Scroll Tree Osteopathy

I think it’s fair to say that chronic pain is not yet well understood.  It’s not well understood by both our health care professionals and by the patients who find themselves diagnosed by conditions such as fibromyalgia, chronic fatigue syndromes, and chronic pain syndromes.  This is partly because we are still accumulating research on the specific mechanisms involved (and there are many), and because chronic pain tends to be illusive in symptomology and difficult to quantitate.  It confuses health care professionals and frustrates patients.  The purpose of this article is to help clarify what roles that health care practitioners and patients play in the treatment of a chronic pain complex.

What exactly constitutes as a chronic pain condition?  Addison (1984) calls chronic pain syndromes (CPS) a psychologic-physiologic disability.  That is to say, there is both a psychological and physical component to the various disorders that fall underneath the umbrella of chronic pain syndromes.  Their etiology is not well understood as it varies from patient to patient depending on their health history and life experiences.  Typically, chronic pain can be defined as pain and dysfunction that is ongoing for months or years even after the initial injury has healed.

What we do know is that most cases of CPS involve a complicated health history on the part of the patient, they involve most of the body’s systems (such as the nervous and endocrine systems), and they do not respond well to conventional medicine.  The symptoms are wide ranging, seemingly unconnected, and persistent.  Symptoms often include physical discomfort or pain, fatigue, sleep disruption of some degree, and are often accompanied by a psychological component such as depression and/or anxiety.  It can be overwhelming for both health care practitioner and the patient to determine how to proceed with treatment. 

To clarify some of the confusion around the physiology of chronic pain, we will start at a basic level:  

What exactly is the purpose of pain?  Pain is the body’s way of communicating with us.  It is fairly straight forward at first and relatively cause and effect: You stub your toe, you feel an immediate response.  You burn your hand on the stove, you feel the pain and remove the hand from the hot surface.  Simple.  That’s what we call nociceptive pain.  It’s job is to protect us and keep us safe.  On a nervous system level, it is the collection and reaction to somatic (sensory) stimuli. 

Next in line we have neuropathic pain.  Neuropathic pain is a little more severe.  It occurs when there is a disruption in the communication between the peripheral nerves and our central nervous system.  Disease or damage to the nerves results in an elevated response to stimulation.  We see these dysfunctional  issues with problems such as diabetic neuropathy or spinal stenosis.  A very common example would be the chronic nerve pain left over from a past herniation at a spinal level.  Some patients never regain a ‘normal’ feeling in their leg or foot following a lower lumbar herniation, for example.  They often have radiating pain that never goes away.  Neuropathic pain is when damage or impingement to a nerve magnifies our perception of normal stimuli.  In this case, it is not quite cause and effect like nociceptive pain.  There is an exaggerated response.

Even more complicated, we can also experience what is called central sensitization of the nervous system.  This is where we really start to get into tricky territory with pain.  In this classification, we start to see very irregular responses of the nervous system to normal stimulation.  This is because the actual central nervous system (brain brainstem, and spinal cord) have been irritated to the point of making changes in its hardwiring.  In layman’s terms our circuitry gets mixed up and messages get blown completely out of proportion.  What would normally not be a big deal (like stubbing a toe) turns into a 2 week complete flare up.  This is advanced chronic pain territory.  This explains why a chronic pain patient can be feeling well for a month and then flare themselves into oblivion by doing something as simple as vacuuming their living room or scrubbing their bathtub.  The patient rarely gets to this point without experiencing multiple physical and/or psychological traumas over a series of years.  Most severe chronic pain patients have a laundry list of trauma ranging from car accidents to surgeries to divorce and other significant emotional trauma.  For some it is a result of a disease process.  Whatever it is due to, it often presents in similar ways.  They are left exhausted, in pain, and trapped in a dysfunctional body that doesn’t follow the normal rules of conduct.

With central sensitization syndromes there is a huge fatigue factor as well.  This is because the body is exerting so much energy trying to stay semi functional that everything exhausts the patient.  Sleep, however, is difficult to attain and not restful in many cases when it does occur.  This is partly due to the irritated brain stem.  The brain stem is the messenger between the brain and the rest of the body.  It also controls our ability to change our state of consciousness.  This is why sleep disruption is such a large part of many chronic pain syndromes.  Because the patient experiences moderate to severe sleep depravation, this further irritates and facilitates the nervous system.  In advanced cases of chronic pain, the patient is stuck in a self maintaining reflex loop of dysfunction.  Because our muscles get their ‘electricity’ from our nerves, they often also get irritated and sore as a response to the neuro inflammation.  Furthermore, stress hormones such as cortisol and adrenalin are released to combat the invisible foe.  Prolonged exposure to these stress hormones burn out our glands and fray our connective tissue.  Normally auto regulated systems start to suffer, leading to digestive issues, sleep problems, fluid retention, blood pressure issues, etc.  At this point, every system in the body is getting involved but none of them are talking to one another.  It is, essentially, mass chaos.

In cases of central sensitization, the client is often drowning in a self perpetuating loop of pain.  It is daunting for their team of health professionals to know where to begin to sort things out.  To the health care provider, they see all the systems in an seemingly unrelated state of distress.  Most treatment at worst flares their patient, and at best provides short term relief.  So what can we do, as health care professionals?  And what can the patient do to take an active part in healing themselves? 

Continued in ‘Part 2: The Pain Body and Perception’.