Research update: Chronic Pain
New research behind chronic pain mechanisms has lead to a paradigm shift in how to best manage chronic pain
A patient-centered approach that focuses on education, graded return to activities, and increasing self-efficacy has shown the best long-term results
Hold your health practitioner accountable to an evidence-based management plan that focuses on your goals and independence
Research over the last 10-15 years has significantly changed how health practitioners view chronic pain. Mechanisms have been discovered to validate symptoms previously seen as purely psychological. These mechanisms help explain why pain lingers for months, even years, despite previously injured tissues having had enough time to heal. In one study they reviewed mechanisms for chronic pain following post-surgical pain, and highlighted 5 main pathways to chronic pain as shown below. Keep in mind that this post is not meant to paint a complete picture on chronic pain, but to briefly illustrate some of the recent developments in the field. The hope is that this information gets the ball rolling for those of us with chronic pain that have had limited success with previous treatments.
Chapman, 2017. Journal of Pain: The Transition of Acute Postoperative Pain to Chronic Pain: An Integrative Overview of Research on Mechanisms
It’s likely that if you suffer from chronic pain that all or some of these are involved to some level. Simply put, they represent a hypersensitive nervous system that responds based on previous injuries. Whereas your initial pain response was very useful in protecting you from potential tissue injury, it is now limiting and no longer reflects injury. This means that in chronic pain – pain does not equal harm (this is actually true for pain in general, but requires a more detailed approach to explain). To make sense of this think of phantom limb pain in amputees – there are no tissues left to generate the pain response from, but the hypersensitive nervous system still manages to send the signal.
With this change in how chronic pain works, a large shift in what we should do about it has also come about. Multiple studies are finding a multidisciplinary approach to be most appropriate in handling chronic pain.
A new guideline published by the Canadian Medical Association journal recommends non-opioid treatments as front-line care for chronic non-cancer pain. For those currently taking opioids who are having difficulty tapering, they recommend a multidisciplinary approach. “Possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist…”.
“Recommendation 1: When considering therapy for patients with chronic noncancer pain, we recommend optimization of nonopioid pharmacotherapy and nonpharmacologic therapy, rather than a trial of opioids (strong recommendation).
Recommendation 10: For patients with chronic noncancer pain who are using opioids and experiencing serious challenges in tapering, we recommend a formal multidisciplinary program (strong recommendation).
In recognition of the cost of formal multidisciplinary opioid reduction programs and their current limited availability/capacity, an alternative is a coordinated multidisciplinary collaboration that includes several health professionals whom physicians can access according to their availability (possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist, an occupational therapist, an addiction medicine specialist, a psychiatrist and a psychologist).”
Busse, et al., 2017. Canadian Medical Association Journal: Guideline for opioid therapy and chronic noncancer pain
In focusing on opioid risk this guidelines represents a step in the right direction in tackling the opioid epidemic in Canada, but also highlights the accumulation of evidence supporting conservative therapies such as chiropractic, and physical therapy in managing chronic pain.
More specifically, treatment strategies rooted in patient education and regaining trust in your body’s durability have shown the greatest long-term results for chronic pain. O’Sullivans group termed this approach “cognitive functional therapy”, which is a handle that means considering pain generation as multi-dimensional, and focuses on both mind and body while treating chronic pain. Specifically the cognitive component aims to break down fears, beliefs, and expectations that may be associated with pain through education on chronic pain mechanisms and myths. The functional component finds painful activities or movements, and desensitizes them over time by teaching non-threatening ways to perform them over time. Here are the results of this approach in one of their studies, as compared to conventional treatments for chronic low back pain.
decrease in pain intensity over twice as much as comparison, with results lasting at final follow up of 12 months
decrease in disability measures over twice as much as comparison, also lasting up to 12 months
overall lasting decrease in fear-avoidance behaviors
O’Sullivan, 2013. European Journal of Pain: Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial.
O’Sullivan’s study is on chronic low back pain specifically, but is one of a many showing better results with this model of thinking compared to conventional treatments. In the clinic we embrace this evidence-based model by ruling out any tissue damage, then continuing treatment with an emphasis on education, breaking down threatening movements, and pacing strategies so you can get long term results. Along the way we provide passive care such as adjustments and soft tissue therapy to help you get there, while focusing on decreasing practitioner dependence. To give you an idea of what this looks like, here’s a sample from the educational aspect of our treatment:
Keep in mind that this approach only applies to those suffering from chronic musculoskeletal pain who have been cleared from tissue damage by a health professional such as chiropractor, or physical therapist. There are certainly situations of chronic pain where repetitive tissue trauma is a primary contributor. In these situations we would suggest a biomechanical approach aimed at facilitating recovery.
If you suffer from chronic pain, visit your local chiropractor or physical therapist and hold them accountable to an evidence-based plan that focuses on your goals and independence to get back to the things you love.
Cornelius van de Wall, DC
More evidence-based posts to look forward to:
-Role of Chiropractic/Physical therapy in senior care