Pain: Persistent Pain
Reviewed November 2007
Brain
Persistent Musculoskeletal Pain is pain comes from the Central Nervous System (CNS). The CNS is the spinal cord and brain. The spinal cord and brain are responsible for reading the messages from our tissues (muscle, ligament, bone, tendon, cartilage, peripheral nerve, etc.) and understanding the messages. Pain referred from the CNS is not from the tissues where the pain is felt, but from the tissues where the message is read and understood. (Melzack) Here is a picture of the pain message from the irritated tissues and how it is sent to the spinal cord for reading and then to the brain for understanding.
Understanding Persistent Musculoskeletal Pain:
To understand Persistent Musculoskeletal Pain, we must go into the spinal cord and up to the brain, the command center of our pain system. When something happens in your tissues and nerves, there will be effects felt through the whole system. Remember it is the brain that has to make the final decision as to whether or not you should be in pain. The most frequently asked question from people learning about Persistent Musculoskeletal Pain is, “So are you saying that the pain is all in my head?” We have to be honest and say ‘yes – all pain is produced by the brain – no brain, no pain'! This does not mean the pain is of psychological origin or not real, actually – all pain is real. Understanding this idea is very empowering for the person who suffers with persistent pain. Understanding the spinal cord and brain processes behind the pain experience can provide you with control.
What does this pain feel like?
• Pain that is persistent lasts longer than 4 months, which is longer than normal healing. Deconditioned healing tissues send messages stating they have been worked. Those messages are read by the spinal cord and brain telling them that the damage is still occurring, that the tissues have not healed and that they need protection. The brain reacts and sends pain messages to that area in order to protect you from moving it. This feeling is persistent pain. (Butler)
• Severe pain can be present in persistent pain. Some people will say that they have a high pain threshold. Remember the pain is normal, but the processes behind it are changed. The brain is being fed information which no longer reflects the true health and abilities of the tissues. The brain is being told there is more danger at the tissues than there actually is. The concept of increased sensitivity is often challenging, but this is what happens in all of us when we are injured. The increased sensitivity should go away once the damaged structures are under control. This misunderstanding of the message happens in the spinal cord which then sends the message to the brain. The brain now understands it as a threat and creates the pain experience. (Butler)
• Persistent pain may spread to areas not originally involved in the initial injury or disease process. (Butler)
• The pain experience can be increased by emotional or social situations as well as physical movements. Common emotional and social factors that can slow down recovery from persistent pain are:
• Attitudes and beliefs about pain
• Behaviors related to the pain
• Financial and reimbursement problems
• Diagnostic procedures and passive treatments
• Emotions
• Family stress
• Work stress
The questions will always be “Are these factors existing? Are they contributing to the pain experience? How are you coping to control these factors?” There are treatment strategies aimed at reducing these factors to the pain experience. Many times people have not been successful with previous rehabilitation because these factors existed. (Kendall)
What can you do for Persistent Musculoskeletal Pain?
According to medical and scientific evidence, it is the combination of education, behavior management, and restoration of function that gets the persistent musculoskeletal pain sufferer back to normal.(Moseley)
• Education is the most important aspect in treatment of persistent musculoskeletal pain. Important topics:
• Explanation of type of pain
• Explanation of signals– the pain is real
• Identification of the emotional and social factors increasing pain
• Identification of coping strategies
• Identification of successful activities
• Behavior management is an important aspect of persistent pain rehabilitation and is performed by chronic pain psychologists. Not all patients who suffer from persistent pain need to be seen by psychologists. However, when the emotional or social factors are not being dealt with physical or occupational therapy then a psychological evaluation is necessary. Sometimes a referral to a pain management program may be the best approach for you. Your psychologist can assist in the evaluation and referral.
• Restoration of function is most successful after or along with an effective education and behavioral program. From what we already discussed, the brain will not allow the body to move unless the messages coming in are less threatening. Once the brain understands these messages in positive ways, it is easier to find successful movements. Function is easier and results with training are long lasting.
Reference:
• Sensitive Nervous System; DS Butler; Noigroup, Adelaide; 2000
• Textbook of Pain; PD Wall, R Melzack; Churchill Livingstone, Edinburgh; 1999.
• Explain Pain; L Moseley, DS Butler; Noigroup, Adelaid, Australia, 2003.
• A New Look at Heat Treatment for Pain Disorders; Proctor and Gamble Heat Responsive Pain Committee, June 2004.