Chronic pain is a diagnosis that many doctors and therapists alike consistently come across in practice. So many questions need to be answered, but what is certain is that chronic pain is a complicated, debilitating and a downright life changing ailment affecting families across the nation.
The lingering questions that come to surface are what causes chronic pain and what is the best treatment approach? Let’s focus on the first component, where does it start? To begin with, we need to define chronic pain, which requires a completely different treatment approach compared to acute pain. Chronic pain is defined as lasting longer than 6 months. When speaking with patients at their initial evaluations, it is always important for me to try and pinpoint when the pain started. Most of my patients are very aware of when, but they often have difficulties telling me exactly what started the pain. The next questions I ask are what increases the pain (positions or activities) and what, if anything, decreases the pain. Most of my chronic pain patients answer with, “Well it may lessen, but it never completely goes away.” If they answer with this particular phrase, I know that we have more work to do than normal because it means that they have entered into a phase called “central sensitization.” This is defined as, “a condition of the nervous system that is associated with the development and maintenance of chronic pain.” More important than the definition is what takes place within the body. The two main characteristics of central sensitization are, “allodynia and hyperalgesia.” Allodynia is when a normal stimulus (touch or massage) causes pain when it should not be painful. When a person with central sensitization has been touched, the nerves send a message to the brain that this normal touch is painful. Hyperalgesia occurs when a stimulus that may be perceived as slightly painful (someone bumps into you) is now excruciatingly painful. This does not mean that the pain is not present or real, it implies that the pain is no longer caused by a noxious stimulus. In other words, the nervous system needs to be rewired because it is in a state of high reactivity. So, what is the best approach?
One conclusion that I have drawn in my experience in patients with chronic pain (regardless of where the pain is coming from) is that there are always muscle group(s) involved that have completely shut down. In other words, the body is no longer functioning the way it was designed to function and is now in a protective state that literally shuts down in an attempt to avoid pain. As you can imagine, this just creates an even worse situation for the individual and leads to other areas of the body now trying to compensate to pick up the slack for the area that is shut down. Once I help to lessen the degree of pain for a patient so they can be more comfortable (often through mobility exercises, manual therapy and education, the next step for me is to begin connecting the brain with the muscle through specific activation exercises. Then, I begin working on motor control (not to be confused with strength). A person may present to me with an excellent amount of strength, but what they are lacking is motor control and sequencing of activation that usually occurs as a result of being in pain. This process is very important and specific to each individuals’ needs. There is no one size fits all approach for dealing with chronic pain, but there is a ton of research showing that physical activity under the supervision of a trained professional can have remarkable results for someone who is stuck on the hamster wheel of chronic pain. One meta-analysis found that, individuals with non-specific chronic low back pain who were placed in an exercise intervention group experienced overall less low back pain compared to the other interventions. Moreover, strength/resistance and stabilization exercises had the greatest effect of reducing pain (these are part of gaining that motor control, which is vital to returning the body to normal function). Another study performed by the institute of chronic pain, showed that, “mild aerobic exercise changes structures within the central nervous system and leads to reductions in the pain of many conditions that are mediated by central sensitization.” This is huge, this means we can literally alter our brain chemistry with exercises, think about that for a moment! My ultimate goal after I have gone through the above steps is to return my patients to being able to perform mild aerobic exercises (brisk walking, walking in general) so that the pain dynamics permanently change. It is important to note, that certain forms of chronic pain (fibromyalgia, rheumatoid arthritis, and migraine headache pain) are treated differently, especially during times of flare up, and aerobic exercises are not the route to take. However, according to the US National Library of Medicine and National Institutes of Health, “Physical activity should be recommended to all patients with chronic pain conditions. Avoidance of exercise during acute symptom flares may be tempting, but sedentary behavior may not reduce symptoms and may promote loss of strength, reduced range of motion, and physical limitations.” In a nutshell, seeking professional guidance can keep you going even during a flare up. This is why it’s so important to speak with a professional. I treat each patient individually with exercise, education on their specific condition, manual therapy techniques (including dry needling, myofascial release, etc) depending on their specific needs. I give my chronic pain patients an “emergency exercise list.” This ensures that they do not become sedentary and they learn what to do during flare ups. My viewpoints on chronic pain have completely shifted since I first became a PT from helpless to extremely hopeful. I am always so excited when I receive a patient in chronic pain, mainly because of my experience with it and seeing lives changed. I have personally had patients in 20+ years of chronic pain break the cycle. It is one of the reasons I do what I do. Seek help, never give up, you are so much stronger than you know!