CHRONIC PAIN MANAGEMENT AND TOOLS FOR PAIN FLARES

We have all experienced pain of some sort. That age-old analogy of the hand touching the hot stove, and the brain reflexing the hand away from that hot stimulus as a means of protection still holds true as the most fundamental definition of pain. More broadly speaking pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage (IASP, 2011).

Until recently, pain was always considered to be a symptom of a much larger problem; a small part to a bigger illness. Triumphantly, the International Association for the Study of Pain recognized in 2019 - after a three year national survey - that chronic pain can in fact be an illness of its own; a manifestation without a link to a primary illness.

Pain Overview

To best understand how to manage chronic pain and why so many of us deal with chronic pain, we have to understand the underlying mechanisms and why it has been difficult to diagnose and treat.

Nociceptive pain is a peripheral nervous system response to a stimulus such as an injury, inflammation or an irritant. Examples of this are osteoarthritis, ankle sprains and rheumatoid arthritis. In fact in this category lies endometriosis and adenomyosis. By and large this is the most common cause of pain and can be acute episode if handled quickly.

Neuropathic pain is when there are lesions or disease of the somatosensory system which disturbs the nervous system (and the nerves) directly. This can range from neuropathies (damage to the nerves), to disturbances in nerve conduction (such as complex regional pain syndrome) to viral causes (such as shingles).

Nociplastic pain, commonly known as ‘central sensitization’, is more widespread and is a result of long term manipulation of pain signals which may be facilitated by the removal of a stimulus. However, we see that even after the stimulus is gone the body has increased excitability and decreased inhibition. This third category of pain is one that is very complex, hard to identify and treat, and can involve mechanisms of both nociceptive and neuropathic pain. An example of nociplastic pain is fibromyalgia, which is widespread and very difficult to diagnose. Another example is persistent pelvic pain after endometriosis has been removed. In this latter example, the patient’s pain pathways have been overly excited for so long, the pathways have conformed (plasticity) to receive these signals and have not dampened after the stimulus has been removed.

Under the umbrella of pain, here are two major aspects of pain - motor and psychosocial - which contribute to perception of pain and quality of life.

Motor ability relates to the person’s ability to move; plain and simple. The peripheral nervous system impacts the musculoskeletal system which would significantly impact the way someone carries out their day. From a therapeutic standpoint, motor ability would be addressed by evaluating the flow of movement including muscle tone and contractions, joint movement, and fascia. Within this realm, motor ability would also encompass heat, swelling and inflammation.

Psychosocial aspects of pain are derived from patient experience. The patient’s feedback on lack of sleep, mental health, diet, and lifestyle would be indicators of psychosocial aspects of pain. Someone with fibromyalgia for instance may report low sleep quality, as well as their peripheral pain. As such, addressing the psychological wellbeing and social constructs of a person’s life is just as valuable as addressing the motor capabilities.

Upper back pain

The neck and upper back are large transit areas for nerves to send messages from the brain down to the body, or the body up to the brain. We have to be extremely careful treating upper back pain, as the spine is an imperative component of movement throughout the whole body. The problem we are addressing may be structural (ie, pulled muscle, a pinched nerve) or it may be stress. Regardless, treatment can happen in and around the problem areas to provide more movement, more circulation and activation of the area so that we can reduce pain and inflammation.

Sometimes the pain is felt in the origin of the issue. Sometimes the origin is along the same structural path but not at the site of the pain. And sometimes we just carry our stress in our backs. Each of our practitioners, through their own manual process, can determine where we need to focus on the body to treat your upper back pain.

When stress is the major player rather than a functional issue, acupuncture can target certain areas in the body that can help alleviate the root of the stress itself. In turn, the tension pain from stress is noticeably reduced. For functional issues such as muscle or nerve derived pain, we can place needles in the location where the pain is originating from; not in the locations that pain is felt per se.

Physiotherapy is ideal for achieving range of motion and movement without fearful sensations of pain. When presenting with a neck or back pain problem, we need to identify what your body's current range of motion and strength is in order to take very gradual steps forward. your physiotherapist can help you discover how to feel safe and in control during movement.

Massage therapy focuses on loosening and stretching. More specifically massage therapy can be helpful for headache relief, (migraine headaches, cervicogenic headaches and tension headaches). For migraine headaches we can be helpful in decreasing severity and frequency of migraines but may not be able to have them go away entirely. For cervicogenic headaches we can often eliminate them entirely. Tension headaches are often resolved in a single session. While these nuances and the massage therapy mechanisms behind them are not entirely understood, we do know there is a nervous system component to the tension headaches. If we can get the nervous system to calm down we can be successful.

Lower back pain

The lower back is the junction between the upper and lower body, where nerves extend into the legs, and interact with the pelvic floor. It can hold a lot of weight and tension, which makes it a convenient place for us to keep our stress. On one hand, the sensations we feel in this area may originate right in the hips and lower back. However, since this area receives tremendous signals from the brain, and connects to a variety of different systems it can be hard to discern the origin of the pain. Working with an experienced practitioner is the best way to find the root cause of your lower back pain to treat & manage it effectively.

When stress is at the root of the problem, acupuncture can target certain areas in the body that can help alleviate the root of the stress itself. For functional issues we can place needles in the location where the pain is originating from. When patients seek acupuncture for lower back pain we often see that the root is a digestion issue, which when treated, we often see the patient experiences relief in their lower back.

There is a close connection between the pelvic floor, low back, and hips - understanding how your pelvic muscles are operating may be the key to unpacking the origin of some of your pain. For non-pelvic floor related issues we need to determine your body's current range of motion and strength to move forward. A physiotherapist can help you discover how to feel safe and in control during movement.

Massage therapy focuses on loosening, stretching. Pain in the lower back is often complex and the source can sometimes be elusive. It could be originating in the lower back, the hips, the legs, or even the abdomen. It can be postural, injury or stress related, brought on by unfamiliar movement/exercise, or a combination of these things unique to the individual. This means we have many avenues to explore in terms of treating lower back pain. Regardless of the cause, many people find massage therapy extremely helpful for managing, or resolving their pain in a natural way. Treatments will be re-evaluated and updated as necessary but if we've explored several avenues of treatment without significant relief, or there has been a recent severe injury we would recommend checking in with a medical doctor for a spinal health analysis.

Pelvic pain

Many adolescents experiencing dysmenorrhea have primary dysmenorrhea which is painful menstruation in the absence of a pathology or stimulus. The first line of defense for patients presenting with primary dysmenorrhea is the use of non-specific anti inflammatory drugs (NSAIDs) such as Advil, as it has shown to reduce inflammation and improve quality of life for these individuals. If a patient does not respond well to NSAIDS, it tends to point to secondary dysmenorrhea which is painful menstruation due to the presence of a stimulus/disease such as endometriosis and/or adenomyosis. At that point a patient should undergo further testing including imaging such as ultrasound, and should be referred to a specialist for medical management.

Acupuncture helps reduce inflammation in a specific area of the body and in the whole body overall. It also encourages the body to produce pain relieving chemicals like endorphins and serotonin. As many patients also suffer from bowel issues associated with their cycle, acupuncture can calm the nerves so the bowels can take a break. The use of acupuncture not only assists with the pain, but it aims at balancing out the blood flow during your menstrual cycle and can help with stress, sleep and overall quality of life.

Pelvic Floor Physiotherapy is designed to train the pelvic floor muscles how to contract and relax, while also taking into consideration any issues with bladder, bowel and/or sexual function that may be affecting quality of life. There is a close connection between the pelvic floor, low back, and hips - understanding how your pelvic muscles are operating may be the key to unpacking the origin of some of your pain. Internal assessment and treatment assist in targeting specific muscles inside the pelvis, however non-internal therapy can also be provided based on patient preference.

Massage therapy can help by providing professional guidance and a safe space where we can reconnect with our bodies after periods of disassociation. Therapeutic touch has also been known to reduce feelings of anxiety and improve symptoms of depression, giving a greater sense of being. A massage therapy treatment aimed specifically at stress reduction and relaxation can help our nervous system shift from sympathetic state (fight or flight) to parasympathetic state (rest and digest) and help us feel a little bit better prepared to face the challenges of every day life.

Complex chronic pain

We talk about pain, we talk about chronic pain, and then we talk about Complex Chronic Pain. How do they differ? Everyone has experienced acute pain. The body reacts to a threatening stimulus by moving away from it to protect the body from harm. The mechanism of how this happens is a brain-body connection that behaves without you needing to think about it. When acute pain becomes chronic pain this is due to some malfunction in the body, be it structural or functional; physical or mental. Learn more about chronic pain.

So what about complex chronic pain? There really isn’t even a good definition for complex chronic pain. The term was adopted by the medical system for individuals who do not respond well to the typical methods of treatment for chronic pain. This could be due to body sensitivities, rewiring in the brain-body connection, trauma, multiple issues occurring at once, and much more. Working with your body and learning more about your body are ways in which we can start to discover how to manage complex chronic pain.

The acupuncture approach to complex chronic pain involves treating the root of the issue to help reduce flare frequency and length. We aim to reduce inflammation in the body as well. Additionally, we encourage the body to produce pain-relieving chemicals to provide relief between appointments, and down-regulate the nervous system to reduce your pain perception.

There are many different approaches that can be taken for physiotherapy. When addressing chronic pain, it is important that care is provided using a biopsychosocial and "brain-centric" framework. This starts with discovering new movements that feel safe and gradually progressing at a pace that feels comfortable to you. If you have had past experiences with physiotherapy that have not been the right fit, let’s talk. There are several approaches and we believe in safe movement.

Our Naturopathic approach to complex chronic pain requires a thorough intake of the patient’s history. The key is to look at lifestyle cues that tell us what areas we need to focus on. Bloodwork and other measures can give us a baseline. Then we need to figure out, together, where you are comfortable shifting to natural based methods.