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Health Psychology https://instituteforchronicpain.org Sun, 29 Jan 2023 16:15:31 +0000 Joomla! - Open Source Content Management en-gb Mind Reading: How to Cope with Pain Series https://instituteforchronicpain.org/blog/item/146-49mind-reading-how-to-cope-with-pain-series https://instituteforchronicpain.org/blog/item/146-49mind-reading-how-to-cope-with-pain-series

No, this post isn't about telepathy. It’s about a common problem faced by people with chronic pain and how to overcome it.

Mind reading defined

The phrase “mind reading” is a piece of technical jargon used in cognitive behavioral therapy and chronic pain rehabilitation programs. It refers to a particular type of thinking in which a person thinks that other people are judging him or her even though the other people might not ever say anything.

As such, mind reading is a type of thinking that involves an assumption – an assumption that you know what others are thinking.

Mind reading involves two essential components. First, it is an assumption in which you think you know what others are thinking. Second, you assume that what others are thinking are negative judgments about you.

Mind reading typically occurs without much awareness on the part of the person who is doing it. When engaged in mind reading, you don’t intentionally set out to do it. Rather, it happens almost automatically. Before you even know it, you’re doing it, thinking that others are judging you and coming to feel judged and reacting accordingly. It's for this reason that psychologists consider mind reading as a type of automatic negative thought. (We have previously discussed a different type of automatic negative thought in our blog post on catastrophizations.)

Typically, mind reading doesn’t accurately represent what others are really thinking. When engaged in mind reading, we tend to think we know what others are thinking of us, but this ‘knowing’ is more often than not an unwarranted assumption. Usually, we really can’t say with any degree of certainty that the assumption is accurate. Indeed, if we step back and think about it, as we are doing right now, it might be more accurate to say that most people don't spend a lot of time judging us as they go about their own life activities. In reality, most people are too involved in their own business to notice us with any more than a casual glance in our direction. Despite this fact, when mind reading, the assumption that others are negatively judging us feels so accurate. We feel so certain that they are judging us. As such, we simply react as if it is really happening when in all likelihood it isn't. Psychologists oftentimes call mind reading a type of cognitive distortion. In other words, mind reading is a type of thinking (i.e., cognition) that distorts reality, leading us to believe things and react to others in ways that aren't accurate to what’s really going on in the thoughts of others.

Mind reading leads to emotional and behavioral reactions that are indicative of being judged by others, even though, typically, in reality, the other people aren’t really judging us. We might feel anxious or ashamed or angry or defensive. We might start fretting about why people are so judgmental or what we might say if they say something first. We might also change our plans in response to these perceived judgments of others. You might, for instance, hurry through the grocery store because you just ‘know’ that everyone is judging you by the way they look at you. Maybe, you leave the family reunion early because you just ‘know’ that Aunt So-and-So is snickering behind your back. Such thoughts and their subsequent feelings and behaviors typically occur automatically, in the background of your awareness, and it all goes on unquestioningly, without you ever checking it out against reality.

Every one of us engages in mind reading. Some people only do it on occasion and as such it doesn’t cause a whole lot of problems. Some people, though, engage in it more often. For them, it can become problematic.

It’s stressful to feel as if you are the object of judgment. It wears on your ability to cope with the problems of life. It saps your enthusiasm for the activities of life. It can also lead to anxiety of different kinds as well as depression. (We bring this fact up not to judge, but simply to acknowledge it and provide an explanation.)

So, while everyone does it, we can see mind reading as a type of thinking that occurs along a spectrum from those who do it less often to those who do it more often.

Mind reading and living with chronic pain

Mind reading can occur in all walks of life including in those who live with chronic pain. No doubt, at least some readers have already started to apply this notion of mind reading to themselves and have begun to identify examples of it from their own lives.

Countless patients over the years have expressed to me their ambivalence over the use of a disability parking permit. They report feeling conspicuous when they park in a disability marked spot, thinking that they need to justify their use of the spot to every passerby. I have had a few patients acknowledge that they really don’t need their cane, in terms of the potential of falling, but carry one anyway because it signals to others that their slow gait is justified. Countless patients have reported that they hardly ever go to parties anymore because they know that everyone judges them if they acknowledge that they aren't working and are disabled.

Notice the assumptions that are happening in these examples. In each, the people think they know that others are judging them for having chronic pain or being disabled by pain and have subsequently changed their behavior as result. It’s like there is a persistent low-grade fear that pervades their daily experience – a subtle worry of what others think and what they might say, given a chance. Notice, too, that such subtle worry or fretting so often goes on automatically and unquestioningly, without a lot of awareness, at least until it gets named.

The persistent, low-grade nature of mind reading can take a toll. Such worry and fretting take energy. It’s one more drain of energy among all the other drains that can occur when living with chronic pain (such as insomnia, sedating medications, and the pain itself). It can come to justify social isolation and lack of activity outside the home. Mind reading can also lead to anxiety and depression and can even trigger panic if you are already prone to such problems.

In all, when it comes to living with chronic pain, mind reading makes coping with pain more difficult.

Common reactions to learning about mind reading

The notion of mind reading is commonly introduced and discussed in cognitive behavioral therapy and in the coping skills training courses that occur in a chronic pain rehabilitation program. Usually, once introduced, patients know exactly what we are talking about and can quickly come up with examples from their own lives. As discussed earlier, everyone does it, including those with chronic pain.

However, some people become troubled by the discussion and express one of two common objections.

One objection is that the notion of mind reading seems like a judgment itself. In other words, it seems like a criticism and that what we are saying is that people worry too much about what other people are thinking.

The intention, here, is not to criticize, but simply to acknowledge a problem that we all share to one extent or another. We don’t want to be in a position in which we maintain a pretense that we never worry or fret about what other people think of us. We all do it. There need be no shame in acknowledging it and nor should it be a criticism to talk about how we each do it. Moreover, it is a mark of strength to acknowledge one’s own problems, learn about them, and to learn about how to overcome them. Our discussion today is simply an opportunity to learn about a common problem and how to overcome it.

The other objection is that sometimes other people really do judge or criticize us. You may have someone in your life right now who does it. Perhaps it is a spouse or other family member or your supervisor at work. Maybe they tend to doubt the legitimacy of your pain or your sense of disability and have expressed, “Aw, come on now, it can’t be that bad!” Such judgments hurt and can make a lasting impression. You fret about it now, having conversations in your head with this person about what you could or should have said. These kinds of judgments from someone close to you and the resulting fretting can easily lead to persistent, low-grade worry that maybe everyone judges you similarly. This worry then can further lead to changing your behavior in public or with family in anticipation of what these other people might say. Notice how easy it is to start mind reading.

So, yes, the objection is a point well taken. Other people can in fact be judgmental.

And yet, is this fact the exception or the rule? Might we not agree that most people, most of the time, are simply too preoccupied by their own thoughts and worries to notice us, let alone think about us for long enough to actually judge us? I think most of us would agree that people don’t judge us as much as we tend to think they do.

It is this tendency that we are discussing – the tendency to mind read. So, while it is true that sometimes people really do judge us, maybe we can also spend too much time and energy worrying and fretting about what others think of us because in reality most people aren’t judging us.

So, what can we do about it?

Overcoming mind reading

The first step in overcoming the tendency to mind read is to simply learn about it, as we are right now. The second step is to learn to identify it in yourself. The third step is to get good at challenging it, once identified, by talking yourself through it in the moment.

As described above, usually the notion of mind reading gets introduced in cognitive behavioral therapy or in the group coping skills training within a chronic pain rehabilitation program. The discussion involves the use of examples, sometimes made up examples, but other times examples from the actual lives of patients. By using examples, the component parts of mind reading are identified and clarified. The use of this post is intended to provide a somewhat similar experience for the reader.

The next step is for you, the reader, to consider the role of mind reading in your life. Reflect on when you might do it and identify some examples from your own life. Perhaps, discuss them with your health psychologist or while you participate in your chronic pain rehabilitation program.

What you are doing while reflecting on examples from your daily life is getting better at identifying instances of mind reading. It's important to develop this skill of identifying instances of mind reading in your life. As you get good at it, you can then use it to identify instances of mind reading in the moment. It’s the skill of becoming more aware of what it is that you are thinking and recognizing in the moment that you are engaged in mind reading – worrying about what others are thinking of you and changing your behavior accordingly.

The skill of being able to identify or recognize that you are mind reading is an example of a more broad skill that psychologists call developing an ‘observational self’ (what was once called an ‘observing ego’). An observational self is the ability to step out of any given moment and reflect on what we are thinking and feeling and doing. In short, it is our ability to think about our thinking. It is our observational self that allows us to be able to step out of the moment and recognize that we are mind reading – “Oh, there I go again, I’m mind reading right now.”

Without an ability to step out of the moment and recognize that we are mind reading, we go on in life engaged in mind reading without awareness, allowing it to guide our behavior and sap our energy and abilities to cope with pain. So, this skill of being able to identify and recognize our thinking is important.

But, what do we do once we recognize in the moment that we are mind reading?

You use your understanding to provide reassurance that your mind reading is unwarranted and as such you can be more self-confident in your daily activities. This further skill takes practice.

Say, for example, you go to the grocery store and park in a disability spot because you have a disability permit. You are not in a wheelchair, though, and so as you get out of your vehicle you start to worry about what others are thinking of you. Initially, you are automatically convinced that they are thinking, ‘Hey, what’s wrong with you? You don’t look disabled! You shouldn’t be parking there!’ You start to feel nervous and look down as you walk into the store, not wanting to make eye contact with anyone. But then you recall our discussion and this notion of mind reading. You use your understanding of it to identify that you are doing it right now! You think to yourself, “Oh, there I go again!”

As a result of this recognition, you talk yourself through it. You recall that mind reading relies on an unwarranted assumption – that just because some people are judgmental doesn’t mean that everyone is judgmental. You subsequently reassure yourself that in all likelihood the people passing you by right now are not judging you. Instead, they are likely lost in their own thoughts, hardly noticing you. You can then say to yourself, “I can be confident right now” and you lift your head up walk into the store. Now, of course, at first you are not going to be very good at it. You might fail to recognize that you are mind reading and only come to think about it long after the fact. At other times, you might recognize it, but be unable to stop it or provide any meaningful reassurance to yourself. For instance, you might try to reassure yourself, but the words seem flat and empty. In other words, the nervousness of worrying what others are thinking might continue to get the best of you.

With practice, however, you will get better at it. Over time, you come to believe your reassuring self-talk more and more. Maybe you also start predicting that you will start mind reading before you even do it and begin providing reassurance preemptively. At some point, with practice, you begin to notice a budding sense of self-confidence. You find that you are a little lighter in your step and have a little more energy when you are out in public or when you are spending time with family.

As you practice, it’s important to recognize that you will never get to the point where you won’t ever mind read again. No matter how good you get at recognizing your mind reading and providing yourself with reassurance, you will never gain one hundred percent control over your thoughts and be able to stop mind reading forever.

A more realistic goal is to get to a point, with practice, where you engage in mind reading less and less often and that, when you do mind read, you catch it early in the process and successfully provide yourself with reassurance. When you can do all that, you will be more self-confident and better able to cope with pain.

Author: Murray J. McAllister, Psy.D.

Date of last modification: 9-8-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Sun, 07 Sep 2014 16:07:50 +0000
CBT and Central Sensitization https://instituteforchronicpain.org/blog/item/145-48cbt-and-central-sensitization https://instituteforchronicpain.org/blog/item/145-48cbt-and-central-sensitization

A study published this month in Pain produced what is likely some of the most important research findings this year for the field of chronic pain rehabilitation. The study demonstrated that basic CBT interventions can reduce central sensitization (Salomons, et al., 2014). Countless studies in the past have shown that CBT and CBT-based chronic pain rehabilitation programs are effective in reducing self-reported pain in chronic pain patients.

In these studies, we have had to infer that CBT reduces central sensitization: because CBT is effective at reducing chronic pain based on verbal self-report, and because central sensitization is a leading cause of chronic pain, we have inferred that CBT must reduce central sensitization. Now, we have a study that directly demonstrates it.

In their well-designed study, Salomons, et al., are the first to experimentally induce a form of central sensitization in a group of previously pain-free subjects, deliver a CBT intervention, and measure the reduction in central sensitization that results from the CBT intervention. As such, they are the first to demonstrate that CBT reduces central sensitization as measured in the laboratory and not simply rely on inferences based on self-reported pain levels.

The study design

The study consisted of 34 healthy women who did not have pain. Through a series of pain-provoking procedures, the researchers induced secondary hyperalgesia in these healthy women. Secondary hyperalgesia is a type of central sensitization. Central sensitization is largely considered a common, if not the most common, cause of chronic pain. In secondary hyperalgesia, the nerves in the general location of the pain become reactive in an increasingly wider area. As a consequence, it takes less and less stimuli to cause pain in this widening area around the site of the original pain.

Along side this series of pain-provoking procedures, the researchers provided half the group of healthy women with a few basic cognitive behavioral interventions for pain. The CBT intervention consisted of both providing the subjects with information about the sensory, cognitive, and affective aspects of pain and engaging them in cognitive restructuring in order to reduce the stress response that accompanies pain. Cognitive restructuring is an intervention that helps people to make sense of their pain differently, from understanding it as something that is alarming or frightening to understanding the pain as something that is more benign and not harmful or perhaps even beneficial. For the other half of women, they provided a psychotherapy focusing on becoming more assertive in interpersonal communication skills.

By comparing CBT for pain with a non-pain related psychotherapy, they attempted to determine the effectiveness of the CBT itself.

The provision of some form of psychotherapy to both groups is important because it controlled for the effectiveness of non-specific therapeutic factors of psychotherapy. Let me explain. To do so, we need to stray from our original topic a bit.

One of the most consistent findings in the last four decades of psychotherapy outcome research has been that a large percentage of what accounts for the effectiveness of psychotherapies are factors that are common to all psychotherapies. So, whether we are talking about cognitive behavioral therapy for pain or diabetes or depression, or psychodynamic therapy for dysfunctional relationship patterns, or family systems therapy for teenage behavior problems, they all tend to have some things in common, which contributes to what makes them effective. That is to say, despite having some obvious differences, they each share certain factors and these factors are in part what make them all effective.

These factors tend to be characteristics of the relationship between the provider and the patient. We tend to refer to these characteristics in general as the qualities of the ‘therapeutic relationship.’ For example, research consistently finds that, in whatever type of psychotherapy that one pursues, the development of a relationship with an expert provider who takes the time to listen to you and provide mutually respectful, caring, and honest feedback leads people to become motivated to make healthy behavior change – whether it is in learning how to manage pain or diabetes, overcome depression, develop healthy relationships, or change problematic teenage behaviors. In other words, the therapeutic relationship that you have with a healthcare provider is what leads, in part, to making healthy changes that can improve health.

So, in a study aiming to determine how CBT is effective for managing pain, Salomons, et al., needed to make sure that they were measuring what is unique to CBT for pain and not the general effectiveness that all the psychotherapies have in common. To do so, they compared CBT to a psychotherapy that was not for pain, but which would have the general therapeutic factors that are common to all therapies, including the CBT for pain. This study design thus allows the researchers to conclude that if CBT for pain is in fact more effective, then what’s making it more effective are those things that are unique to CBT. In other words, the therapeutic relationship might play a role in both psychotherapies equally, but if one is more effective, such as the CBT, then what’s pushing it over the top are those things that are unique to CBT.

So, let’s get back to what Salomons, et al., found.

Cognitive behavioral therapy and central sensitization

While both groups of study subjects reported less pain intensity, those who underwent CBT reported that the pain they had was less unpleasant and therefore more tolerable. These findings that CBT reduces pain and makes pain more tolerable are largely similar to most clinical trials of CBT for pain.

The more interesting and important finding was that the subjects who received CBT exhibited a 38% reduction in the area of secondary hyperalgesia. Recall that secondary hyperalgesia is a form of central sensitization in which the nerves around the site of pain become more reactive in a widening area. In this increasing area around the original site of pain, less and less stimuli are required to generate pain. Secondary hyperalgesia is thought to be one of the ways an acute injury can transition to chronic pain even after the acute injury has healed. In their study, Salomon, et al., experimentally induced secondary hyperalgesia and subsequently showed that CBT can reduce it.

To my knowledge, no previous study has directly demonstrated a reduction in a form of central sensitization with CBT interventions.

A possible explanation for this finding is that CBT reduces the stress response that occurs with pain. By coming to think about pain differently, the change in thinking corresponds to changes in the neural network of the brain. These changes in the brain might subsequently alter the hormonal and inflammatory responses of the stress response, which subsequently makes the nerves in the peripheral area around the site of the original pain less reactive. As such, the cognitive restructuring corresponds to changes in the brain that reduce the stress response, which lead to downstream reductions in nerve reactivity.

Whatever is the explanation, the findings of Salomons, et al., are important as they can lead us to greater confidence as to why CBT and CBT-based chronic pain rehabilitation programs are effective at reducing chronic pain.

References

Salomons, T. V., Moayedi, M., Erpelding, N., & Davis, K. D. (2014). A brief cognitive-behavioral intervention for pain reduces secondary hyperalgesia. Pain, 155, 1446-1452. doi: 10.1016/j.pain.2014.02.012

Author: Murray J. McAllister, Psy.D.

Date of last modification: 9-2-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Cognitive Behavioral Therapy Mon, 01 Sep 2014 20:54:35 +0000
Opioid Tolerance https://instituteforchronicpain.org/blog/item/144-47opioid-tolerance https://instituteforchronicpain.org/blog/item/144-47opioid-tolerance

When engaging in long-term opioid management for chronic pain, should healthcare providers discuss with their patients the fact that the medications won’t typically remain effective for the rest of their life? That is to say, should healthcare providers fully review the implications of opioid tolerance prior to beginning long-term opioid management for patients who have chronic pain, but who are neither elderly nor sick with a terminal illness?

If you have chronic pain and are on long-term use of opioids, and are middle-aged or younger, did your healthcare provider discuss the implications of opioid tolerance with you? The Institute for Chronic Pain website has a new content page that tackles this important yet complex issue.

While the issue of addiction tends to dominate debates over opioid management for chronic pain, the field remains largely silent about another important issue with regard to the long-term use of opioids. It is the issue of opioid tolerance. Tolerance is a phenomenon that occurs when an individual over time requires greater amounts of a drug to continue to obtain the original degree of its desired, therapeutic effect (Savage, et al., 2003). Tolerance to a medication becomes problematic when, on the one hand, patients taking the medication have many years yet to live and, on the other hand, it is not feasible to expect that they can continue to periodically increase the dose of the medication indefinitely. As such, this problem is particularly applicable to chronic pain patients on long-term opioid management who have a reasonably long life expectancy – another twenty or thirty or forty more years to live.

It leads to the inevitable question: What will chronic pain patients do when, after years of periodically increasing the dose whenever their opioid medication started to become less effective, they find themselves on the highest dose of an opioid and even this level of the medication no longer effectively reduces their pain? In other words, what happens when patients become opioid tolerant to the highest doses of the medication and still have many years yet to live? The field of chronic pain management has now had patients on the long-term use of opioids for almost two decades and as a result it is increasingly common to see opioid tolerant patients in clinic – patients who have been on these medications for many years and are finding that the medications are no longer very effective even when they are on the conventionally agreed upon highest doses.

This increasingly common clinical problem is chockfull of ethical implications:

  • What now is our shared responsibility for the care of such patients?
  • Should the field have done better at predicting this problem, given what historically we knew about tolerance to drugs and medications?
  • Are we as a field routinely providing informed consent by discussing with our patients the long-term consequences of opioid tolerance with our current patients?
  • How much are we helping patients if we allow them to become opioid tolerant to the highest doses of the medications when they have many years yet to live?
  • How are we going to treat such patients in the future if they have an altogether different painful injury or illness? How will we manage the opioid tolerant patient’s pain if, for instance, the patient later in life develops a terminal cancer or falls and breaks a hip and requires surgery when elderly?
  • Should we continue the practice of long-term opioid management for patients who are neither elderly nor terminally ill (i.e., people with chronic pain for whom we might reasonably expect to live more than a decade or two)?
  • Should we continue to engage in long-term opioid management for such patients when we know we have an empirically supported, effective alternative to opioids for people with chronic pain – the interdisciplinary chronic pain rehabilitation program?

Despite our persistent failure to discuss it, the topic of opioid tolerance demands of us to openly acknowledge it. It is an increasingly common clinical problem for chronic pain patients and their providers alike. Moreover, it leads to a slew of ethical problems that require resolution.

For a more in depth discussion of these issues, please read Tolerance to Opioid Pain Medications on the Institute for Chronic Pain website.

References

Savage, S. R., Joranson, D. E., Covington, E. C., Schnoll, S. H., Heit, H. A., & Gilson, A. M. (2003). Definitions related to the medical use of opioids: Evolution towards universal agreement. Journal of Pain and Symptom Management, 26(1), 655-667.

Author: Murray J. McAllister, PsyD

Date of last modification: 7-18-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Opioids Fri, 18 Jul 2014 12:22:55 +0000
How Stigma Prevents Self-Management https://instituteforchronicpain.org/blog/item/143-46how-stigma-prevents-self-management https://instituteforchronicpain.org/blog/item/143-46how-stigma-prevents-self-management

We tend to stigmatize pain because we misunderstand its nature. Specifically, we fail to acknowledge the role that the nervous system plays in producing the experience of pain. If we more fully appreciated this role, we would understand that chronic pain is similar to other health conditions that we don’t stigmatize much, such as high hypertension (i.e., high blood pressure) or type II diabetes.

Stigma of chronic pain defined

Stigma is someone’s negative judgment or criticism of you for having a condition that is not of your choosing. You didn’t choose to have chronic pain, but when getting stigmatized, you are getting blamed for having it or not coping with it well enough. It’s often in the form of a rhetorical question: ‘How could you possibly have so much pain?’ ‘How could you hurt when all I did was hug you?’ ‘Why are you suffering so when others with the same condition don’t suffer as much as you?’ The assumption that leads to these stigmatizing rhetorical questions is that the severity of pain should always correspond to the severity of injury or illness. Small injuries or mild illnesses should cause only mild pain, whereas only large injuries or serious illnesses should cause severe pain. However, more often than not, chronic pain patients don't fit this mold. Herein lies the rub. Patients with chronic pain seem to have severe pain often beyond what this assumption leads us to believe they should have. Simple movements seem to cause severe pain. Hugs can cause pain. Common conditions like chronic back pain lead to severe suffering in some people. This assumption subsequently leads to stigma. It can't be the injury or illness that causes such severe pain or suffering. It must be something personal about you that causes such pain or suffering. In other words, you are to blame.

In reaction to stigma, chronic pain patients can often assert that they didn’t choose to have chronic severe pain and, as such, there’s nothing they can do about it. They go on to assert that it is not something about them, but the condition they have. It is inherent to the pain, not something personal about them. Anyone, they assert, would be the same way if they had such pain.

In its blame of the victim, stigma insinuates that you are choosing your suffering. In defense of such blame, you emphasize your lack of choice in either having pain or its subsequent suffering. ‘It’s not me,’ you might say, ‘it’s the pain.’

Control over unchosen events

As described in previous posts on stigma, this defense is problematic in two ways. First, in asserting your lack of choice in the matter, you can easily fall into the trap of asserting that you have no control over the pain. That is to say, in response to stigma, it’s so easy to go from, say, “Don’t blame me. I didn’t choose this...” to “There’s nothing I can do about it.” As such, we tend to equate lack of choice with lack of control. If we don’t have control, we couldn’t have chosen it and if we couldn’t have chosen it, we can’t be blamed for it. While it might be a successful defense against stigma, the argument wins at the cost of coming to see yourself as powerless to pain. (Indeed, many patients with chronic pain often feel this exact way: like they have no control over their pain.) Powerlessness, however, is not a good thing as it leads right to suffering. Those who suffer have no power to affect the problem from which they suffer. Second, it is not factually accurate. It is possible to have some control over our health, including pain levels and how much one suffers. Now, of course, some patients with chronic pain might have to learn how to improve their health or how to gain better control of their pain and to cope better. However, the fact that some may need to learn how to manage pain well is different than the notion that it is impossible.

We thus arrive at a dilemma that chronic pain patients face: either they acknowledge that they have some degree of control over their pain and suffering, and subsequently become the object of blame or criticism if they are not doing a very good job of it, or they deny that they have any degree of control over their pain and suffering, and subsequently see themselves as powerless.

This dilemma can essentially shut down the possibility of learning how to effectively self-manage pain. To learn how to effectively self-manage pain, people with chronic pain have to learn how to acquire control and responsibility over their health, including their pain. This possibility opens the doors to stigma. To prevent the stigma, it is easy to assert that having some degree of control over pain is impossible -- buying relief from stigma at the cost of denying the possibility of any meaningful ability to effectively self-manage pain. The dilemma, however, is a false dilemma. It is based on a failure to understand the true nature of pain. Like stigma itself, the defense against stigma assumes that there are only two possible causes for severe pain: a severe injury or illness on the one hand or some personal weakness on the part of the patient who has pain. Everyone seems to fail to recognize that there may be a third option. Specifically, they fail to take into account the role of the nervous system in producing the experience of pain.  By taking it into account, you can skirt the dilemma of stigma and learn to effectively self-manage pain.

A subjective experience with neural underpinnings

We tend to think of pain as a physical sensation. However, we are only partly correct. It’s also a subjective experience. We can’t divorce the sensation from the perceiving subject – the person who has the sensation. It’s also not just any old sensation. While involving a bodily sensation, the experience of pain also inherently includes a cognitive appraisal of threat, an emotional sense of alarm or distress, and an automatic behavioral reaction to protect, usually through resting and/or guarding. These are the things that differentiate pain from other sensations, say, tickles. We simply don’t perceive a tickle to be threatening or alarming. We cry when in pain, yell out in distress, grimace, and guard the painful area. We laugh and squirm when tickled.

Pain, in this sense, is a danger signal. It signals to us that something is wrong in the area of the body that has the pain. A tickle doesn’t signal to us that there is anything wrong. Pain does. Inherent to the sensation is this sense that it is threatening and alarming. These are the essentially cognitive and emotional aspects of the experience of pain. (See the generally accepted International Association for the Study of Pain’s definition of pain.)

The nervous system is what produces this experience. The nervous system consists of all the nerves in the body, including nerves in limbs, in our bodily organs, as well as the spinal cord and brain. When an injury occurs, nerves in the affected area detect it. They subsequently send an electro-chemical message from the site of injury to the spinal cord and then up the spinal cord to the brain. Multiple areas of the brain become involved to produce the sensation and its inherent cognitive appraisal of threat, the emotional sense of alarm, and the behavioral reflex of guarding and grimacing (Melzack, 1999; Moseley, 2003).

In this way, the nervous system functions like a fire alarm in an office building. With a fire alarm, a smoke detector senses smoke and sets off the entire alarm system. The loud sound of the alarm signals threat. As a result, everyone becomes alarmed at the threat of fire and leaves the building. Fire fighters come to the rescue and put out the fire. The next day everyone is back at work and things return to normal.

Similarly, the nervous system, acting like an alarm system, can detect some bodily disturbance and sets off the alarm of pain. Pain, like the loud sound of a fire alarm, signals the threat. Inherent to the sense of alarm, the person becomes alarmed and reacts reflexively. Like fire fighters coming to the rescue, the person with pain and/or healthcare providers fix what’s wrong or the body naturally heals and the alarm of pain subsides. Things return to normal.

Alarm systems can become set at different levels of sensitivity

Now, with any alarm system, we want its sensitivity to stimuli to be set just right. Imagine if an office building’s fire alarm system was set too high -- where it doesn’t detect smoke until the fire is raging. It wouldn’t do us any good, would it? We also wouldn’t want the sensitivity of the alarm system to be set too low -- where it goes off, say, every time someone walks by the building smoking a cigarette. Rather, we want our fire alarm systems set at just the right level of sensitivity.

Similarly, we want our nervous system set at just the right level of sensitivity as well. We want to be able to feel pain long before an injury, say, becomes life threatening. Our nervous system wouldn’t be very useful to us in such a case. But, we also don’t want to feel pain in response to stimuli that is typically not painful – such as touch or the light pressure of hugs, normal movements like getting up from a chair or walking, changes in barometric pressure, or emotional stress.

Nonetheless, that is what’s happening in chronic pain. Chronic pain is like what happens with a faulty alarm system – one where the threshold for sounding the alarm is set too low and so it’s getting set off in response to stimuli that is typically not threatening (i.e., painful).

By definition, chronic pain is pain that continues past the normal time of healing. There is no longer a bodily disturbance for the nervous system to detect because the injury has healed. With chronic pain, though, the nervous system remains reactive, detecting normal stimuli as if they are threatening and, as a result, sounding the alarm of pain.

It’s how people can develop pain in the absence of any objective findings of injury. It’s also how people can have pain in response to normal stimuli like touch, mild pressure, simple movements, changes in barometric pressure, or emotional stress.

It’s important for people with chronic pain and the people around them to know that they are not making this pain up. The pain is real. And there is a real explanation for their pain. It’s being produced by the nervous system in much the same way as any other pain. The only difference is that their nervous systems are stuck in a heightened state of reactivity, and so the threshold for sounding the alarm of pain has come to be set too low. It is sounding the alarm bells of pain in response to stimuli that is typically not sufficiently dangerous to elicit the alarms bells of pain – just like an office building’s fire alarm going off when someone walks by outside on the sidewalk smoking a cigarette.

Chronic pain is real pain due to central sensitization – not tissue damage

This heightened state of reactivity of the nervous system is called central sensitization. It’s a real health condition that can be the cause of chronic pain. It maintains pain beyond the normal healing process of an injury or, as commonly occurs, when scans show normal age-related osteoarthritic findings. In such cases, chronic pain is not necessarily due to healed injuries or normal, age-related osteoarthritis in joints or the spine, but rather due to an up-regulated nervous system that is setting off the alarm of pain in response to stimuli that is not typically associated with pain. In other words, central sensitization is what maintains pain on a chronic basis.

Central sensitization is as real as hypertension or type II diabetes. In each of these health conditions, some bodily system or aspect of a bodily system is abnormally elevated – the nervous system having become too reactive in the case of chronic pain, the cardiovascular system becoming regulated too high in the case of hypertension, and heightened levels of blood sugar (an aspect of the neuroendocrine systems) in the case of type II diabetes. All three conditions are common examples of an up-regulation of a bodily system or an aspect of a bodily system that over time has become problematic (i.e., symptomatic).

Why stigmatize pain when we don’t stigmatize hypertension or type II diabetes?

When we understand this role of the nervous system in the production of the experience of pain, we see that chronic pain is real pain that has a real explanation. People make up chronic pain about as often as people make up having hypertension or type II diabetes, which is to say, they don’t make these things up. So, why stigmatize chronic pain?

We typically don’t stigmatize these other conditions because we understand that we don’t choose to have these conditions – at least not in any sense of the word “choose” that we typically use. For instance, no one decides to have hypertension or type II diabetes as if it was a choice between having one of these conditions or not. Choices typically involve having a ready or easy control over a set of options. ‘Would you like coffee or tea?’ – now that is a choice. There is no similar use of the word “choice” that might apply to hypertension or type II diabetes. No one ever faces a decision such as, ‘Would you like to be diabetic or not?’ No, it just doesn’t make sense to use the notion of “choice” with regard to conditions like hypertension or type II diabetes.

Similarly, no one chooses to have chronic pain. Just as we don’t have ready or easy control over our cardiovascular systems or our blood sugars, we don’t have ready or easy control over our nervous systems. It’s not like you can just make a decision and choose to no longer have chronic pain, hypertension or high blood sugar levels. No, it doesn’t work like that.

As such, stigma is misplaced blame. It relies on an overly naïve view of pain as something that one can just make up or will into (or out of) existence. However, as we see, having chronic pain is not the product of a choice or decision.

Chronic pain is not impossible to control

While chronic pain is not the result of a choice, it is possible to control it to some meaningful extent. This control, however, is not readily or easily attained – it’s not like we choose between health and ill health as we choose between coffee and tea. Nonetheless, we can affect change to our health over time and with a concerted effort.

The analogies between chronic pain and hypertension and type II diabetes continues to be helpful here. With a concerted effort over time, we can affect significant and meaningful changes in each of these conditions. It often requires a team effort between medical and health psychology providers and the patient (and possibly even their families). The focus of care is self-management: assisting the patient to make healthy changes over time that will positively affect the condition that the patient has.

In the case of hypertension, the focus of change is a combination of multiple approaches that might include, but may not be limited to any of the following: use of medications, stress management, achieving a healthy weight, improvements in diet, engaging in an aerobic exercise, cessation of tobacco use, and treatment of any type of anxiety disorder or depression. By pursuing these health behaviors over time, hypertensive patients come to down-regulate their cardiovascular system and subsequently lower their blood pressure.

In the case of type II diabetes, the focus of change is a combination of multiple approaches that might include, but may not be limited to any of the following: use of medications, achieving a healthy weight, improvements in diet, stress management, engaging in an aerobic exercise, and treatment of any type of anxiety disorder or depression. By pursuing these health behaviors over time, type II diabetic patients come to down-regulate their blood sugar levels.

Notice that these health behavior changes are difficult to achieve. They take time. They often require coaching and support from medical and health psychology providers, as well as support from family members. However, they are not impossible. That is to say, it is possible to affect significant and meaningful change to conditions like hypertension and type II diabetes. We all recognize that if we were to come to have either of these conditions, we would not be fated to uncontrolled hypertension or type II diabetes. We know that we can affect them. Through a process of learning how and sticking with it over time, we can come to have meaningful control over these conditions.

Chronic pain is the same way. Learning how to manage chronic pain well is possible, but it takes a concerted effort over time. It often also requires a team effort that includes health psychology providers, medical providers, physical therapists, and the patient (and often the patient’s family too). This kind of team is typically found in an interdisciplinary chronic pain rehabilitation program. It also tends to require an accurate understanding of the role of the nervous system in maintaining pain on a chronic course. Why? It’s because the focus of care is to down-regulate the reactivity of the nervous system through a combination of medical, health psychology, and self-management approaches that we know to be effective. By pursuing these changes over time, patients come to reduce pain and increase the ability to cope with the pain that remains.

These therapeutic approaches consist of, but are not limited to, the following:

  • Effective non-narcotic medication management (particularly anti-epileptics and antidepressants)
  • Cognitive-behavioral therapy involving coping skill training
  • Mild aerobic exercise
  • Relaxation therapies
  • Exposure-based therapies to reduce fear-avoidance
  • Stress management & treatment of any co-occurring depression or anxiety disorders
  • Cognitive-behavioral therapy for insomnia
  • Tapering of opioid medications, if applicable

When patients pursue these therapies and strategies, they learn how to engage in them independently and take over doing them on their own. Over time, they come to affect their nervous systems by down-regulating its reactivity and subsequently have less pain. Because they do it themselves, they come to see that they are no longer powerless to pain and subsequently it is one of the most empowering experiences of their life. For the first time in their life with chronic pain, they have successfully learned how to control their pain at tolerable levels and have proven to themselves that they can do it. Such know-how and empowerment comes to further increase their abilities to cope with pain. As such, they develop a positive cycle of increasing self-management that leads to less pain, which in turn leads to improved empowerment and coping, which subsequently leads to improved self-management.

Notice, though, it takes work. In fact, it takes a lot of work. Successful self-management is the product of a long and concerted effort to make healthy changes over time.

As anyone who has ever attempted to make long-term changes to their health, this sense of control is not an object of stigma, but rather an object of admiration.

References

Melzack, R. (1999). From the gate to the neuromatrix. Pain, S6, S121-S126. Moseley, G. L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140.

Author: Murray J. McAllister, PsyD

Date of last modification: 6-27-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Self-management Sun, 22 Jun 2014 18:54:58 +0000
Therapeutic Neuroscience Education: A New ICP Website Content Page https://instituteforchronicpain.org/blog/item/142-45therapeutic-neuroscience-education-a-new-icp-website-content-page https://instituteforchronicpain.org/blog/item/142-45therapeutic-neuroscience-education-a-new-icp-website-content-page Therapeutic Neuroscience Education: A New ICP Website Content Page

As an educational and public policy think tank, the Institute for Chronic Pain (ICP) brings together thought leaders from around the world to provide information about chronic pain and its treatments. We make every effort to provide academic quality information in ways that are also approachable to patients and their families. We also aim to bring this information to healthcare providers, third-party payers, and public policy analysts.

We envision a day when all stakeholders in the field of chronic pain management have a scientifically accurate understanding of the nature of chronic pain and how best to treat it – a day when healthcare providers deliver and patients demand treatments that science has shown to be effective.

The information that we provide on our site meets various important criteria. These criteria are the following:

  • The information is of academic quality while at the same time being approachable by patients and their families.
  • The information is empirically (i.e. scientifically) supported by high quality research and appropriately referenced.
  • The information is unbiased by financial support from the pharmaceutical and medical technology industry.
  • The information is unbiased by any need to maintain discipline-specific traditions or positions of authority (i.e., no need to maintain a specific discipline’s “turf”).
  • The information is provided within a forum that allows for open, respectful dialogue and social connectedness.

By providing information that meets these criteria, we aim to provide accurate and trustworthy information about chronic pain and its management from an organization that is trustworthy, transparent and community-based.

In doing so, we hope to raise our cultural understanding of the nature of chronic pain to a level that is as accurate as the current state of science allows.

Our educational and public policy mission also has significant ethical implications. Care for chronic pain patients (or for patients with any health condition, for that matter) should be as effective as possible. When multiple treatment options exist for a particular condition, we maintain that treatment decisions should be guided by science – by the question of what’s most effective, regardless of other possible concerns, such as the profit-motive or tradition-bound practices. Similarly, patients and their families should educate themselves about the nature of pain and what treatments have been scientifically shown to be effective. However, patients and their healthcare providers have historically lacked a trustworthy and easily accessible source for such information. At the ICP, we aim to fill this gap and provide accessible information about the nature of chronic pain and how best to treat it. With such information, both healthcare providers and patients can improve their decision-making by relying on a scientifically accurate understanding of pain and its treatments. In these ways, we aim to raise the quality of care for chronic pain. It’s the right thing to do and, if successful, we might just change how we manage chronic pain for the better.

As stated, in pursuing these efforts, the Institute for Chronic Pain brings together thought leaders from around the world to provide this scientifically accurate and trustworthy information. Today, we announce a new content page to our website on Therapeutic Neuroscience Education, authored by Adriaan Louw, PT, PhD, CSMT. Adriaan is a leader in Therapeutic Neuroscience Education (TNE). A physical therapist by training, he is a frequent lecturer, a researcher, and an author of a number of patient-friendly books, such as Why Do I Hurt?, among others. He is also the CEO of the International Spine and Pain Institute, an educational seminar organization for healthcare professionals.

His piece on TNE fully meets our criteria for inclusion on the ICP website. It is scientifically accurate and yet accessible by patients, their families, their healthcare providers, and the third-party payers who pay for their care. Indeed, teaching people about pain -- providing them with scientifically accurate yet easily understandable information about pain -- lies at the heart of therapeutic neuroscience education.

Therapeutic Neuroscience Education is a relatively new therapeutic intervention that aims to change patients' perception of pain by providing them with a more accurate understanding of the nature of pain. Akin to a cognitive behavioral intervention, it employs verbal-based lessons along with visual illustrations and diagrams with the goal of changing how patients make sense of their pain. In other words, it helps patients to understand their pain in a more scientifically accurate and less threatening way. Once this more accurate understanding is achieved, patients are typically more willing to engage in therapies that have been shown to be effective.

Typically associated with physical therapy, TNE is actually an intervention that most any healthcare provider might pursue given sufficient training. With such an expertise, chronic pain management providers of all kinds might provide TNE while engaging in their own discipline-specific interventions. Thus, it might be considered a cognitive-based meta-therapy that can be provided at the same time as other therapies.

We appreciate Adriaan’s expertise and contribution to the ICP. Please read his important piece on the ICP website and talk to your healthcare providers about whether TNE might help you to manage chronic pain more effectively.

Author: Murray J. McAllister, PsyD

Date of last modification: 6-7-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Therapeutic Neuroscience Education Sat, 07 Jun 2014 15:10:05 +0000
ISPI Conference Next Month https://instituteforchronicpain.org/blog/item/141-44ispi-conference-next-month https://instituteforchronicpain.org/blog/item/141-44ispi-conference-next-month

This year's educational conference by the International Spine & Pain Institute focuses on the nature of pain and evidence-based treatments for pain, including chronic pain. The target audience for the conference is physical therapists and physical therapist assistants. I have no doubt, however, it would be beneficial for most any clinician working in the field of chronic pain management. It will be held in Minneapolis, MN, USA, from June 20-22, 2014.

Author: Murray J. McAllister, PsyD

Date of Last Modification: 5-23-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) News & Recent Events Fri, 23 May 2014 07:46:27 +0000
Epidural steroid injections: FDA provides safety warning https://instituteforchronicpain.org/blog/item/140-43epidural-steroid-injections-fda-provides-safety-warning https://instituteforchronicpain.org/blog/item/140-43epidural-steroid-injections-fda-provides-safety-warning

Last month, the United States Food & Drug Administration (FDA) issued a warning on the safety of epidural steroid injections for back and neck pain. Epidural steroid injections, they said, “may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death.” They advised providers who perform epidural steroid injections and their patients to discuss these risks prior to making the decision to undergo the procedure.

When used for back or neck pain, epidural steroid injections deliver steroid into the epidural space of the spine. The steroid has anti-inflammatory properties. The goal is to reduce inflammation around the nerves of the spine and thereby produce a temporary reduction in pain. The FDA states that this warning is unrelated to the issue in 2012 when a number of patients became ill and even died because they had been injected with steroid that had been contaminated in the manufacturing process.

Timely nature of the FDA warning

This warning is important because epidural steroid injections are an increasingly common procedure for chronic back or neck pain. Their widespread use has occurred over the last twenty to twenty-five years. From 1994-2001, their use increased by 271% in the US (Friedly, Chan, & Deyo, 2007). From 2000-2008, their use increased another 186% (Manchikanti, L., et al., 2013).

Epidural steroid injections are not FDA-approved for back or neck pain

This widespread use of epidural steroid injections is controversial. Research shows that on average epidural steroid injections are ineffective for chronic back and neck pain (see, e.g., Bickett, et al., 2013, Staal, et al., 2008) or for radicular pain, such as sciatica (Iverson, 2011). At best, in some clinical trials, epidural steroid injections have been shown to provide statistically significant improvements in the leg pain of sciatica, but the improvements are so small that from the real world perspective of a patient the improvements are irrelevant (Carette, et al., 1997; Quraishi, 2012). No published studies show that epidural steroid injections reduce disability related to back or neck pain.

Proponents of the procedure often argue that that the use of epidural steroid injections can reduce the need for spine surgery. However, empirical research does not support this argument (Carette, et al., 1997).

Due to the lack of evidence for the effectiveness of epidural steroid injections, a number of pain experts question their widespread use (Deyo, 2009; Schofferman, 2006; Taylor, 2011).

The FDA, in their warning, explicitly emphasizes this lack of evidence for the effectiveness of epidural steroid injections. They state that the use of epidural steroid injections for the treatment of back or neck pain is not an FDA-approved procedure because the procedure has not been shown to be effective.

References

Bickett, M. C., Gupta, A., Brown, C. H., & Cohen, S. P. (2013). Epidural injections for spinal pain: A systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials. Anesthesiology, 119(4), 907-931. doi: 10.1097/ALN.0b013e31829c2ddd

Carette, S., Leclaire, R., Marcoux, S., Morin, F., Blaise, G. A., St. Pierre, A., Truchon, R., Parent, F., Levesque, J., Bergeron, V., Montminy, P., & Blanchette, C. (1997). Epidural corticosteroid injections for sciatica for herniated nucleus pulposus. New England Journal of Medicine, 336, 1634-1640. doi: 10.1056/NEJM199706053362303

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102

Friedly, J., Chan, L., & Deyo, R. (2007). Increases in lumbosacral injections in the Medicare population: 1994-2001. Spine, 32, 1754-1760.

Iverson, T., Solberg, T. K., Romner, B., Wilsgaard, T., Twisk, J., Anke, A., Nygaard, O., Hasvold, T., & Ingebrigtsen, T. (2011). Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: Multicentre, blinded, randomized controlled trial. BMJ, 343, d5278. doi: 10.1136/bmj.d5278

Manchikanti, Pampati, V., Falco, F., & Hirsch, J. A. (2013). Growth of spinal interventional pain management techniques: Analysis of utilization trends and Medicare expenditures 2000 to 2008. Spine, 38(2), 157-168. doi: 1097/BRS.0b013e318267f463

Quraishi, N. A. (2012). Transforaminal injection of corticosteroids for lumbar radiculopathy: Systematic review and meta-analysis. European Spine Journal, 21(2), 214-219. doi: 10.1007/s00586-011-2008-y

Schofferman, J. (2006). Interventional pain medicine: Financial success and ethical practice: An oxymoron? Pain Medicine, 7, 5, 457-460.

Staal, J. B., de Bie, R., de Vet, H. C., Hildebrandt, J., & Nelemans, P. (2008). Injection therapy for subacute and chronic low-back pain. Cochrane Database of Systematic Reviews, 3(3). doi: 10.1002/14651858.CD001824.pub3

Taylor, M. L. (2011). The impact of the “business” of pain medicine on patient care. Pain Medicine, 12, 5, 763-772.

Author: Murray J. McAllister, PsyD

Date of Last Modification: 5-4-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Epidural steroid injections Sun, 04 May 2014 14:06:27 +0000
HONcode Certification https://instituteforchronicpain.org/blog/item/139-42honcode-certification https://instituteforchronicpain.org/blog/item/139-42honcode-certification

We are pleased to announce that the Institute for Chronic Pain website and blog has obtained Health On the Net Foundation (HONcode) certification. HONcode certification indicates that the reporting of health-related information on our sites complies with the Ethical Code of Conduct of the Health On the Net Foundation. You can find their seal at the footer of our website pages and the sidebar of our blog.

The Health on the Net Foundation is a non-governmental organization that provides certification to health information websites. They are the “oldest and most used ethical and trustworthy code for medical and health related information on the internet.”

Author: Murray J. McAllister, PsyD

Date of last modification: 4-24-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) News & Recent Events Thu, 24 Apr 2014 20:34:35 +0000
An Alternative to Opioids for Chronic Pain https://instituteforchronicpain.org/blog/item/138-41an-alternative-to-opioids-for-chronic-pain https://instituteforchronicpain.org/blog/item/138-41an-alternative-to-opioids-for-chronic-pain

It’s an interesting fact about the field of chronic pain management that there is a safe and effective alternative to the use of opioids for chronic pain, but relatively few people know about it. The alternative to opioids is an interdisciplinary chronic pain rehabilitation program.

Chronic pain rehabilitation programs

Interdisciplinary chronic pain rehabilitation programs are a traditional form of treatment that provides patients with the ability to self-manage pain and return to work, all without the use of opioid medications. They bring about these goals by providing chronic pain patients with the opportunity to 1) make a number of lifestyle changes, which, when done over time, reduce the physiological basis of pain, and 2) learn a number of advanced ways to better cope with the pain that remains chronic. Patients learn both of these two prongs of self-management from a safe and supportive team of chronic pain rehabilitation experts who coach patients on how to do them.

For the motivated patient who is open to learning and wiling to practice these changes and skills, it becomes possible over time to self-manage pain without opioid medications and do it successfully. Many people with chronic pain learn to do it everyday in interdisciplinary chronic pain rehabilitation programs. As such, they are the traditional alternative to opioids for the management of chronic pain.

While currently not as common as other types of pain clinic (such as long-term opioid management clinics or interventional pain clinics), most every major city across the United States, Canada, Western Europe, Australia, and New Zealand has a chronic pain rehabilitation program. Most of the well-known destination healthcare centers through out the world have an interdisciplinary chronic pain rehabilitation program. Many smaller, local clinics have such programs too. Literally, countless numbers of patients go through interdisciplinary chronic pain rehabilitation programs everyday and in doing so they learn how to live well without opioid medications despite having chronic pain.

Interdisciplinary chronic pain rehabilitation programs have high quality research evidence that demonstrate their effectiveness as an alternative to opioids (Chou, et al., 2007; Gatchel & Okifuji, 2006). There are numerous well-designed studies that show patients routinely have considerably less pain once they complete an interdisciplinary chronic pain rehabilitation program. On top of it all, they are no longer taking opioid medications. That is to say, following participation in such a program, they have less pain than when they were taking opioids, but are now no longer on opioids (Becker, et al., 2000; Cosio & Linn, 2014; Crisostomo, et al., 2008; Meineche-Schmidt, Jensen, & Sjogren, 2012; Murphy, Clark, & Banou, 2013; Rush, et al., 2014; Townsend, et al., 2008).

Despite the large number of programs and despite the well-documented evidence supporting their effectiveness, many people with chronic pain who are seeking care, perhaps even a majority, remain unaware of chronic pain rehabilitation programs as an option available to them – let alone know that it is a safe and effective alternative to opioids for chronic pain.

A short history of chronic pain management

It wasn’t always this way. For a few decades prior to the 1990’s people with chronic pain obtained treatment in interdisciplinary chronic pain rehabilitation programs on a much more routine basis. Moreover, there were significantly more interdisciplinary chronic pain rehabilitation programs in existence (Gatchel, et al., 2014; Schatman, 2012). So what changed?

In the decades prior to the 1990’s, it was significantly less common to manage chronic pain with opioids. As such, interdisciplinary chronic pain rehabilitation programs were largely the only type of pain clinic there was. Patients with chronic pain knew of them and tended to seek out care within them.

With the advent of widespread use of opioids in the 1990’s, interdisciplinary chronic pain rehabilitation programs tended to get overshadowed. Some pain clinics offering this traditional model of chronic pain management closed and new pain clinics, offering long-term opioid management, opened in large numbers.

There are many possible reasons for this state of affairs. The newer form of chronic pain management is more lucrative than interdisciplinary chronic pain rehabilitation programs. Long-term opioid management tends to obtain insurance reimbursement easier than interdisciplinary chronic pain rehabilitation programs. The use of opioids also appears to at least temporarily resolve the need for interdisciplinary chronic pain rehabilitation programs. Who wants to go through the hard work of making large-scale lifestyle changes and learn advanced ways of coping to reduce pain if a medication can temporarily reduce it for you? (A similar argument could be made with regard to the widespread use of interventional procedures and spine surgeries beginning in the late 1980’s and into the 1990’s). Moreover, an increasingly common belief among patients, providers and society generally is that it is impossible to manage chronic pain well without opioids – that intolerable suffering would be the inevitable result. When firmly held, this belief subsequently leads to a great deal of skepticism about the wealth of clinical and research evidence that shows interdisciplinary chronic pain rehabilitation programs are a safe and effective alternative to opioids for chronic pain.

An alternative to opioids for pain that few know about

So, we have an odd state of affairs at present in the field of chronic pain management. We know that we have a safe and effective alternative to opioids for chronic pain but few people know of it or take advantage of it, at least relative to the number of people who manage their pain with opioids.

How do you think the field should tell the public about interdisciplinary chronic pain rehabilitation programs? Why do you think they have difficulty getting widely recognized as an effective alternative to opioids for chronic pain? If you find yourself skeptical of the above-noted research, what would convince you to participate in such a program?

References

Becker, N., Sjogren, P., Bech, P., Olson, A. K., & Eriksen, J. (2000). Treatment outcome of chronic non-malignant pain patients managed in a Danish multidisciplinary pain centre compared to general practice: A randomized controlled trial. Pain, 84, 203-211.

Chou, R., Amir, Q., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.

Cosio, D. & Linn, E. (2014). Efficacy of an outpatient, multidisciplinary VA pain management clinic: Findings from a one-year outcome study. Journal of Pain, 15(4), S110.

Crisostomo, R. A., Schmidt, J. E., Hooten, W. D., Kerkvliet, J. L., Townsend, C. O., & Bruce, B. K. (2008). Withdrawal of analgesic medication for chronic low-back pain patients: Improvements in outcomes of multidisciplinary rehabilitation regardless of surgical history. American Journal of Physical Medicine & Rehabilitation, 87(7), 527-536. doi: 10.1097/PHM.0b013e31817c124f

Gatchel, R. J., (2014). Interdisciplinary chronic pain management: Past, present, and future. American Psychologist, 69(2), 119-130. doi: 10.1037/a0035514

Gatchel, R. J. & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 17(11), 779-793.

Meineche-Schmidt, V., Jensen, N., & Sjogren, P. (2012). Long-term outcome of multidisciplinary intervention of chronic non-cancer pain in a private setting. Scandinavian Journal of Pain, 3(2), 99-105.

Murphy, J. L., Clark, M. E., & Banou, E. (2013). Opioid cessation and multidimensional outcomes after interdisciplinary chronic pain treatment. Journal of Pain, 29(2), 109-117.

Rush, T., Huffman, K., Mathews, M., Sweis, B., Vij, B., Scheman J., & Covington, E. (2014). High dose opioid weaning within the context of a chronic pain rehabilitation program. Journal of Pain, 15(4), S111.

Schatman, M. E. (2012, December). Interdisciplinary chronic pain management: International perspectives. Pain: Clinical Updates, 20(7), 1-5.

Townsend, C. O., Kerkvliet, J. L., Bruce, B. K., Rome, J. D., Hooten, W. D., Luedtke, C. L., & Hodgson, J. E. (2008). A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: Comparison of treatment outcomes based on opioid use status at admission. Pain, 140(1), 177-189.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-5-2019

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

The assertions and opinions of this piece are solely those of the author and do not represent the views of Courage Kenny Rehabilitation Insitute, part of Allina Health.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Programs Sun, 20 Apr 2014 18:05:56 +0000
Is Degenerative Disc Disease Painful? https://instituteforchronicpain.org/blog/item/137-40is-degenerative-disc-disease-painful https://instituteforchronicpain.org/blog/item/137-40is-degenerative-disc-disease-painful

Correlation doesn’t imply causation. It’s a commonly expressed caution in the health sciences. What it means is that two things can tend to go together without necessarily causing each other.

The classic example that statistic professors like to give is that air conditioner use is significantly correlated with street crime. Does the use of air conditioners cause street crime? No, of course, not and yet they do tend to go together. It’s actually only because they both tend to occur in the summer. When it’s hot outside, it’s true that people tend to use their air conditioners and it’s also true that people tend to loiter outside in the city, getting into trouble more often than in the cold winter months when people tend to stay indoors. With the example, we can see that just because things tend to go together they don’t also always cause each other.

What about things that hardly go together or things that don’t go together at all? Could we say that low levels of correlation or an altogether lack of correlation imply causation? On the face of it, it seems absurd to think that lack of correlation or even minimal correlation might imply causation. Who would think that A causes B when A and B have no relationship to one another or only a minimal association with one another? That inference, however, is exactly what we assume when we think that degenerative disc disease causes chronic back or neck pain.

The logic of correlational studies of degenerative disc disease and chronic spine pain

Degenerative disc disease is a common explanation for chronic back or neck pain. Degenerative disc disease is a general phrase that refers to a number of conditions or changes of the spine, such as loss of disc height, disc bulges, annular tears, disc herniations, endplate changes, neuroforaminal and spinal canal stenosis, among others. Healthcare providers typically identify their occurrence with either X-ray, CT or MRI scans. When these tests identify degenerative disc disease in the spine of someone experiencing chronic back or neck pain, many healthcare providers and their patients consider that the degenerative disc disease is the cause of the chronic pain. In other words, they believe that the degenerative disc disease is painful.

Healthcare providers and their patients commonly justify particular types of treatment with the notion that degenerative disc disease is causing chronic back or neck pain. Spine surgery and interventional pain procedures, in particular, but also certain types of physical therapy, all attempt to reduce pain by modifying specific types of degenerative changes of the spine. Again, the underlying justifying belief is that such degenerative changes of the spine are painful.

How valid is this justification? In other words, how true is it that degenerative disc disease causes chronic back or neck pain?

The question is actually tricky to answer, especially if we want to show that it is in fact true. Theoretically, the best way to answer it would be to run a true experiment, where we induce various degenerative changes to the spine in a number of people and see whether they have pain in the back or neck (wherever the degenerative change was induced). However, we don’t know how to make degenerative changes to the spine, at least not exactly as they occur naturally. Additionally, even if we did know how, there would be all sorts of ethical problems in producing degenerative disc disease in human subjects. For instance, we don’t know how to reverse it and so we’d be inducing permanent damage to people. Because of these challenges, we don’t tend to perform true experiments when looking at the relationship between degenerative disc disease and chronic neck and back pain.

Instead, we generally rely on a different form of research in the scientific study of chronic pain – correlational research. In correlational research, we measure certain variables, such as the occurrence of degenerative disc disease and back or neck pain, and see whether they tend to go together. If two things, such as degenerative disc disease and pain, are highly correlated (i.e., they tend to go together almost always), we can at least say that one may cause the other. As we discussed in the introduction of this piece, though, we cannot say with confidence that there is a causal relationship when two things are highly correlated. There may be other factors that cause the two to occur together all the time (i.e., think of the air conditioner use and street crime example). Nonetheless, it is helpful to see whether they correlate together and what the strength of the correlation is. The reason is that if they don’t correlate at all or if the correlation is very weak, then we can say with confidence that they don’t cause each other.

To understand, we need to look at the following reasoning: when one thing causes another thing, they must occur together in some demonstrable way; if, however, when one thing occurs, another thing may or may not occur, they have no relationship to each other and so we cannot say that there is a causal relationship. A causal relationship presupposes a correlational relationship. Now, as we have said before, a correlational relationship is not enough to demonstrate a causal relationship, but to have a causal relationship, there at least has to be a correlational relationship. We have to at least be in the right ballpark, as it were. Without a correlational relationship, though, we can say with much greater confidence that we are not even in the right (i.e., causal) ballpark. In other words, if we find no correlation, we can safely assert that there is no causal relationship.

A similar, albeit slightly different logic holds with weak correlations – the situation in which two things go together in some minimal ways. With such correlations, we can say that there may be a causal relationship between the variables, just as we said with strong correlations, but we can’t know for sure because correlation doesn’t imply causation. Now, with weak correlations, however, we can go a step further. We can assume that even if there was a causal relationship between the two variables, we know that there has to be more to the picture than simply the two weakly correlated variables. In other words, there has to be additional causal variables coming into play, because if there weren’t the correlation would have to be strong. The weak correlation, even in cases where we might assume a causal relationship, shows that the variable is only part of the cause – and only a small part at that.

It would be helpful to take an example. Let’s suppose that we did a study of the relationship between the presence of eating utensils and cookware in the kitchen on the one hand and how much food people ate on the other hand. In a sample of 1,000 people, we measured a) the extent to which they had eating utensils and cookware in the kitchen and b) how much they ate on average over the course of a month. Let’s further suppose we found a weak, statistically significant, relationship between our two variables of interest. It’s a fantastical example, of course, but we might see how it could be true: the presence of eating utensils and cookware could play some small role in how much you ate on average – if you don’t have a way to prepare and eat food, it could affect how much you eat. However, we can also immediately see that there’s more to the picture in terms of what goes into the fact of how much food people eat. The extent to which you have ways to prepare and eat food are not the only variables that can lead to eating a little or a lot. People can eat raw foods; they can eat with their hands; they can buy prepared foods in the grocery store, delis, and fast food restaurants; they can go out to eat in sit-down restaurants; and so on. Personal characteristics of the people can also play a role: how hungry they are or how much stress they are under or how busy they are can also affect how much people eat – even in people who don’t have adequate means to prepare food. In all these ways, we can see that a weak, statistically significant, correlational relationship cannot explain the whole nature of the relationship between two variables, even when we assume that they are in some ways causally related.

As we will see in the following review of the correlational research on degenerative disc disease and chronic back or neck pain, degenerative changes of the spine fit into one of these two categories: they either have no relationship at all with chronic back or neck pain, or they are only weakly related to chronic back or neck pain. As such, we can conclude with confidence one of two things, depending on the type of degenerative disc disease we are discussing. First, in the case where research repetitively shows no correlational relationship between certain types of degenerative disc disease and chronic back or neck pain, these particular types of degenerative changes do not cause pain, despite the common belief that they do. Second, in the case where research repetitively shows a weak, statistically significant, correlational relationship between certain types of degenerative disc disease and chronic back or neck pain, these particular types of degenerative disc disease may play some role in producing pain, but we know that it is only a minimal role, even if we assume that the correlation reflects a causal relationship. In other words, the weak correlation between certain types of degenerative disc disease and pain shows that the lion’s share of what’s causing the pain is something else entirely. This statement too stands in stark contrast to the common belief that degenerative disc disease is the predominant cause of chronic back or neck pain.

Let’s, then, review the correlational research on the relationship between the different types of degenerative disc disease and chronic back or neck pain.

Correlation (or lack thereof) between pain and degenerative disc disease

In a review of early studies, van Tulder, at al., (1997) found weak significant associations between back pain and disc space narrowing, Image by Tsunami Green Courtesy of Unsplashosteophytes, and sclerosis, with odds ratios in the range of 1.2-3.3. Other degenerative changes, such as spondylosis, spondyolisthesis, and kyphosis had no relationship to back pain.

In their review of the literature on the natural history and clinical significance of disc herniation, Grande, Maus, and Carrino (2012) conclude that there is no relationship between any characteristics of disc herniation, including size or severity, and subsequent symptoms of patients.

Mitra, Cassar-Pullicino and McCall (2004) found no relationship between evidence of an annular tear in the disc and pain.

Jarvinen, et al., (2015) found no significant correlation between Modic 1 or Modic 2 changes and low back pain.

de Schepper, et al., (2010) studied the relationship between osteophytes, disc space narrowing, and low back pain. They found that disc space narrowing, especially, at more than one level, was most significantly related to low back pain, but only weakly, with an odds ratio of 2.4.

In a more statistically oriented review, Chou, et al, (2011), systematically searched the literature and combined studies to determine the odds ratio for having lumbar degenerative changes and chronic low back pain. They found a significant, yet weak, association between the two. The range for the odds ratio was between 1.8-2.8.

Livshits, et al., (2011) found a significant relationship between all degenerative changes of the spine and pain with an odds ratio of 3.2.

In a study published after the Chou, et al. findings, Nemoto, et al., (2012) found a significant correlation between vertebral osteophytes and low back pain, but the odds ratio was a little greater at 3. In contrast to the de Schepper, et al, study cited above, they found no correlation between disc space narrowing and back pain.

All these data are what likely led Bogduk (2012), one of the founding fathers of interventional pain management, to conclude, “Degenerative changes [of the spine] lack any significant correlation with spinal pain.”

These findings are also similar to the relationship between degenerative disc disease and pain related disability. Quack, et al., (2007) found either no relationship or only weak correlations between lumbar degenerative changes and mobility. Sirvanci, et al., (2008), found no significant relationship between lumbar spinal stenosis and perceived disability, as measured by the Oswestry Disability Index. Lohman, et al., (2006) found no relationship between spinal stenosis and pain or scores on the Oswestry Disability Index. Remes, et al., (2005) in a cohort of patients who underwent fusion for spondylolisthesis twenty years ago, found no relationship between lumbar degenerative changes and the same measure of disability. Similarly, looking at a number of biological and lifestyle factors, Wilkens, et al., (2013) found that degenerative changes as found on imaging failed to correlate with perceived disability one year later as measured by the Roland-Morris Disability Questionnaire.

Conclusion

This review of the literature shows that the various types of degenerative disc disease either have no relationship to pain and disability or only a weak correlation to pain and disability. What this means is that degenerative disc disease is likely not painful. At best, it plays a minimal role in the cause of chronic back or neck pain. The true cause of chronic back or neck pain must be something else entirely.

For more information on degenerative disc disease, please see the previous blog post and the Institute for Chronic Pain content pages on Degenerative Disc Disease and Whatever Happened to Backache?

References

Bogduk, N. (2012). Degenerative joint disease of the spine. Radiology Clinics of North America, 50(4), 613-628. doi: 10.1016/j.rcl.2012.04.012

Chou, D., Semartzis, D., Bellabarba, C., Patel, A., Luk, K., Kisser, J. M., & Skelly, A. C. (2011). Degenerative magnetic resonance imaging changes in patients with chronic low back pain: A systematic review. Spine, 36, S43-S53. doi: 10.1097/BRS.0b013e31822ef700

Del Grande, F., Maus, T. P., & Carrino, J. A. (2012). Imaging the intervetebral disk: Age-related changes, herniation, and radicular pain. Radiology Clinics of North America, 50(4), 629-649. doi: 10.1016/j.rcl.2012.04.012

de Schepper, E., Damen, J., van Meurs, J. B., Ginai, A. Z., Popham, M., Hofman, A., Koes, B. W., & Bierma-Zeinstra, S. M. (2010). The association between lumbar disc degeneration and low back pain: The influence of age, gender, and individual radiographic features. Spine, 25(5), 531-536. doi: 10.1097/BRS.0b013e3181aa5b33

Jarvinen, J., Karppinen, J., Niinimaki, J., Haapea, M., Gronblad, M., Luoma, K., & Rinne, E. (2015). Associations between changes in lumbar Modic changes and low back symptoms over a two year period. BMC Musculoskeletal Disorder, 16, 98. doi: 10.1186/s12891-015-0540-3

Livshits, G., Popham, M., Malkin I., Sambrook, P. M., MacGregor, A. J., Spector, T., & Williams, F. M. (2011). Lumbar disc degeneration and genetic risk factors are the main risk factors for low back pain in women: The UK twin spine study. Annals of Rheumatic Disease, 70(10), 1740-1745. doi: 10.1136/ard.2010.137186

Lohman, C. M., Tallroth, K., Kettunen, J. A., & Lindgren, K. (2006). Comparison of radiologic signs and clinic symptoms of spinal stenosis. Spine, 31(16), 1834-1840.

Maus, T. (2010). Imaging the back pain patient. Archives of Physical Medicine and Rehabilitation, 21(4), 725-766. doi: 10.1016/j.pmr.2010.07.004

Mitra, D., Cassar-Pullicino, V. N., & McCall, I. W. (2004). Longitudinal study of high intensity zones on MR of lumbar intervetebral discs. Clinical Radiology, 59(11), 1002-1008.

Nemoto, O., Kitada, A., Naitou, S., Tsuda, Y., Matsukawa, K., & Ukegawa, Y. (2012). A longitudinal study for incidence of low back pain and radiological changes of lumbar spine in asymptomatic Japanese military young adults. European Spine Journal, 22, 453-458. doi: 10.1007/s00586-012-2488-4

Quack, C., Schenk, P., Laeubil, T., Spillmann, S., Hodler, J., Michel, B. A., & Klipstein, A. (2007). Do MRI findings correlate with mobility tests? An explorative analysis of the test validity with regard to structure. European Spine Journal, 16(6), 803-812.

Remes, V. M., Lamberg, T. S., Tervahartiala, P. O., Helenius, I. J., Osterman, K., Schlenzka, D., Yrjonen, T., Seitsalo, S., & Poussa, M. S. (2005). No correlation patient outcome and MRI findings 21 years after posterior or posterolateral fusion for isthmic spondylolisthesis in children and adolescents. European Spine Journal, 14(9), 833-842.

Sirvanci, M., Bhatia, M., Ganiyusufoglu, K. A., Duran, C., Tezer, M., Ozturk, C., Aydogan, M., & Hamzaoglu, A. (2008). Degenerative lumbar spinal stenosis: Correlation with Oswestry Disability Index and MR imaging. European Spine Journal, 17(5), 679-685. doi: 10.1007/s00586-008-0646-5

van Tulder, M. W., Assendelft, W. J., Koes, B. W., & Bouter, L. M. (1997). Spinal radiographic findings and nonspecific low back pain: A systematic review of observational studies. Spine, 22(4), 427-434.

Wilkens, P., Scheel, I. B., Grundes, O., Hellum, C., & Storheim, K. (2013). Prognostic factors of prolonged disability in patients with chronic low back pain and lumbar degeneration in primary care: A cohort study. Spine, 38(1), 65-74. doi: 10.1097/BRS.0b013e318263bb7b

Author: Murray J. McAllister, PsyD

Date of publication: 5-31-2015

Date of last modification: 3-27-2021

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Degenerative Disc Disease Sun, 30 Mar 2014 20:49:01 +0000