Not all chronic pain is the same

One of the things I constantly teach to medical students as well as clinicians of different background, is that “not all pains are the same” and that “before you treat you must first diagnose” the origin of pain. Furthermore, the term “chronic pain” may include several subgroups such as:Chronic pain due primarily or solely to persistent nociceptive pathology (ie severe knee osteoarthritis), neuropathic pathology (eg. nerve damage), or both (eg. failed back surgery syndrome).Chronic pain primarily due to centrally mediated pathology (altered brain wiring, called as well nociplastic pain) in the absence of persistent tissue damage, or when residual tissue damage is unable to explain the majority of a patient’s pain. It is in this subgroup primarily that chronic pain is coupled with high levels of disability and psycho-emotional distress and need different management than the other groups.Understanding chronic pain in the context of underlying mechanisms (nociceptive, neuropathic, mixed or centrally mediated) is of paramount importance in order to design proper treatments. Unfortunately, the term “chronic pain” is used indiscriminately for all the above categories. It is not unusual for me to receive referral of a patient with serious biomedical pathology with the physician asking for “alternative pain management” implying CBT or mindfulness meditation when treatments targeting the actual biomedical pain generator have not been employed.On the other hand, I see numerous patients labelled as “intractable chronic pain” and submitted to infusion, injections or even opioid medications, when the primary pain mechanism is centrally mediated/nociplastic.A further important concept is that the degree of underlying biomedical pathology does not correspond to the experience of pain. This is best illustrated by the following two examples. Many years ago, before I established my centre in Vaughan, I saw CX, a 27-year-old man with four siblings and a very closely knit family. CX worked in his family’s very successful roofing business. He had injured himself somewhat in the chest doing roofing and had just a bit of pain here and there, that never stopped him from doing the things he liked or work. His overprotective mother, however, brought him to his family doctor who referred him to a surgeon. The surgeon told him he had gotten “sterno-manubrial subluxation” (despite the absence of overt significant trauma!) and offered fusion. After the surgery, things got much worse, as pain now became constant accompanied by a “grinding sound.” CX never worked since the surgery and had abandoned his gym, his guitar and his friends. Desperate, the family sought other opinions and ended up with another surgeon who said there was “non union” and he intended to repair it. He assured CX and his family that the solution would be permanent this time. Unfortunately, 14 months and two surgeries later, CX was in worse desperate position, with ongoing pain and grinding. When I met CX (disheveled, stooped, in obvious physical and emotional distress and with exuberant pain) I had to figure out first whether there was persistent nociceptive pathology accounting for the patient’s complaints. At the same time, due to his immense distress, I put him through formal psychological assessment. Multiple radiographs, CT and bone scans provided clear indication that the fusion wires were broken and there was continuous non-union. So, I had an answer as to the physical origin of the patient’s complaints. But could the unstable fusion account for this profound degree of my patient’s pain? It was extremely unlikely. According to my psychologist, CX’s pain had much deeper roots to factors that were not physical. CX had never experienced physical or financial hardship. Secure within a highly protective environment at home, he never really had to work outside the family business. He also viewed his physique as one of his major assets, if not the greatest. For CX, his injury and the subsequent failed surgeries meant that he could no longer rely on his physical prowess. He was left desperate and confused, with no answers as to what was wrong, or what was going to happen to him in the long run. After I collected all the answers I wanted, I met CX and his family who appeared quite anxious. I said to CX, “what do you want first, the bad news or the good news?” He replied: “The bad news.”“I am afraid that you were right when you complained about this grinding sound and pain in your chest. We found that your fusion is not solid despite what you were told. I also have to tell you that it is highly unlikely that the problem can be fixed unless you want a third surgery.”“I knew it!” he shouted. “That . . . (used an unflattering term for his surgeon) was lying to me!” “Now,” I continued. “Here comes the good news. Even without another surgery, I certainly think that you can get much better. Ongoing pain led to fear of movement and anticipation of more pain, so you developed all kinds of guarding behaviours like walking stooped, not moving much and so on, and naturally you became depressed. All of these feelings and behaviours can change with a good pain management program. I will not promise you that you are going to be 100% the way you were before, but I can assure you that you can be much better than what you are now and you can go on having a very good life.” CX appeared quite happy with my explanations and the fact what he was feeling was validated.Unfortunately, those years, the pain management program I wanted to send him to had to be paid privately for a substantial charge but the family was happy to do so.Few months later, CX accompanied by his parents came to see me. Vaguely I recalled the elderly couple. But . . . who was that tall, extremely good looking fellow with the beard and an armful of roses? “Hi Doc,” he said.I could not believe my eyes. The young well-dressed man was standing tall, walking fast and freely into the room. “You look really good,” I said. “I had hard time recognizing you.”“Well, you see doc, I finished the program you sent me. It did me good. I think I am getting back on track.”CX had attended the program with enthusiasm. He was taught how to reduce his pain by learning that “hurt” does not necessarily mean “harm.” how to pace himself and to start restoring activities gradually. He had started training again in his home gym, he was jamming on his guitar now regularly, he had gotten back to the groove of seeing his buddies, and he was planning soon to try returning to his father’s roofing business. The grinding and some discomfort were still there but he was able to manage well with all the skills he was taught.“Thank you doctor,” he said. “I owe you so much.”I never heard from CX again. I am sure he is doing well. But I have used his case on numerous occasions to teach first year medical students about the multiple dimensions of pain, and how mind over matter can make so much of a difference. The experience of another patient, YZ, whom I also saw many years ago, was totally different—yet mind over matter played an equally important role. This fellow, 68-years-old, was a wealthy Hong Kong businessman who had just immigrated to Toronto with his family. He came to see me accompanied by his exquisitely dressed wife, his son, and an interpreter. His primary complaint was that of “minor neck ache” as the interpreter put it. “Oh, yes, there is some numbness as well in the first three fingers of both hands but not much pain there.”On examination, YZ hardly moved his neck (actively and passively) beyond a few degrees in each possible plane of movement. He assured me with a gracious smile that he only felt “kind of stiff and a little achy, but nothing much.” When I examined him, I found clear indication of significant cervical radiculopathies bilaterally, but thankfully no signs of myelopathy. Through the interpreter YZ made it clear he did not wish to go for any tests and informed me that he had taken acupuncture, to no avail. He also said he had brought some “old” x-rays, since he did not want the test repeated. My jaws literally dropped when I saw his >5-year old x-rays that showed multilevel advanced degenerative changes with great loss of disc height and severe foraminal encroachment. Given YZ’s resistance to further treatments or tests, I asked him, what did he expect of me? He replied that he thought “maybe . . . there was a pill to just decrease his discomfort a little.” I prescribed a COX-2 selective inhibitor and PPI. I saw YZ (and his family) six weeks later. He was a happy man. His range of movement had not changed one iota, his muscle weakness and wasting had not improved, and his reflexes had not come back, but his subjective feelings of stiffness and discomfort were nearly gone. TAKE HOME MESSAGE: These two patients who reacted so differently to pain and expressed their discomfort in such startlingly different ways, teach us again that the degree of underlying biomedical pathology does not correspond to the experience of pain, and that the experience of pain can be dramatically modified by thoughts, experiences, interpretations and expectations.

Not all chronic pain is the same

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Dr. Angela Mailis

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