Making sense of chronic pain

In this post, I will share my perspective on why the explanations we use to make sense of the patient’s suffering and to justify our choices of therapy, are an integrated part of the therapy.  This means that the words we use ought to be considered a part of the therapeutic intervention, with all the merits and caveats of any other therapeutic intervention.

I’m sure most people today will agree that pain is an experience and that the understanding of the (proposed) underlying processes are complex, multifaceted and not fully understood. In other words, experiencing pain and relief from pain should be a natural part of life. However, it is a completely different beast when pain is no longer relieved and it becomes the driving experience that leads to the loss of life quality, mood changes, loss of socioeconomic status and/or functional limitations.

As a clinical academic, I’m intrigued by complexity and the mystery involved in diagnosing and putting together a plan that could help the person in front of me (aka my patient). My patients sometimes share this enthusiasm for critical thinking and nerdy details, but most don’t. Most patients that I see just want to get rid of their pain and/or return to their lives as they were. While this seems rational and possible in many cases of acute pain, the prospects of curing chronic pain is challenged by the evidence: While many treatments may affect pain in the short to medium term (Artus 2010), pain appears to be a stable phenomenon in some people’s life (Dunn 2013 and Landmark 2019).

In the Lancet-Series on Low Back Pain (LBP) the authors write: “Low back pain is increasingly seen as a long-lasting condition with a variable course rather than episodes of unrelated occurrences” (Hartvigsen 2018). This contrasts with the desire to find a specific trigger of LBP that we can remove, but it may lead us to a more pragmatic approach in which we help the patient recover (or live with) the episodes as they come. To me it means that I need to understand what problem(s) my patient has that they need to solve in order to move forward with her/his life. Initially, Peter felt that it was the pain itself that was causing his frustrations. Or as he said it: “They weren’t there before the pain flared up”. Later on, he started to feel that his frustrations were more related to the way he was thinking about his future; he was afraid that he would lose his job, he felt guilty about not managing his pain better in the years leading up to the recent situation and in particular he was tormented by a feeling of being insufficient as a husband or father due to all his pain related disabilities. As we discussed these aspects of his life, we were able to come up with new solutions to his frustration without changing the pain itself.

There is an increasing focus on pain-related stigma against patients with painful syndromes, such as fibromyalgia. However, some pain syndromes are so common that we cannot comprehend the complexity that they reveal; derangement syndrome, subacromial impingement and overuse injuries are examples. To many clinicians these common syndromes still represent pathoanatomical problems that can be fixed by the right expert. For some patients, this under-appreciated misconception leads to years of searching for a rational explanation or a cure for their pain. I understand why it is attractive for patients and clinicians alike to have a cause, which they can treat. I even think that it is essential that we can name the beast we are fighting. But we should not be misled by it! By this, I refer to the base of evidence that non-specific pain does not need specific treatment schemes to improve (see Karayannis 2016 for example). In the words of Daniel Kahneman:

“The mystery is how a theory that is vulnerable to obvious counterexamples can survive so long. I can explain it only by a weakness of the scholarly mind that I have often observed in myself. I call it theory-induced blindness: Once you have accepted a theory and used it as a tool in your thinking, it is extraordinarily difficult to notice its flaws. If you come upon an observation that does not seem to fit the model, you assume that there must be a perfectly good explanation that you are somehow missing. You give the theory the benefit of the doubt, trusting the community of experts who have accepted it.”

It feels so appealing to accept that Peter’s pain has a ‘physical’ cause (i.e. something in his muscles). But there is no scientific explanation to support that muscles hurt, and the fact that he has used stretching and light exercises to relieve his pain, does not make it any more likely. What his story does tell us is that:

1. He has had low back pain for many years
2. He has been able to manage flair-ups alone until last year
3. Last year he had a sudden increase in his known pain, which forced him to be on sick leave. In the same period a disc herniation at a relevant level was found on MRi, indicating a likely acute inflammation as the cause of his change in pain.
4. No history of nerve root being compromised or of phenotypic changes, however
5. following this episode, he has not been able to control his flare-ups with the tools he had been using before (light exercises, heat and stretching)
6. he’s frustrated and conceptualises his pain as a muscle pain
7. he’s goal is to be able to play soccer with his son for 20 minutes without increasing the pain, and to be able to explain to his work colleagues that he’s fine but sometimes his back hurts and that during these times his pain will flare up if he lifts even lighter weights in awkward positions (which is not part of his job but it is something he’s frequently asked to help with).

In the case that I have used for this post, here are some examples of how I would navigate my patient-education towards a mutual understanding of “what is wrong” and “what can Peter do about it”.

1. Re-ignite Peter’s positive expectations of self-management and validate pain-reducing behaviour, e.g. “You mentioned that exercising helped you before. In fact, I also think that exercising your muscles could be part of the solution. But maybe you need a bit of help to get back to where you were.”
2. Facilitate learning, e.g. “You told me that you keep stretching and resting but that neither seems to do you any good or in fact they may even worsen things. Have you tried to stop these strategies without avoiding resting or moving altogether?”
3. Provide a rationale, e.g. “The pain you feel is not dangerous but I understand that it frustrates you because you can’t control it. Since you were able to control your pain before it flared up, I think you should be able to control it again once you return to baseline. In my experience, and based on what you tell me, this should be possible if you learn to move without provoking your pain.”
4. Build a narrative, e.g. “I noticed that you had a metaphor you used about your pain; it was like a toddler because it cries (hurts) no matter what you do, and you have no idea what’s wrong. So, to use this metaphor, what we think you need to do is a) make the toddler stop crying (they do eventually), and then b) see if we can figure out what you can do without making your back hurt (cry) again. How does that sound for a plan?”
5. Create a coherent plan that includes all of the above, e.g. “To make your pain get back to the baseline level, I think you should try a systematic approach where you combine the things that help (even if they only help momentarily) such as heat and exercise, and avoid the things that may trigger your pain to flare-up.” [this would be structured with drawings, videos, descriptors etc. and include a day-to-day plan until next visit]. “Also, could I ask you to practice your narrative with your girlfriend before the next session? It’s important that you can identify yourself with this narrative explanation, so if you have any questions or doubts, just send me an email.”
6. Address all other concerns. The narrative explanation and the first plan usually have short-term focus because I want to know how he responds to them (both in terms of understanding his pain and dealing with it). But it is important to validate all concerns that Peter has, even if they are long-term goals. In Peter’s case, this meant that we also discussed a prognosis for when and how he could return to soccer training.