For the Patient – Why is my pain not getting better?

Since starting this blog I have been planning on posting information for patients to read and hopefully provide them some assistance.  So this post is written for patients and is based on the research evidencen presented in this blog thus far.

I thought I might start with a post relating to a question I get many patients asking:

Why is my pain not getting better?

Now this is not necessarily an easy question to answer, but what we (the therapist and you) can attempt is to identify the “factor”, or a “mix” of factors, that might be contributing to your continuing, or worsening, pain.

What are some of the potential factors? Bearing in mind this is not an exhaustive list:

• “A Structural Problem”
  • One of the obvious factors is that patients think they have a significant “Structural Problem” with their injured area.
  • Interestingly in most areas of the body it is more common to NOT have a “Structural Problem”. For example in chronic lower back pain we see that most patients, following scans such as MRI, have an unidentifiable “structural” cause of their pain. In addition the research evidence shows very strongly that disc bulges, facet joint arthropathy and general “wear and tear” are found in people who are PAIN FREE. Up to 85-90% 0f people with back pain do not have a “structural” problem! We also see scans on PAIN FREE people that show things such as tendon tears, “cartilage wear and tear” and “arthritis”.
  • The obvious question that arises from this is:

What if I am in the percentage that do have a “Structural Problem”?

• Interestingly we see that many of these people do well with “conservative” treatment i.e. physiotherapy, medical management etc. and do not need surgery. Interestingly in some cases the pain settles over time and the “Structural Problem” still looks the same on scan……but no pain!
• So for most patients the reality is that they do not have a “Structural Problem”. But the concern of having a “Structural Problem” and the thoughts and behaviours that this can creates (see below) can contribute to ongoing pain.

• “Muscular Issues”
  • This relates to strength, flexiblity, posture etc. These issues are not uncommon and can contribute to ongoing pain. The key thing being that each patient is different and hence will require different “exercises”.
  • An individual assessment is critical in identifying what “exercises” you need to do.
  • Often the key reason that your body has developed these issues is due to factors relating to the thoughts you have regarding your injury.

• “Pacing of activity and coping strategies”
  • Basically this refers to how you undertake activities e.g. work, household duties.
  • Often patients either do too much or too little. Doing too much and continually aggravating pain levels can keep “inflaming and irritating” the painful area. This is often then followed by a period of not being able to do much at all. This type of pattern is often referred to as a “boom and bust” cycle…..excessive activity followed by nothing at all because pain levels are too high. Not surprisingly this approach is not usually helpful.
  • On the other hand, doing too little (e.g. lots of rest) can contribute to further loss of strength/flexibility etc and the “mental” effects of  not doing activities you would normal like to do. This makes it very hard when you then try to re-commence activities again as often the pain returns as a result of the loss of strength/flexibility.

• “Psychosocial and lifestyle issues”
  • One of the great advances we have seen recently in the field of pain science is the effect that psychosocial and lifestyle issues can have on pain.
  • To keep it simple, our brain has systems in place that attempt to “control/reduce” our pain levels. Think of it like a natural “pain medication” system in our body. Unfortunately this system can be disrupted and not work as well, the end result often being worsening of pain. Some of the common “factors” that can disrupt these systems are:

1. Stress
2. Anxiety
3. Depression
4. Fear
5. Poor sleep
6. General health issues

• “Your Beliefs”
  • Via the clever researchers in the field of chronic pain, we are seeing that the “Beliefs” that patients have regarding their pain/injury can have an exceptionally strong bearing on the development of chronic pain. Commonly, but not always, people often have beliefs relating to having a “structural” issue (see above). In addition the “Beliefs” you have might contribute to the “psychosocial” issues outlined above. “Your Beliefs” might be in relation to not only your thoughts but faulty messages given to you by friends, family and even health professionals. These “Beliefs” might make you:

1. Overprotect the area and hence become fearful of moving and using the area.
2. Become negative about not improving.
3. Impact on your mood.

How can I tell if some of these factors above are impacting on my pain?

The first way this can be achieved is by reflecting on your current situation to see if you think some of these factors might be present.  Often people aren’t aware that these “factors” even exist and can impact on pain. In addition I think it is critical to see a physiotherapist experienced in the assessment and management of chronic pain. What they may do is:

1. Ask you questions to identify if any of these types of factors might be impacting on your pain.
2. Give you questionnaires to fill out that ask you questions relating to the factors listed above.

Once the potential factors contributing to your ongoing pain are identified your physiotherapist will begin to give you strategies, and possibly suggest involving other health professionals, to assist.

The next obvious question being what strategies can help? ……..That will be the next post in this series.

For additional information I can highly recommend the following site:

painHEALTH

Thanks for reading.