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Meeting the challenge of treating patients experiencing chronic pain

Posted: Jun 10, 2019 by Cheryl Van Demark PT, C-IAYT

Are you familiar with the clinical pearls from our medical ancestor Hippocrates? He has actually offered the mother of all pearls in understanding how we can strategically apply recent advances in the neuroscience of chronic pain and principles of resilience to our clinical practice: “it is more important to understand what sort of patient has a disease than what sort of disease a patient has.” Over this next decade, patients experiencing chronic pain will become a growing part of your caseload.  I challenge you to examine the extent to which you utilize Hippocrates’ sage advice to act as facilitator and guide to engage with your patient in crafting self-care to optimize their healing. 

 

Can you see the treatment opportunity inherent in understanding chronic pain as a construct of the nervous system?

It is helpful to have some simple ways to explain pain. If the chronic pain experience is a construct of the nervous sytem then a logical treatment approach would be to systematically deconstruct the construct. The literature on the efficacy of pain neuroscience education suggests clinicians should include this approach in treatment. Explaining pain to patients reduces fear of the unknown. The brain receives a multitude of sensory data from both the outer and the inner body environment with a primary mission of moment to moment survival. Our basic biological drive would ideally like to accomplish our survival with the least possible amount of energy expenditure and the most pleasure.  Acute pain is necessary to inform the organism of a possible need for action to avoid harm.  Chronic pain is understood to evolve when repeated attempts at protective actions have failed to resolve a potential threat.

The data being used by the nervous system to inform the construct of a chronic pain experience does not arrive via dedicated “pain tracts” and there is no real estate in the brain dedicated to “pain perception”. The brain constructs a pain experience by integrating sensory data that has been shared with multiple brain regions, including the limbic system and those associated with memory. We can regard all somatic experience as ever changing present moment data on the status of the organism-YOU.

Sensory data is generated from specialized receptors monitoring tissue temperature, chemistry, pressure/load, position/movement. Chronic pain is not dependent upon nociception. It is predominantly modulated by fear, catastrophic thinking and individual beliefs about the reasons for its presence. When the organism fails repeatedly to resolve acute pain, our nervous systems (CNS, PNS, ANS (including ENS/ enteric) must devote additional attention and divert resources toward a now persistent stream of somatic data that the perceptual brain has not successfully assigned to a cause / determined to be a familiar somatic experience. A construct is made in an attempt to satisfy the mind. The unknown is determined to be a threat.

 

How does the body protect itself from real or perceived threats?

The easy answer is that the body mounts a protective response, utilizing the physiology of the stress response (fight / flight/ bite).  We must remember the body’s first line of defense / protection will initially involve activation of the HPA (hypothalamic pituitary adrenal) axis as that which powers our stress response.  This includes mobilizing our inflammatory response and elevating blood glucose levels. When stress response activation occurs repeatedly and without resolution of the threat, as in the chronic pain experience, then we eventually experience immune system suppression.  Deconstructing the construct of chronic pain requires a strategy to reduce the body’s many mechanisms of over protection being generated in response to real or perceived threat.  These overprotection mechanisms often include the following responses. Tools to address these mechanisms can be included in the plan of care to support the pain neuroscience education that explains the chronic pain experience. 

  • CNS Hypervigilance
    • Contributes to sleep disturbance
      • Teach sleep hygiene.
      • Rule out sleep apnea as a significant source for chronic inflammation
    • Alters Breathing Patterns
      • Introduce breath awareness

        Fear of Movement

  • Reframe physical activity as the analgesic it is 

    Take the time to understand what it is the patient fears and how they came to believe this 

  • Catastrophic Thoughts  
    • Find ways to gently reveal these to the patient within the biopsychosocial interview process
  • Elevated inflammatory biomarkers
    • Inflammation can add interneurons that “exaggerate the conversation” between the dorsal and ventral horns and make the CNS more adept at perpetuate chronic pain
    • Increases in circulating blood sugars
      • Promote physical activity as anti-inflammatory
    • Educate and refer for nutritional means of reducing inflammation and use of supplements
  • Chronic muscle tension that becomes active with a perpetuation of our SNS (especially in phasic muscles- RUN!)
    • Teach the relaxation response in addition to stretches, ergonomics etc.
  • Immune system suppression
    • Teach stress coping.
    •  Work with physicians who will explore vitamin and mineral deficiencies
    • Address chronic dehydration
    • Address problematic elimination
  • Mood changes
    • Be aware of the relationship between chronic inflammation, depression and sleep disturbance
  • Hypertension
    • Pain often elevates BP, putting patients at risk for CVA and MI
    • Breath holding is common (and compressive to spine)
      • Teach patients to break these patterns
  • Suppression of Digestion and Elimination from SNS
    • major contributors to fatigue and body aches in these patients

 

Do you train these ABS?: Attend  Befriend Sanctify

We get better at whatever we practice, so I encourage both patients and clinicians to train their A.B.S. through self-care to build resilience. Training the A.B.S. is a tool to deconstruct the construct of chronic pain – or to find ease from any source of our suffering. We can learn to Attend to our sensory experience of our body, breath, thoughts and emotions. Sensing our inner body environment is part of many energy/prana/chi practices. There is evidence that teaching our patients to cultivate such interoceptive skills build resilience. The mechanisms appear related to vasovagal parasympathetic tone. 


It is useful to teach the patient to redirect their attention from the dominating sensory input of the symptoms
(distorted data) and the brain’s self evaluative default mode network, to other aspects of our rich human sensory landscape (inner and outer) that create experiences of sensory pleasure (beauty, wonder, awe). Simple mindfulness tools are utilized. A phenomenon of distorted embodiment involving a type of smudging of the somatosensory and somatomotor cortex can accompany a chronic pain experience.  Helping the patient figure out if such distortion is present can be very helpful in resolving fear of movement.

An unreliable body, one that has become grossly de-conditioned, overweight, not considered sexually desirable etc. must be befriended again as part of our healing process. Repeated experiences of movement as threatening can be gradually disproven to the nervous system. We get better at whatever we practice. Physical activity practiced as a SAFE movement experience deconstructs the mind-body habits of over-protection. (hurt does not equal harm). The patient is also taught to befriend the brain and body using movement to reawaken our amazingly effective neuropharmacy. Finally, the patient’s religiosity or spirituality is welcomed into the treatment plan to sanctify the rehabilitation in ways that align with their beliefs and values.

I hope you have enjoyed collecting some clinical pearls that are immediately applicable to your practice.  As a yoga therapist as well as a physical therapist, I study wisdom traditions and infuse them into my clinical practice and personal self-care. My 35 years of treating patients has shown me that movement matters - quite literally! ( we are comprised of matter and movement alters form and function) The Yoga tradition suggests human form evolves from Consciousness and the collective consciousness of humans continually evolves as we move in creative play with our environment. When we consider the impact of chronic pain and chronic illness upon the scope and quality of movement our plans of care take on a much more broad context.  Intriguing concepts for considering how science might approach the study of movement as it relates to healing of both individuals and societies into the future!