I have a clinical interest in pain so it happens that I see a lot of people with chronic pain syndromes – mainly with low back pain. I am part of a team which consists in my town of psysiotherapists, family doctors, a pain management specialist (who is an anaesthesthetist), and a physician who runs a group-based pain management programme. I do hypnotherapy and medical acupuncture.
Back pain is common -at any one time 30% of the population will report some pain. Its the second commonest reason for seeing a GP. And the longer the person is in pain the more likely they will develop a comorbid psychiatric disorder . About 60% will develop at 6 months either anxiety disorder, depression , or substance abuse. Most back pain resolves 60% at 6 weeks; 85% at 12 weeks. If it is still present at 6 months there’s a 50% chance of making it back to work and if its still present at 12 months the odds for a rtw are low indeed. We rate in the middle for frequency of back surgery – UK 0.19 – AUS 0.44 -USA 1.0.
Most pain starts out as local inflammation or mechanically caused. However by six months the brain and spinal cord readjust their pain sensitivity and start responding to pain that is not there locally ( this is called Neuropathic Pain to distinguish it from Mechanical or Inflammatory Pain) This process is called central sensitisation. Its why someone with severe leg pain may continue to have severe leg pain even after the leg is amputated! The significance of this is three fold:
(1) Neuropathic Pain is particularly worsened by depression and anxiety and its important to treat these. Cymbalta is the preferred anti-depressant for its analgesic properties. It can be combined with various augmenting agents for anxiety/depression.
(2) Neuropathic Pain is often accompanied by sensitivity to touch, tenderness over the area, swelling, odd sensations , discolorations, and temperature changes over the area.
(3) Opioid Analgesics work well for Mechanical Pain but not very well for Neuropathic Pain. Instead Neuropathic Agents such as Gabapentin and Pregabalin are more effective.
Cognitive Behaviour Therapy has an important role to play in pain management:
Common poor coping behaviours are-
- ‘I am completely at the mercy of my pain”
- ”I cant stop thinking about what I used to be able to do”
- ” I have to protect myself from reinjury”
- ” I have nothing to offer friends anymore”‘
- ” I am only going to be more disabled in the future”
Good coping strategies are-
- ” The pain levels vary day to day”
- ” I can set goals that I can accomplish – building social networks
- – developing new pastimes
- – increasing personal fitness
- ” I need to communicate clearly with my partner about how I am doing”
- ” I need to foster my independence as much as possible”
- ” I need to plan and develop strategies with my doctors for flare ups in pain”
- ” I should look at this pain as a challenge to my resilience to a crisis”
Its important that partners are not oversolicitous and that they support the patients independence and self-efficacy.