Journal of the Physiotherapy Pain Association Page 7

Author: Oldfield G

Affiliation:Physiotherapist & Founder of SIRPA.

Email: georgie@sirpa.org

20 years ago, I was becoming increasingly disillusioned with how little we could do to help people with chronic pain. I couldn’t understand why we were only expected to be able to help people ‘manage’ their pain, especially when they were only in their 20’s or 30’s for example and/or no physical cause could be found. No wonder so many Physiotherapists tell me they aren’t keen to work in this field. Personally I was frustrated and felt there must be something more we could do. As Physiotherapists our role is to help people, but to me helping people live with their pain was not good enough.

Gradually, over time I began to question the various anomalies I was noticing between how a patient presented and their diagnosis or the findings from their test results. For example, so many people were presenting with persistent pain following a minor RTA or other accident and/or with no obvious physical abnormalities, even on scans. I was also treating people with chronic back pain and/or sciatica who had been advised to have surgery for a prolapsed disc or spinal stenosis, yet they fully recovered following my very gentle treatments. I was pleased, but bemused at the same time. I had also begun to notice how many patients presented with acute pain onset after doing something completely innocuous or something they usually did without any problem. In fact, numerous clients couldn’t pinpoint any specific cause for their pain and if they had woken up with pain they blamed it on their pillow or mattress, despite sleeping on them for months of years without problem.

I attended a few well-renowned biomechanical courses and I had also jumped on the ‘core stability’ bandwagon in the early days. I attended a Pilates course for Physiotherapists to learn how best to help my patients, yet I did not observe any additional benefit to what I was already doing. In fact, on leaving the NHS and setting up my own private pain clinic, many of the patients I took on had already been working on their core stability for months or more with no easing of their pain. When they began to respond to my treatments without focus on specific exercises, it made me question even more what other explanation there might be for their pain.

I spent months researching and reading, discussing the situation with colleagues and trying to find an answer to what I was observing. I was able to relate to this personally too because over the years I had been experiencing an increasing number of health problems, including recurring episodes of: back pain, sciatica, neck pain, thoracic pain, plantar fasciitis, headaches and other joint problems.

I would always blame something physical on the pain onset, whether that was opening the garage door (even though usually I did this every day with no problem!), bending over to pick up something or sitting at my computer for too long. I put my recurring back pain and sciatica down to all the manual handling I had done prior to the introduction of the EEC manual handling regulations and I believed somehow my back must be damaged – even though I would go months with no problem at all. I also believed my recurring knee pain and neck pain were due to a skiing injury and a horse riding accident respectively, despite them occurring decades earlier. I was also told time and again by colleagues and other therapists I saw over the years that the various pains were due to slight leg length discrepancy, poor posture or sitting at the computer too long etc but no treatment, nor anything I did myself to try and address these, helped at all.

Inattentional blindnessMy Physiotherapy training and the culture around pain for decades has been based on it being a physical problem, which clearly therefore requires physical treatment approaches. With my focus on this, why would I even consider that there might be something else at play, especially as I was completely unaware of the evidence which contradicts this theory? Interestingly though, there have been studies demonstrating how easy it is to miss things that might be right in front of our eyes when our focus is on something else, called ‘inattentional blindness’.

Many people have heard of the selective attention study1 which asks people to count the number of times one of the teams of players pass a basketball amongst themselves. However, while they were focusing on the members of the white team passing their ball, about 50% of people actually miss a man in a gorilla suit walking right through the players, pausing in the middle of them to pound his chest and then continue through them. I’ve ruined this for you if you haven’t seen it, but it’s fun to show it to family and friends and see their reaction.

In 2013 they undertook a similar study2, but this time they asked 24 radiologists to perform a familiar lung nodule detection task and for this study they inserted an image of a gorilla, 48 times larger than the average nodule, into the scans of the last case. 83% of radiologists did not see the gorilla, despite eye-tracking revealing that the majority of the those who missed the gorilla looked directly at the location of the

CHRONIC PAIN: IMPROVING OUTCOMES BY ADDRESSING

THE HIDDEN CAUSES

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gorilla. I would suggest that when our focus is on looking for a purely physical explanation for our patients’ pain, we are likely to be missing other factors that might well be very relevant.

One of the first patients I clearly remember from about 2002 was a 79 year old lady who presented at a multidisciplinary clinic I was involved in. Looking back there was definitely something going on to explain her sudden onset of debilitating pain, but we were unaware of it at the time. She walked in holding on to her daughter’s arm because, when she was weightbearing, the soles of her feet were so numb that she couldn’t balance. She was also complaining of debilitating back pain and bilateral sciatica. After her examination by the Consultant Geriatrician she was referred for MRI scans and other suggestions were made, including for me to do a home visit and provide her with a zimmer frame. I also suggested that I treat her with a very gentle therapy I had begun to use which is a specialist reflextherapy treatment used specifically for spinal pain. The Consultant agreed, although expressed his concern that it was unlikely she would show any benefit because it was clear from her objective signs that she had severe spinal degeneration.

In fact, about 6 weeks later her MRI scan report showed that she had “Widespread degeneration throughout the lumbar spine with almost total effacement of the epidural and CSF signals at the L4/5 level, confirming subtotal spinal block”. Surgery had been discussed, but dismissed, because of her age and the severity of the multi-level spinal degeneration shown on the scans. However, by this point the lady’s symptoms had resolved completely and she had become completely pain-free and independently mobile again.

The Consultant was shocked when he saw her and decided to use her as a case study at a meeting with the hospital’s team of Radiologists, who would not accept that reflextherapy had ‘cured’ her or even that she had no symptoms. Eighteen months after I discharged this lady I wrote her up as a case study for the ACPIRT special interest group and on getting in touch to check her outcome at this point, she confirmed that she was still well with no pain.

I must admit that at the time I believed her pain had resolved as a result of my treatment. Having said that, both the Consultant and I were bemused because spinal degeneration to that extent would have been developing over a period of decades, yet she had only had pain for 10 weeks in total. Although at the time I had no real explanation for this, later I will explain why I believe her pain presented at that point.

Moving on from a biomechanical approachIt wasn’t until around 2005 that I began to realise that maybe

stress, our emotions and our mindset might be playing a significant part in the triggering, and then the perpetuation of, chronic pain conditions. After a lot of reading and researching to try and find an answer to all the anomalies I was observing, in 2007 I came across the work of John E Sarno MD, a Rehabilitation Specialist at the New York University School of Medicine3. This was an epiphany for me and as I began explaining this to more and more of my patients, I frequently observed lifechanging results with patients whose pain I had only been able to help them manage up to that point.

I began to believe that this approach had huge potential in the treatment of chronic pain conditions and was determined to find out more. With no-one on this side of the Atlantic to learn from, I contacted Dr Sarno who allowed me to visit him, shadowing him as he worked with his patients. This was the start of a complete change in the way I understood and worked with chronic pain. It also enabled me to at last focus on helping my patients recover and regain their lives, rather than just helping them ‘manage’ their pain.

Due to his controversial work, Dr Sarno was ‘like marmite’ and in fact despite his outstanding patient outcomes over a period of more than 40 years, he was ostracised by most of his colleagues after he began to realise that, where any serious tissue-damaging condition had been ruled out, chronic pain was nearly always psychophysiological and part of our primal ‘fight or flight’ response. As he was a clinician, any studies undertaken to demonstrate his clinical outcomes were retrospective and not rigorous, double blind and random-controlled, which means that his work is still frequently not taken seriously. Due to the lack of evidence at the time Dr Sarno was also unable to explain clearly what was happening in the body but thankfully, with the growing evidence in the pain science field, this is becoming clearer and is demonstrating the unequivocal links between chronic pain and stress, emotions and beliefs.

Thankfully after my visit to him in 2007, there was enough interest by health professionals in his work worldwide for a conference to be organised which allowed us to start discussing how we could help develop this approach, begin some research and raise awareness amongst the medical world and the public. The past 10 years has seen awareness expand through the publication of a number of studies4,5,6 looking at the use of an emotional awareness and expression therapy (EAET) for chronic pain, plus two documentaries and numerous books (including my own7).

Currently there is also another study being undertaken, alongside world-renowned neuroscientist, Tor Wager PhD, which is looking at the use of EAET for chronic pain. fMRI scans are being used to monitor any changes in the brain

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before and after treatment and from what I hear results are already demonstrating that changes known to occur with people in chronic pain, are reversible. Another documentary is also being produced alongside the study, which is following the progress of some of the participants in the study in order to demonstrate a more personable insight.

Pain experience has been shown to be strongly modulated by interactions between ascending and descending pathways8. Through fMRI scans of the brain and nervous system, studies9,10 are demonstrating that negative emotions, anxiety, ruminating and anticipation can exacerbate pain, plus one study11 demonstrated that in the brains of people living with chronic pain, the activated areas are not in the somatic regions, but the limbic region. Tor Wager PhD and his team hope that their study could be the first to demonstrate that the neuroplasticity related to the changes to the brains of people living with chronic pain can be reversed, as their pain resolves.

As someone who has followed Lorimer Moseley’s12 work for many years, it is pleasing to see how his work has helped our understanding of pain science and to observe the direction his own work has gone, in the past 10 years especially. Both his research and Peter O’Sullivan’s13 work integrates beautifully with the understanding in our field, yet I believe there still needs to be more emphasis on the impact current and past traumas and repressed/avoided emotions have on the triggering and perpetuation of chronic pain. Unfortunately, I would suggest that these are areas that tend not to be asked about or addressed by the majority of therapists and Doctors in the chronic pain field.

Widely accepted approaches to pain management When we consider some of the widely accepted approaches to chronic pain, we can begin to see why a Cochrane14 review that looked at effect sizes of treatments for non-specific LBP compared to no-treatment comparison groups, concluded that ‘there is a dire need for developing more effective interventions’. This might have been published in 2007, but I feel we still have a long way to go for an effective treatment for chronic pain, with the emphasis on recovery, to be widely accepted and utilized.

To begin with, despite the introduction of the EEC Manual Handling15 regulations in 1992, which focused on there being a physical cause for musculoskeletal conditions, there has continued to be an increase in neck and back pain. In fact, in 2012 there was a study16 that reviewed impact of proper manual handling techniques in over 21,000 subjects and they concluded that there was ‘No evidence that training and provision of assistive devices prevented LBP (Low Back Pain) when compared to no intervention, or another intervention’. This is a huge and

complicated subject in itself and no doubt it will take many years before there will be any significant changes to this, for a number of reasons.

Also, in 1992 the Health and Safety Regulations17 were published which included the display screen regulations. Again, despite trying to improve workers’ posture and physically how they work in an office situation, there has continued to be an increase in musculoskeletal conditions, including RSI.

Sadly there is also evidence that many commonly used treatment approaches for chronic pain are not as effective as was once thought, yet they are still commonly in use. A few of the main ones are listed below with some of the evidence.

Opioids The current opioid crisis is a case in point where one study18 concluded that morphine was no more effective than paracetamol, NSAIDs or placebos and often even induce hyperalgesia. Another study19 stated that ‘The effectiveness and safety of long-term opioid therapy for treatment of Chronic LBP remains unproven’.

Spinal InjectionsSpinal injections have also commonly been used for chronic back pain, yet studies20 now show that there is insufficient evidence to support the use of injection therapy in subacute and chronic LBP. Even when used for radiculopathy, any benefits from epidural corticosteroid injections are small and not sustained21.

Spinal Surgery In a study in 200922, they concluded that ‘Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials’. And for non-radicular back pain, they found that fusion was no more effective than intensive rehabilitation, yet in many places fusions are still being used for this type of pain.

Another study23 found that in subjects going through work compensation, lumbar fusion for disc degeneration or herniation and/or radiculopathy was associated with increased: disability, opiate use, prolonged work loss and poor return to work.

CBTCBT is commonly used in pain ’management’ clinics and is widely believed to be the best psychotherapeutic approach, despite the lack of evidence supporting this. It clearly has it’s strengths, but these two review articles24,25 challenge the use of CBT as a ’one size fits all’ approach.

Lack of correlation between physical findings and chronic pain When we consider the evidence related to the normality of spinal degeneration as we age, including prolapsed discs, then it becomes clearer why some of the interventions mentioned above aren’t as effective as might be expected. Thankfully the evidence around this topic is becoming more widely known and accepted these days. However, 15 years ago I had so many questions and at that time I didn’t have the answers and was also not aware of the mass of evidence which has been unable to find a link between the amount of pain someone presents with and the degeneration found on their MRI scans.

For example, one study26 looked at the prevalence of lumbar disc herniation, annular fissures and nucleus degeneration in a group of asymptomatic people with an average age of 46. Their findings were that the prevalence was 81.4%, 76.1%, and 75.8% respectively. In a similar study27 by the same researchers, but this time looking at the cervical spine, the figures were even higher at 81%, 85.9% and 95.4% respectively.

Another study28 from Japan, also published in 2013 concluded that ‘MRI showed degenerative changes in both the lumbar and cervical spine in 78.7 % of the (asymptomatic) volunteers, demonstrating that this is common in healthy people”

Add to this the findings of a study29 that demonstrated that the degree of disc displacement, nerve root enhancement or nerve compression in MRIs did not correlate with any subjective sciatic symptoms and we can begin to see why we needed to move on from the confining biomechanical explanation for chronic pain.

In an article written by Osteopath, Eyal lederman30, he reviewed how science is challenging the postural, structural, biomechanical model related to lower back pain. The points below were his main findings and certainly backs up the growing understanding that we as clinicians must move our focus from just the physical when people present with pain.

• Postural-structural-biomechanical (PSB) asymmetries and imperfections are normal variations — not a pathology.

• Neuromuscular and motor control variations are also normal.

• The body has surplus capacity to tolerate such variation without loss to normal function or development of symptomatic conditions.

• Pathomechanics do not determine symptomatology.

• There is no relationship between the pre-existing PSB factors and back pain.

Another area that is often publicly discussed, is the onset of pain in adolescents, which is often blamed specifically on them carrying heavy bags, sitting for long periods, poor posture and lack of physical activity. I’m sure these are all relevant, but as the following study’s findings demonstrate, not the specific cause of their pain. They looked at low back pain in adolescents aged 15-16 years old and they found that the occasional low back pain reported by 38% of the children was not related to posture, spinal mobility or physical activity31.

Moving on from the spine, the following studies also support the findings that there is no link between pain and physical abnormalities found on MRI.

For example, in a group of asymptomatic people in sports teams, a significant number of individuals had degeneration, yet were playing at a professional level with no problem.

• 47.5% of professional basketball players had articular cartilage lesions in the knee32

• 77% of hockey players had MRI findings of hip or groin pathologic abnormalities33

• 40% of the dominant shoulders of a team of baseball players had partial or full thickness tears34

Whiplash Associated Disorder – an epidemic Another major problem in the UK is whiplash, which is of epidemic proportions, despite significant money being spent on trying to tackle the issue over the years. There is growing evidence though that this is more of a psychosocial problem, than a physical one. For example, studies investigating whiplash in Greece35 and Lithuania36 would support this because despite having less safety regulations for cars than in the UK or US, they found that persistent whiplash associated disorders are almost unheard of in those countries.

Another study which looked at the significant rise in back pain in the former eastern Germany37 after the Berlin wall was taken down might begin to explain this, suggesting that back pain is a ‘communicable disease’ and related to beliefs, attitudes and behaviours. The former eastern Germany was found to have had significantly less back pain within the population than the former west Germany, yet within 10 years the levels in eastern Germany had risen until they were almost identical.

According to the previous studies, it seems that in Greece and Lithuania there is no preconceived notion of chronic pain arising from rear end collisions, whereas I would suggest the opposite is the case in the UK and the US, with significant fears related to potential problems after a crash.

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Unless you are a demolition derby driver in the US it seems! In a study38 of 40 demolition derby drivers only 2 had had neck pain lasting more than 21 days, despite them having had an average of 156 collisions!

This does seem incredible, unless maybe persistent whiplash is a psychosocial problem? Demolition derby drivers deliberately crash into each other for fun and do not have any fear about whiplash or injuring themselves and when you consider some of the factors involved in why pain becomes persistent (below), this begins to make sense.

With the evidence showing that anxiety, fear, anticipation and ruminating exacerbate pain, we can see why the following study39 was able to predict who would have pain a month after a placebo, low velocity, rear-end collision.

Their findings showed that:

• approximately 20% of subjects had whiplash symptoms, even though no biochemical potential for injury existed

• certain psychological profiles placed an individual at higher risk for the phenomenon 4 weeks after the placebo collision, and

• symptomatic volunteers had been predicted with 92% accuracy by the initial psychological profiles

This certainly indicates that we should take into account our patients’ personalities when assessing them. This is supported by a study40 of women living with fibromyalgia where they found that life events were experienced as more negative than the life events experienced by the healthy controls. Cognitive behavioral therapy (CBT) can certainly help with this, but the other finding from this study was that stressful life events in childhood/adolescence and in adulthood seemed to be very common, which is not addressed through CBT.

Current stress and pain When we consider stress in general, the following studies considered all aspects of the subjects’ lives, including biomechanical, psychological and social and their findings were that psychological stress plays a major part in predicting the onset of musculoskeletal pain.

• 2,808 employees from 28 organisations, were tracked for 2 years. Conclusions: ‘the most consistent predictors of back pain were lack of ….decision control, empowering leadership and fair leadership.’41

• Nursing students were studied every 6 months during their 3-year training and a year later. Conclusions: ‘Other than a history of LBP, pre-existing psychological distress was the only factor found to have a pre-existing influence on new episodes of LBP.’42

• Work stress and incidence of newly diagnosed fibromyalgia: prospective cohort study. Conclusion: ‘Stress seems to be a contributing factor in the development of fibromyalgia.’42

This might be a good time to remind you about the 79 year old lady I saw back in 2002 who had only had pain for 10 weeks, despite having significant spinal degeneration. When you consider the psychosocial factors related to her life at the time, we can begin to understand why her pain might have been triggered.

Her daughter was her only family and popped in every day to support her, yet she was about to go to Australia for a month. My patient was determined not to let her daughter see just how upset she was and how scared she was of being on her own, as well as having ‘strangers’/Home Care coming into her home each day, so she put on a brave face and coped.

According to a study44 by Aybek et al in 2014 previous traumatic events ‘can definitely trigger a physical response’, which was determined using fMRI scanning. Our findings are that when someone bottles things up/represses emotions and tries to cope, without acknowledging and expressing how they feel, this can manifest as very real symptoms which, in this lady’s case, was her debilitating back and leg symptoms. I do remember her opening up to me and having a cry and as time went on she got to know me and the carers, plus her daughter returned, by which time her symptoms had completely resolved. It would seem to me that the placebo effect, a positive therapeutic alliance, possibly the physical contact through a gentle therapy and her being able to offload her fears, played a big part in her recovery. This is just one of the cases that I clearly remember from my NHS days, which when remembered with a new understanding, made perfect sense to me.

Most pain clinics in the UK now work on a biopsychosocial model and include CBT and mindfulness, but I believe there are still areas which the medical world and we as therapists, should help our patients explore, therefore giving them the chance to potentially do more than just manage their pain, as this two-part blog explains.45

Factors involved in acute pain becoming persistent The one study47 that can help us consider what to enquire about in our patients when they present with pain is a study published in 2008 which looked at what factors contribute to acute pain becoming chronic. They concluded that:

• greater exposure to past traumatic life events and depressed mood were most predictive of chronic pain, and

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• depressed mood and negative pain beliefs were most predictive of chronic disability.

They also went on to explore what factors contributed to an increased severity of subsequent pain and disability and these included:

• more cumulative traumatic life events,

• higher levels of depression in the early stages of a new pain episode, and

• early beliefs that pain may be permanent

Unfortunately, in my experience and those of my patients, it is not routine for medical professionals to ask about any of these or discuss the relevance to their condition.

Adverse Childhood Experiences and chronic pain Trauma of course is not just about physical traumas, but includes mental and emotional trauma, throughout our lives. Unfortunately, despite the mass of evidence linking adverse childhood experiences (ACE) since the 1990s, this is only now really beginning to reach public awareness and the clinical interface.48

Felitti’s study in 199849 was the first and biggest study exploring the relationship of health risk behaviour and disease in adulthood to the breadth of exposure to childhood dysfunction. This study has continued to evolve and clearly demonstrates that:

• the number of categories of adverse childhood exposures has a graded relationship to the presence of adult diseases, including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.

• the categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life.

The categories of ACE found to be linked with ill-health in later life can be seen in Table 1 below.

Below there are some findings of a few studies that specifically looked at the relationship between chronic pain and trauma, for example;

• Jones et al in 2009 found that children (age 7 years) were statistically more likely to be suffering from chronic widespread pain as an adult at follow up (age 45 years) if they had experienced: hospitalisation from car accident, institutional care, maternal death, or familial financial hardship.49

• Anderberg et al in 2000 found that ‘children who had experienced hospitalisation, institutional care, maternal death or familial financial hardship were more likely to be suffering from chronic widespread pain as an adult’.50

• Goldberg et al in 1999 recorded a history of abuse in each group: fibromyalgia (64.7%), myofascial (61.9%), facial (50%), other pain (48.3%)51

SummaryThis article is primarily aimed at raising awareness of some of the evidence which, I believe, many clinicians are still unaware of. It is studies like those mentioned in this article that are thankfully beginning to make many of us in the chronic pain field reconsider our understanding of chronic pain and it’s treatment and not just to continue using a treatment approach just because that’s the way we’ve always worked. Certainly this has been transformational for me both in the way I work and in my own health, having resolved all the recurring health problems I used to regularly suffer from.

For those clinicians who are currently working with the biopsychosocial model I hope this paper encourages them to consider the psychosocial side more actively. I believe that even just asking a few additional questions of our patients during assessment could enhance this awareness further, for example:

• ‘What was going on at the time your pain came on?’

• ‘Was there any time in your childhood when you felt unsupported?’

Personal Related to another family member

Emotional abuse Absence of a parent through divorce, death or abandonment

Physical abuse A mother or stepmother who was treated violently

Sexual abuse A household member who abused alcohol or drugs

Emotional neglect A household member who was diagnosed with a mental illness

Physical neglect A household member who went to prison

Table 1: Categories of ACE from a personal and family-member perspective

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• ‘Are you feeling stressed in any area of your life?’.

This is a start and for some patients might well be enough for them to start to make some connections between their pain and what was going on in their life. Through knowledge and a self-empowering approach, they are often able to recover by making the links between their pain and psychosocial factors (past or present) and learning how to acknowledge and express any unresolved emotions.

Having said that, especially for clinician’s new to this, asking questions like this might well bring up issues that are outside your scope of practice to work with, in which case referral on to someone more experienced in this field or to a psychotherapist might be advised.

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