What Is Chronic Pain: Can We Prevent It?

What is Pain?

This question likely needs an encyclopedia series to do it justice. There are tons of great books out there, Why Do I Hurt, The Sensitive Nervous System, Explain Pain: Supercharged, Sticks and Stones to name a few, which get into the specifics and strategies of how to help you or someone you know with managing pain. There are also tons of great blogs written by Jarod Hall, Barbell Medicine, Greg Lehman, Bronnie Lennox Thompson, and many others who cover these topics. I hope to further add to this abundance of info about pain, focused on the person who is dealing with pain in an effort to help you better understand what is going on and, I hope, to help reduce the fear that is so commonly accompanied with pain. 

Many of us fear pain. We view it as an enemy, and say things like, “this shouldn’t be happening to me.” Our fear is driven by the unknown. What will happen to us if it doesn’t go away? Is it something more insidious and dangerous that needs further medical workup?

Chronic or persistent pain costs an estimated $635 billion, with a 'B,' per year in the United States. That is more than that of cancer ($309 billion), heart disease ($243 billion), and diabetes ($188 billion). Many factors contribute to this statistic including an overmedicalization of patients, and an overreliance on unidimensional pain measures. Overmedicalization, in a nutshell, is: 1. Unnecessary surgeries, 2. Excessive pharmacological (drugs) intervention, 3. Use of diagnostic imaging when not necessary and 4. Language from healthcare providers that is unhelpful and creates high amounts of fear and distress. There are more types of overmedicalization however the four cited above are most prevalent. Additionally, these are likely made possible due to poor health literacy among the general population. 

According to one study completed in 2016, 50 million people in the United States deal with chronic pain and 10 million deal with high-impact chronic pain. High-impact chronic pain is defined as chronic pain that limited life or work activities on most days or every day during the past 6 months. This is a major public health issue and one that needs to be addressed at not only a grass roots level but at a public policy level.

In this article I will be delving into what pain is, strategies we can use to live well with pain, and strategies we might use to reduce the risk of developing chronic pain in ourselves, and others. 

Let’s jump in! 

What to expect:

Word count: ~4500
Read time: ~18-22 minutes

Key Points:

1. > 50 million people in the US are struggling with chronic pain.
2. $625 billion is spent each year treating chronic pain.
3. Pain is not always due to an injury.
4. Pain is multifactorial including biological, psychological, and social contributors.
5. Social media, friends, family, news agencies, and healthcare providers are rife with misinformation which contributes to increasing rates of chronic pain.
6. Beliefs are powerful. They can lead to intense fear and avoidance of meaningful activities which can contribute to more people dealing with chronic pain and lower quality of life. 

Glossary and important definitions:

1. Nociception:     the neural process of encoding noxious (potentially dangerous) stimuli (heat, pressure) 
2. Pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
3. Biopsychosocial (BPS): The biopsychosocial approach systematically considers biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery. 
4. High-impact Chronic Pain: High-impact chronic pain is defined as chronic pain that limited life or work activities on most days or every day during the past 6 months.
5. Tissue Damage: A lesion of muscular, neural, ligamentous, tendinous, or various other tissue structures of the body.
6. Clickbait: a form of false advertisement which uses hyperlink text or a thumbnail link that is designed to attract attention and entice users to follow that link and read, view, or listen to the linked piece of online content, with a defining characteristic of being deceptive, typically sensationalized or misleading.
7. Biomedical: The biomedical model of health focuses on purely biological factors and excludes psychological, environmental, and social influences. It is considered to be the leading modern way for health care professionals to diagnose and treat a condition in most Western countries.
8. Pathoanatomical: causes of disease based on the examination of organs and tissues.

https://www.jpain.org/article/S1526-5900(12)00559-7/fulltext

What is the purpose of pain?

This is a loaded question as it assumes we can scientifically measure a “why?” behind something. It assumes that there is some sort of justification for sensations we experience. While we can’t necessarily measure this objectively, we can take an educated guess as to why we experience pain. At its most basic biological level, pain is a great asset. It is one of the components of our biology that has helped the human race survive as long as it has. Pain alerts us to danger which then provokes us to act and is an incredibly important evolutionary tool.

Pain alters our actions. If it’s a broken leg, pain prevents us from putting more pressure through the leg and potentially injuring it more. It acts as a protection mechanism. If it’s emotional pain such as a break-up or a friend being unkind to you, then this pain typically results in avoidance, anger, sadness, and ultimately caution when presented with the same situation as we are trying to avoid feeling this way in the future. Pain provides an experience of which we can decide whether we will alter our decisions in the moment or in the future.

Perusing the internet, you’ll find tons of marketing tactics, mainly clickbait, that want to help you “fix your pain,” “rid you of your pain,” “become 100% pain free,” “how to fix low back pain instantly,” and many more. I view these clickbait titles as incredibly unhelpful for a few reasons:

1. They are not realistic. The only thing this does is catch your attention and focus it completely on your pain, not on the meaningful activities that will actually make you feel better. Each person is different; some will improve quickly. Others will require much more time before they see discernible progress. 
2. Pain is only one of the reasons you want help. 
   1. Pain typically only becomes a problem when you can’t do the things you want to do. It only begins to “bother” us when we notice it enough and it distracts or stops us from the activities that are meaningful to us.
3. Inflammatory, clickbait titles like these create their own narrative which is then perpetuated throughout society.
   1. This is the most insidious problem with marketing to people dealing with pain. In order to grab the reader’s attention, businesses will put out sensationalist titles in an effort to get clicks. 
   2. The more people who read the title, share it with their friends and family, and tell everyone about it, tends to then create a false narrative, or a half truth about how to address and manage pain. This then translates into a nationwide or worldwide narrative, although false.

Focusing on point three, above; this is a societal issue. Healthcare providers, the media, and government agencies that perpetuate false and harmful beliefs about pain are likely causing more harm than good. We are collectively perpetuating nocebo’s which is creating more fearful people and more people who now are dealing with chronic/persistent pain.

Nocebo: Adverse events produced by expectations. 

Colloca L, Miller FG. The nocebo effect and its relevance for clinical practice. Psychosom Med. 2011;73(7):598-603. 


Fix... 

I despise the word “fix” when it comes to pain.  It implies pain can be "fixed," when what really need first is to understand our pain. Imagine having an alarm sounding, and not knowing what it meant! It’s an ‘alarming’ experience. Instead of fix, we need to learn how to manage pain when we have it, not fix it. And, more importantly, we must alter our perception of what pain is. Managing pain does not mean that it will never go away, however, in many cases we cannot control how fast or slow our body decides to reduce pain. As is the case with many cases of chronic pain, it may never go away completely, however, it is possible to live well with pain. To learn more about coping and managing, please read some of Dr. Bronnie Lennox Thompsons work. https://healthskills.wordpress.com/coping-skills/

It seems that we view pain as some sort of defect in how we function, that it has no value in our lives, and should it be completely eradicated we would live blissful lives without a care in the world. If we hold this viewpoint, pain becomes the adversary, versus an impartial entity, or an ally. What if instead we viewed pain as an important feature of our biology?

Is it possible that we can view pain as neither good nor bad but rather something that just IS? It’s a challenging thought as this likely goes against our primary belief that pain is always bad. 

Pain is an important part of our biology. Without it, we would not live nearly as long as we do. It protects us from touching scalding hot objects, from staying in ice cold water too long, from stepping on nails and other sharp objects, and protecting a joint that might be injured. As we talked about above, it also changes our actions. Instead of touching the hot pan without an oven mitt, next time you remember to use it. Instead walking barefoot in an area that you’re aware has some sharp objects, you make sure to wear shoes. These are all GOOD adjustments that pain provokes us to do.

Fixing... oh how I love that word...

So… Why Do I Have Pain?

While pain does have a good side it can also have a downside, particularly when it lasts longer than we expect it to even after an injury has healed. Let’s take lower back pain as an example. Typically the course of low back pain with or without sciatica improves dramatically within six weeks of onset. There are, however, a subset of people who don’t improve in six weeks and do end up having persistent pain for months, or even years after they initially started experiencing pain. Assuming all red flags have been ruled out (cancer, fracture, inflammatory autoimmune disease) then we can safely say that one’s back is safe and not in danger of deteriorating or having a disease that leads to complications. But, the question remains, why do people have pain if there is not something more dangerous going on? 

Greg Lehman puts it well when he describes over-amplification of the nervous system. Similar to other sensations in our body, pain tends to become over amplified and this is incredibly common in people with persistent pain. Let’s take hunger for example. Humans can go > 20 days without any food and survive, however the sensation of hunger after not eating for 3-4 hours may manifest as intense hunger pain causing us to eat more regularly. Similarly, allergies pose the same response. We may only be exposed to the slightest amount of pollen yet the allergic response that follows is INSANE. I know this as my eyes get incredibly itchy and my nose begins to run uncontrollably in the spring and early summer. 

When comparing pain to allergies we can see that these same physiological principles apply. There is some stressor introduced, our body overcorrects or overamplifies and then depending on dozens of factors we either return to baseline or stay in an overamplified or hypersensitive state. Some people will stay in this hypersensitive state for quite a long time while others will recover rather quickly. Chronic and persistent pain is a chronically heightened state of the nervous system.

If you’re wanting to read a bit about the more in depth nervous system response to pain modulation, read through this next bit, if not, skip past it as it gets a bit into the weeds and continue reading at “Enter BPS Model.”

Overamplification and hypersensitive; what do these words actually mean? To understand these two words we need to talk about another term, nociception, and contrast it with pain.

• Nociception: “the sensory nervous system's response to certain harmful or potentially harmful stimuli.”
• Or: “detect and protect”
• Or: the neural process of encoding noxious stimuli
• Pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

An example of nociception would be your hand accidentally touching a hot stove. The sensory fibers in your fingertips that are stimulated, due to the extreme heat, have free nerve endings which are then depolarized and send an action potential along the nerve, to the spinal cord, and up to the brain stem. Notice I don’t use the word pain in that sentence. The pain only occurs once the signal has traveled up to our brain stem and the stimulus has become large enough to warrant a response and thus our attention. The response in this scenario is that we pull our hand off of the handle.

As you can see, nociception is a good thing. It protects us from potential tissue damage by causing us to change or alter our movement. 

When Does Nociception Become Unhelpful?

Nociception becomes unhelpful when there is no inflammation, no tissue injury, yet you are still experiencing pain. What we see in this instance is that although there is no significant dangerous incident, the threshold with which the neuron requires to be activated will be significantly lowered, and, descending inhibition from the brain is also blunted. In layman’s terms; the fire gets kindled (lots of nociception) much easier and there is not enough water (from the brain) to put it out. This is where things get a lot more complicated regarding what actually causes this to happen. In a 2010 paper by Wolff, he describes chronic pain as a disease of the nervous system where the peripheral nerves are intact, there is no neuronal lesion, no inflammation, yet someone is still experiencing pain.

In this regard it is worth discussing all of the different aspects that could potentially lead to a chronically or persistently lowered nociceptive threshold and decreased descending cortical inhibition.

Enter Bio-Psycho-Social (BPS) Model of Pain
​

We know that there are physiological processes that take place in regards to nociception and the sending of noxious stimuli (danger signals) to the brain. We know that the brain then must interpret these signals and determine whether they are in fact dangerous or not. The cognitive processing that takes place in this moment is a combination of prior experiences of pain, beliefs about a particular injury, often formulated by friends, family, social media, healthcare providers, and society at large. How much pain we experience and when we experience is impacted by all of these factors and is represented nicely in the graphic seen below.

Much of healthcare still utilizes a biomedical or pathoanatomical approach to patients which primarily looks at tissue damage as a cause of pain. With emerging evidence over the past 30+ years, we now realize that pain is an experience that is influenced by the following factors and not just tissue damage:

Physical/Biological:

1. Nociceptive
2. Injury
3. Trauma
4. Infection
5. Illness
6. Nerve Damage

Psychological

1. Mood
2. Sleep
3. Anxiety
4. Depression
5. Fear
6. Beliefs
7. Coping skills

Psychosocial

1. Relationships
2. Work and Employment
3. Social networks
4. Isolation

Other Factors

1. Drug abuse/dependence
2. Financial difficulties
3. Cultural barriers
4. Litigation
5. Language barriers
6. Lack of health insurance

 


Infographic is from: https://www.pinterest.com/pin/148267012706043918/?lp=true

​While this looks complicated… and it is complicated, it’s also refreshing (at least to me) knowing that although we may experience pain that it likely is not a dangerous occurrence but could be due to a variety of different factors. 

**As a disclaimer, I am not saying there is no such thing as pain that is dangerous. People fracture bones, develop cancer, kidney stones, appendix rupture, tendon ruptures, and much more. These disease processes and injuries clearly are issues that must be addressed quickly.** 

As depicted above, there is NEVER only one input with pain. See the below analogy for an explanation of what I mean by this.

Let’s say you have a cup and it holds 10 ounces of water, or juice, or beer, whatever liquid you like. This cup is representative of your body. As we pour in more liquid, there is a certain point when it will start to pour over the edges of the cup as this cup is not large enough or we just poured too much in. Water is now spilling all over the place and it’s going to take you some more time to clean it all up.

Let’s then compare this to how our body responds to stressors. Let’s say we have 10 points of tolerance before we exceed our threshold. We’ll call these ‘resilience points.’ You add in 3 points of stress due to some difficulty at work, 1 point of stress from your workouts, 2 points of stress from a lack of sleep, 2 points of stress from erratic eating habits, and to top it all off 3 points of psychological stress because your dog got out last night. That’s 11/10 resilience points and you’ve now exceeded your tolerance of stressors. 

In this real life example, when stressors exceed our stress capacity, we are at a higher risk to experience pain. In the event that we are going through a season of life like this it’s important to either work on identifying and reducing modifiable stressors and/or increasing our resiliency to these stressors. 

One example of modifying stressors in the above example would be focusing on sleep quality, identifying the cause of difficulty at work, and putting a better latch on the gate so that the dog doesn’t get out anymore. These are simple modifications that could likely help. 

It’s important to note that this isn’t necessarily a measurable phenomenon at this point in time. We can’t take all the different experiences your are having in your life, give you a questionnaire and then deduce that 50% of your pain is due to lack of sleep. Our science is not there yet. What we do know, as stated above, is that there are a multitude of factors which contribute to how much pain we experience and when we experience it. It is worth exploring each of these factors and adjusting one at a time to see if there is a positive effect in pain levels. 

The Case for Less Fear

Many of us are downright afraid of pain. We don’t want to experience it and we do everything we can to avoid it. When you try to avoid something that is inevitable, when it does occur, the response is usually amplified towards the negative. While this avoidance can be helpful in certain situations, I think we need to learn to lean into that fear a bit, delve into why we fear pain so much and begin reconciling.

In a book i’m currently reading, “The Art of Learning” by Josh Waitzkin, he writes about a similar concept of reconceptualizing pain. Waitzkin is a chess grandmaster and martial arts world champion. In his training, he would routinely need to push himself to new mental and physical limits which required going through tremendous amounts of pain. When describing his training preparing for national or world championships, he would routinely put himself in situations where he knew that he would experience pain. In one instance he described how he would pair himself with opponents he knew would fight dirty, poking the eyes, going for the throat, groin, etc. Knowing that he would experience pain and being exposed to it over and over again effectively decreased his fear when he did experience it. This took time, however his mindset completely shifted once he did not fear the pain any longer..

What I am not saying from this paragraph is that we should repeatedly try to make ourselves hurt, but, that it’s likely a good thing to do things that are hard, that do cause some level of discomfort and pain. When we do this, we can condition ourselves and in turn become more resilient, not only physically, but mentally. A few examples of this are performing challenging mental tasks and vigorous exercise. With individuals dealing with chronic pain, although exercise is usually an arduous task in the beginning, it’s often a great asset in managing pain. It is possible to find types of exercise that one does enjoy and that one is able to complete even if there is some pain in the process. More exercise (that we enjoy) can typically aid in improving sleep, too, which helps manage various other stressors in our lives. Managing chronic pain is obviously more complex than this and these are just some examples and ideas to play with in your own process of navigating pain. 

Another great book that I highly recommend is “GRIT” by Angela Duckworth. In this book she describes how out of all measures, our success in life, is highly correlated to this thing called grit. There is actually a grit scale, you can take the test here: https://angeladuckworth.com/grit-scale/. This test looks at how resilient one is based off 10 questions. She describes many different scenarios regarding when grit is incredibly important, and I encourage you to take a deep dive into this book as it’s applicable to all areas of life. The ability to experience failure, pain, and to keep going is a tremendous skill. This is a skill that can be developed and it’s best if we start this from a young age or as soon as possible.

Society has placed pain and failure in the negative column, that it should be avoided at all costs, and that it is something that needs to be fixed. What we see when people have mindset is that they have a higher likelihood to become more fragile physically and mentally, people who when faced with adversity, are more likely to catastrophically fail as opposed to failing and getting back up. We will all experience adversity at some point in life and I truly believe that if we fail often, fail fast, and learn from our experiences that we will become more resilient, capable, and experience less suffering from chronic pain as a society. 

Conclusion

1. We don’t need to fear pain so much, especially musculoskeletal pain. If we can catch ourselves early and prevent ourselves from going down this dark road of fear and catastrophization it may help us prevent or reduce the risk of developing chronic pain.
2. Persistent and chronic pain in musculoskeletal conditions is typically due to an ovamplication or oversensitization of the nervous system not severe tissue damage. In other words, it’s likely not dangerous (doesn’t require immediate surgery or medical intervention) 
3. There are dozens of factors which contribute to how much pain you will experience and we are not able to measure the percentage contributions of different factors at this time.
4. Sometimes pain is not good or bad, it just is.
5. To reduce the risk of developing chronic pain and its effect on our lives it is a good idea to routinely practice doing challenging tasks where you do feel discomfort. Examples are rigorous exercise, difficult mental tasks, etc. 
6. > 50 million people suffer with chronic musculoskeletal pain on a daily basis and it’s possible some or much of it could have been prevented or the impact of it reduced.
7. Of the millions of people living with chronic pain, it is possible to live well with pain, to reduce the consuming nature of it and to take your life back.

I wrote this article in an effort to shine a different light on pain and to offer a different perspective; not to blame individuals for experiencing pain. Pain is unsettling, especially when it lasts for much longer than we expect and it takes a tremendous amount of courage and grit to live with pain. I commed all of you who have read this who are living daily with pain, it’s no easy feat. 

To those of you who aren’t dealing with chronic pain, I encourage you to examine what pain means to you, how you could think of it differently, and in what ways you can condition yourself to reduce your risk of developing persistent pain.

Please leave comments and questions below, i’d love to hear your experiences. I hope this can be a time of learning for us all.
​

Dr. Nathan Kadlecek, PT, DPT

Nathan is a physical therapist, powerlifter, pain nerd, and is rather obsessed with how to think in better in different ways. He graduated from Harding University with a degree in exercise science and his doctorate of physical therapy from Columbia University in New York City. He is passionate about reducing the prevalence of chronic pain, improving the efficiency of the healthcare system, and teaching people how to lift.

Want to follow me more regularly? Follow me on instagram, facebook, or LinkedIn. If you have a question, shoot me an email!

Fear, success, Confidence: Read More here

References:

1. Dahlhamer J, Lucas J, Zelaya, C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1001–1006.
2. Meints SM, Edwards RR. Evaluating psychosocial contributions to chronic pain outcomes. Prog Neuropsychopharmacol Biol Psychiatry. 2018;87(Pt B):168-182.
3. Duckworth, Angela. Grit: the Power of Passion and Perseverance. Scribner, 2018.
4. Waitzkin, Josh. The Art of Learning: an Inner Journey to Optimal Performance. Simon & Schuster, 2008.
5. Colloca L, Miller FG. The nocebo effect and its relevance for clinical practice. Psychosom Med. 2011;73(7):598-603.
6. Traeger AC, Hübscher M, Henschke N, Moseley GL, Lee H, Mcauley JH. Effect of Primary Care-Based Education on Reassurance in Patients With Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA Intern Med. 2015;175(5):733-43.
7. Bujak BK, Regan E, Beattie PF, Harrington S. The effectiveness of interdisciplinary intensive outpatient programs in a population with diverse chronic pain conditions: a systematic review and meta-analysis. Pain Manag. 2019;
8. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13(8):715-24.
9. St john smith E. Advances in understanding nociception and neuropathic pain. J Neurol. 2018;265(2):231-238.
10. Woolf CJ. What is this thing called pain?. J Clin Invest. 2010;120(11):3742-4.
11. Barsky AJ. The Iatrogenic Potential of the Physician's Words. JAMA. 2017;318(24):2425-2426.
12. Darlow B, Forster BB, O'sullivan K, O'sullivan P. It is time to stop causing harm with inappropriate imaging for low back pain. Br J Sports Med. 2017;51(5):414-415.