Pain is often a symptom of a disease. And in some cases, pain can become a disease in and of itself.
About 10 percent of the time after an illness, pain persists for months, or even years after an episode.
Imagine you’re stroking your arm with a feather, while your brain is telling you it feels like a blowtorch.
How can the human body get this sensation so wrong? You’d think the nervous system is hard-wired, like the wires in your house that connect electricity to the lights.
But the situation in the body is far more complicated. Neurotransmitters spill out in three dimensions, inter- acting with other cells in the body. Glial cells play a vital role in the experience and amplification of the sense of pain. If enough glial cells are activated by chronic pain, people will begin to feel abnormal responses to normal stimuli.
As a result, people are given pain-killing drugs to calm down these sensations, or given physical therapy (which can be uncomfortable) to retrain the nerves in the nervous system to respond normally. There is also the despair and depression that accompany prolonged pain. New drugs may be developed that don’t just mask the symptoms of pain, but address glial cell malfunction, too.1
The noise of nociceptors
William S. Marras, PhD, holds the Honda Endowed Chair in the Department of Integrated Systems Engineering at Ohio State University. He notes that 80 percent of people will experience at least one episode of low-back pain at some point in their lives. And people spend approximately $100 billion per year in treatment for it.
“If you have lower back pain, chances are it will resolve itself in about two weeks. However, if it lasts more than six weeks, then it becomes chronic.” He’s a proponent of wellness programs that address multiple domains, such as social, occupational, financial, intellectual and spiritual health.
Lorimer Moseley, PhD, is a graduate of the University of Sydney Pain Management Research Institute. He describes pain as being an illusion. Rather, transmitters of sensation send messages to the brain asking the questions “What does this pain mean?” and “What should be done about it?” But 100 percent of the time, pain is constructed in the brain.
Moseley describes an experiment he’s conducted, where they touch something very cold to a participant’s hand: “We just show them a red and blue light, and we ask them how much does it hurt?” he says. If they see a red light, they report higher levels of pain.
In a similar experiment, the patient sees that the researcher can turn a dial, and when the researcher turns it higher, the patient reports increased pain. “But the dial isn’t connected to anything,” Moseley says.
Of course, patients do experience pain, and it’s a powerful phenomenon. The experiments mentioned above are only meant to underscore that how people perceive pain is highly subjective and context-driven.
The psychology of pain
Even though the brain is constructing it, pain is a real thing, and it can vary in location, intensity and quality. At the same time, pain is personal and individualized.
While neuroscientists at a number of universities have managed to image pain and associate it with a quantitative state using functional MRI, that’s obviously not an approach to pain measurement available to the average field practioner.2 Accordingly, the general tool will be some type of subjective report.
The numeric pain rating scale (NPRS) is one of the most commonly used clinical tools, and it is generally efficient.
You simply ask the patient, “How is your pain level, on a scale of zero to 10?” The answer will give you a general sense of a patient’s subjective assessment of discomfort.
Each patient is unique, and what registers as a “three” on one patient’s scale might well be a “five” on another’s. (See Figure 1.)
The McGill Pain Questionnaire (or the McGill Pain Index), developed at McGill University, is a more detailed scale for rating pain. It consists of a self-report questionnaire that patients use to give a doctor detailed descriptions of the quality and intensity of their pain. For example, in one section, patients are asked to pick one or more of the following to describe their pain: flickering, pulsing, quivering, throbbing, beating, or pounding. In another they are asked if the pain is spreading, radiating, penetrating, or piercing.
What pain is
You’d think by now researchers would have a solid handle on the etiology and mechanisms of the pain response, but it is only partly understood. Pain is generally an awareness of potential or extant tissue damage or trauma, and nociception is more related to the body’s response to harmful stimuli. These overlap but aren’t exactly identical.
Most descriptions of what pain is will refer to the nervous system, and nerve cells and fibers. The traditional idea promoted by medical science was that pain is a warning signal to the body that damage is imminent (or present), encouraging the individual to find a more hospitable environment.
The hypothesis was that the more pain fibers that are active, the more information they receive, so the greater the subjective perception of the degree of pain involved. Thus, for example, stubbing one’s toe can be quite painful, but not in the way burning it by stepping on a hot coal would be. In the latter case, there is more trauma inflicted on the body’s tissues, thus the amount and intensity of the pain is significantly greater.
This line of thinking was refined and reassessed in the 20th century as researchers came to understand that pain has physical, emotional, and psychological components and is much more complex than had been previously thought. A commonly cited case report from 1995 published in England chronicles the case of a contractor who stepped onto a nail, which fully pierced his shoe and came out the top.
He was in such panic and distress that fentanyl had to be administered before treatment could begin. Upon removing the nail and his work boot, doctors were astonished to discover the nail had passed harmlessly between his toes.3
In 1996, the neuroscientist V.S. Ramachandran developed a treatment for phantom limb pain. It involves the use of mirrors and boxes. For example, if a patient with only a left arm feels burning or a clenched fist in their missing right arm—the phantom limb—they put the patient’s left arm in one box, and they see it reflected as their right arm. When the patient sees the missing limb whole and relaxed, the phantom limb sensation is reduced or eliminated.4
In these kinds of cases, the pain and its treatment are almost entirely psychological.
Another study looked at two groups of older Americans who had surgery for hip replacement. One group had planned surgeries, and the other had unplanned surgeries, likely the result of trauma such as a slip and fall. Three months post-surgery, participants were asked about their memories of pain. The planned group had accurate memories, and so did the unplanned group when reflecting on their post-surgical experiences.
But the unplanned group had more psychological problems in processing the event and its impact on them.5
From your own experience, you’ve seen how a patient can present with trauma and have little to no reported pain, while a similar patient might report a great deal. Just as stress, if unrelieved for too long, can create difficulty for the body to return to stasis, pain can also become its own type of illness.
One of the insidious side effects of chronic pain is the way it can drive a patient toward unhelpful and negative thought patterns, leading to self-defeating behaviors. There is virtually no health care story larger at the moment than the opioid crisis, which is now about the seventh most-common cause of death in the U.S.6,7
And the heart of this crisis isn’t pain medication itself, but rather the pattern of addiction and drug abuse it often creates—a physical problem that stems from misguided goals.
Proven approaches
When patients come to you in search of relief for the pain they are experiencing, they are hoping you have a procedure or a product that can help them. Their natural inclination will be to view the effectiveness of your treatment in terms of the degree to which you can lessen their discomfort. And, to an extent, that’s normal and you’ll try to help them. Experts in pain management, however, suggest that you might want to re-focus the patient’s objectives away from pure pain mitigation and more toward the restoration of function.
As the saying has it, “pain is inevitable; suffering is optional.” Once a person is concentrating on overcoming their limitations, pain becomes a secondary consideration and eventually is no longer the primary reason they are seeking care.
As a chiropractor, you offer musculoskeletal treatments, particularly spinal care. You may also provide instrument-assisted soft-tissue mobilization (IASTM) to loosen fascia, and perhaps laser therapy as well.
Depending on your outlook and training, you might have additional modalities to assist patients. But the discussion above sounds more like psychology, doesn’t it? It should also ring a bell.
D.D. Palmer’s famous trio— trauma, toxins, and thoughts—have a direct bearing on pain management. He posited that anxiety, stress, negative thoughts, and pain can all work to affect muscles and posture, gait and movement. Eventually, bones and vertebrae can subluxate, but if thoughts are leading to these subluxations, then adjustments will mainly address the symptom and not the cause of the patient’s dis-ease.
Reinforcing patterns
Physiologically, a patient in pain will start exhibiting guarding behaviors, avoiding activities, and eventually start to become deconditioned.
This leads to increased pain, further activity avoidance, and further deconditioning. You can see how pernicious this cycle can be.
Mentally, a similar thing can happen as well. Prolonged pain can easily generate negative emotions, such as anger, fear and anxiety.
This leads to decreased mood and eventually can result in depression. Depression tends to cause increased awareness of pain, generating more negative emotions and this cycle becomes self-reinforcing as well.
When evaluating a patient presenting in pain, look for interventions that can disrupt the vicious physical and mental cycles that rein- force chronic responses. And you’relikely quite knowledgeable about the gate-control theory of pain. Factors that “keep the gates open” include:
- Focusing on pain
- Stress
- Poor sleep
- Lack of exercise/activity
- Depression
Get SMART with solutions
You might consider using SMART goals with this type of patient.
SMART goals are specific, measurable, attainable, relevant, and time- bound. Telling a patient, “You should try walking more” isn’t as SMART as, “Twice a day, can you try taking a walk around the block? I think you could manage that. It will improve your energy and mood. The next time you come in, we’ll see how you did.”
Relaxation can be excellent therapy for your pain patients. Deep breathing, mindfulness, guided relaxation exercises and similar can lessen the sympathetic nervous system’s response to stress. In turn, muscular tension can be eased, and the mind can be distracted away from the source of pain.
And don’t overlook the power of pleasant activities. Find out what this patient enjoys doing and see if you can facilitate a return to their enjoyable pastimes. This can lead to improved mood, more social activities, and a return of self-confidence.
Whether acute or chronic, at some point pain can stop serving the patient and become a cruel taskmaster controlling what and how the patient does things. If you can re-orient that relationship, the patient can get back in control—which is empowering.
Your primary tool, the adjustment, both facilitates the innate healing response and also reduces inflammatory cytokines, which are a component of chronic pain conditions. Adjustments can also relieve muscle tension and decrease oxidative stress. Your particular specialty can address some of the physical challenges your patients have, but consider the mental and psychological aspects of pain that may be holding them back.
Ultimately, some patients may not respond and you’ll need to refer them to another specialist. But the reason they’re choosing you first is the hope of avoiding dangerous drugs and surgery if possible. Know all the tools you have at your disposal.
Daniel Sosnoski is the editor-in-chief of Chiropractic Economics. He can be reached at 904-567-1539, dsosnoski@chiroeco.com, or through ChiroEco.com.
References
1 Aamodt Sandra. “Focus on glia and disease.” Nature Neuroscience. 2007;10: 1349. [online]
2 Wager TD, Atlas LY, Lindquist MA, et al. An fMRI-Based Neurologic Signature of Physical Pain. N Engl J Med. 2013;368:1388-1397.
3 Johnson MI. Trauma and Pain: A Fragile Link. J Trauma Treat. 2017;6:378. doi:10.4172/2167-1222.1000378.
4 Ramachandran VS, Rogers-Ramachandran D. Synaesthesia in Phantom Limbs Induced with Mirrors. Proceedings of the Royal Society B: Biological Sciences. 1996;263(1369):377-86.
5 Halicka M, Bąbel P. Factors Contributing to Memory of Acute Pain in Older Adults Undergoing Planned and Unplanned Hip Surgery. Clin J Pain. 2017;Nov 17 [epub ahead of print].
6 National Center for Health Statistics. “Number of deaths for leading causes of death.” Centers for Disease Control and Prevention. https:// www.cdc.gov/nchs/fastats/leading-causes-of- death.htm. Updated: March 2017. Accessed Dec. 2017.
7 National Institute on Drug Abuse. “Overdose Death Rates.” https://www.drugabuse.gov/ related-topics/trends-statistics/overdose-death- rates. Updated: Sept. 2017. Accessed Dec. 2017.
