What is Chronic Pain?
Chronic pain refers to pain that tends to last longer than three months and, in some cases, years. The exact cause of Chronic Pain is still not fully understood, though it usually starts with physical trauma or injury to the body. There are many possible causes of trauma, including diseases, physical injuries, surgery and more. Many types of trauma may also involve forces, and these affect tissue structures. How such structures and tissues react to forces depends on many factors. Factors can include the type of force, amount, angle, duration and how the materials respond to the force. The topic of trauma is beyond the scope of this article, as it covers physics, material science, (tissue healing, adaptation, biotensegrity (see related articles)) and more. Trauma and forces can create multiple changes and injuries throughout the body, not just the apparent injury site. For tissues to heal correctly, they need a suitable environment, which prevents further injury. Unresolved trauma in one area could easily affect another due to biotensegrity and tissue adaptation. Such a situation could easily impact the ability of tissues to heal as normal and increase the chance of reinjury.
The human bodies reaction to any of these possible types of trauma includes an inflammatory response. Although inflammation is a necessary part of the healing process, it can also create further tissue trauma (see related articles later - tissue healing). Such trauma can affect both the structure and function of tissues, mobility and pain sensitivity. Any trauma can also create symptoms far from the initial site of trauma due to the effect on connective tissues and fascia, which run throughout the body. The fascial network also may play a large part in Chronic Pain, which logically makes a huge amount of sense even if still not fully understood. Equally, myofascial trigger points (MTrP)'s can also play a major part persistent pain conditions and some types of headaches.
Physical and Psychological aspects of long-term pain
Chronic pain can be hugely debilitating for anybody who has ever experienced it. Pain of any kind is a form of "stressor", and stress activates the human stress response. Pain is a normal bodily response to injury and trauma and protects the human body from further harm. Pain also has physical and psychological aspects at the time of injury, during healing, and post-injury. Any physical trauma will create a memory, even if a subconscious one, which may help avoid a similar event in the future. The human body also tries to avoid pain and so adapts at the time of injury. Adaptations mean that we move differently while healing and this provides tissues with the best chance of healing while minimising the chances of further injury. Our brains learn these new movement patterns and the tissues adapt accordingly, as with exercise. Such movement patterns often then become "normal" and can remain long after a trauma seems to have healed. It is worth noting that the human body is extremely good at hiding injury through adaptation. Hence unresolved historical injuries are very common. Equally, how we move has more of a global effect due to biotensegrity (see related articles later - biotensegrity).
How we move and Pain as a "stressor"
Besides adapting and learning new ways to move during tissue healing, one can also learn a "fear" of movements (see related articles later- tissue adaptation). Although pain is a "stressor", so is "fear" and this will also initiate the human stress response. This very process can then reinforce the link between certain movements and pain. Such a situation does not mean that the pain is imaginary either and is likely to increase the chances of longer-term unresolved trauma, including chronic pain. Constant initiation of the human stress response also impacts many bodily systems over time, affecting everything from sleep to the reproductive system (see related articles later- human stress response articles 1 to 3). Chronic pain can often negatively impact physical and psychological well-being, though it can impact far more aspects of life. Hence, treatment for Chronic Pain needs to look at a wide variety of factors, not just the physical pain or viewing the pain as imaginary, even if the processing or thought of pain happens in the brain (imagined per se).
"Stressors", hormones, sleep and pain perception
Research has shown that a lack of sleep can negatively impact our perception of pain and make pain seem worse (hypersensitivity of pain). Problems sleeping are a common issue in cases of chronic pain, and this may relate to the initial trauma and then the effects of the initial pain on the stress response longer-term. Hormones are hugely relevant in the stress response, and some hormones help reduce inflammation, moderate pain, and our sleep patterns. The stress response controls the speed at which various bodily systems work and, in essence, turns these systems on and off. Hormones can also have a huge impact on our mood, explaining why depression is common in chronic pain. Diet and exercise can also impact hormone levels positively or negatively, adding more complexity. When in pain and stressed, we are less likely to be active and more likely to eat certain comfort foods, such as highly processed carbohydrates. Such foods can effectively increase stress levels by reducing beneficial hormones and the added stress associated with weight gain. Furthermore, a prolonged and continuous initiation of the human stress response reduces our bodies ability to cope on many levels. These factors can leave one feeling physically, emotionally and psychologically exhausted, which is common in chronic pain cases. Breaking such a cycle is a key element of any treatment and recovery strategy.
The need for a holistic treatment approach
Treating Chronic Pain requires a holistic approach due to the wide range of related factors. Imaging such as x-rays and MRI does not show everything and can equally show pathologies when there are no symptoms. Hence, the cause of chronic pain may not be visible on imaging, so a detailed history is needed. Any initial consultation should involve a very detailed look at all aspects of health, current and past. The history details are the basis for understanding why pain occurs, combined with a physical assessment and medical knowledge. Only through this process can one educate the consumer about what is happening and formulate a recovery plan. Such a plan might include soft tissue therapy (STT) and Myofascial Release - MFR methods, combined with prescriptive exercises, habitual changes and other aftercare advice. There are a lot of STT and MFR techniques, and some methods are not suitable in some cases, such as Trigger Point Dry Needling. Equally, the person's skill and experience applying the method is just as relevant as the consultation process. It is a case of applying the right method in the right circumstances and at the right time. Hence, just because one type treatment did not work with one type of professional, does not mean it will not work with another (see the article on Finding a good MSK Professional).
A multi-disciplinary approach is needed in more complicated cases, as no one discipline can resolve all aspects of the condition. In some cases, people may have experienced physical and psychological trauma relating to their chronic pain condition. Hence, such a situation may require a physical, psychological and emotional-based approach. Such a recovery approach requires a high degree of coordination and openness between the consumer and the professionals involved. When treating in an MSK therapy clinic, one sometimes sees a form of "emotional release" in the case of chronic conditions and while treating physically. If a consumer has lived with restricted mobility and pain for a considerable time, it is all they know. Relieving such pain and mobility issues can result in the consumer bursting into tears for no apparent reason and not understanding why at the time. Treatment does not have to be painful to elicit such a response, hence why the consumer may be surprised at the time. However, if one has had pain for such an extended period, it has hugely impacted many aspects of daily life. Equally, it is easy to become resigned to the fact that the pain will never go, especially when no treatment has helped before. Hence, there is often a huge amount of "emotional" investment surrounding the feelings and experiences of suffering with chronic pain conditions.
The general medicine approach to Chronic Pain often involves medications and, in many cases, a combination of medications. Although medications can prove helpful in the early stages of injury and healing, they can effectively hide pain and not address the cause. Also, much like hormones, medications affect bodily systems and can often have side effects. There are also more invasive methods for treating pain with varying severity, such as steroid injections, paralysing nerves (botox) and nerve ablation (effectively burning the nerves). These methods may stop the pain but have other consequences due to the affected nerves no longer working as normal. However, people with Chronic Pain can become desperate to be rid of the pain and willing to do almost anything to get relief.
The article was written by Terry Davis MChiro, BSc (Hons), Adv. Dip. Rem. Massag., Cert. WHS.
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About the Author
As of December 31st 2020, the author chose to leave the Chiropractic profession, due to a planned move back to Australia and where is training and education are not recognised. He no longer works as a Chiropractor and works as a Myotherapist in Morningside, Brisbane. The author possesses an unusual background for somebody who trained in the McTimoney Chiropractic technique. His education, training, and practical experience span over two decades and relate to both health's physical and mental aspects. He has also needed to push his own body and mind to the limits of physical and psychological endurance as part of his time serving in Britain's elite military forces. His education includes a bachelor of science degree in Business Management, with a specialisation in psychology and mental health in the workplace, an Integrated Masters in Chiropractic, MChiro and a multitude of soft-tissue therapy qualifications (see the about section for more details). His soft tissue qualifications range from certificate level right through to a BTEC Level 5 Advanced Diploma in Clinical Sports and Remedial Massage Therapy. Terry also has extensive experience in security, work, health and safety and holds relevant certifications. He has also taught as a senior course coach at Advanced Diploma level (Myotherapy / Musculoskeletal Therapy) in Australia, both theoretical and practical aspects including advanced Myofascial Release Techniques and has certification in training and assessment. Terry will have taught many of the first students to train as Myotherapists in Brisbane. Terry's combination of knowledge through education, training, elite military service, and personal injury history has paid dividends for the consumers he sees and has treated over the last 15 years. He has extensive experience treating chronic pain and work and sports-related musculoskeletal injuries. Terry is still very active and enjoys distance running, kayaking, mountain biking and endurance-type activities.