Treatment of Chronic Pain?

Hopefully anyone seeing the title of this post will not be clicking on it thinking that I have the answers to chronic pain……please note the maze in the cover image and the question mark at the end of the title!

Lets be honest, the outcomes that chronic pain patients are achieving, via all forms of treatment, is really no different than it was 10  years ago. As an example the following statement relates to back pain:

Data from the USA shows that the proportion of physician visits attributed to back pain has changed little in the past decade, but the cost has increased substantially (Balague et al, 2012).

How can we possibly treat chronic pain better?

Lets start with a review of the common factors, or predictors, for development/maintenance of chronic/persistent pain. The following list being compiled from the references at the end of this post:

• Psychological Factors
  • Depression, Anxiety, Somatization, Psychological Distress, “Non-organic signs”, Psychiatric co-morbidities.
  • 35.0% of chronic pain patients have a co-morbid mental disorder.
  • See my The Role of Psychosocial Aspects and Beliefs in Persistent Pain post for more information.
• Cognitive/Behavioural Factors
  • Pain control and perception of the patients control over their pain:
    • Beliefs about the extent to which pain can be controlled appear to be among the most powerful determinants of adjustment to pain or the development of incapacity.
    • High baseline pain intensity (greater than 5.5/10) in acute whiplash patients is associated with greater likelihood of poor outcome.
  • Coping Strategies (active versus passive). Hopefully fairly self explanatory, but I am happy to elaborate.
  • Sleep disturbance – see my Sleep post for information relating to sleep and chronic pain.
  • Fear Avoidance:
    • Please see my Fear post for further information.
    • Factors like pain catastrophizing, self-efficacy, depressive thoughts and physical inactivity are important psychosocial factors known to perpetuate chronic musculoskeletal pain.
    • Pain catastrophizing has been linked to:
      • Pain-related fear, disability, pain intensity, depression, and psychological distress.
      • Amplified pain experiences and disability, back pain chronicity, and inception of LBP in pain-free workers.
    • Fear of movement/(re)injury is more strongly related to decreased performance on behavioural tasks, disability in daily life situations, and work loss, than biomedical symptoms and pain severity.
    • Fear avoidance beliefs are related to subsequent inception of LBP in pain-free people and course of LBP.
  • Patients expectations (beliefs about getting better/returning to work/sport etc):
    • In general, those who believe more strongly that their pain means they should avoid physical activities and abandon normal roles report higher levels of disability than those with opposite beliefs.
    • General outcome/recovery expectations, irrespective of treatment, have been shown to influence outcome:
      • Patients with very low baseline recovery expectations were 3 times more likely to be off work at 6 months.
      • Patients’ who expect their back pain to last a long time, who perceive serious consequences and who hold weak beliefs in the controllability of their back problem are more likely to have poor clinical outcomes 6 months after consultation.
      • Within 3 weeks of the onset of non-specific low back pain, low recovery expectations can identify people at risk of a poor functional outcome up to 6 months later.
      • The odds that adults with acute or subacute non-specific low back pain and negative recovery expectations will remain absent from work due to progression to chronic low back pain are two times greater than for those with more positive expectations.
      • Patients’ perceptions that the problem will last long, that many symptoms are related to their back problem, their weak beliefs about self-control and low confidence in their own ability to perform activities despite the pain, are even better predictors of disability at 6 months than fear avoidance, catastrophizing or depression.
      • Predictors of Recovery at 1 Year:
        • Low levels of fear avoidance.
        • Low levels of functional impairment.
• Social Factors
  • I won’t go into details regarding, these as they are extensive and require an individual post, but I am sure we can theorise why these issues could potentially perpetuate a disorder e.g. increased stress/anxiety and or effects on mood etc. This can create disruptions to the HPA Axis as one example.  Potential social factors being:
    • Socioeconomic status
    • Work status
    • Relationship status
    • Job satisfaction
    • Compensation issues
    • Social support
• Lifestyle Factors
  • Exercise levels – see this post as to why reduced exercise, or lack of it, may contribute to perpetuation of a disorder. General de-conditioning following injury also makes sense to potentially be a factor in persistency of symptoms.
  • Hobbies – as per the social factors section above, a lack of ability to undertake normal hobbies and social activities can create stress/anxiety and other mood issues.
  • Smoking:
    • Smoking appears significantly associated with disorders such as LBP.
  • General Health and Co-morbidities:
    • 55.3% of chronic pain patients have at least one comorbid chronic physical disorder.
    • 68.6% of all persons with chronic spinal pain have another chronic pain condition.
    • 35.0% of chronic pain patients have a co-morbid mental disorder.
    • 87.1% of all persons with chronic pain have at least one of the above listed three forms of comorbidity.
    • The number and severity of co-morbidities does not differ based on the anatomical region of musculoskeletal pain.
    • Co-morbidities such as asthma, diabetes and osteoarthritis appear to be associated with LBP.
    • Obesity appears to be associated with LBP.
    • See my Co-morbidities post for more information.
• Genetics:
  • An emerging topic but there are studies beginning to demonstrate genetic components for disorders. For example the genetic component appears higher for more chronic and disabling LBP than acute and less disabling LBP.

My Thoughts?

So my big question from the above is should we not prioritise screening for, and when present management of, the above negative prognostic indicators?

Two other things jump to mind:

1. There does not appear to be a significant amount of literature that suggests that typical “musculoskeletal” factors (strength, flexibility, motor control etc) are tied into being predictors for development, or maintenance, of persistent/chronic pain. Now I certainly see chronic patients who have “musculoskeletal” issues that are dominant in their presentation and can be successfully treated, but these patients are in the minority. I am sure some would argue that treating “musculoskeletal” factors can alter some of the negative prognostic factors. I don’t discount that, but lets be honest we, physiotherapists and others, have been trying that for a long while now and the outcomes for treatment of chronic pain are no better.  So I contend that it doesn’t work for most chronic pain patients. Nothing wrong with trying it, but set realistic treatment goals and instigate referral/involvement of other practitioners if sufficient progress is not being made.

2. I often hear the view that treatment of pain is the key priority. The argument being that severe pain can cause, or contribute to, the development of many negative prognostic indicators. For example severe pain can cause:

• Fear of movement/activity.
• Poor sleep.
• Poor beliefs.
• Negative views about recovery.
• Anxiety/depression.
• The list could go on….

The view being that perhaps if we can adequately treat/reduce the pain that we can improve the negative prognostic indicators such as fear, and in turn promote recovery. The other way this can be thought of is that the pain creates a “state” such as fear. Adequate treatment of the pain can rectify the fear “state” and promote recovery i.e. “treat the pain, treat the fear”. Once again I don’t disagree with this view, it is well worth trying. What I would contend however is that  if treatment of pain via accepted methods such medications, pain management procedures and allied health was that successful then surely we would be achieving better outcomes than what we are? For an example see my Pharmacotherapy for Treatment of Neuropathic Pain post. Once again, I know examples of chronic pain patients that have responded remarkably to a pain management procedure or medication change but these patients, in my experience, are in the minority.

Conclusions:

Are the above thoughts a solution to chronic pain? Most likely not. But I think it is a way for us to move forward as a profession and treat these patients better with an improvement in success rate.

How we as physiotherapists can treat the factors outlined above is a complete whole set of future posts. For those interested (and not wanting to wait for me to post about it!) I would suggest seeing the Pain-Ed site. In my opinion, this group is leading the way in developing assessment and management strategies for the treatment of chronic pain.

Other additional sites I find very useful are:

painHEALTH

Physio Development

I would encourage you to check them out.

Thanks for reading.

References:

Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91.

Beales DJ, Smith AJ, O’Sullivan PB, Straker LM. Low Back Pain and Comorbidity Clusters at 17 Years of Age: A Cross-sectional Examination of Health-Related Quality of Life and Specific Low Back Pain Impacts (2012). Journal of Adolescent Health.

Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010 Apr 7;303(13):1295-302.

Coronado RA, Alapattu MJ, Hart DL,  George SZ. Total number and severity of comorbidities do not differ based on anatomical region of musculoskeletal pain. Journal of orthopaedic & sports physical therapy (2011) 41;7:477-485.

Ferreira PH, Beckenkamp P, Maher CG, Hopper JL, Ferreira ML. Nature or nurture in low back pain? Results of a systematic review of studies based on twin samples. Eur J Pain. 2013 Jan 20

Hallegraeff JM, Krijnen WP, van der Schans CP, de Greef MHC. Expectations about recovery from acute non-specific low back pain predict absence from usual work due to chronic low back pain: a systematic review. Journal of Physiotherapy 2012;58:165–72.

Leeuw M, Houben RM, Severeijns R, Picavet HS, Schouten EG, Vlaeyen JW. Pain-related fear in low back pain: a prospective study in the general population. Eur J Pain. 2007 Apr;11(3):256-66.

Main CJ, Foster N, Buchbinder R. How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Pract Res Clin Rheumatol. 2010 Apr;24(2):205-17.

Nijs J, Roussel N, Paul van Wilgen C, Köke A, Smeets R. Thinking beyond muscles and joints: Therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther. 2012 Dec 28. pii: S1356-689X(12)00244-5.

Ramond A, Bouton C, Richard I, Roquelaure Y, Baufreton C, Legrand E, and Huez J. Psychosocial risk factors for chronic low back pain in primary care—a systematic review. Family Practice (2011); 28:12–21.

Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain. 2012 Dec 4. doi: 10.1002/j.1532-2149.

Von Korff M, Crane P, Lane M, Miglioretti DL, Simon G, Saunders K, Stang P, Brandenburg N, Kessly R. Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication (2005). Pain 113: 331–339.

Walton DM, Macdermid JC, Giorgianni AA, Mascarenhas JC, West SC, Zammit CA. Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43(2):31-43.