Chronic pain syndrome is a complex multifactorial disease that affects 1 in 5 Australians over the age of 45. It is the third largest disease burden (surpassed by cancer and cardiovascular disease), and costs approximately 139 billion dollars through reduced quality of life and productivity losses. 

Typically speaking, pain is a normal sensation felt as a reaction to illness or injury which subsides after the cause is gone. However, chronic pain can result from the unfortunate conclusion of improperly managed acute pain or injury that lasts for more than 3 months, to constant never ending pain. Chronic pain can also develop as a result of certain disorders such as but not limited to:

• Arthritis and other joint problems
• Back pain
• Headaches
• Muscle strains and sprains
• Repetitive stress injuries, when the same movement over and over puts strain on a body part
• Fibromyalgia, a condition that causes muscle pain throughout the body
• Nerve damage

The characterisation of chronic pain is usually accompanied by far more than just pain and dysfunction, but also presents with psychological manistifisations including stress, anxiety, depression, pain cataphrosing, fear and avoidance of movement. This creates complexity and difficulty in patient management – not only are practitioners required to tackle the problem in a biological/structural direction, but are also required to treat (or aid in the treatment of) the psychological manifestation of chronic pain; hence the biopsychosoical model of chronic pain. 

The mind map below shows how all factors (biological, psychological and social) affect pain, and how pain affects them right back – highlighting that treating the structural factors of pain usually won’t provide the long term benefits that patients are looking for.

In this blog I will address only two of the many factors that affect the incidence of chronic pain which is pain catastrophising, and fear of avoidance. During pain or injury our peripheral nerves send signals up through the central nervous system into the brain where it is processed and acknowledged.

The Amygdala is part of the brain that associates particular events with fear and anxiety. E.g when a patient bends over to pick something up and feels pain, the event will be associated with pain, and the Amygdala can create fear and anxiety around that particular movement. In the acute stage of injury this is inherently good to reduce movement in the area to stop further damage. However long-term fear of movement and pain catastrophising can lead to chronic pain and disability even after tissue damage has long healed.  

The flow chart below gives a simple view of the vicious cycle of pain catastrophising and fear of avoidance. 

The fear-avoidance model of chronic pain based on the fear-avoidance model of Vlaeyen and Linton, and the fear-anxiety-avoidance model of Asmudson et al. (picture taken from Domenech, Julio & Sanchís-Alfonso, Vicente & Espejo, Begoña. (2011). Influence of Psychological Factors on Pain and Disability in Anterior Knee Pain Patients. 10.1007/978-0-85729-507-1_9.) 

Amongst various other biological and psychological factors, catastrophising and fear can cause sensitisation to pain (central sensitisation), exacerbating the feeling of pain, disuse of musculoskeletal structures and increase risk of long-term disability. 

So, what is the take home message? Your pain is real, yes it hurts! But the more we focus on our pain and fear, the greater chance you may fall down the hole of chronic pain and disability. Rather embrace your pain, understand that pain is a normal biological function and get moving. 

– Dr. Tayyar Celiker (Osteopath) – BSc (Clin Sc), MHSc (Osteo) 

References:

Australian Institute of Health and Welfare. (2020). Chronic pain in Australia. Canberra: AIHW 

Domenech, Julio & Sanchís-Alfonso, Vicente & Espejo, Begoña. (2011). Influence of Psychological Factors on Pain and Disability in Anterior Knee Pain Patients. 10.1007/978-0-85729-507-1_9. 

Craig A. Wassinger, Gisela Sole. (2021) Agreement and screening accuracy between physical therapists ratings and the ?rebro Musculoskeletal Pain Questionnaire in screening for risk of chronic pain during Musculoskeletal evaluation. Physiotherapy Theory and Practice 0:0, pages 1-7.