Chronic Pain Treatment
Treating Persistent Pain
The Brisbane MSK Therapy Clinic in (Morningside) specialises in the treatment of Chronic Pain or Persistent Pain conditions. Besides many initial possible causes of pain, many other factors can influence our perception of pain over time, resulting in a gradual worsening of symptoms and Chronic Pain. In the sixteen years that Terry has been treating, he has seen many patients seeking Chronic Pain Treatment with varying origins of pain. Typically, such patients have seen many medical practitioners, specialists, allied health and other types of therapists with little to no success. Equally, such patients have usually undergone a wide range of expensive tests and investigations, which indicate nothing wrong or provide no explanation for the pain. It is very common for patients experiencing Persistent Pain to have been prescribed various medications or undergone additional invasive procedures, injections and surgery/surgeries. Often, patients are told that "the pain is all in your head" (see later) after various medical tests have proved negative or inconclusive. Such experiences often make patients feel completely exasperated and exhausted (physically, psychologically, emotionally, financially etc.). Chronic pain can impact every aspect of a person's life, adding complexity and even compounding symptoms. Incidentally, many types of soft-tissue injuries can create pain yet not be visible with imaging or other testing methods.
Chronic pain is so complex one needs to take a holistic view of each patient's unique circumstances. Unfortunately, many clinics tend to operate a production line mentally, providing little time for practitioners to gain a detailed holistic view of the individual patient situation. One could say similar in a general medicine context and 15-30 minute appointment slots. Terry has always worked differently and invests time to develop a detailed understanding of the specific factors (for which there can be many) surrounding each unique patient's circumstances and Chronic Pain symptoms. He then uses his higher education medical training, experience and knowledge covering physical, psychological and emotional health aspects to develop a holistic and strengths-based treatment strategy. Terry has been using multiple evidence-based soft-tissue therapy techniques for over sixteen years and to significant effect. He believes his successes result from a combination of his training, experience and differences in his holistic treatment approach.
What is Chronic or Persistent Pain?
Chronic pain refers to pain that lasts 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 some trauma or injury to the body. However, the injury fails to heal within an expected timeframe, and pain persists, hence the other commonly used term for Chronic Pain, Persistent Pain. In some cases, there may appear to be no obvious trauma or injury, yet one develops chronic pain symptoms. There are many possible reasons why Persistent Pain may occur with or without an apparent injury history. Tissue adaptations can play a role in both cases of a clear historical injury or no injury. Equally, an injury may not heal as usual due to no early treatment intervention, ineffective treatment, re-injury, lack of rehabilitation and recovery etc.
The most typical causes of chronic or persistent pain relate to trauma or previous injury, which can take many forms. Examples may include diseases, physical injuries, surgery, medical treatments, pharmaceuticals, psychological trauma (which can affect muscle physiology) and more. The body consists of many materials, forming structures enabling various functions. The material, structure and condition of tissues all play a part in how tissues respond to traumatic forces. The type of force, amount, angle, duration and how the materials react to the force are also relevant. The topic of trauma is beyond the scope of this article, as it covers physics, material science (soft tissue repair, adaptation, biotensegrity (see related articles)) and more. However, the important takeaway is that trauma or forces can alter tissue structure and function.
Furthermore, many tissues within the body can store potential energy from applied forces, which the author would refer to as unresolved trauma. An elastic band is an excellent example of how tissues can store energy. One can use a force to stretch an elastic band resulting in stored elastic potential energy, which remains until the force is released. Equally, elastic behaves differently according to its condition, surrounding temperature and speed of force application, enabling the band to stretch or snap. The same principles apply to tissues and other structures within the body and has relevance in cases of Chronic Pain onset.
The forces involved in trauma can create multiple changes throughout the body as forces travel through different tissues and structures within the body. Hence, injuries often occur beyond the initial point of trauma. For tissues to heal correctly, they need a suitable healing environment to prevent further injury. Unresolved trauma in one area could easily affect another due to biotensegrity and tissue adaptation. Such a situation can easily impact the ability of tissues to heal as normal and increase the chance of re-injury and persistent pain.
Pain, it's all in your head
Those who have experienced the often debilitating effects of chronic pain will have no doubt been told at some point that the "pain is all in your head, or imagined". Such a situation can often occur after a patient has been through a barrage of medical tests which cannot identify a "medical" explanation for the pain and after medications have proven to have limited effect. However, this does not mean that chronic pain is a mental health issue, though Psychologists and Counsellors often work with patients experiencing persistent pain symptoms. It is crucial to understand that medical tests and forms of imaging do not always provide all of the answers due to their limitations. For example, research has shown that routine imaging may highlight both related and unrelated issues (pathologies). In some cases, people may have symptoms (symptomatic) of such pathologies, yet in other cases, they do not (asymptomatic) see Back Pain article. In many respects, being told that "pain is all in your head or imagined" is not helpful. However, there is an element of truth to "pain is all in your head".
The interpretation of pain occurs in the brain, so saying "pain is all in your head" is technically correct, though it is not that simple. Sensors around the body transmit information to the brain, with some signals interpreted as pain. There is a vast array of such sensors throughout the body, and multiple sensors may share information about pain along similar or different routes. Hence, it may prove challenging to identify the specific problem area with imaging or other tests. Although imaging can be good, there are limits on what it can detect or show, though it is constantly improving. For example, General Medicine has historically believed that Myofascial Trigger Points are pseudoscience, partly because imaging made it impossible to detect them. However, imaging and techniques have improved, with researchers showing the presence of Myofascial Trigger Points in cases of Chronic Neck Pain and Chronic Back Pain. Much like myofascial trigger points, the general medicine's historical reductionist approach placed little to no relevance on the fascia within the body. However, fascia has enormous global bodily relevance for transmitting forces, sensory information and possibly immunology. Equally, fascia has relevance to myofascial trigger points and complex pain.
Sensors within tissues around the body respond to various stimuli (things that activate them). For example, sensors may interpret physical or chemical injury, heat, cold, compression or stretch as pain. Most forms of trauma are likely to include multiple sensors detecting multiple stimuli (triggers). Physical trauma is likely to create injury, compression and stretching of tissue structures, heat (inflammation) and further compressive and stretching forces due to the inflammation. Such a situation will likely occur in areas beyond the initial injury site. Hence, subtle changes can activate sensors, which the brain interprets as pain, yet neurological testing, imaging etc., might prove negative or inconclusive.
Physical and Psychological aspects of long-term pain
Chronic pain can be hugely debilitating for anybody who has ever experienced it and can impact all aspects of life and overall wellbeing. Physical pain, especially persistent pain, can also harm our psychological and emotional wellbeing. Pain can affect our physical activity levels, the types of social activities we partake in, our diet, and the types of foods we choose to eat. Such changes in our life, as a result of persistent pain can have a subtle and combined negative impact on our overall perception of pain.
Any pain 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 during injury, healing, and post-injury. Any physical trauma will create a memory, even if that is not a conscious memory, and so may be subconscious, which may help avoid a similar event in the future. The human body also tries to avoid pain and adapts at the time of injury. Adaptations mean we move differently while healing, providing 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 and training for specific sports. Such movement patterns often become "normal" and can remain long after a trauma has healed. It is worth noting that the human body is extremely good at hiding injury through adaptation. Hence unresolved historical injuries are very common, especially when there was no adequate early intervention (treatment). There is a tendency to think that purely because something has stopped hurting, it is fixed, yet we have adapted to move differently and avoid pain. Equally, how we move has more of a global effect due to biotensegrity (see related articles later - biotensegrity). Unresolved historical injuries often gradually lead to other seemingly unrelated problems at a later date.
How we move and Pain as a "stressor"
Besides adapting and learning new ways to move during soft tissue repair, one can also learn to avoid certain movements due to "fear" of pain (see related articles later about tissue adaptation). Although pain is a "stressor", so is "fear", which will also initiate the human stress response. This very process can then reinforce the link between specific 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 situations. There are many types of "Stressor" in cases of chronic pain, and so there can be a combined and cumulative impact on our perception of pain in cases of persistent pain, especially longer-term cases. Stressors are hugely relevant as they can lead to the continual initiation of the human stress response, affecting every bodily system and our overall perception of pain.
Physical pain and the fear of pain can also have a psychological impact, leading to anxiety or depression. Other aspects of chronic pain can have similar psychological impacts. Hence, besides anatomy and physiology, it is also good to have a wider understanding of behavioural science and human psychology when working with persistent pain cases. However, a holistic treatment approach will address such factors as part of an overall treatment strategy and may require a multidisciplinary approach in some cases.
"Stressors", hormones, sleep and pain perception
The constant initiation of the human stress response has a huge impact on every bodily system affecting everything from basic maintenance systems and repair processes to the reproductive system. Stressors can also majorly impact various hormone levels within the body, affecting sleep and bodily system functioning. Research has shown that a lack of sleep can negatively impact our perception of pain and make pain seem worse (hypersensitivity to pain). Sleep problems are common with chronic pain, which may relate to the initial trauma, the effects of the initial pain, and the cumulative impact of the stress response longer-term on pain perception. Hormones are hugely relevant in the stress response, and some hormones help reduce inflammation, moderate pain, and affect 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 hugely positive or negative impact on our mood and how we feel. Hence, hormone levels are likely one of the many possible factors affecting why anxiety and depression are common in long-term cases of chronic pain . Diet and exercise can also impact hormone levels positively or negatively, adding more complexity. When in pain and experiencing stress, we are less likely to be active, which can impact our social activities and the positive physical, psychological and emotional aspects such activities bring. Equally, we are more likely to eat certain comfort foods, such as highly processed carbohydrates. Such foods can effectively increase stress levels by reducing beneficial hormones and adding to the stress associated with additional weight gain. These factors are relevant in treating persistent pain cases. Prolonged and continuous initiation of the human stress response reduces our body's ability to cope on many levels. These factors can leave one feeling physically, emotionally and psychologically exhausted, common feelings in chronic pain cases. Breaking such a cycle is key to any treatment and recovery strategy.
Although many complexities surround an individual's experiences of persistent pain, many people live perfectly normal lives. Equally, many options assist with pain perception, so there is hope. In other cases, a different approach can resolve pain symptoms. 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. It is all they know if a patient has lived with restricted mobility and pain for a considerable time. Relieving such pain and mobility issues can profoundly impact a patient, partly due to all the emotions tied to the pain. Terry has seen patients spontaneously burst into tears for no apparent reason and who could not understand why. Treatment does not have to be painful to elicit such a response, hence why the patient may be surprised at the time. However, if one has had pain for 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 to date. Hence, there is often a huge amount of "emotional" investment surrounding the feelings and experiences of living with chronic pain conditions.
Persistent Pain Treatment, Fatigue and Beliefs
Invariably, seeing many different professionals over an extended period and with little to no tangible benefit can also impact future treatment. For example, somebody may have invested a year's worth of time, money and emotional investment in seeing a particular professional with little change to symptoms. In long-term cases of persistent pain, such a situation may have repeated multiple times. These experiences can leave one feeling emotionally exhausted, dejected and believing that the pain will never end. Such feelings can understandably lead to a reluctance to invest more time and effort in seeking further treatment and reinforce personal views around one's chronic pain experiences rather than positively challenge such beliefs. It is important to understand that practitioners work differently, even within the same profession and who have trained at the same education provider. A different approach can make a huge difference in treatment outcomes, and one should not have to undertake a long treatment process to be able to evaluate progress.
Differences in how practitioners work can also impact the subsequent effectiveness of aftercare advice, such as prescriptive exercises. Prescriptive exercises aim to build on the work done during treatment, and a single session provides no opportunity to get any real benefit from the combined effects of treatment and exercise prescription. However, many changes can occur in cases of chronic pain, and it is crucial to understand this. Symptoms can appear to improve during a single session and then appear worse later that day and for a day or two later. In some cases, symptoms may even worsen at treatment's end. Chronic pain cases involve a complex mix of soft tissue changes and inflammation impacting mobility and causing pain. Any treatment assessment can further irritate symptoms as tissues and structures get assessed. Equally, treatment involves working on tissues that have not been working correctly for a sustained time. The assessment and treatment can result in the initiation of tissue healing and the inflammatory process, which may result in symptoms appearing worse for 24-72 hours post-treatment. Other body areas may also notice changes for 7-8 days post-treatment as treatment affects the biomechanics and will challenge previous soft tissue adaptions. Hence, just because symptoms can seem better or worse with a single treatment, one cannot gauge the effectiveness of a different approach in a single session. However, equally, that does not mean that one has to enter into another long treatment cycle. Generally speaking, one should notice some positive change within at least three treatment sessions and when combined with following aftercare advice. Personally, if Terry needed treatment from a professional practitioner and had no improvement in symptoms within three sessions, he would find another professional.
The need for a holistic treatment approach
In many respects, general medicine has taken a reductionist approach to persistent pain, effectively with experts in many specialist fields of medicine, as opposed to Hippocrate's ("the father of medicine's") holistic view of health.
Taking a Holistic view of Health and Wellbeing
Although a reductionist Western medicine approach can provide helpful insight, it tends not to look at the other relevant aspects of overall health. As per the diagram, many other factors impact overall general health and wellbeing and have relevance to persistent pain and other conditions. Medical tests such as Nerve conduction tests, tests for inflammatory markers, and various forms of imaging can provide helpful information, but they have limits. Imaging such as X-rays and MRIs do not show everything and can equally show pathologies when there are no symptoms. Hence, the cause of chronic pain symptoms may not be visible on imaging or other tests, yet pain is still felt or perceived.
Myofascial Pain Syndrome, Fibromyalgia and Chronic Fatigue Syndrome have a controversial history in general medicine. Historically, diagnosing such conditions with a specific medical test or imaging was impossible. Sadly such a situation led to some medical professionals labelling patients as faking, imagining the pain or being time-wasters. Not a huge amount has changed regarding a single definitive test for the diagnosis of these conditions as of the time of writing in 2023. Historically, diagnoses were formed from a history and group of symptoms rather than a positive test result, with such diagnosis being controversial (the view that no such condition exists) within parts of the general medical profession. Although the process for diagnosing such conditions has changed little, the conditions are far less controversial and more accepted today.
Although general medicine has proven extremely good at treating many conditions, the track record for persistent pain conditions is not so good. In essence, general medicine tends not to take an individualised treatment approach. Instead, a diagnosis (label) is given to the condition, followed by a drug prescription or referral to another specialist, physiotherapist or surgeon. People experiencing persistent pain often have a long history of being prescribed various drugs, seeing multiple specialists, undergoing numerous tests, and in many cases having surgeries and other procedures. Although drug medications have a valid place, they can often cause other issues in cases of chronic pain and long-term use, as demonstrated by the opioid crisis in many countries.
The article was written by Terry Davis MChiro, BSc (Hons), Adv. Dip. Rem. Massag., Cert. WHS.
The Morningside clinic occasionally runs promotional treatment rates for new and existing patients, which are available via the online booking calendar. If you liked this article or found it interesting, feel free to share the content with others. There are lots more articles available via the TotalMSK main Health, Wellness and Sports Injury blog page, which has a brief description of all the articles to date.
About the Author
As of December 31st 2020, the author chose to leave the Chiropractic profession due to a planned move back to Australia, where his training and education are not recognised. Terry no longer works as a Chiropractor and works as a Myotherapist in Morningside, Brisbane. He developed an early interest in soft tissue therapy techniques and advanced myofascial release methods in 2006 for treating various conditions. Terry's interests in human performance and trauma have naturally led to him developing a specialism in treating work and sports-related musculoskeletal injuries and Persistent or Chronic Pain.
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 health's physical and mental aspects. He also needed to push his 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. He has also taught as a senior course coach at the 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 patients he sees and has treated over the last 16 years. Terry is still extremely active and enjoys distance running, kayaking, mountain biking and endurance-type activities.