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How to Break the Cycle of Chronic Pain

As many as 50 million Americans have chronic pain at any one time. It affects one in five people globally, and is the primary reason people seek medical treatment. The costs for treating pain-related conditions are estimated to exceed $125 billion each year.

Pain is a personal sensation. It can’t be measured objectively, and yet it can have a powerfully negative effect on mood, interactions with others, and physical functioning. It can also be isolating and poorly understood by others. When pain isn’t properly managed, it can sometimes devastate people’s lives.    

Most patients who visit Zacharia Isaac, MD, a physical medicine and rehabilitation spine and pain care specialist Brigham and Women’s Hospital (BWH), are in chronic pain. Their backs or necks may have been hurting for months, even years. Often, it’s all they can think about.

Empathetic listening: The first step toward recovery

Dr. Isaac listens intently as patients tell him that few interventions have dulled their pain, including physical therapy, epidural steroid injections, pain-relieving medications, antidepressants, and psychotherapy, in some cases. He acknowledges their struggles and then commits to helping them get their life back.   

Empathetic communication is use of language that aides the process of healing by bolstering a patient’s strengths, validating their perspective and encouraging self-reliance. 

It’s a well-known technique in medicine, known as empathetic communication, the use of language that aides the process of healing by bolstering a patient’s strengths, validating their perspective and encouraging self-reliance. In other words, it’s compassionate care, otherwise known as bedside manner.  

The many, many possible causes of pain

As the medical director of the Comprehensive Spine Center at BWH, and chief of the division of spine care and pain management at Spaulding Rehabilitation Hospital, Dr. Isaac educates patients about the mechanisms by which the brain and neural pathways can lock them into a chronic pain state.  

After taking a patient’s history and understanding their worries and concerns, Dr. Isaac searches for the causes of their pain, though it’s not always easy. Take back pain, for example. There are numerous possible pain generators, including:

  • The degeneration of intervertebral discs   
  • The inner nucleus of a disc can herniate outward and start a chemical cascade of inflammatory mediators that injure spinal nerves
  • A facet joint, a small stabilizing joint between vertebrae, can develop osteoarthritis
  • Ligaments can become injured and strained
  • Muscles can sprain or spasm chronically
  • Compression within arthritic vertebrae can result in reduced blood flow to spinal nerves and the spinal cord   

Pain doesn’t necessarily mean damage

“Most structural abnormalities, including bulging, degenerated or herniated discs, are not the source of the pain. Contrary to popular thought, it’s possible to have a herniated disc without pain,” says Dr. Isaac. 

Link to: https://www.brighamandwomens.org/comprehensive-spine-center

Right: Triathlete with significant disc degeneration and only occasional back pain. Left: Patient with chronic back pain and no structural abnormalities.

In many cases of chronic back pain, most structural abnormalities, including bulging, degenerated or herniated discs, are not the source of the pain. Contrary to popular thought, it’s possible to have a herniated disc without pain.

For instance, the MRI on the right (picture) belongs to a triathlete whose spine has several significantly degenerated discs, and yet this patient has only occasional back pain. The MRI on the left belongs to a person with chronic back pain. Their imaging shows no abnormalities, and yet this person is debilitated by pain.   

Dr. Isaac says, “Patients in chronic pain who don’t have significant structural issues are often extremely frustrated. The go from doctor to doctor, receive study after study, and get no firm answers or treatment solutions. These patients feel more invalidated when their doctors can't find an identifiable source of their pain, and their friends or family can't understand their plight.”

Such severe and disabling pain can lead to a cycle that can cause a fear and avoidance of physical activity. This avoidance behavior can lead to deconditioning, sleep disturbances, changes in brain chemistry, all of which can lead to the recruitment of neural pathways that can lock the pain into a deeply ingrained, self-reinforcing state.

Nociceptive vs. neuropathic pain

In many cases of chronic pain, the inflammation has gone down and tissues have healed, but the brain has become hypersensitive to even slight pain signals. It’s the difference between nociceptive pain—pain associated with tissue damage—and neuropathic pain that involves the nervous system.

If pain is constant and has persisted for over three months, it’s likely a sign of neuropathic pain.

Neuropathic pain involves pain pathways that have become ingrained and reinforced over time. If pain is constant and has persisted for over three months, it’s likely a sign of neuropathic pain. Other signs of neuropathic pain may include:

  • When it’s difficult to know what makes symptoms worse  
  • Symptoms may be triggered unpredictably
  • The pain is worse at night
  • The pain affects you emotionally

There are several factors that may predispose a person to develop neuropathic pain, including:  

  • Unique brain chemistry
  • Being overweight or obese
  • Poor posture, or deconditioned muscles that can expose structures to abnormal loads
  • Exposure to whole-body vibration
  • A history of depression or anxiety

“Neuropathic pain is associated with an area of the brain known as the default mode network, a part of our brain that’s active when our minds are wandering or daydreaming. Most of the time our minds mull over problems around our daily lives. The default mode networks of chronic pain patients fixate on pain,” says Dr. Isaac.

Addressing chronic pain at multiple levels  

The habit of fixating on pain can be reversed, says Dr. Isaac, but it can take weeks or months and requires a multi-pronged approach.   

The following interventions address the complex issue of chronic pain at many levels. Each component is designed to stimulate the brain’s ability to change, known as neuroplasticity.

  • Knowledge: Remember, pain doesn’t necessarily mean damage, and structural abnormalities don’t predict pain intensity. Acknowledge that some deeply-held thoughts, fears or misconceptions about pain may be undermining your recovery.
  • Anatomical: Mechanical deficiencies are corrected with strengthening exercises during physical therapy or in-home exercise programs, and attention to posture.
  • Biochemical: Inflammation can be corrected with oral medications and/or corticosteroids injections.
  • Neurological: Knowledge (above), exercise, meditation, and healthy sleep
  • Surgery: Some patients with severe spinal stenosis or herniated discs may have symptoms that can be surgically corrected.

“The last component of recovery is emotional. How you ‘deal with’ pain matters significantly,” says Dr. Isaac. “Some people have pain, but it doesn’t bother them, whereas some people with the same pain can become overwhelmed by fear, worry, and anxiety, even depression. The emotional component is addressed with coping strategies, such as psychotherapy, cognitive behavioral therapy, meditation, and medications, in some cases.”

It may seem paradoxical, but you should remain physically active when you are in pain, especially when you are in pain. According to the most up-to-date research, it’s the most effective way to resolve a back-pain episode.

Exercise: A key component of recovery

The role of physical exercise in resolving back pain can’t be overstated. Many people with chronic back or neck pain stop their usual activities, thinking it might make their situation worse. However, according to new guidelines from The American College of Physicians, avoiding physical activity can lead to the atrophy of core and back muscles that support the spine.

It may seem paradoxical, but you should remain physically active when you are in pain, especially when you are in pain. According to the most up-to-date research, it’s the most effective way to resolve a back-pain episode.

“Exercise is the key to undoing ingrained chronic pain pathways. Exercise creates new brain cells and neural pathways. It also stimulates blood flow, and has an anti-inflammatory effect on discs in the spine,” says Dr. Isaac.   

Other benefits of exercise for resolving chronic pain include improvements in:

  • Muscle mass  
  • Strength, flexibility, balance and bone density
  • Cardiac function and conditioning
  • Memory
  • Mood
  • Pain tolerance (e.g., triathletes have higher pain tolerances)    

Aim to exercise at least 150 to 180 minutes a week at moderate intensity. If you have pain during exercise, try to work through it. Due to increased blood flow, pain will likely diminish during physical activity.

Over the course of weeks and months, the pain should lessen with improved strength and conditioning. Perhaps more importantly, the fear of activity or hurting yourself should fade as well.  

“Make no mistake, breaking the cycle of chronic pain is difficult. It takes commitment and determination, but I’ve seen patients break free of chronic pain and get their lives back,” says Dr. Isaac.

For more information about how to manage back pain, read our three-part series on low-back pain on Brigham Health Hub.

- Dustin G. 

In this video, Zacharia Isaac, MD, a physical medicine and rehabilitation spine and pain care specialist Brigham and Women’s Hospital (BWH), discusses the pathophysiology of chronic pain.