Chapter One

1. What Is Chronic Pain?

First, a bit of bad news: developing an understanding of how the body’s pain circuitry works in chronic pain is no easy task. Not only is the anatomy, physiology, and neurology complex, but there are also several theoretical models of chronic pain—even the experts cannot agree on exactly how the chronic pain phenomenon unfolds.

At best, the explanations for chronic pain that many family physicians offer to most patients are not well understood, in my experience. At worst, they are confusing to the point that patients simply don’t have a good idea of what is going on. More distressingly, quite a number of patients enter a pain management program claiming they have not been given any explanation at all. Some patients report that their perception of the advice they have received seems like an overwhelming tangle of factoids, accompanied by what looks like a near-impossible-to-enact treatment plan, given the low energy level, sleep dysregulation, depression, and anxiety they usually face. It is challenging to develop an interest in and remain motivated by any treatment plan when you have little understanding and insight.

You probably have no wish or will to wade through the various theories and models that have been generated in attempts to explain the phenomenon of chronic pain; if you are interested, you could explore gate theory, the pain avoidance model, the matrix model, psychological flexibility, and several other theories. Just remember that models are not, and don’t have to be, a completely true reflection of what is going on; they merely have to be plausible (likely) or relatively easy to explain in terms of what we already know, and they also have to have utility. In other words, they should be useful in terms of explaining how things may work and expanding our current knowledge base.

If you’d rather cut to the chase, let me share what I’ve taken from those models, all of which have added value to our knowledge and are still discussed today. They also share a common theme: broadly speaking, they call for the same sorts of potential solutions—a multimodal (having many aspects) treatment plan, as opposed to a single approach, a reduction of the patient’s focus on pain and an expansion of their social interactions, physical activity, and self-efficacy (effectiveness).

Here’s what we know. Chronic pain can become worse for patients when they adopt “pain behaviors,” a group of behaviors that include constant reporting of negative detail, a significant reduction in healthy physical activity, and the adoption of pain-relieving postures or protective stances. All of these responses, of course, make complete intuitive sense when you are in pain. Unfortunately, these behaviors also inevitably lead to worsening pain over time, even if you suffer no further aggravation of the original injury.

Studies show that chronic pain patients actually have better outcomes if they do the opposite of what intuitively makes sense—that is, if they keep up their activities, even when those activities are quite challenging. It’s interesting to note that when spouses of chronic pain patients are somewhat less helpful and accommodating, requiring the patient to do more for him- or herself, the patient makes greater progress and generally has a better outcome. Here I am not at all suggesting that they should in any way become indifferent, disconnected, or neglectful as caregivers.

There are theories that further explain this phenomenon. One holds that chronic pain is actually a form of conditioning or learned behaviors; those behaviors are clearly maladaptive (do not serve the person well), even though that is, of course, never the patient’s intention. Another suggests that those new behaviors become ingrained, because with time, pain pathways tend to extend into an area of the brain that is associated with emotion and memory, called the prefrontal cortex.

Now for the good news: what can be learned can also be unlearned. Once we understand what’s going on in our bodies and brains, and the explanation makes sense to us, it becomes easier to find the motivation to correct it. When we know the why, we are more enabled to figure out the how. Sadly, the majority of patients I have seen in programs have not been given an adequate explanation of their disease state.

The Chronic Pain Trajectory

Having performed multiple detailed file reviews, including those of patients with decades-long chronic pain, an obvious pattern soon emerges: behavioral changes precede the other disorders associated with chronic pain, such as hypervigilance (exaggerated awareness of what is going on in one’s body and surroundings), catastrophization (imagining that a trivial negative event in one’s life can have a disastrous outcome), depression, anxiety disorders, and sleep disorders. These changes appear to be consequences of the behavioral changes. Soon after an injury or onset of disease, physicians note on file that the patient appears pain-focused and activity-avoidant, afraid that any effort at engagement of the affected part will result in more pain. They appear hypervigilant when even considering an attempt at activity involving the affected body part, and when monitoring symptoms or mild changes in sensation.

Weeks and months later, these patients display increased catastrophization; their files become filled with their symptoms, fears, and concerns. They report that the pain is getting worse with time, even though they’ve suffered no further injury. They may delay returning to work, and some may never again return to a job.

Still later, long after recovery should have occurred, pain levels rise higher, and the patient withdraws even further from physical activity and demonstrates a reduced willingness and ability to perform activities of daily living, such as food preparation, house maintenance, and personal hygiene functions in extreme cases, which require home care. Furthermore, their sleep has become disordered, they have become clinically depressed, and their anxiety is documented to have increased.

Not only does this withdrawal pattern cause harm, but it also means that these patients neglect or give up almost entirely on the normal, everyday, function-maintaining activities that promote healthy living and recovery. It’s always a tough moment when a patient realizes this; many are saddened to discover that they may have inadvertently had some role in their poor outcome by not having been more active. I remind them that their behaviors are entirely understandable—in the face of increasing pain that does not appear to make any sense, it’s only natural to want to withdraw. When something hurts a lot, you’re going to want to use it less. That’s just how it goes. But this approach cannot be maintained for long. It is also a mistake to assume that all forms of hurt equal harm or tissue damage. Those who have played robust sports will recall muscles strains and pains that plagued them early in the season when they were not yet optimally fit.

We now clearly see that what serves one best during an acute (recent onset) injury such as a broken ankle, behaviors such as guarding the body part and refraining from weight-bearing for a defined period, can quickly morph into an unhealthy choice if continued indefinitely or even over an extended period.

So from a clinical viewpoint, pain focus appears to be a major early driver of chronic pain. This soon leads to hypervigilance, a state in which patients tend to ruminate and constantly, carefully monitor how the body part feels or changes with activity. Even the thought of undertaking an activity is cause for a cautious and constant weighing up of whether they can or should partake in the activity at all. When this very adversarial state of affairs is prolonged, a so-called increased allostatic load (stress burden), or what is really a prolonged “flight or fight” response, becomes established and creates an environment where recovery and healing are difficult to achieve. We see the same pattern in other chronic illness states as well, and this partly explains why the outcomes in these chronic conditions are still fairly disappointing when compared to other medical categories of illness such as acute diseases or surgical conditions.

That state of hypervigilance wears patients down. Several pain patients have told me that the pain itself is not the worst for them. What makes life so hard is the constant dread they feel. Their situation seems to alternate between living with significant pain or, when the pain is more tolerable, living with the dread that yet another flare-up can take hold of them at any time. Therefore, even tolerable pain periods provide little respite, as they never quite know when the next shrill “alarm” will discharge, an event one patient described as “the next bomb going off.” It seems entirely conceivable that dread could itself be a major driver of chronic pain, as the brain is most uncomfortable with uncertainty and will apparently do almost anything to avoid it, according to neuroscientists. Over time, the pain simply gets worse in both intensity and duration, by this point,...