What Is Chronic Pain?

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Welcome to the Back Pain Solutions Podcast – What Is Chronic Pain?

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Introducing ‘What Is Chronic Pain’?

Everyone understands how pain feels but just when does an initial episode of pain become a chronic issue? Why do some people experience pain for sustained periods of time whilst others do not? What are the physiological mechanisms that cause chronic pain, and is that different to acute pain? These are questions we look to answer in this episode of the Smartstrong podcast.

In this episode we introduce chronic pain and how we approach the management of chronic pain, with a particular focus on chronic low back pain. We highlight how some people seem to accept that low grade, chronic pain, is something they just have to live with. We discuss how individuals should work to identify the pain triggers that are contributing to their pain, and how removing these triggers will help to alleviate discomfort by allowing the healing process to occur. As we have discussed in the past, back pain always has a cause, and so understanding how to remove that cause will help you to remove the pain!

Chronic pain is a serious matter

Chronic pain can be very debilitating and frightening. In a number of cases the chronic pain can be related to a specific injury and removing the cause results in resolution. However, in many cases the intersection between pain and injury is more complicated with some sufferers experiencing continued symptoms long after the injury itself occurred. In these cases a 2 pronged approach is required which involves treating any underlying injury directly as well as treating the pain itself.

Our approach involves introducing movements that do not elicit pain, or elicit only very mild symptoms. That movement, in some cases, is minimal but it is important to try to introduce activities and work to build on those movements overtime. A lot of the work involves reassuring patients that specific exercises are safe to perform and whilst they may feel there is some discomfort at first they’re not putting themselves at further risk. This allows patients to see the discomfort differently and start to build movement into their daily activity which will ultimately help with their long term prognosis.

Show Highlights – What Is Chronic Pain

Chronic pain is serious, and it is real. There is often a negative stigma around chronic pain due to the close relationship it has with depression. There is also the stigma around work related absenteeism but the pain often starts with an injury. Appropriate management in the acute phase can help prevent the risk of chronic pain but when it occurs a sensitive approach is required. The patient clearly experiences pain, even if examination doesn’t identify an obvious cause. The key is to introduce activities that are safe for the patient to perform and provide continuous reassurance to support a gradual recovery.

Interview Transcription for ‘What Is Chronic Pain’?

Ben James 0:00
When we’re young, we move with freedom and confidence with a great resilience to injury. Somewhere along the line, we’ve developed poor habits and become more vulnerable to back pain, smart, strong features, evidence based and practical advice to help you take back control of your health and get back to the activities you love. This is your guide to better health through me. So join us as we demystify some of the commonly held beliefs about back pain.build your confidence, stronger back, the smart way.

Welcome back to the smart strong podcast everybody. I’m your host, Ben James and my co host as always, Jacob Steyn. Morning Jacob

Jacob Steyn 0:35
Morning Ben

Ben James 0:37
So last time, we talked about acute pain, and we talked about some of the physiology behind acute pain to try and help the listeners understand just exactly what pain is, particularly as we talk about back issues and back health. Pain is clearly the first thing that a lot of people experienced that gives them the perception or The understanding that they’ve got a problem, and how does that acute pain register? And what do we do to try and manage it? Today we’re talking about chronic pain and chronic pain is a little bit more multifactorial, it’s a little bit more confusing in terms of the research, when does acute pain become chronic? And how do we how to some patients become chronic and get chronic pain? And how do we manage that? And also, we want to touch a little bit about neuropathic pain, which will explain as we go through and how, when that noxious stimuli and that peripheral problem is gone, some patients can go on to continue it and experience pain. Why is that? And what can we do to help those patients that are at that stage? What can we do to help those patients avoid getting to that stage? So Jacob, we talked about acute pain last time and then as I mentioned in the opening chronic pain is a little Bit more confusion in terms of timelines. I know when we were discussing it, there’s some evidence in the research and it’s two weeks some evidence to say when it’s over, over six months, it becomes chronic. But it’s certainly something that we see. A lot of patients will say, they’ve been experiencing pain for maybe months, or even on and off for a year or so. Is that something you get with your patients? And some of the patients that you see?

Jacob Steyn 2:26
Yes, of course, you know, as a chiropractor, we, we we get a lot of patients I think most of our patients are chronic pain patients. Not always continuous, but maybe the same place, being painful for a couple of months and then easing off and then coming back and sometimes just being painful throughout. So it’s something we deal a lot with, and yes, I hope we can give more information to listeners about how we approach this man.

Ben James 3:00
Absolutely, and as I say, we talked last time about the acute pain and how the, the physiology works that peripherally, let’s say we’ve got a problem or, and when we say periphery, we don’t just mean arms legs, we just mean outside of the central nervous system. So back pain for example, is it is an example of a peripheral pain so we might have a disc herniation we get that noxious stimuli. That’s telling the nervous system and ultimately the back to the brain that we’ve we’ve got pain. Now, as we said last time that that acute pain can be controlling is often controlled, initially with some painkillers but we said very much about getting back to movement and and ensuring that we don’t get into that fear avoidance with chronic pain. We’re still experiencing that that noxious stimuli peripherally. So the best analogy again is back to that place. That may have disk pain, or a disc injury that is then sitting at a desk all day. So the first incident occurs, that might be the acute event, let’s say. So you’ve, you might have that, that disc problem ongoing for some time. But gradually, it is recognized as pain, which there’s not necessarily an acute event that causes that acute pain. So some of these terms are somewhat confusing because the acute pain, that is the first pain you experience isn’t necessarily for a member and a significant acute event. But let’s say that over time that disc is becoming irritated. And your first awareness of it is that discomfort in that pain. That’s the acute pain we’re talking about. But over time, if you are then sitting at a desk, for periods of work, or you’re going to the gym after work, and you’re doing those activities that we talked about, that are constantly kind of the analogy being picking scab, you’re going to continually experience those noxious stimuli peripherally, that are going to tell your brain that you’re in discomfort and you’re in pain. So the physiology is very similar, similar for chronic pain. But really, the differences in timing and the timelines of pain. Is that the best way you think, Jacob, to explain it to the listeners, that it’s more a timing than it is a different way of that pain been registered?

Jacob Steyn 5:32
Yeah, I think the main focus on especially the chronic pain situation and how to explain it is looking at what you said, especially the pain triggers. So you keep coming back to not injuring it over and over but hurting the painful place over and over. And that’s how you create a constant stimulation of the the injured tissue. In this case, you Explain the desk for example, by sitting maybe in the posture that’s not good for that disc, the disc is not enjoying that the pressure is on the going. So you have this, this, this constant pain trigger that you’re entering. And so this is not allowing it to heal. So the problem is becoming chronic and like we’ve discussed before already that it’s multifactorial, so they will be other factors also playing upon for example, if you look at diet, your, your, your, your ability to heal through controlling the inflammation in your body, stress, sleep, your overall ability to recover. And so if you keep hammering that pain trigger, in other words, hurting that painful place or that tissue in this case, you’re stimulating the same pathways. So you’re not actually allowing the acute injury, which is what we want to we discussed in the previous podcast, to, to allow your immune system and your body to just go to that place and heal it and and within a few days already experiencing relief and so then we we go into that chronic stage. And like you said, maybe it can be a few days or a few months, it doesn’t really matter if it’s ongoing, it becomes chronic.

Ben James 7:23
Yes, yeah. And I think the the biggest point there is, and often what we find is that, like you said that chronic pain, that low grade pain may be there for some months, some time, or someone might have experienced that acute event that is significantly more uncomfortable, and that almost makes them take more action because of the concern initially, whereas those people with chronic pain center, potentially or some patients with chronic pain tend to have a lower grade pain before they do anything about it, if that makes sense.

Jacob Steyn 7:55
Yeah, yeah. And it’s good you say that not only Being a low grade pain, I think people also get used to the situation. And there’s a sort of subconscious accepting of the situation. And so they’ll be, you know, I have a patient at the moment he’s sitting behind the desk a lot, is his own business. He’s quite driven, maybe mid 40s. And he plays hockey. But when I do my tests, and you know, the he’ll drop test and all the tests that puts pressure through, he’s low back. They’re all positive, and we have some nerve tension going on. He’s so used to the situation. It might have started gradual and never, you know, never gotten really bad, but it’s bad enough to come to me that he’s used to it and he’s just he’s, he’s playing hockey and he’s sitting on a desk and kind of accepting of the situation.

Ben James 8:56
Yes, yeah. And he almost just interprets that as well. This is just part of the work that I do this is the problem I have as a result of that. And that’s just the way it is.

Jacob Steyn 9:06
Yes, yes. And and luckily, what good thing is that he came to me and I could do the test and I can explain to them look, you know, this can progress and get much worse. Or we can actually take charge of it, then we can fix it. But there’s a very good example of months of chronic pain.

Ben James 9:23
Yeah, and I think there’s two, there’s two elements there that I think we we felt were important to cover in, in the podcast here, and that is that chronic pain over time can lead to well, first and foremost, it’s telling us that there’s an ongoing problem. And that problem or that structure that is injured again back, let’s say to the disk. Over time, we can see a exacerbation of the problem where if we’re doing the wrong things, then we can be causing that disk to become worse and worse. As we get older, as we’ve said before that desk, make grisel, etc, etc. But before we’ve got to that point, that pain may become more uncomfortable, it may become more regular, because that disk in itself is getting is getting worse, it’s degenerating more because of the things we’re doing. So there’s one element in terms of the tissue and the structure behind this pain initially, but also the other part of it is the risk of becoming more aware of that pain. And again, back to these multi multifactorial and nature of pain, there is the risk that that pain can become neuropathic, it can become centralized. And what we find there is that the original noxious stimuli and the irritation peripherally may have gone but because of changes in the central nervous system, and we talked last time where those 5% of the dorsal horn in the spine cord before then relayed up to the brain to be interpreted as pain. If there are changes there which research has shown can happen, then general sensation which enters the nervous system at a similar point can then be interpreted as pain and the classic analogy there is the phantom limb pain where someone’s had a serious injury maybe or the The classic example with with regards to phantom limb pain is his suffers in the the war who had to have limbs removed, and they still feel pain in that right leg or that right arm which has been removed. That means the pain is centralized. So there’s two elements here that that are important for us. There’s the removing the constant irritation and degradation of tissue. And there’s trying to remove the risk of this phenomenon of Central sensitization.

Jacob Steyn 11:56
Yeah, central sensitization on neuropathic pain yaquis Called it and yes, just to clarify on that little bit, we were discussed that before, Ben and we said we were not quite sure when exactly and what triggers the central sensitization. But when you have a chronic injury and you, you obviously keep picking that scab and you keep staying within those pain triggers, that gives you pain you have the risk of actually developing the central sensitization. So you have the risk of the chain undergoing the changes in the spinal cord that registers pain at at the place where you originally had pain when you have a stimulus that’s not actually strong enough to give you that painful experience. Yes. And, and I think that’s something that we absolutely want to try and avoid. And we’re going to discuss now what we can do when, when we get there when we get through this situation.

Ben James 12:58
Yeah, and I think The good news really is that the approach is not dissimilar to when you’d have that initial acute pain that you might experience whether that initial acute pain is is significant or whether it’s low, low grade, you’ve initial, you’ve experienced that initial event, you know, yeah, the approach to managing that, as we’ve discussed, is going to be very similar to managing your chronic or your potentially even neuropathic pain. And I think first and foremost, as always, it’s about reassurance and the best treatment, I know, as we’ve said before, is often providing reassurance to the patient first and foremost.

Jacob Steyn 13:46
Yeah, I think the the the approach is absolutely this. It’s absolutely similar. The only thing that we would do slightly different when we have this central sensitize sensitized A patient is will actually be a little bit more cautious and starting to get them move in the right way again, because they will be, like, like you mentioned, there will be a lot of fear avoidance. Yeah, they’ll avoid specific movements because from a little bit of stimulus, they will already have already experienced a lot of pain. So we gotta get the person, we’ve got to get that person to understand that, first of all, you know, these some of these movements or moving that engine area and moving it in some ways would experience would give them more pain than moving in different ways and other ways. And so if they start experimenting with that, and will they need the guidance to do it the safe way, then they can they can overcome that experience of, of pain. From a from a very small stimulus.

Ben James 14:58
Yes, yeah. We’ve almost got We’ve always got to work into the discomfort to a degree, but be mindful of the fact that, that the movements in doing that have got to be minimal and very gradual in terms of the progression.

Jacob Steyn 15:13
Yeah, exactly. That’s it. That’s just have to take care. And then, of course, it’s a building up process. And sometimes it takes time. I’ve seen it take time, maybe take a month, initially to get over that and to desensitize that central sensitisation.

Ben James 15:29
Yes,

Jacob Steyn 15:30
But once the person gets going, then, you know, then you can, you can bond it out, depending on the tissue damage. But it’s it’s very doable, and I’ve seen that many times.

Ben James 15:41
Yeah. And I think that’s the important point there is that, you know, this is absolutely reversible. In it takes some work. It takes some time and you need the confidence and reassurance that what you’re doing is, is right, but with the right advice and with the right activities. You can Absolutely move away from this kind of Central central sensitization a centralized state of of pain. And similarly with, with chronicity, and with chronic pain that may not be neuropathic in nature, doing the right activities and the right exercises will help to relieve or prevent that noxious stimuli affecting that peripheral tissue, which in itself allows that to heal and you’re not picking that scab. So again, you’re able to confidently take an active approach to let those tissues heal to be allowed to then progress to more complex movements and better strength to help prevent recurrence.

Jacob Steyn 16:44
Ultimately, just yet. Yes, and that’s what you want. We want to create that environment where we can heal. And if we look at that environment, what’s the ideal environment to recover and heal? It’s removing the pain triggers. Letting letting the brain know that certain movements we can do with freedom. Understanding how we protect the area, if it would be the low back, especially the bracing techniques. And if we’re going to be picking things up off the ground, or from a low place, and we want to be able to use our posterior chain, the glutes and the hamstrings, we want to transfer the the bending and the work being done not by the back muscles, but by especially the glutes. Yeah, and then we want to look at things like relaxation exercises, and we want to look at, for example, walking, marching would be a very good idea to to get the movement back in there in a very neutral state for the low back. And I think we have to mention also just creating that environment where we’re removing inflammation if we’re in a state of inflammation, so if we’re eating poorly and we’re not getting the nutrients in that we need, especially as building blocks. This is a crucial than we’re already doing, we’re also doing ourselves a disservice in terms of healing.

Ben James 18:13
Yeah, I think that, you know, back to the point of, you know, the multifactorial nature of of pain, you know, often we, you know, you can find the, the vicious cycle of where these issues if someone is suffering from that, that neuropathic pain or even chronic pain, then often the impact of that, psychologically, can have a negative, clearly, which then may mean that they’re not eating as healthfully, and they’re not as motivated by, you know, those other things that that are potentially going to influence and exacerbate the problem. So I think it’s, it’s back to that reassurance and that advice, that movements can be incorporated that can be safe, and I think the point there is that it’s finding those advice and those movements that are not going to exacerbate or cause damage. If you can confidently do an activity again back, specifically to the low back, if you can confidently do an exercise that we know is not going to have a negative effect on the tissue structures of the back, even if that causes some discomfort First, we can be safe, that it’s the right thing for you to do. And it’s going to help down regulate that potential neuropathic centralized state. And certainly, it’s going to help to avoid any tissue irritation, or certainly avoid any tissue exacerbation in terms of again, back to the desk, influencing that discrimination, it’s going to prevent that so you can confidently do these exercises and work into a bit of discomfort. Knowing that those activities mean that that discomfort is going to is going to go away. A time. But it does take persistence. And it does take commitment, as always, as we’ve said, to do, but that active based approaches is so important.

Jacob Steyn 20:12
And I just want to share my own story with, you know, when we look at, especially the fear, the fear of using a specific part of your body, and how strong the brain is actually in protecting that part of the body. There’s a couple of weeks ago, I heard my big toe doing Brazilian Jiu Jitsu, and it’s been recovering. It was pretty bad for about a week, and then it was recovering quite well, in every day after a week I was making a lot of progress when I woke up in the morning was a lot better. But I’m so protective over my toe because it had so much pain that even if my wife would be sitting next to me, I’d be like looking at her feet the whole time to make sure she’s not gonna stop my toe. I just want to say that, you know, the brain, it’s also good for us to understand how certain patients can be so incredibly protective. And I’m still in more or less the acute phase. So if it would carry on, I think it’s something that goes into the subconscious. And we’re not so acute, we’re not so, so aware of it anymore. It’s more a very, it’s more a protective thing that sinks into the subconscious part of your brain. And so you are avoiding these movements without actually thinking about it so much.

Ben James 21:36
Yeah, I know, it’s a great point. It’s a great point, it becomes, like you said, a subconscious mindset that, that there’s that fear avoidance that you’re not necessarily aware of. But over time, that means that, you know, maybe you’re, you’re developing poor habits that are and then, you know, having a negative impact that you’re not even aware of, and it’s kind of Breaking that cycle and, and ensuring that you’ve got the confidence to do the right movements. But, but taking action every day, I think, to ensure that that you’re moving forward because it is so easy to get into that negative cycle and that vicious cycle of avoidance, and all those are the factors that that that can become part of this economy of complex pain management then makes it not impossible, but it makes it more difficult the further along that road you, you become, you become, you know,

Jacob Steyn 22:34
Yeah. And that’s, if you if you enter the sort of subconscious fear avoidance, that’s where we develop these compensation compensator II movement patterns. That that the main thing that we focus so much on and that’s where, for example, you’d have pain in the low back, and all of a sudden the muscles tighten up and the low back. So now we create like What we call a lower cross syndrome. So the low back muscles are taking over their work in the core and the front of the core would, would would would go asleep. And in a similar way would have the glutes actually getting weak. And we get the hip flexors in the front of the hip, hips to become very tight. And so now we get extra and more pressure through the spine and the low back. Yeah, and we get most of this in the hips. And that’s exactly what we don’t want. Yeah. Yeah. And, and that’s what we will also try to avoid with this central synchronization or chronic pain state is those those compensator movement patterns that we develop because of the subconscious avoidance of, of the fear of those movements. We don’t want to initially we don’t want to make because of the initial problem.

Ben James 23:57
Yeah. So I mean, I think the the tech A message there is that, that whether you’re suffering an acute event, whether you’ve had persistent pain over a number of months, or whether even you, you know, you suspect or you fear you may have this neuropathic central sensitized pain. The actual approach is very similar in terms of the movements. We’re going to recommend, again, specific to the low back, as always on this podcast, the actual movements and things that we’re going to do a very similar and there’s the first point in terms of the reassurance is that the approach for those different problems is going to be very similar in terms of the movements and the active approach we want to take. It may be that the intensity and the the number of exercises that are recommended for someone that is suffering that central sensitized state and neuropathic state is a fight. lower than someone in maybe the acute phase or certainly in that kind of chronic low grade pain phase. But the approach is the same in terms of the actions and the movements. Importantly, I think that’s where the confidence should come for the listeners that are either experienced, you know, experience in any number of those states. It is absolutely reversible. Is it absolutely manageable. It may take more time, it may take a more conservative approach for some than for others. But the important message is, if you get the right advice, and you do the right exercise and the right movements and an active approach, which is super important, then the outcome can be the same for everybody. Yep, that’s, that’s it. So I think we’ve talked about a coupon. We’ve introduced current pain and talked about this neuropathic pain. We haven’t gotten too much into the physiology because again, there are blurred lines in terms of when acute becomes chronic, the timelines, how do things get to that stage of Central sensitization, neuropathic pain, how does that occur? Actually, that in itself is not too important for us. We’re not too concerned that the listeners understand that what we want them to understand is that they can get better with the same approach. And I think next time what we want to focus on is diet and pain. And talk a little bit about nutrition and how nutrition can influence pain and how that can influence not just acute but chronic and neuropathic pain so that we are giving the body not just the best exercises and the best movement based approach to heal, but we’re giving it the best environment as a whole and nutrition plays and impact Rolling that so I think the takeaway message for today is whether you’re in acute pain, chronic pain, or you suspect or fear, you may have this neuropathic pain management of that problem, specifically with regards to the back is going to be very similar. It is reversible. It can be managed, it takes effort and dedication. But it can absolutely be achieved by using the active exercise based approach that we recommend and that we support on the website that we have. So head on over to that, take some of that advice and start to introduce those exercises that are recommended to help manage that discomfort. And next time, we’ll talk about the dietary nutrition approach that will help you even further in terms of managing that inflammation but in terms of giving your body the best environment for not just short term but long term recovering. Thanks again, Jacob. The Guys head over to the iTunes to give us a rating helps get the message out will be continually improving our podcasts and adding more content adding more content to the website and over the long term will help improve those back pain sufferers and get you back to the activities that you love.

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