Chronic pain is a worldwide epidemic, affecting 1.5 billion people1. In the USA we spend over $635 BILLION dollars treating chronic pain, visiting multiple medical practitioners, getting tests, injections, prescription medications, and surgeries2. With all the amazing advances made in treating cancer, diabetes and heart conditions, the numbers of people suffering with chronic pain has not lowered; in fact it’s increasing.
The good news is that we have learned more about pain in the past 10 years than ever before. The fields of neuroscience, physical therapy, psychology and nutrition have unearthed a treasure trove of knowledge to help people truly heal from chronic pain. There are a number of non-invasive, low risk self-help treatments that people with chronic pain can do simultaneously while they receive treatments by their doctors, physical therapists and other health practitioners to achieve total chronic pain relief.
Chronic Pain Defined
Chronic pain is pain that lasts longer than the normal tissue healing time of 3-6 months. Note: this blog does not include the pain caused by active cancers nor end of life pain issues. So, by the end of 6 months all tissues (skin, muscles, fascia, tendons, ligaments, nerves and bones) should be completely healed barring no major complications such as infections, disease processes or re-injuries.
3 Phases of Healing
Below is what our body does after getting a physical injury:
Inflammatory phase 3-7 days from original injury: when you feel most pain or see redness and swelling. Swelling shows that your body is doing an excellent job of healing and prevents further injury to the area.
Repair (Proliferation) phase 2-6 weeks from original injury: depending on the tissue (skin heals faster than bone). New collagen is laid down, like weaving a basket or sewing up a hole in your socks. Collagen replaces the torn, strained, or fractured tissue.
Remodeling phase 3-6 months from original injury: this phase starts when production of new collagen stops. New collagen is usually stiff, inflexible and needs to be remodeled, lengthened, and strengthened to your pre injury state and function. This is best achieved by going to physical therapy and doing your exercises.
Acute Pain Process
If the normal healing timeline takes 6 months at most, why do so many people experience chronic pain for years, sometimes decades past the original injury? Before we can understand how pain becomes chronic, here’s how our nervous system and brain works when we are experiencing acute injury pain.
When we first sprain our ankle, specialized sensors in our skin called “nociceptors” are activated (see red "Nociceptive Information" ). Nociceptors are not pain sensors- rather pressure sensors, chemical sensors and stretch sensors. In fact, we don’t have actual “pain sensors” in our bodies. Nociceptors sense that your ankle ligament is overstretched or your muscle fibers are torn and sends this information to the brain.
Brain is our Protector
Your brain’s main role is to protect your body, so when your brain receives the nociceptive signals about the overstretched/torn tissues, it also checks your surrounding environment and assesses the situation to decide how best to protect.
Let’s say you twisted your ankle in a pothole while crossing a busy NYC street. You need to run quickly or you may be hit by oncoming cars. The brain decides that you need to get to safety first so it allows you to run on your injured ankle WITHOUT PAIN by sending pain reducing chemicals to the area. Once you are safely on the sidewalk, the brain sends pain signals to your ankle so you immediately take your weight off your foot. Your brain has effectively protected you from harm both by decreasing and increasing pain. This whole process happens in milliseconds.
Brain is the Boss of Pain
Our brains are capable of learning and creating new nerve pathways throughout our whole lifetime. This is called “neuroplasticity”3. Areas of the brain that are used very frequently show high levels of activity (as seen in brain MRI scans) and may actually increase in size4. Before iPhones and Google Maps, London cab drivers had to memorize the whole intricate street map of the city before they could get their licenses. Studies show that they actually have enlarged areas in the brain associated with memory. The brain changes based on how we use it.
The brain is the center where the actual sensation of physical pain originates from and gets relief. People who experience chronic pain have a brain and nervous system that has learned to be in a heightened state, always on guard awaiting the next danger signal. What leads to this “faulty wiring” of our brain and nervous system? Some factors include:
- Childhood and early social experiences - did you suffer loss/lack of love or did you feel safe and supported? These experiences affect how we respond to both physical and emotional pain.
- Daily thoughts and self-talk - are they positive or tend to be negative/fear based?
- Current social interactions - are they mostly supportive, like seeing a good friend, petting your cat or stressful, like fighting with your spouse/children?
- Your Expectations- are you afraid of bending forward because years ago a doctor said it could flare up your back pain? 5,6
Nutrition, exercise, restful sleep plays just an important role in total healing which we will discuss in the next few blogs. While we can’t change what happened to us in the past, the good news is that our brains can relearn healthy patterns to lower/stop chronic pain.
While receiving medical care from your doctor, you can simultaneously retrain your brain to learn healthy processes, decrease fear based movement patterns, use mindfulness to stop negative catastrophizing thoughts, breathing techniques to lower fear/anxiety and much more.
At EMH Physical Therapy, we offer a chronic pain recovery program, called re·lieve, which educates patients in the new science of pain and teaches them a scientifically proven self-help program along with providing any needed manual and movement therapies.
Stay tuned for Part 2 of "Solutions for Complete Recovery of Chronic Pain".
1.Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: Institute of Medicine of the National Academies; 2011.
2.Darrell J. Gaskin, Patrick Richard. The economic costs of pain in the United States. The Journal of Pain 2012;13(8):715
3.Draganski B, May A. Training-induced structural changes in the adult human brain. Behav Brain Res 2008;192:137-42
4.Johansson BB. Brain plasticity in health and disease. Keio J Med 2004;53:231-46.
5.Seifert F, Maihofner C. Functional and structural imaging of pain-induced neuroplasticity. Curr Opin Anaesthesiol 2011; 24: 515-523
6.Sandkühler J. Learning and memory in pain pathways. Pain 2000; 88: 113-118
7.Jensen M. Magnetic resonance imaging of the lumbar spine in people without low back pain. New Eng J Med. 1994;331: 69-73.
8.Katharina A. Schwarz, Roland Pfister, Christian Büchel. Rethinking Explicit Expectations: Connecting Placebos, Social Cognition, and Contextual Perception. Trends in Cognitive Sciences, 2016