While chronic pain can be caused by sprains, accidents, falls, ligament and tendon injuries, arthritis, disc lesions and poor sleeping and working postures, the purpose of the chronic pain is not as clear as in the case of the acute pain. The pain may be a warning that the patient must change a particular habit in his life, or treat his injury. However, the level of pain does not reflect the extent of the injury. Many people have evidence of end stage arthritis or severe spinal disc protrusions whilst managing to live life with few limitations, while others with minimal evidence of damage do not cope with performing simple tasks. Moreover, when a person is in chronic pain, his mood and sleep are both affected, and both of these have been proven to amplify the cycle of chronic pain. Pain is a subjective experience.
That being said, it is important to undergo a full examination to determine, as much as possible, what the causes of pain are. If pain remains at the same level and does not get progressively worse over time, then the likelihood of harboring a serious disease is less. Serious diseases can often be ruled out, even if only by a clinical history and examination. One must rule out musculoskeletal dysfunction and asymmetries and address them. Faulty biomechanics, if not left too late, can often be corrected with appropriate exercises, good ergonomics, and sometimes more active treatments such as dry needling, prolotherapy and platelet rich plasma as discussed in separate sections. If there is real neuralgic pain, a pain resulting from a dysfunctional nerve, various medications can be prescribed and depending on the region of the pain, epidural injections or nerve blocks can be performed.
Treatment of chronic pain should involve a comprehensive approach addressing the cause, the associated musculoskeletal dysfunction, poor ergonomics as well as the psychological and emotional attitudes to the pain. It cannot be stressed enough that movement is imperative. In addition, stress and fears should be dealt with and an attempt must be made to lead as much of a normal life as possible.
The effect of emotional stress on pain
Normally, in healthy people, the brain and the spinal cord have the abilities to block the sensory input from these C and A delta fibres to some extent so that the pain will not be felt as much by the brain. Opioids manufactured within the body (endogenous opioids, or endorphins) also normally work on inhibiting this pain. However, anxiety, stress and depression can all block this inhibitory effect so that the brain senses only the excitatory so called “alarming” pain signals coming from the periphery. These psychological states amplify pain overwhelmingly. Fear avoidance behaviour often sets in, whereby the person is so scared to perform any activity that increases the pain with the belief that this will cause further damage. This fear is based on a total fallacy, to such an extent that much more damage is caused by not moving. Fear avoidance behaviour has negative effects, both locally on the area causing the pain as well as systemically affecting the whole body. Here are just a few of the negative consequences of fear avoidance behavior (McMahon 2013):
- local muscle disuse, muscle atrophy
- local bone osteoporosis
- mechanical dysfunction of the surrounding joints
- general inactivity, osteoporosis
- increased isolation
- increased stress levels
- diabetes and hypertension (both resulting from increased stress levels and reduced mobility)
People with poor coping strategies and fear avoidance behaviour are much less likely to improve no matter what medications and therapies are given, whether interventional or not. It is imperative for the patient to “control the pain”and not “let the pain control him or her“.
Resorting to psychological help does not mean that you are a failure!!! Psychology is not just to assess and screen for psychological factors, but can also treat pain. There are very brave people who choose to have hypnosis instead of a general anesthetic when they have an operation. Just as you can be hypnotized into anaesthesia for a surgical procedure, you can learn to hypnotize yourself out of your pain. No drugs involved! Also when using cognitive behavioural therapy you can learn different methods of coping with the pain. An attitude of desperation to cure the chronic pain as fast as possible will often lead to increased stress when the pain is not cured as speedily as hoped; attempting to reduce the fear associated with the pain will in itself often reduce the level of chronic pain.
Some links to therapists who use these methods are shown here:
While these methods will help, they usually must be combined with other treatment methods.