Explaining Pain (Part 2): Chronic Pain
IMPORTANCE OF EFFECTIVELY MANAGING CHRONIC PAIN
Chronic Pain is pain that lasts beyond the expected recovery time (typically more than 3 months) for a certain injury, surgery or other condition. Employing an evidence-based, multi-disciplinary approach with an emphasis on self-management is essential in the management of chronic pain. Effective management of chronic pain is particularly important considering it is one of the leading causes of disability, it has a high prevalence (1 in 5 Australians live with Chronic Pain) and a dramatic impact on the economy ($34.4 billion per year).
The goals of this approach to management include controlling pain levels, reducing distress and subsequently improve quality of life by empowering individuals to participation in social and physical activities which are important to them.
THE ROLE OF PHYSIOTHERAPY:
Physiotherapists have an important role in facilitating the management of chronic pain in areas of education, goal-setting, tailoring exercise programs as well as the use of adjunct modalities.
Understanding the fundamentals of chronic pain is an essential step in its management. This includes:
A) What exactly is chronic pain? Education involves explaining the processes of pain, as we discussed in our previous blog. It also involves avoiding excessive investigations, such as repeated MRIs, to identify a sole physical cause of the pain. Reliance on imaging can reinforce negative pain beliefs and fear about an individual’s pain. For example, and MRI scan may reveal a herniated disc, the revelation of which may cause someone to view their discs as ‘slipping’, and their back as ‘damaged’, which can drive negative pain beliefs and fear. This can further contribute to the pain, despite evidence suggesting herniated discs have the capability of regressing on their own, and with conservative management including physiotherapy. Although MRI has a role in some instances, care must be taken to avoid over-reliance on imaging, particularly when recognising that imaging findings often does not correlate with the severity of pain.
B) Self-Managing Chronic Pain Being empowered to manage pain independently is a vital component to improve long-term outcomes. Three steps to self-manage pain, as outlined by Pain Australia include:
Pain Acceptance – Accepting the pain and recognising that, although pain may not completely alleviate, there are strategies to minimise the severity of pain, and that restoring quality of life and social/physical participation is realistic..
Changing Pain Beliefs – This involves ‘retraining’ the brain to recognise that pain in and of itself is not harm, and breaking down the instinctive, psychological negative response associated with harm.
Pacing – Pacing involves maintaining a steady level of physical activity every day and avoiding large variations of physical activity to avoid deconditioning and exacerbations.
C) What should be expected from treatment? It is also important to understand the expectations and goals from management. Unlike pain from acute injuries, chronic pain is less likely to fully resolve. Ensuring expectations involve controlling pain, rather than eliminating pain, can improve confidence with management and avoid those negative beliefs which can reinforce chronicity. This also involves not waiting for complete relief before returning to daily activities and work.
A mutual setting of goals between therapist and patient is an effective method to clearly identify aspects of life most important to the person in pain to achieve. It also assists in monitoring the progress of management. This can take the shape of SMART goals - Specific, Measurable, Achievable, Relevant and Time-based. These goals can be set in the short and long-term and tend to revolve around participation in a particular activity, reducing pain-levels, reducing medication use, or restoring work-load. The use of a pain-diary can often be effective when constructing goals relevant to pain-levels. This generally involves noting the location, severity, frequency and triggers of pain while they happen, in order to tailor goals and aid management.
Exercise is perhaps the most well-known and integral component of management guided by physiotherapists for chronic pain. These exercises commonly focus on a program of stretching and strengthening, which the physiotherapist has tailored to the individual and their physical impairments. Being engaged in the process of exercise prescription assists in improving adherence with the exercise program, contributing to improved outcomes.
The numerous benefits of exercise have been well-established and demonstrate the prevention of chronic conditions, including cardiovascular disease, obesity, osteoporosis, cancer and depression (which we’ll get to later), as well as improving pain and function in people with chronic pain, particularly low back pain. Higher levels of physical activity are associated with lower levels of chronic pain and, the inverse is also true, in that a lack of exercise has been demonstrated to be associated with chronicity (although a causal relationship cannot be confirmed).
It’s important to note that pain does not need to be fully relieved before participating in exercise. This means manageable levels of pain shouldn’t act as a barrier, as further harm is unlikely. Considering the potential benefits and minimal risk associated with exercise and chronic pain, it’s evident to see why it is one of the most wide-spread management options globally.
OTHER PAIN-RELIEVING STRATEGIES:
In addition to the fundamental aspects of chronic pain management outlined above, other adjuncts to aid in pain-relief in the shorter term can be effective when implemented effectively.
Pain-relief with temporary modalities such as ice for injury exacerbation and inflammation or heat for relieving pain associated with muscular tightness can be used. It is important to be cautious to avoid relying on these strategies, however, due to their passive nature. Most benefit is likely to be gained by using these strategies when it can relieve the pain to a point of being able to participate in activities, which pain would have otherwise served as a barrier. Other treatment options which can be used as an adjunct to supplement management include dry-needling, taping and massage.
Nonsteroidal Anti-Inflammatories (NSAIDs) are commonly the first point of pharmacological prescription for musculoskeletal pain, however medications with codeine and other opioids are also prescribed. These medications present a similar concern, however, as medication-dependence can develop in people with chronic pain and their effect on pain can be limited in the long-term, particularly due to tolerance to opioids. Unwanted side-effects can also potentially develop.
Medication can similarly have a role to play in pain management, however care to avoid excessive reliance should be taken, particularly as a sole management option,
OTHER MANAGEMENT APPROACHES:
1. The Role of Psychologists
A) Chronic Pain and Depression Considering the role of pain-beliefs and behaviours in chronic pain, as we discussed in Part 1, it stands to reason that psychology, and subsequently, the role of psychologists can play an important role in chronic pain management, particularly in the presence of mental illness, including depression. Chronic pain and depression commonly manifest together, whereby 30-40% of patients presenting for treatment for chronic pain, demonstrate major depression as a co-morbidity. This presence of depression appears to negatively impact function and response to treatment for those with chronic pain. The vicious cycle fuelled by inherent negative responses to chronic pain, including fear of further injury, uncertainty about pain resolving, sadness and grief, can be challenged with various psychological-based treatments.
B) Psychology Treatments In addition to pharmacological treatment to manage depression, psychology-based treatments most commonly include Cognitive Behavioural Therapy (CBT). This process challenges negative beliefs including pessimism, hopelessness, low self-worth, catastrophisation and fear-avoidance. Similar to physiotherapy, goals are established to decrease symptom levels and improve functional capacity, as oppose to eliminating pain.
2. Pain Specialists
Pain Specialists are doctors who specialise in specific areas of chronic pain such as post-surgical pain, neuropathic pain or migraines. When management through GP proves insufficient, referrals to pain specialists can be made to assist with coordinating multi-disciplinary management and guide medication use, when management through a GP has proved insufficient.
Although chronic pain is a complex entity, of which the cause is often difficult to identify, we can begin to manage it through a biopsychosocial, multi-disciplinary approach which aims to target the potential physical, psychological and social contributors to pain, with a focus on independent management.