CHRONIC PAIN
Classically chronic pain is defined as any pain which persists for 12 weeks or longer. How long is longer? As long as a piece of string……..literally. Chronic pain can last anywhere from a few months, few years or even a whole life time. Chronic pain however is not only defined by its duration…..
True chronic pain is persistent pain which is no longer associated with nociception (pain signal from tissues) but rather altered sensory outputs from the brain.
“What does this mean for me suffering with chronic pain?”
The initial injury to the tissues has healed but you are still left with persistent pain, disability and concern.
“But why I am left in pain when everything is apparently healed?”
The nervous system is a complex beast and I would confuse you if I went into depth on pain science. However, it is important to know a few things ……
1) The brain (sensory cortex) is the control center for all sensation experienced in the body inclusive of pain, vision, smell, touch etc.
2) Nociception (pain reception) is a sensory input from body tissues to the spinal cord and brain.
3) Pain experienced is an output from the brain.
4) Pain experienced is influenced not only by nociception and sensory cortex but also other areas of the brain including the amygdala (center for memory and emotion) and limbic system (long term memory, behaviour, emotion and motivation) . Therefore …….
5) Pain experienced is vastly influenced by beliefs (both positive and negative), anxiety, and/or fear related to the pain.
Remember point 5, it will be important later.
With chronic pain the sensory cortex of the brain becomes smudged and changes occur in the brain which lead to an increase in representation of your area of pain in the brain mapping. This leads to increased sensation felt from the area. Increased sensation equals more pain and the cycle continues. There will also be changes in the sensory receptors at both tissue level and within the spinal cord.
Let me tell you a little story…..
I was treating a 60 year old male patient recently who was having some discomfort in his right buttock region. Symptoms had been on/off for around 6 months.
The patient was highly concerned that his hip was arthritic and had sought the advice of a GP who referred him for an x-ray. When presenting to me for the first time the patient had an x-ray penciled in for a few weeks time.
I am going to pause the story for a minute………. and talk a little about osteoarthritis as it will be important to understand this condition from a clinicians stand point. Osteoarthritis is a condition of wear, tear and repair which leads to thinning of the articular cartilage (stuff that covers the end of bones) within synovial joints (knee, hip, shoulder, fingers etc).
It is important to note that this process can begin as early as 25 years of age and is much more common in joints which have experienced trauma and surgeries in the past. Osteoarthritis is NOT always a painful condition. It is common for patients with Grade 4 (late stage) osteoarthritis to experienced no pain and sometimes patients with Grade 1 (very, very early stage) have pain.
Like I mentioned earlier, pain is complex so if you take away anything from this post let it be this. Pain does not correlate to tissue damage.
Anyways back to the story…….
From my examination findings it was clear that most of the pain experienced by this patient was from soft tissue spasm. Pain was heightened by the patients anxiety related to the potential of osteoarthritis.
The patients hips were fully functional with full range of motion in all directions, pain free.
I explained my clinical findings to the patient and voiced my professional opinion that the x-ray would not be necessary. The patient took reassurance from this and we arranged a treatment program to move forward with.
Over a period of a couple of weeks the pain experienced in the buttocks slowly started to decrease until….
The patient went for the x-ray and was given the diagnosis of osteoarthritis of similar grade in both hips.
Now given the x-ray findings of osteoarthritis of similar grade in both hips you would expect that the pain felt would be experienced on both sides. However in this recent example the patient only has pain in one hip. What is the reason for this? Remember what I said earlier about osteoarthritis and pain.
Osteoarthritis is NOT always a painful condition.
AND
Pain does not correlate to tissue damage.
In fact in this example I do not believe the pain was caused by the arthritic process at all but by soft tissue spasm around the hip area but let’s not get hung up on the minor points.
Back to the final part of the story…..
After the x-ray diagnosis I receive a phone call from the patient which went something like this;
“Hi Dale, I had my x-ray results and I have arthritis in both hips. I know that once you have arthritis you can’t get rid of it and I am going to be stuck in pain until surgery. I am waiting to see the surgeon to see what he says.
I am also getting some wrist pain which I think is my arthritis too, as that’s what happens when you get it in one place you get it in other places as well don’t you…..”
I attempted to explain that I didn’t feel the pain was caused by the arthritis but it was too little too late. The x-ray findings had taken yet another victim.
END OF STORY
WHY I’M SAD
The end to this story makes me sad for a million and one reasons.
1) The x-ray findings confirmed the patients fear and may facilitate chronic pain in not only his right hip but potentially his left and even his wrist.
2) The patients beliefs that he will be stuck with pain and that things will only get worse are highly correlated to behaviours associated with chronic pain.
3) The patient has taken ownership of his pain. The words ‘my arthritis’ imply that the arthritis is his and he is stuck with it. This belief is not beneficial for recovery.
4) The patient was improving steadily prior to the x-ray diagnosis but has ceased care due to his beliefs that there is nothing that can be done for him.
5) The patient is very little confused about how different types of arthritis can effect him.
So at this point it would be good to differentiate between the two main types of arthritis as this patient as many others may get them confused.
The two main types are;
Osteoarthritis AND Rheumatoid Arthritis
Osteoarthritis as mentioned earlier is a condition of wear, tear and repair of the articular cartilage in synovial joints. Once the cartilage wears away bony surfaces come into contact which leads to new bone being laid down (sclerosis and osteophytosis) and subchrondral cysts.
The joint can become disorganised and MAY become painful. It is common for a lot of the pain to be coming from tight and sore muscles around the joint.
Osteoarthritis (OA) commonly effects one joint and can not spread from joint to joint. This joint quite often has experienced prior trauma or surgery at some point in the patients life. Osteoarthritis can occur without trauma.
It is not uncommon for elderly individuals to have osteoarthritis in more than one joint.
Rheumatoid arthritis (RA) is a chronic systemic inflammatory joint condition which leads to over proliferation (increased growth) of the capsules surrounding synovial joints. This condition commonly effects both sides of the body and more commonly the small joints of the wrists, hands and feet. It can in theory effect any joint within the body.
Patients will commonly experience redness, swelling and stiffness of multiple joints at once and may feel unwell or have a fever associated. OA and RA are two completely different animals so it is important to know the basic differences. I will write a more in depth post about the differences at a later date.
Take away point – Not every form of arthritis is created equally.
Back to the x-ray findings………
You are probably wondering why I don’t give much weight to the x-ray findings in this case. An x-ray in itself is just one piece of information. This information does not warrant a diagnosis to the cause of pain.
X-ray findings must be correlated to the patient history, symptoms, and clinical examination findings. In this instance the x-ray findings do not correlate with the patient history, clinical examination findings or the patients symptoms.
If I x-rayed the hips of 100, 60 year old men who have no history of hip related pain, a large amount of these men would have osteoarthritis without even knowing it. This osteoarthritis causes them no pain or no concern and why should it?
Similarly if I MRI your neck (which I assume you have no pain in) there is a strong possibility that I would find some degeneration, a disc bulge or two or possibly a trapped nerve.
Just because this finding is apparent on x-ray/MRI doesn’t mean it has any significance clinically or more importantly in the context of your life.
This has been shown in many studies over the last few years.
CONCLUSION
Just because you have a structural finding from your imaging which is considered abnormal, it doesn’t mean you are going to have pain. If you are already in pain, it doesn’t mean you are going to be stuck with that pain for the rest of your life.
I know this concept all too well but I am sure there are many of you who have been told your pain is caused by arthritis and that you have it for the rest of your life. It is partly true, you will have the arthritis for the rest of your life, this however does not mean you are going to be in chronic pain.
So we return full circle to where we began at chronic pain. Chronic pain is heavily influenced by our fears, our anxieties, and our beliefs. The more importance you give the pain, the more fear associated with it, the more pain you will feel.
For that reason x-rays, MRIs and other investigations can take an already worried patient who is in acute pain and viciously propel them into a chronic pain state at the blink of an eye. If you are seeing a good osteopath, chiropractor, physiotherapist or GP, imaging will only be recommend if they believe if further care is needed for your condition and conservative treatment is not beneficial.
One of our key roles as clinicians is to reassure you as a patient. No matter how intense, with correct care, most of the time your pain will be short lived. If this pain is worrying you we are here to address your beliefs around the pain and facilitate you in becoming pain free and returning to full function.
Just because your x-ray tells you that you have arthritis, it doesn’t mean you are destined for a life of pain.
Don’t let that x-ray finding dictate the rest of your life.
After all whose to say your pain is even caused by the arthritis in the first place…..
Catch you soon!