The source: Three Sources of Chronic Pain

• Possible structural problem
• Inflammation of soft tissues
• Neurophysiological Disorder – “short circuits”

The receptor—your brain

Three additional variables affect your perception of pain:

• Sensitization
• Memorization
• The “Modifiers” –1) anxiety 2) anger 3) sleep

Chronic pain is a complex problem and even more so, as each person is unique. It won’t respond to isolated simplistic treatments. The approach that is successful in solving pain is similar to that of fighting a forest fire.

“I Can Only Fix What I Can See”

These concepts apply to pain in any part of the body regardless of the source. I will discuss low back pain as one example. The exact source of your LBP is usually unclear.  Many assume if you are pursuing a diagnosis with your doctor then there must be an indentifiable problem that is solvable with surgery. Surgery is felt to be the “definitive” solution.

• It is only definitive if you can see the problem.
• Even then the potential benefits must outweigh the risks.
• I often compare spine surgery to dentistry. (Back Pain vs. Mouth Pain)

A high percent of spine surgery should never be performed.

• What many surgeons are defining as “structural” is simply normal aging anatomy.
• Degenerative disc disease is not a disease.
• All intervertebral discs lose water content with age.
• They have been shown not to be the source of your chronic LBP.
• A fusion for a degenerated disc has a success rate of < 30%.

Video: “Get it Right the First Time”

Surgical Results Overly Optimistic

Marsha’s Three Needless Spine Surgeries

The post Understand Chronic Pain first appeared on Back in Control.

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Dr. Howard Schubiner is board-certified in pediatrics, adolescent medicine, and internal medicine. He was a full time professor at Wayne State University for 18 years and now works at Providence Hospital in Southfield, MI. He is the founder of the Mind Body Clinic and the co-author of several of my posts on the Neurophysiological Disorder.

Neurophysiological Disorder is news to a surgeon

I am a surgeon. Like all surgeons I am focused on finding a source of pain that I can fix. When this happens, my patient is happy. When I make my patient happy, I’m the hero, and that makes me happy. Not finding an exact cause of your pain is almost as frustrating for me as it is for you. The Doctor is Missing Something

Neurophysiological Disorder (NPD)

Dr. Schubiner presented recent neurological research demonstrating that the brain has a quality called neuroplasticity, the ability to create new nerve pathways in response to life events. When you learn to ride a bicycle or play the piano or swing a golf club, your brain cells develop new neural circuits that are connected to your body. They consist of millons of nerve cells. What most doctors do not know is that pain can be caused by these learned embedded circuits. Even when there is no tissue damage in the body, such as a tumor, fracture, or infection these connections can cause real physical pain.

Emotional Pain = Physical Pain

Recent research done in Pittsburgh has shown that the brain can create pain which is identical to the pain of a physical injury. We have also learned that an emotional insult is processed in exactly the same way in the brain as a physical injury (Kross). We now know that stressful life events and our emotional reactions to them can cause severe pain. Treating this type of pain with pain medications, injections, or surgery is usually not effective. These treatments often leave the patient extremely frustrated and depressed. However, when the true cause of the pain is recognized, these pathways can be reversed by programs utilizing NPD principles. Dr. Schubiner’s book Unlearn Your Pain outlines one process. This website is also another resource along with the book Back in Control. The key is using tools that create alternative neurological detours.

Your brain can generate pain

The notion that all pain has an identifiable structural source overlooks several key points:

• Soft tissue injury can occur at a level that is below the sensitivity of any diagnostic test.
• Tissues can be irritated without being torn—another undetectable injury. The irritation occurs through inflammation, which is a chemical, not mechanical, source.
• There is no routine diagnostic test to specifically tell us that the nervous system is “short circuiting” from the Neurophysiological Disorder.We do know that if a “functional MRI” (which shows what part of the brain is “active”) was performed on a patient who suffers from NPD, then the pain parts of the brain would light up.

Fibromyalgia

We enjoy treating NPD – especially chronic pain

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I believed that pain was always structural–I was wrong!!

During my first five years of practice, it was my assumption that if a patient had experienced low back pain for six months, then it was my role to simply find the anatomic source of pain and surgically solve it. I was diligent in this regard. The test I relied on most heavily was the discogram. The discogram is a test where dye is injected into several discs in the lower back; if the patient’s usual pain was produced at a low injection pressure, it was considered a positive response. The only patients I did not fuse were those who did not have a positive response or had more than two levels that were positive. I performed dozens of low back fusions and felt frustrated when I could not find a way to surgically solve my patients’ low back pain.

I have a physiatrist friend, Jim Robinson, who is a strong supporter and contributor to the DOC Project. From 1986 to 1992, we both served on the Washington State Worker’s Compensation clinical advisory board and helped set standards for various orthopedic and neurosurgical procedures. Our discussions were based on this assumption that there always is an identifiable “pain generator.” That means there was always some anatomical problem generating a pain impulse and we need to discover it to save the problem. It was just a matter of figuring out what test is the best one to discern it. We did not think in terms of structural versus non-structural sources of pain. We knew about the role of stress, but did not fully appreciate how large a role it played in altering the body’s chemistry and perception of pain.

BTW, our original concept of a “pain generator” was wrong. The only place in the body where pain is felt is in the brain. Sensory input has to be first interpreted by the nervous system and if a certain threshold is exceeded, your brain sends out a pain signal that indicates danger and your body will respond with an appropriate action to keep you safe. A bone spur has no inherent capacity to generate pain.

Structural problem

I define a structural lesion as one that is distinctly identifiable on an imaging test, which correlates with the patient’s symptoms. An example would be a ruptured disc pinching a nerve that causes pain down the leg. A ruptured disc between the fourth and fifth lumbar vertebrae will cause pain down the side of the leg. This is the pathway of the fifth lumbar nerve root. A ruptured disc between the fifth lumbar and first sacral vertebra will cause pain down the back of the leg, which is the pattern for the first sacral nerve. If in either of these two examples the pain was going down the front of the leg, it would not be considered the cause of the pain because that is the path of the fourth lumbar nerve root and it does not match.

Other examples are:

• Bone spurs on one or both sides of the spinal canal with matching leg pain and/or nerve damage
• Central spinal canal constricted by bone or ligaments with one or both legs feeling weak, tired, or painful
• Isthmic spondylolithesis (slippage) with corresponding leg pain.
  • More that 3 mm of back and forth motion on X-ray if only back pain; This would be considered unstable.
• Degenerative spondylolithesis (slippage) AND canal constriction with corresponding leg pain or fatigue
  • >3mm of instability if just back pain; considered unstable.
• Acute compression fracture with fluid on the MRI (indicates bleeding).
• Acute unstable fracture/dislocation
• Tumor
• Infection
• Flatback—whole body tilted forward because the normal curvature of the lower back has been straightened – many causes.
• Scoliosis that progresses over time-just the presence a curve does not count.

Pain problem

Many of you experience pain whose source is not identifiable on any test modern medicine has to offer. When there is no identifiable structural source of your pain, we cannot surgically treat it. But we can still help you and the good news is that you don’t have to undergo the risks of spine surgery.

The only scenario that surgery should be even considered is in presence of an identifiable problem with matching symptoms. Other factors such as the severity of the pain compared to the involved risks must be taken into account. If you can’t see it you can’t fix it.

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You are Not a Machine

“Pain-Generator” thinking takes the human body to be like the body of a car–when there is something wrong with the body, all you need is a good mechanic. The mechanic replaces mechanical parts, and the problem is solved. However, your body is not a machine. There is little resemblance of your body to a mechanical device:

Automobiles are DEAD and do not react to a pain signal. They do not have:

• Pain fibers
• A nervous system that interprets pain signals
• Hormones
• Emotions
• Memories

There is NOTHING in the mechanical world that remotely resembles pain. In fact, serious attempts have been made to reproduce pain in the mechanical world has failed miserably. Yet it is understandable for patients to become focused on finding the physical source of their pain. Your pain problem is solvable once you understand the various aspects of pain and then address ALL of them simultaneously.

• Pain is complicated–it is entangled in an intricate web of mental and physical states. It is a necessary part of being alive and human.

The post You are Not a Machine first appeared on Back in Control.

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I look at the source of the pain and it’s receptors in reference to back pain and one’s spine. I also discuss the difference between a structural and non-structural source of the pain. Read more about this topic in discussing structural sources of pain.

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Sources of pain

With pain in any part of the body, there are potentially three components of the problem:

• Structural problems – identifiable problems with matching symptoms
• Non-structural issues – soft tissues such as ligaments, discs, fascia, etc. that cannot be seen on a test
• The central nervous system is always a factor and can independently create symptoms

The first step is for your physician and you to get a clear idea about whether there is possible structural problem that should be surgically addressed. If there is a correctable problem, then you need to decide whether you pain is severe enough to undergo surgical intervention. If it is, then we have discovered that it is critical to spend a few months optimizing the outcome by normalizing sleep, decreasing anxiety, stabilizing meds, etc. We call this “prehab” or rehab before surgery. If the pain is not severe enough to warrant the risk of surgery or the problem is not structural, then surgery is off the table.

Overview

The DOC program is organized around the following variables:

• Education
• Sleep
• Stress management
• Medications
• Goal setting/vocational issues
• Physical conditioning/ rehabilitation
• Family dynamics

The central nervous system

You might notice that the first five of the categories, either directly or indirectly, affect the central nervous system. Improving sleep will decrease the perception of pain and improve your sense of well-being. Stress is an obvious issue regarding the central nervous system. Everyone has stress and most of us have a lot of it without ever being taught effective stress-management skills. The additional stress of chronic pain is a major problem. Medications are used to decrease the pain on a short-term basis to help improve function. Education and goal setting will decrease your anxiety and frustration.

Physical considerations

Rehabilitation of the soft tissues and general care of your physical health is an important step. However, it is necessary to first calm down the central nervous system before they can be adequately addressed. Otherwise, when painful soft tissues are aggressively manipulated, there will be an exaggerated pain response. What exactly is done within each category is not as important as having ALL of the categories successfully defined and treated. Fighting a forest fire-your pain

You will already have been through many of the treatments that will be described. However, it is the self-directed structured combination of these variables that will make an impact on your pain and quality of life.

The post DOC – A Framework of Care first appeared on Back in Control.

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• Understand the complexity of chronic pain and how it evolves from acute to chronic.
• The factors to consider are the source, sensitization, memorization, and the “modifiers” of anxiety, anger, and sleep.
• Breaking chronic pain into its component parts allows them all to be systematically addressed and it becomes a solvable problem.
• Each person’s journey is unique and the only way to heal is to understand pain through your eyes and take control.

Chronic pain has traditionally been defined as, “pain that lasted longer than the expected healing time.” We now know that this is incorrect. It is a neurophysiological problem. Based on current neuroscience research, chronic pain is, “…an embedded memory that becomes associated with more and more life experiences, and the memory cannot be erased.”¹ Therefore, interventions focused primarily on anatomy and structure cannot and will not work. As in any arena of life, it is necessary to thoroughly  understand a problem before you can solve it.

Chronic pain is a complex disorder

 There are many factors that affect your perception of pain, and The DOC Journey systematically presents the variables and tools to deal with them. The skills are not difficult, but it requires learning and repetition to master them. What doesn’t and hasn’t worked is applying random simplistic treatments to the complexity of chronic pain. An important early step is learning how chronic pain evolves. Aspects of it to consider are:

1) The source

2) Sensitization process

3) Memorization of the pain circuits

4) Modifying factors – sleep, anxiety, and anger.

 Sources of pain

• Structural – identifiable abnormalities with matching symptoms
• Non-structural – Inflamed/ sensitized soft tissues/ overuse – cannot be seen on a test
• Sustained exposure to threat physiology

Much pain originates from anatomical abnormalities that are clearly identifiable on an imaging study. For the lesion to be considered a structural source of pain, the symptoms must be specific and correlate with the expected pattern of pain. For example, back pain is widespread, and a localized abnormality would not be expected to cause this pattern of pain. This contrasts with a pinched nerve from a bone spur that causes pain only in the pathway of that nerve.

Non-structural pain is defined as pain arising from soft tissues, such as tendons and ligaments, and testing cannot identify the source. For example, shoulder pain can be created from irritation from the tissues around the rotator cuff and imaging tests are usually unrevealing. Pain can also be caused by a torn rotator cuff, which is easily seen on an MRI – and that would be a structural issue.

Both structural and non-structural sources of pain can be effectively treated with various surgical and non-operative treatments. But most chronic symptoms in your body are caused by sustained exposure to stress hormones, elevated metabolism (fuel consumption), and inflammation. It is the neurochemical makeup created by your body’s flight or fight response to threats. There is never an identifiable source of pain, as your physiology (your body’s function) changes every second.

Environmental cues of threat set off a defensive response. Immediately, before you are even aware, your immune system girds for the possibility of injury by initiating inflammation (to protect cells against bacterial or other invasion), elevates metabolism to provide fuel for defense, increases the speed of nerve conduction–which increases your alertness but also your pain sensitivity, and elevates the levels stress hormones (cortisol, adrenaline, noradrenaline, histamines). Much of this defensive state is modulated by small signaling proteins called inflammatory cytokines.

So how do you think you feel when you are in this physiological state? Your heart is racing, you are sweaty, tired, anxious, overwhelmed, nervous, stomach feels tight, blood pressure is elevated, pain is worse, and your breathing is rapid. The bottom line is that you don’t feel great when your body is in this heightened neurochemical state. Are these symptoms imaginary? Not a chance. None of them.

Sensitization

When your brain is hammered week after week, month after month, and sometimes year after year with the same pain impulses, it becomes efficient in processing them. It takes less of an impulse from your back to elicit the same response in the brain. The same impulse causes more neurons in the brain to fire. It is this process that causes patients to complain that their pain is getting much worse despite no additional trauma.

This phenomenon was clearly documented in a clinical study done in 2004.² Volunteers who had no experience with chronic pain had a light pressure applied to a finger. The researchers measured the response in the brain with an MRI that can track metabolic activity. It is called a “functional MRI (fMRI).” They consistently identified one small area of the brain that responded to this pressure. The same pressure stimulus was then applied to patients who were experiencing chronic pain. There were two chronic pain groups: one consisted of people with chronic LBP of more than three months; the other consisted of people who suffered from fibromyalgia. In both groups, five areas of the brain lit up. Although the fibromyalgia group experienced more diffuse body pain, anxiety, and depression than the CLBP group, the fMRI scan data was almost identical. This carefully done study documents clearly how the brain becomes sensitized to repetitive impulses.

Memorization

 Pain circuits become etched into your nervous system with repetition. The process is like an athlete, artist, or musician learning a skill. However, the frequency of chronic pain impulses is more like a machine gun. These circuits have been documented by dynamic brain imaging to become deeply embedded within six to twelve months.³ Similar to knowing how to ride a bicycle, they are permanent.

A classic example of this is “phantom limb” pain. It occurs in patients who require an amputation, usually because blood supply to the limb is compromised by vascular disease. Common causes are diabetes or atherosclerosis, when there is not enough blood to sustain viability to the limb. Prior to the amputation, lack of oxygen causes the limb to become very painful. After the limb is removed, up to 60% of patients feel the pain as though the limb were still there.  Almost 40% of sufferers characterize the pain as anywhere from distressing to even more severe than before.⁴

There is not a more definitive operation than removing the entire source of the pain by performing an amputation. The nervous system does not even know the leg is gone, and it still feels the same sensations and pain. From those of us who have the visual experience of performing these amputations, this is a dramatic example of the power of the nervous system. It is also a reminder that the brain also is an extremely complex sophisticated computer, which is programmable. “Reprogramming” requires specific skills that are not difficult to master and persistence. What doesn’t work is positive thinking and will power.

The “modifiers”

 Anxiety, anger, and sleep are all factors in the chronic pain experience. They will be each discussed in detail throughout this guided course of The DOC Journey.

 The sum of all these elevated stress hormones/ inflammatory markers is a strong unpleasant feeling that compels us to take action to resolve the threat. All animals experience this heightened state, but humans have language and consciousness. We can label it. This feeling of dread is what we call anxiety. It is so deep and uncomfortable that there is no choice but to act. Once the threat is gone/resolved and the body is back in balance (homeostasis), you can go on with your life.

Anxiety describes the cumulative sensation caused by threat. It is not the cause of a threat. It is a symptom, not a diagnosis, disease, or disorder. Therefore, it isn’t treatable by addressing it as the primary psychological problem.

 Anger describes the feelings generated by a more intense survival response. The solution to anxiety is to control you or the situation to resolve the threat. When you cannot accomplish this, your body kicks into a stronger survival response to increase the odds of survival. Anger is anxiety with an extra kick. They are the same entity. Both reactions sensitize the nervous system, increase the speed of nerve conduction and you will experience more pain.

When this sustained state of high alert is sustained, it has negative effects on your health, resulting in a variety of chronic physical and mental diseases. Each organ system will uniquely respond to this heighted physiological state, and it is why so many different symptoms and diseases are possible.

Sleep is a major factor affecting your perception of pain. Lack of consistently restful sleep has been shown to CAUSE chronic low back pain and not the other way around.⁵ There is a higher correlation of insomnia with disability than the severity of pain.⁶ Lack of sleep is inflammatory and increases pain. Insomnia is addressed early in the course and is addressed as a separate issue from the pain. Getting a consistently restful night’s sleep is a concrete step in allowing other tools to be effective. Conversely, it is difficult to move forward without adequate sleep.

Recap

Understanding the evolution and complexity of chronic pain is an important step in approaching it with a dynamic multi-pronged self-directed approach. The source of pain can be 1) structural 2) non-structural 3) in response to your body’s chemical makeup (threat physiology). Over time your nervous system becomes sensitized to pain impulses, and then they become permanently memorized. When you add in the “modifiers” of poor sleep, anxiety, and anger, life becomes truly miserable. It is also clear that the complex nature of it explains why simplistic treatments focused on symptoms cannot work.

References:

1. Mansour AR, et al. Chronic pain: The role of learning and brain plasticity. Restorative Neurology and Neuroscience (2014); 32:129-139.
2. Gieske T, et al. Evidence of augmented central pain processing in idiopathic chronic low back pain. ARTHRITIS & RHEUMATISM (2004); 50:613–623.
3. Hashmi, JA, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain (2013); 136:2751–2768.
4. Gallagher P, et al. Phantom limb pain and RLP. Disability and Rehabilitation (2001); 23: 522-530.
5. Agmon M and Galit Armon. Increased insomnia symptoms predict the onset of back pain among employed adults. PLOS One (2014); 9:1-7.
6. Zarrabian MM, et al. Relationship between sleep, pain, and disability in patients with spinal pathology. Archives of Physical Medicine and Rehabilitation (2014); 95:1504-1509.

Listen to the Back in Control Radio podcast The Evolution of Chronic Pain

The post The Evolution of Chronic Pain first appeared on Back in Control.

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