risk and continued activity would cause more injury. Rest makes sense. This, along with the proper treatment, your body begins to heal and your pain lessens. You then feel better and get back to activity. Resting is important so your body can heal.

With chronic pain, despite your body healing, your pain persists. You want to rest but unfortunately resting does not improve your symptoms. You may find yourself in a feedback loop where the more you rest, the worse you feel. However, you don't feel well enough to do anything, so you are caught in a strange 'Catch-22' in which you do not find improvements in your pain and your functioning now is suffering.

The nervous system is composed of both the central and peripheral nervous systems. The central nervous system includes the brain and the spinal cord. The peripheral nervous system is comprised of the sensory, motor, and autonomic nervous system.

Thus, there are numerous components that can be affected to modulate the pain experience.

Peripheral input sensors are located in the skin, gut, muscle, bone, joints, vasculature, as well as the sensory organs of vision, hearing, taste, and smell.

While normal functioning is associated with a cohesive choreography of these functions, chronic pain and symptoms can result when these sensory pathways become upregulated, and out of control. This is a function of neuromodulation, or plasticity of the nervous system that is occurs based on factors in our environment. Our bodies respond to the environment we create around it, for better or worse. The central nervous system in an environment of chaos will respond very differently than when in an environment of calm and balance.

Everything that happens in the body is registered in the brain; brain maps show us the relationships of these regions of the brain to one another.

From https://askabiologist.asu.edu/brain-regions

Notice the proximity of these regions in association with others. Seeing this relationship should make it easy to understand that as the sensory cortex becomes sensitized, it responds to a greater degree over time (neuroplastic response), which explains why pain can become increasingly intense over time. This is called amplification.

Any physical sensation you experience can increase over time including pain, fatigue, dizziness, nausea, numbness, burning, itching, tingling, to name a few. Looking at the map of the brain, it is not difficult to understand that activity in one part of the brain can trigger activity (and therefore a symptom). Triggers can include lights, sound, smell, physical touch, taste, and temperature. And as the symptoms get worse, more things can be found to trigger the response.

This framework can also explain why some individuals with pain also have their motor activity or ability to move affected by pain. Motor issues in those with chronic pain can include tremors, seizures, spasticity, tremors, and spells.

Taking into account how the brain can be affected over time by the presence of pain, it is imperative to take a differing perspective when treating and managing this type of pain which is chronic pain. Chronic pain is a long-standing pain that occurs on a regular basis for at least a period of 3-6 months and persists beyond the expected duration of pain with the appropriate treatment. While all chronic pain begins as acute pain, the management of chronic pain demands a very different approach than that of acute pain.

Many patients will admit that their pain seems to change and worsen over time. This is the classical experience of chronic pain and is a hallmark of central sensitization which is the result of the amplification of our sensations and the neuroplastic responses of our brains.

It is NOT a somatization disorder, nor a psychological disorder.

Chronic pain management is complex and requires the targeting of four domains:

- physical

- emotional

- behavioral

- chemical

These are the reactive and maintaining factors. It is important to address all of these domains simultaneously, otherwise the symptoms and the physical deconditioning will persist.

Physical

We call some of these actions 'reactive' as it is the normal reaction to acute pain and makes sense at the time. For example, with an acute ankle injury, one rests the foot, applies ice, and protects the foot for some days to assure ongoing tissue trauma does not occur. It makes sense in the acute setting and therefore is reinforcing. We eventually start to heal, the pain subsides, and we increase our activity.

In contrast, when we continue with these restrictions should the pain not subside after months (chronic pain), it could have debilitating consequences, such as deconditioning, muscle atrophy, increased sensitivity to stimuli, worsening pain, etc. Physical deconditioning can happen to any of us and is related to increased frailty, decreased mood, and the like. Thus an important part of chronic pain treatment is whole body reconditioning, where the entire body is treated and we strive for a 'fit-for-life' state of being. This state puts the body in the best condition for the pain to subside over time.

Reactive actions include not exercising because of chronic pain, refusing to bear weight because of pain, etc.

Maintaining pain-These actions can also result in persistent and worsening pain. Ironically the goal of these actions is to decrease pain; however, it is common for pain to actually increase when one seeks to decrease their physical activity in an extreme fashion.

Emotional

Addressing emotions that accompany chronic pain is instrumental in recovery as individuals find it distressful to be unable to complete the tasks they desire when they want to do. Emotions such as anger, depression, anxiety and the like may arise from the presence of central sensitization (remember the brain map). And some of these emotions are pre-existing in individuals and are therefore worsened when chronic pain is present. Getting assistance in the form of emotional therapy (psychological counseling) or in some instances, medication therapy, can be instrumental in helping an individual move out of a chronic pain situation.

Reactive-it is sometimes normal to have lower mood when we have pain. This is human nature. But we can be mindful of this fact and be proactive in addressing our emotions.

Maintaining-it is known that depressed mood is associated with decreased tolerance for pain and is likely associated with decreased self-efficacy. So while depression doesn't cause pain per se, treating depression with therapy and/or medications can help keep the body in balance, setting the stage for a decrease in pain

Behavioral

The behaviors of individuals with chronic pain needs to be addressed for two reasons: pain behaviors and the concept of moderation. Pain behaviors are words, thoughts, or actions that reminds the individual or others that pain symptoms are present. This includes rubbing your head, grimacing, limping with pain, talking about pain, worrying about pain. This is a complex construct and is not meant to invalidate the individual's experience of pain. Of course in an acute pain situation, these actions may be very normal. However, they are not helpful in chronic pain and serve to increase the propensity towards central sensitization and worsening pain.

Moderation of physical activity is an important skill for many of us to learn; it is even more important for those with chronic pain. Because there are some days when activity is impossible and tasks cannot be accomplished, on the days one feels well, individuals may find themselves overdoing, working late because they know when the next 'bad day' happens, they will have difficulty accomplishing their duties. Rather than balancing out the responsibilities, this often leads to a 'crash and burn' situation, which only serves to worsen central sensitization. An individual can become to feel hopeless that they will continue on this rollercoaster of under- and over-achieving, not really finding any balance and with continued pain.

Chemical

Management of pain with medications is often a double-edged sword. While medications might be helpful for acute pain, when taken for an extended period of time, they often fail to continue working and may be associated with other side effects. But taking medications might be the only thing individuals can think of to do despite the medications not working as expected. Some medications can become addictive, and larger doses are needed over time for the same effect. In addition, the physical act of taking a medication can signal subconsciously that one is not well, thus keeping alive the internal dialogue of suffering with chronic pain.

To better explain the differences in treatment, Dr Sletten likens acute pain to a camp fire. (Actually Dr Sletten likens it to a house fire but I did not want to include a picture of a housefire). When you are leaving camp and it is time to extinguish the fire, it demands immediate attention with lots of water to put out the fire completely, in hopes of it not re-igniting when you walk away. Similarly, with acute pain, treatments are given immediately, the wounds heal, pain decreases, and life goes on without problematic pain.

Chronic pain on the other hand is more like a forest fire. The impact can be well beyond the boundaries of the burning land. The fire can change a lot of things like the quality of the air and the ecosystem and the fire is not easily extinguished even with a lot of water. What is necessary is a proactive strategy to cut the burning materials away from the non-burning stuff.

Similarly with chronic pain, not only the individual but also those close to them may be affected in a negative way. Pain may impact the ability for one to work and earn money, pursue an education, interact with others, socialize, feel good about themselves. With children with chronic pain, parents may not be able to work because of caring for the child with pain. Chronic pain in one family member can have an effect on the activities of all individuals. The effect of chronic pain is far-reaching. With chronic pain management, comprehensive pain management programs distinctly address several of the other factors in an individual's life that at first glance may not seem to be related to the pain. Although chronic pain programs may or may not offer different medications or treatments such as injections or implantable devices for pain, they all do work to cut the fuel from the fire, so to speak, and seek to separate the pursuit and enjoyment of activities from the truth that chronic pain is present. They CAN be mutually exclusive: one can have chronic pain but not suffer from it and still have an enjoyable life and live fully.

Here are four concepts that are fundamental to the efficacy of chronic pain management whether this is within a comprehensive pain management program or done in an outpatient setting by a primary care doctor:

- introduce physical conditioning in a slow and gradual fashion

- reducing emotional distress

- normalizing behaviors in a typical, age-appropriate fashion

- tapering patients off medications that have been ineffective or may lead to

dependency

As mentioned, this approach does not need to occur within the framework of a formal pain management program. The strategies above focus on establishing a new pattern of daily living for the individual with pain, focusing on improved functioning and participating in desired and necessary activities, teaching individuals to work through the symptoms they experience, and to reduce the negative impact of their symptoms over time.

These strategies can be helpful for all types of chronic symptoms that have a negative impact on one's life. Chronic pain management is complex and one must be cautioned to pursue the 'Quick Fix' or be enticed by strategies that don't require some work on your part.

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I am aware that some of this dialogue about chronic pain and its etiology and management can be challenging for some to read about a process. If you would like to comment on any aspect of chronic pain you or a loved one has experienced, we'd love to hear from you. If you have questions of any of the content I have attempted to explain, don't hesitate to reach out.