Chronic Pain: Insights and hope.

Chronic pain has traditionally been seen as a symptom: we die in pain, we don’t

die of pain. Now researchers are recognising that chronic pain can be a disease in its own right: a disorder that happens when the nerves in our body — either peripheral ones, like those in our limbs, or central ones, like those running from our spinal cord to our brain — become hyperactive, or “sensitised.”

This can happen for a host of reasons. For example roughly one in seven people who have surgery to fix a hernia will develop chronic pain, and millions of people have hernia surgery every year. The risk for breast surgeries, including mastectomy, is even higher: between 40 and 60 percent. And the pain is frequently severe — an average of 8 on a 10-point scale, or roughly the same as patients who have had a limb amputated.

The causes of these problems have long been mysterious. For years, researchers were baffled by the fact that some people with relatively mild tissue damage would experience terrible pain, while others with severe damage would feel mostly fine. This was true regardless of whether the injury was an endometrial lesion, whiplash or osteoarthritis.

Ordinarily, when a person is injured, the body releases a flood of chemicals that spur healing processes, like inflammation. Those same chemicals also activate our nociceptors, or “pain fibres,” a set of peripheral nerve endings that alert the brain to tissue damage and that exist in our skin, muscles, stomach and even internal organs. Typically, that process lasts just while an injury is healing. But in some cases, those pain signals keep firing, driven by what researchers now think is a complex set of genetic, endocrinological and immunologic processes.

The discovery that the pain-signalling chain itself could become faulty was a crucial shift. Nociceptors are essentially bundles of sensors attached to long, thin nerves that run all the way up to the brain, which in turn send signals back down to the site of injury. Along the way, pain signals pass through “gates”: neurological filters, located in the spinal cord, that release chemicals to either amplify a pain signal or turn it down.

It’s now thought that chronic pain can be caused by problems at any point along the chain. In some cases, the problem might be the nociceptor itself, triggered by inflammation, as happens with autoimmune diseases like rheumatoid arthritis and lupus. In others, the problem might be hyperactivity in the spinal cord, the brain or both. In still other cases, the cause is unclear. Fibromyalgia and irritable bowel syndrome (which is considered a chronic pain condition) are both driven by overactive signalling, either by the central nervous system or by the nociceptors in our muscles or gut, but it’s not clear how or why the switch for that hyperactivity gets flipped.

One of the big insights of the past decade is that chronic pain is a disorder of the central nervous system. It has been a huge change in how we understand these conditions. Before, we were basically just mystified by persistent pain.

Increasingly, though, it’s looking like chronic pain, like cancer, could end up having a range of genetic and cellular drivers that vary both by condition and by the particular makeup of the person experiencing it. What we’re learning is that pain is not just one thing. It’s a thousand different things, all called ‘pain.’

The thing that makes chronic pain so awful is that it’s chronic: a grinding distress that never ends. For those with extreme pain, that’s easy to understand. But even less severe cases can be miserable. A pain rating of 3 or 4 out of 10 sounds mild, but having it almost all the time is gruelling — and limiting. Unlike a broken arm, which gets better, or tendinitis, which hurts mostly in response to overuse, chronic pain makes your whole world shrink. It’s harder to work, and to exercise, and even to do the many smaller things that make life rewarding and rich.

A cruel Catch-22 around chronic pain is that it often leads to anxiety and depression, both of which can make pain worse. That’s partly because focusing on a thing can reinforce it, but also because emotional states have physical effects. Both anxiety and depression are known to increase inflammation, which can also worsen pain.

As a result, pain management often includes cognitive behavioural therapy, meditation practice or other coping skills. But while those tools are vital, it’s notoriously hard to reprogram our reactions. Our minds and bodies have evolved both to anticipate pain and to remember it, making it hard not to worry. And because chronic pain is so uncomfortable and isolating, it’s also depressing.

That because chronic pain has an emotional component, people may feel ashamed if they’re not able to control their symptoms. With the self-help culture we have, there’s this feeling like you should be able to fix it. But the truth is that while things like cognitive behavioural therapy can help, you often won’t be able to eliminate the pain.

It’s still not clear why one person goes on to develop chronic pain when another doesn’t, but research has increasingly shown that some people are more susceptible. Women are more likely to develop chronic pain conditions, possibly because, they’re at higher risk for autoimmune disorders, and because hormonal fluctuations can aggravate pain. And once a person has one kind of chronic pain, they’re more likely to develop another. The idea is that if your central nervous system isn’t functioning properly, you’re more likely to develop chronic pain of some kind: migraine, temporomandibular disorders, back pain, pelvic pain. And then, because your body isn’t processing pain the way it should, you’re more likely to develop other conditions. For instance, if you have chronic pain and undergo surgery for something unrelated, you’re much more likely to end up with chronic pain in that other part of your body afterward.

The attitude that chronic pain is mostly psychological and not a medical condition is deeply rooted but this can and is changing, as it has done with other conditions previously. For years, people with migraines were often institutionalised and in some cases even lobotomised. Then, in the 1950s, a drug called methysergide was discovered that prevented migraine in a huge number of people. All of a sudden, migraine stopped being a psychiatric diagnosis and became a medical condition.

How chronic pain is recognised and treated is changing and the true nature off the beast is being comprehended from all the angles it requires.

There’s also a growing awareness that chronic pain requires individualised treatment plans and ongoing support.

For people living with chronic pain, it’s almost like being in a long-term relationship both with the condition and the therapist that is working with you.

An analogy I use with my clients is that your pain is like this destructive, obnoxious roommate that’s always interfering in your daily life — but it’s a roommate you cannot evict. So instead of feeling like you’re battling your body every day, it’s like, ‘How do I work with this body on a daily basis and have a healthy coexistence with it?’”

It’s hard not to wish for a real fix: one in which you are magically returned to the body that, for years, simply worked. A body that you don’t have to constantly have to think about. Though the prospect of a new era of pain treatment gives hope, it’s also still excruciatingly out of reach. For everyone who has lost months or years or decades of their life to pain, the future can’t come soon enough.

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If you are suffering from chronic pain and are looking for a bespoke multidisciplinary approach to your health and wellbeing then the team at Turra Physio Therapy and our associates can offer you caring proactive approach that your condition requires.