Sunday, September 1, 2013

Chronic Pain Is a Pain in the Butt

This is a little more technical post that may not be of interest to everyone, but several people were interested in the chronic pain stuff and since I've been working on turning it over in my brain so much, it might help me to straighten it out better in my head if I write it.  And it sounds like it might be beneficial to some people that either have or know people with chronic pain. This will probably be a number of posts because it's such a complex thing and I've got a lot on my mind in regard to it.  

I'm a physical therapist, and chronic pain has been a pain in my butt since I started practicing.  I have met tons of wonderful people with this horrible problem, and it is SO frustrating to be so incompetent in the face of it. Things like fibromyalgia, chronic fatigue syndrome, chronic back and neck pain after things like a car accident or falls, ongoing extreme pain and sensitivity after an traumatic fracture, and many more things. All too often, there is lots of pain, but little known reason for it.  I treat lots of pain every day, but these are the kinds of things that I dread seeing walk through the door, because these are some of the people that most need help, and they seem to be the people that I can help the least.

When they come to see me, there is always a specific problem that I am supposed to be treating.  Back pain. Neck pain. Arm pain.  Muscle and joint pain. Trigger points.  The thing is, I'm usually pretty good at treating those things in a scenario when things are mostly caused by a mechanical reason.  For example, I remember one patient who came in with back pain and he'd had a surgery for it, but was still having pain.  I took one look and saw one shoulder sitting back farther than the other.  I took him in front of the mirror, showed him how he was rotated and stood him up straight.  His pain decreased immediately, and we identified some work areas where he was constantly twisting in that direction and fixed him.  Ahh, I like the easy ones like that.

What I don't like are the ones that have been in for numerous back surgeries for a number of different things with a varying degree of success, but never manage to be pain free.  They've already been to a number of physical therapists and they've already done a lot of exercises, and with only limited progress.  Those are the ones that I know are going to go out the door with only a limited amount of progress.

Or people who have had a car accident and they are so fired up with muscle and soft tissue pain that all the things that I normally do that usually leave people feeling fantastic just leave these folks feeling worse.  And why does it last so freaking long (sometimes years) after a car accident?

Here's what's always gotten me about chronic pain.  I am only going to treat the body part, right? But when I'm taking a history, people with chronic pain often have a whole host of things going on:

-Depression (makes sense; seems like dealing with unexplained, ongoing pain that is often not well understood by healthcare providers would be awfully depressing.)
-Anxiety (again, makes sense)
-TMJ syndrome
-High blood pressure (a body under that much stress? Makes sense.)
-Chronic fatigue
-Insomnia (those two are often present and are completely unfair that they exist together.)
-Pain in multiple sites
-Pain that's often fairly generalized and hard to describe exactly where it is or what is causing it
-Sometimes complain about being cold all the time
-Poor hair growth or hair loss
-Don't feel like themselves and wonder who they are and how they got to be where they are
-Chronic knots/trigger points in the muscles
-Difficulty concentrating or thinking

I'm sure there's others, and not everyone has everything on the list, but usually it's a combination of several of those things.  These are the people that I have to be really careful with my treatment, because too much often brings about an exaggerated pain and/or fatigue response. These are the people that usually have lots of knots that are causing pain, and feel better when I release those knots, but come back and report that they felt good for a few days (if we're lucky) or maybe only a couple of hours.  And when I get my hands on the knots again, they're back to where they were when I started.

Then there are often those people that I treat that have some very mild forms of some of those symptoms, but it's not quite as bad and is not enough to be completely debilitating, even though it's affecting the quality of life. In so many people, they tell me about these different symptoms with a hint of helplessness in their tones and attitudes that breaks my heart.  They usually finish with some sort of a comment about how "maybe I'm just crazy."  I can see how they would feel that way, given that there's this huge variety of things going on that seem to be so unrelated on the surface, and because they've usually had a number of tests that don't show anything and doctors are baffled by what to do with them.  The good doctors tell them "we just don't know."  Other doctors say "there's nothing wrong with you" or they want to send them only to a psychiatrist.  It's even worse if there was some sort of an accident claim and someone is questioning whether they are really feeling all the things they say they feel. Patients end up feeling defeated, and I don't blame them. I can't tell you the number of times someone shrugs and tells me that they live with daily pain and they've just learned to ignore it.

I had no idea why some of these symptoms would show up so many times.  It was frustrating, because I'd be addressing this one small bit of a huge problem.  I knew they needed more, but I didn't know what, or where to send them to try to find more relief.  All pain clinics want to do is to find the right drug cocktail (or so it seems). Many of the patients had already had many of the most modern medical tests in our arsenal. I would straight up tell patients that I don't know why these things are happening, but they aren't making it up.  And I would wonder why these things were happening, wonder why we could get something to loosen up, but not stay that way, why chronic pain is so freaking resistant to treatment.  But I had no idea where to start with it all, so I usually just left it at that. I wondered why, and tried to treat the muscles and nerves (mostly peripheral nerves) and joints as best I could and figured a tiny bit of progress is better than no progress at all.

That is some of my professional experience of chronic pain. Next time, I'll tell you about a bit of personal experience (though I never had a lot of the symptoms listed above, and didn't even really recognize it in those terms for a while... Well, how about I wait and explain it then, hmm?)


  1. From my experience with chronic pain (my own troubles, but also my mom's fibromyalgia & chronic fatigue), I feel like most pain isn't caused by one event or reason. There can be a trigger - an emotional event like a divorce, a physical event like a car accident - but the body was probably already in distress and they didn't know it. People ignore signs that their body is giving them because they just think it's normal to have bowel issues, or regular headaches, or tons of cramps during AF, for example. Add in stress, poor nutrition, sedentary lifestyles, drug or alcohol usage, etc and the body just finally gives up and says "well you didn't listen when I said owie, so now I'm saying OWWWWWWWWIIIIEEEE!". Or something like that :).
    My mom has turned a real corner since she's lived with us. We did saliva hormone profile and started supplementing with bioidentical hormones and suddenly her insomnia improved overnight and her mood swings were gone! It helped her depression, but then so did waking up to her grandson every day :). As she got more sleep and felt less depressed, she was able to get out of the house more and get more exercise, which led to less pain. She also didn't have to worry about preparing healthy meals (I've got that covered) and so she lost weight and has more energy, and decreased inflammation. Which again helped her move more, feel less pain, etc.
    She still needs PT or regular exercise to help her regain core strength and eliminate some back and shoulder pain, but you see how the cycle can be interrupted?
    It's just incredibly hard to get someone to change EVERYTHING about their life. This was a huge change for my mom, but she was at the end of her rope, basically, so she had no choice.
    Anyway, sorry for the diatribe, but I love this topic you're writing about and obviously feel passionately about it :).
    I'm looking forward to your next post!

  2. This post really hit home. About a week after I got married I ruptured 2 discs in my back. I ended up having surgery and came out beautifully. About 3 months after surgery I fell down some slippery stairs and shortly thereafter my discs ruptured again. I had a second surgery at the end of that same year. I didn't heal as well from the second surgery. Chronic pain is a part of my daily life. I am making small strides- for a while there I was on a fentanyl patch and oxycontin. Today I've been able to get off the patch and only use Norco every 8 hours and Tramadol for break through pain. I've done physical therapy and water therapy and it did help but the pain never goes away. I have every symptom you listed above. We want to have children but I don't even know if I can live without my pain medication at this point. It's always an uphill battle, some days are better than others... any day with extreme weather seems to irritate things... if I do too much activity (too much walking or house work etc) I pay for it for many days after. It was kind of comforting to read your thoughts on it, with you being a professional and having the compassion and empathy you do makes me feel like I'm not alone in this. People try to understand but unless you live it you never really get it 100%. It's so hard to make plans now because I never know how I'm going to feel when I wake up that day. It's created so much social anxiety because for the longest time I was confined to my home and I started to get used to being alone all the time (before my second surgery I couldn't walk without a cane and was basically bedridden). At 29 years old I continue to grieve the fact that my body is kinda failing me. This is something I never expected to experience so young in life. I have hope that it will one day turn around but right now I just try to focus on one day at a time. I'm sorry I wrote a novel here, I just couldn't go to sleep without saying something. Thank you for the work that you do and at least attempting to help others like me get some relief. Also thank you for writing about this and shedding some light on this "condition" so others may start to understand. I hope you have a blessed week.


  3. I didn't mean to make my comment sound judgmental toward those in pain. I didn't express myself very well, but basically I'm absolutely flabbergasted at how many layers there are to injury and illness and how difficult it is to find the source of the pain.
    After all, I'm dealing with this very thing myself!

  4. Wow, the connection between IBS, anxiety and chronic pain really stood out to me. I can see that with my grandma and her fibromyalgia. I can also see the connection between my digestive track and anxiety. When I was a kid I would get stomach aches because of the food I was eating but also the amount of anxiety that I had. I notice that now that I have learned to deal/treat my anxiety I will only have stomach issues when I eat the wrong foods for me. Such a fascinating topic, I can't wait to hear more :)

  5. I am very interested in this topic. I had a herniated disc and was dealing with sciatic nerve pain until I had surgery and came out beautifully. I think now I'm more like the first patient you described. I probably have a shoulder that's higher than the other or something like that. I blame this on my heavy backpack when I was in high school and I would walk from and back to school carrying it. I also don't have good posture. I suffer from back pain, especially after my week of driving. Other than that I'm okay most of the time, nothing a good massage or lying on my back on the floor for a couple or ten minutes won't fix. Anyway, looking forward to reading more of this.

  6. interesting post, thanks..
    what about treatment with Cannabis? will it work for us against the horrible pain??

    treating chronic pain