WHAT IS CHRONIC PAIN?

Definition

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. As such, they stated:

Chronic pain is defined as persistent or recurrent pain lasting longer than 3 months.

Mechanisms

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.

Models of pain mechanisms

Under the umbrella of pain, Sluka et al classified two major aspects of pain - motor and psychosocial - which contribute to perception of pain and quality of life. This is an adaptation of the BioPsychoSocial model of pain which states that biological aspects (eg. tissue damage / inflammation / genetics), psychological aspects (eg. mental health) and social aspects (eg. culture, environment) contribute to the overall experience of pain. Here in this model, the mechanisms of pain all fall within the breadth of motor capability and psychosocial aspects.

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.

Therapeutic approach: Literature

As we stand behind scientific validation it is important and interesting to see what outcomes have been repeatable and reliable in literature. Here are some of the finding:

• Sluka et al identified exercise as a multimodal therapy across all pain mechanisms, having a therapeutic outcome across the board. If you continue reading our approach below, it may be helpful to replace the word exercise with movement as it has more of a personal connotation which incorporated individual limitations and goals.

• The literature states that acupuncture has shown to be quite effective for lower back pain, migraines, and has shown almost complete resolution of CRPS. These are just a few of the examples that have been studied.

• Osteopathic manipulation has shown to be effective in functional improvement in patients with migraines; with lowered number of days with migraines, lower consumption of pain meds, lower pain intensity, and lower functional disability. These are just some of the examples of how manual manipulations can aid in the motor aspects of pain.

• Studies have also pointed to the effectiveness of massage therapy - in addition to the musculoskeletal component - on psychological factors of pain. For example, reduces stress and anxiety, while also lowering blood cortisol levels in those with autoimmune disorders, migraines, and rheumatoid arthritis.

Survey Results

While the literature provides guidance on some of the modalities that have proven to be helpful we decided to capture the comments of the Canadian Chronic pain population on what has helped them. Our national survey showed that many of the modalities we offer inhouse are helpful for individuals who suffer from chronic pain and as such we continue to broaden our scope of offerings to fit the patient needs. Specifically, we asked patients who suffer from pelvic pain (+ endometriosis / adenomyosis), fibromyalgia, lupus, ME/CFS, rheumatoid arthritis, migraines, and IBS to comment on management tools that are effective for them.

Our respondents indicated that massage therapy is a very useful tool for chronic pain management. While we did not beg the question, it is likely that massage is being used both for musculoskeletal (motor) pain and stress management (psychological). Acupuncture, Pelvic Floor Physiotherapy, Physiotherapy and Osteopathic Manual Therapy are clearly all useful tools for our patients, but we identify more appropriately on our individual illness pages which modalities are a good fit for that population.

Femade approach to managing chronic pain

From a holistic perspective our goal is to do a thorough intake on a patient to identify all (yes all!) of their medical history, family history, medications, lifestyle, stress and anxiety, mental health as a whole, and all the symptoms the patient is feeling. Based on this information and the patient’s preference, we identify which treatment types would be ideal for this patient. Our decisions are based not only on literature, education, and experience but is founded on patient feedback.

Acupuncture treats many issues. A patient usually comes in with one or two main issues to address. However, the patient will often notice that other seemingly unrelated issues improve. Acupuncture should be done consistently at the beginning to get the most effects. Treatment frequency decreases as the issue improves.

Massage therapy is a modality that is often thought of as being spa-like. The reason behind this imagery is because of both the mental and physical aspects of pain that are targeted through massage. Massage promotes healing of injured/inflamed tissue, acts on the muscles, can work on the fascia, and certainly reduces stress and anxiety. For this reason, in patients with chronic pain, we often suggest treatment through massage to achieve a level of relaxation that helps remind the body how to move and function (a mind-body communication effect) without constantly holding the body in protection mode.

Physiotherapy often comes to mind as a treatment to help recover from an injury, however it is also helpful for individuals experiencing persistent pain or functional difficulties due to chronic conditions or the natural aging process. As the data from the literature above indicates, exercise is recommended to help manage all types of pain. We recognize that a recommendation to exercise may feel out of reach for many people experiencing pain. Instead, we like to reframe it as adding movement to your day, whatever that may look like, in a way that feels accessible and therapeutic to you. We need to identify what your body's current range of motion and strength are in order to take very gradual steps toward your personal movement goals. Seeking this out can sometimes evoke fear - your physiotherapist can help address these feelings and help you discover how to feel safe and in control during movement.

Pelvic Floor Physiotherapy falls under the umbrella of physiotherapy, but specifically targets the pelvis, including the pelvic floor muscles. The pelvis houses an important network of muscles, connective tissue, nerves and organs. Pelvic physiotherapy helps with building awareness of the pelvic floor muscles, lengthening and strengthening them, and working on building habits that can be effective in alleviating symptoms. If you're having pain, your physiotherapist can work with you on desensitizing the tissue. Anyone experiencing issues with their bladder, bowels, vulva/vagina, hips and abdomen could benefit from understanding how their pelvic floor is functioning and what can be done to help improve their symptoms.

The Multi-modal approach is one we are passionate about. Often a patient will find reprieve in a single modality but has underlying issues that can be addressed with other treatment types. Our favourite example is pelvic pain. A patient may gravitate toward pelvic floor physiotherapy as it would address the localized pain as well as breathing and exercises to mitigate pain. Additionally, the patient may also be looking to conceive. With chronic pain at the forefront of their life, it can be difficult to conceive if sexual intercourse is painful, if there is outside stress to have a child, and any other illnesses that may affect fertility. We would suggest layering the pelvic floor physiotherapy with acupuncture (addresses pain, fertility, stress, hormones), and subsequently massage therapy (psychological pain, anxiety, emotional trauma and stress). There are many circumstances in which a multi-modal approach may be useful and we will continue to gather information on outcomes to share with others.

The multi-modal approach, may lend itself to naturopathic medicine which compliments the manual therapies from the inside out. Our naturopathic doctor works in tandem with your allopathic journey to respect the medications and decisions you and your doctor have made. In addition, the naturopathic doctor looks at deficiencies in your body using a variety of tests such as blood work, and then works with you to identify how we can optimize the functionality of your unique body. This isn’t just based on the ‘here and now’, but is based on your own evidence, prior lab work-ups and your specific goals.

Lastly - we round out our service offering by providing patients with a number of mental health services. Namely, we offer patient-led virtual social support groups to those who are looking for a community, and we offer personal one-on-one peer help or psychotherapy for those who need an ear to listen to them. These services are encouraged and are open to everyone.

References

A Comprehensive Review of Alternative Therapies for the Management of Chronic Pain Patients: Acupuncture, Tai Chi, Osteopathic Manipulative Medicine, and Chiropractic Care https://pubmed.ncbi.nlm.nih.gov/33184777/

A Mechanism-Based Approach to Physical Therapist Management of Pain https://pubmed.ncbi.nlm.nih.gov/29669091/

Physiotherapy Alberta Chronic Pain Management: a toolkit for physiotherapists

Chronic Pain: What Does It Mean? A Review on the Use of the Term Chronic Pain in Clinical Practice https://pubmed.ncbi.nlm.nih.gov/33833560/