When talking about persistent pain, we need to start by clarifying a few things. Take the nomenclature, for instance. You probably think of long-standing pain as chronic pain. Health care practitioners have shifted away from using the term.  "Chronic" has negative connotations and makes patients believe that their pain is cannot be managed or cured.

Persistent pain needs to be defined. Feeling acute pain, which is short-lasting pain that signals some form of threat to the bodily tissues, is a normal part of being alive. Acute pain and the learnings that come from it are essential to our survival. Conditions such as congenital insensitivity to pain (where an individual cannot feel pain) are often life-threatening as the individual lacks the early warning system that acute pain provides.

Persistent pain and acute pain are different and distinct. Persistent pain provides no biological or evolutionary advantage to the individual. It does not help us heal or keep us alive. It is rarely a sign of ongoing tissue damage but rather a sign of threat - alarm bells ringing when they shouldn't be.

Finally, persistent pain is a lot more complex than the current medical model would have us believe. In order to better understand pain we must shift our mindset away from the bio-medical and towards the bio-psychosocial.

Matthew Camilleri is a physiotherapist with a special interest in musculoskeletal physiotherapy and persistent pain management

 

 
An Anecdotal Pain Story

This highlights the power of our mind on the experience of pain

"A builder aged 29 came to the accident and emergency department, having jumped down onto a 15 cm nail. As the smallest movement of the nail was painful, he was sedated with fentanyl and midazolam. The nail was then pulled out from below. When his boot was removed a miraculous cure appeared to have taken place. Despite entering proximal to the steel toecap, the nail had penetrated between the toes: the foot was entirely uninjured."

So what can we learn from our friend the builder? Pain is not a cumulative sum of the amount of damage in the body, rather it is a sum of how much damage the brain perceives is in the body. This may sound complicated but it's really quite simple.

If the body feels highly stressed, at threat and needing to defend itself, then pain will be one of its responses. If the brain believes that there is a threat, the individual is going to feel pain. In certain situations, this can benefit us, even keep up alive. In persistent pain though, this is not the case.

 

Biopsycho- what?

The bio-psychosocial model was proposed in 1977 by George L. Engel in an article in the journal 'Science'. It offered an alternative to the overly medical views of the time. Many prominent clinicians felt that prescribing increasing dosages of pain killers (opioids especially) was having minimal, short-lasting effect on pain patients; masking symptoms rather than treating them. They realised that there must be something else going on, outside of the biology which we had been working so hard to treat.

The model conveys the fact that to understand a person's holistic (overall) health, we must consider their biology (medical input), psychology (emotions, beliefs, etc.) and sociology (family structure, employment, financials, etc.) equally. Each is equally important when trying to figure out why a person is experiences persistent pain.

The implications are that to cure pain, we must consider all three levels and ensure that an individual is healthy throughout, rather than simply being biologically well. Although ever-growing amounts of research point towards this being the case, as far as pain is concerned, the bio-medical model still dominates in many aspects of medicine. I believe that the reason for this is that as health care practitioners we are trained to deal with "red flag" (life-threatening) conditions or relatively easy to solve routine issues. Everything in between scares us tremendously. This results in patients jumping from clinic to clinic, looking for a cure.

"Persistent Pain Has Become Part of my life"

The first, essential thing to realise is that you are not alone. Socio-economically, persistent pain causes a huge burden on society. Let's put this into perspective. Persistent pain costs global economies more than cancer and diabetes put together. More than 20% of Europeans are living with chronic pain.

If you are looking to manage your condition, finding the correct team is essential. I must emphasise the word team. Persistent pain is rarely something that can be managed single-handedly by one practitioner. I suggest avoiding miracle cures which promise to cure your ailments. Rather, inter-disciplinary (multiple practitioners working together) pain clinics are the way to go.

Search for holistic pain management, a process including education, management techniques, review of medicinals, psychotherapy (when necessary) and physiotherapy to promote a gradual return to movement.

At the end of the day, it is quite simple. Pain is less painful when we feel that we are safe. Education, changing beliefs and a return to previous activities (including movement and exercise) are essential.

 

A Few Wise Words....

What happens once our nerves detect a potentially harmful stimulus? Dr. Lorrimer Moseley, one of the world leaders in pain research explains this perfectly.

Once a danger message arrives at the brain, it has to answer a very important question:

"How dangerous is this really?" In order to respond, the brain draws on every piece of credible information - previous exposure, cultural influences, knowledge, other sensory cues - the list is endless.

Pain really is in the mind, but not in the way you think. - Lorrimer Moseley (TheConversation.com)

This helps us begin to understand the complexity of pain. The brain uses all of its resources, past beliefs and experiences to decide if the body should be in pain, or not.