Chronic pain is a funny and allusive thing. Generally speaking pain is classed as chronic when it lasts longer than 3 months. It’s not quite this clear cut but it is a good rule of thumb. The reason is that when you get injured, tissues should really have pretty much fully healed as much as they are going to within this time frame. In most cases it’s actually much faster than 3 months. So if pain lasts longer than this then the pain is no longer about how injured the tissues are but rather becomes a much more complex picture.
The video link takes just 5 minutes to explain how our nervous system interprets pain and what happens when the message gets confused. It will really help you understand the rest of this article. It’s an Aussie made video, so let’s support it by adding to the page views!
Here is the quick summary.
“Having a brain that keeps on producing pain, even after the body’s tissues have been restored and are out of danger, is no fun”. This statement directly from the video pretty much sums it all up. Note that the wording is no accident – the tissues have substantially healed but the brain is still producing a persistent pain message. That’s not a typo – it’s the brain that is producing the pain message – not the injured tissues. So at this stage we say that the pain is less about structural changes in the body or damage to the tissues but rather a sensitised nervous system. Many reading this who experience chronic pain will want to reject this idea – that the pain is no longer related to actual physical injury but rather a “fear” response produced by the brain.
The video explains things very well. However to expand things a little bit and help you understand exactly why this occurs we need to consider a part of the cortex of our brain referred to as the “homunculus”. The picture below shows a slice of the brain looking at it from front on. You can see that each part of the body has “real estate” on it’s own piece of the cortex. So messages that are received from the legs are processed at the top centre part of the brain. If you injure something in your leg, messages are sent from the nerves in the leg, to the spinal cord, and eventually to this dedicated part of the cortex. If this area of the cortex is constantly bombarded with pain messages, the cortex can actually build a type of map of the pain. A worse case scenario of this type of mapping is the phantom limb pain an amputee can suffer. Following this leg pain example, if someone has had a leg removed, they may still feel pain in a leg that is no longer there!
If you think carefully about this you can see that chronic pain is actually an output of the whole nervous system – rather than an input from injured tissues.When this occurs the whole system responds to a lower than normal level of stimulus and the nervous system is said to be “wired up”.
We have all had the experience of something being sore for a few days and then settling down on its own. When this happens your body is actually responding normally – releasing areas of minor local inflammation and returning quickly to full function. In a wired up nervous system, your nervous system over responds creating way more pain for much longer than it should in response to a minor localised spot of inflammation.
Pain responses also pass through the a section of the brain known as the amygdala. This is the part of the brain is involved in emotional responses. The reason pain is linked to emotion is pretty obvious – nature has taught us that pain is unpleasant and things that hurt us are best to avoid. But if the pain message is getting through too easily, too often and with increased intensity, its understandable that the pain will make us irritable and can even lead to a feeing of hopelessness and depression. This is actually one of the key reasons why chronic pain sucks so much and why the video makes such a point understanding your mental state when in pain and/or at the time of the injury.
There are even dietary triggers for chronic pain – gluten being a very well known example. Long term sugar consumption is becoming increasingly accepted as another trigger. However this area is so important it probably deserves its own article some time in the future.
Chronic pain can happen to anyone. In fact for the last year it’s been affecting me too! So I thought it might be worth taking some time to explain my own experiences so that you know it’s all in my head too!
About this time last year, I had to break up a concrete slab in our backyard. Not just any slab but rather an old style slab 10 inches thick with plenty of crushed rock for re-enforcement. In fact when I paid a visit to Moss Vale Hire down the corner from the clinic and explained the thickness of the slab and what was in it, I was told that I was in for a very long day and a very sore back. And he was right. Well partly anyway, the prediction on being sore was spot on but not in my back.
After I used the concrete saw to cut the slab, I tried to break it up with a 32kg jack hammer. The jack hammer was so ineffective that I actually watched a youtube video to make sure I was doing it right. I was – the jack hammer just wasn’t up to the task! So I had to prop the slab up on brick piers and use a running start with a sledge hammer to break it up. My right shoulder went into an acute spasm. Work on Monday was no fun at all. Work on Tuesday was worse.
In fact a combination of training for another martial arts competition combined with work meant that the shoulder pain never really had a chance to settle down for the next several months. Now I know how many of you feel about the type of competitions I enter so before I hear “I told you so”, it was mostly due to work – because the pain almost entirely disappeared over the Christmas break when I continued to train but wasn’t in clinic.
Not terribly surprisingly, a chronic pain pattern set in. Logically I knew that the pain could not be due to injured tissues as it had been way too long for any actual structural damage to remain. If there were any structural damage it would have continued to get far, far worse. Think about it this way, if there was a structural injury – then every time I used that shoulder, it should have hurt exactly the same and become progressively worse rather than having the good days and bad days that typically goes with chronic pain.
To cut a long story short – the shoulder is almost (but not quite) back to normal. The real question is what did it take to get it back to a reasonable working state. First off, through a process of elimination, I determined that it was mostly work that was responsible for the aggravation, the constant forward pressure with the arms out in front doesn’t really give the rotator cuff much of a chance to rest. The spine also forward bends which puts the rotator cuff in an even more mechanically disadvantaged position – similar to that of sitting all day at a desk. This is a repetitive strain injury (RSI) and is a classic type of chronic pain. The tissues are under load, mildly inflamed and are not able to fully heal. Of equal importance however is that the brain over-reacts to the level of actual injury, resulting in a lot of pain rather than simply a mild aggravation. The thing is that once it’s there, the pain is “real” to your brain, in other words it’s real to you!
The first step was to remove some load from the shoulder. So I scheduled in a morning and afternoon break into each work day. Yes this did make it harder to reduce the size of my cancelation list but recognising that you can’t get through the workload you are used to is just a hard fact when you have chronic pain. I no longer take a morning break any more but note that I still go backwards if I don’t have a break in my afternoon session. I also find I have to be very strict with the number of people I see in a day or again, I go backwards fast.
Even more important than rest is to re-pattern the shoulder and upper back movement. By this I mean “re-train” the brain to move the shoulder without pain. Unfortunately this is a long drawn out process requiring a bit of trial and error to work out the best exercises but most importantly a HUGE amount of persistence! For a year now I have done various progressive exercises EVERY day before work. I started out with the passive shoulder pulley that I show virtually everyone with a shoulder impingement. I have moved on to other more technical exercises but seriously that pulley is a brilliant exercise for keeping the shoulder joint mobile.
Constant low grade inflammation also means adhesions can form in the soft tissues so I also use a foam roller EVERY night before bed. I even have a few exercises that I can do very quickly between patients that helps re-pattern the shoulder blade position to take the strain off the ball and socket joint. It’s amazing how much this can relieve the pain. But here is the thing – these exercises are re-patterning the correct movement and can’t possibly be “healing” the tissues between patients, so this adds further evidence that the pain is due to a chronic pattern and NOT to actual tissue injury.
The fact that there is pain with no “real” injury may sound discouraging but it is possible to take another point of view. Every time this works I replace the discouraging thought with another – instead I take it as a validation that the shoulder is indeed improving and therefore I can expect that it will be completely normal again down the track. Brain plasticity works like that – you can take a “negative” thought, replace is with a “positive” and the brain builds new and better circuits. Your wish is it’s command.
This keeps the focus on what you can do rather than how much pain you feel. This is why in clinic we focus so much more on what you can do rather than on how much pain you feel. Think about it this way – would it make a difference to the quality of your life if you could do 3 times as much before the pain stops you? Of course you may not be happy that we can’t magically make the pain disappear but I think you would agree that life would be better if you could enjoy 3 times as much living as you currently do.
The sad fact is that for a variety of reasons, chronic pain is on the increase in society and the answers aren’t clear cut. I would love to be able to give you a magic bullet solution but the fact is that none seems to exist. The good news is however that with persistence and appropriate management, you can get way more out of living even if pain still persists. The only real bit of advice that matters is to never give up!
Rod Harris