One of the challenges when I treat a patient who suffers from chronic pain is that there are various nuances along the pain pathway that can influence the pain. It starts at the end organ where there might be an injury or mechanical stress, but then the pain pathway makes its way towards your spine, to your spinal cord, up the cord to your brain stem, and then through your central thalamus and to parts of your brain for processing. Pain can be influenced along this pathway in multiple ways.
One of the traps that people fall into when they have had pain affecting the for a while is that at the very highest level of the pain experience, they will tend to “catastrophize” their pain. Pain catastrophizing is a way that your brain processes your pain, but it does so in an exaggerated way. You might be focusing more attention than what is healthy to your pain. You might be interpreting your pain in a way that is not actually true for the injury that you have. Your brain might be processing the pain differently because of your past experiences–experiences that magnify the level of pain that you experience. It might be simply an effect that the pain that you experience has been there for so long that your brain has made reinforced connections through neuroplasticity that is not allowing your to override these signals so easily.
Our pain experience is no longer thought of as 1:1. This is the old Cartesian model of pain. You sprain your ankle, and you experience pain to the same extent as there is tissue damage. But now we are learning about new mechanisms of pain. Brain interactions can influence your pain. It turns out if you have anxiety or depression syndromes, you are going to process pain differently. It’s all in your head, and literally so, because brain connections influence the important pain pathways and pain experience centers. There is emotion in pain and suffering, and this is a problem that was ignored for centuries, and is now being understood more and more.
A new study this year looks at people suffering from chronic shoulder pain. Shoulders are very mechanically vulnerable to imbalance. There’s lots of range of motion in your shoulders, and we as humans can allow this circumduction range of motion because our shoulders do not need to be weight bearing. We can also get away with poor shoulder biomechanics for a little while as long as we have the proper mechanisms in our central processing to inhibit mechanical pain. Your shoulder joint can rub against your subacromial bursa for a little while without consequences. But over time, and with a little emotional trauma added in, your shoulder might start to ache. For some people, they’ve met the perfect storm of trauma to the shoulder and trauma to their mental coping mechanisms.
This study by Coronado published in 2017 in the Journal of Orthopedic Sports Physical Therapy looked at the effects of increasing optimism on patients with chronic shoulder pain. It turns out that When you can adopt a more positive optimistic attitude, you will have less suffering, but the same amount of pain. You brain takes a more realistic assessment of the pain signals that you are experiencing. Pain intensity stayed the same, and the patients did not change their fear-avoidance behavior, but they did not catastrophize the pain like they did before.
Now the challenge remains, how do you treat a patient to de-catastrophize the pain, as well as simultaneous reduce pain levels and their fear avoidance behavior. It seems like an approach that will rely on a team of people to intervene, but also empower the patient to take matters into their own hands.
What are your thoughts?
Latest posts by Ryan Todd Lloyd, DC (see all)
- The most common source of shoulder pain in clinical practice is subacromial pain syndrome (SAPS) - April 18, 2017
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