Frequently Asked Questions About Chronic Pain:
Q: Can you explain the difference between acute and chronic pain?
Sure. Acute pain is defined as a recent onset of pain associated with a particular
event or cause such as stepping on a thumbtack. Generally, these pains go away in
a few minutes or even a few weeks. Once pain persists past the 3 months point it’s
defined as chronic pain. It is the treatment of chronic pain that eludes most
practitioners of the healing arts.
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Q: Is there a difference in terms of treatment and approach to treating chronic pain as opposed to acute pain?
Well, let’s just say that there should be a difference although many therapists
treat chronic pain as an acute pain that has been around for a while. I think this
is flaw in our approach. There are fundamental differences between acute and chronic
pains and there are physiological differences that occur in the body when a pain has
persisted for a long time. The toolbox of techniques that we have for the acute pains
is actually quite large and quite effective and when we try to use that same toolbox
for chronic pain we may run into trouble because it doesn’t seem to be as effective.
We need to use a different set of tools for chronic pain.
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Q: In terms of the initial evaluation to determine what the best treatment would be, is there a difference in terms of how you evaluate a patient with chronic pain as opposed to acute pain?
Yes, in the evaluation there is the subjective component and the objective component.
The subjective component is the interview where I sit down and I discuss the
complaint that the person has and I go over their history and so on before I even
do the physical examination. The idea behind doing the interview is to get an idea
of how to approach the physical examination and there are certain cues and clues
that the therapist can gain from the interview that would lead one to suspect that
not only is this a more chronic condition but that the pain that the pain may be a
blend of peripheral, neurogenic and central mechanisms. Peripheral means at the
level of the tissues (the skin, muscles, ligaments, tendons, etc). Neurogenic is at
the level of the nerves which feed the signals to the spinal cord and central refers
to all the processing of that information in the spinal cord and the brain.
People sometimes confuse the latter with psychological but the two are completely different.
I am not here to talk about psychological phenomena but only about physiological
facts. Unfortunately, many of us are stuck at the level of the tissues and we
believe that something must be wrong with the tissues in order to feel pain there.
This is simply not true. The best proof of that is the amputee with no leg who feels pain
in the foot.
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Q: People with chronic pain may try very hard to figure out what’s causing their pain and they go through a lot of tests and imaging to find out the cause. What are your thoughts on that?
We have a wonderful technology these days in terms of MRIs, CT scans and nerve
conduction studies which can give us a lot of information. However, I think that
where we’ve gone wrong is that we’re trying to answer the question of “what is
causing my pain?” because we seem to think that as soon as we find out what is
causing the pain then we’ll be able to get rid of the pain and that’s a very, very
tempting thought. So often times I’ll hear the patients say “Oh, nobody has been
able to figure out why my shoulder is hurting but we’re going to do an MRI to find
out what is causing my pain”. So it seems that if not the doctors then at least the
patients are convinced that with these advanced imaging or testing techniques the
smoking gun will be found and we’ll be able to pinpoint a cause. And unfortunately,
that leads us down a path where we’re trying to find the smoking gun. However,
because chronic pain is such a complex experience that is built up on many different
dimensions, often there is no smoking gun. That’s why I like to move away from the
paradigm of finding the ‘cause’. In fact, searching for that one abnormality may be
counter-productive because it may not exist. It may be a constellation of factors
that come together to give this person their pain experience.
In that sense the concept of pain is similar to the concept of patience. I want you to imagine that
someone has cut you off in traffic and you lose your patience.
Now let’s analyze what ‘caused’ your impatience. You could say that it was the idiot in the Suburban
who caused it. But last week people were cutting you off left, right and center and
you were ok with it. What is different today? Did it make a difference that you
haven’t eaten all day and that you only slept 3 hours last night worrying about that
meeting with the boss this morning that went horribly wrong? There are many factors
that affect how patient we are. If we want to solve our impatience problem, it may
be unhelpful to just deal with drivers cutting us off. With this in mind, it is
easier to appreciate the extent to which we limit ourselves by trying to find the
‘cause’ of our chronic pain. back to top
Q: Some patients with chronic pain after going through several diagnostic procedures find out that based on the diagnostic procedures there is nothing wrong with them yet they still are in pain. How would you explain that?
That brings up a good point that follows up from the last point. Tests like an
MRI’s or X-rays show physical abnormalities. An abnormality is just a deviation
from the norm. The physical abnormality does not prove whether there is pain or not.
Let’s say somebody has a pain in the shoulder. They have an MRI and it shows that
there is a tear in the rotator cuff. We could assume that the tear is causing the
pain, but it is still an assumption and we don’t actually know.
There are other physiological factors that could be contributing to the pain and we don’t have a
guarantee that the tear has much or anything to do with it.
So whenever we’re discussing these tests we have to be very clear that they reveal abnormalities,
they don’t reveal any pain transmission. We know this is the case because there
are people walking around with muscle tears, herniated discs and cancers who have
no pain whatsoever.
However, many doctors use these tests to explain why the patient is in pain and when
no abnormalities are found it may create a new problem. Some doctors just say,
“I don’t know why you are hurting”, which is appropriate. Sometimes patients are
told things like, “you shouldn’t be hurting” or “there’s nothing wrong with you”
which puts the patient in a very difficult spot. They may feel that their honesty
is being challenged or that they are going crazy. In either case the added distress
can only serve to contribute to the collection of factors already present. Again,
this shows how using physical abnormalities to explain chronic pain is limited at the
very least and can end up contributing to more pain experience.
There is one more point I’d like to make about testing. You have to choose the area to test based on certain factors. If you assume a pain in the wrist is caused by an abnormality in the wrist, then you may do an x-ray of the wrist. Often times, even with peripheral conditions, there is an extensive pattern of pain referral.
The diagnostic test may miss a significant factor because it was done too close to the location where the pain was felt by the patient.
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Q: Once patients go through all the diagnostic tests and there are no problems to be found, their doctors may end up concluding that the pain is in their head and there is nothing wrong with them. What are your thoughts on that?
Well, I am very clear about imagined pain. I just don’t think it exists.
Or, if it does exist, I’ve never seen it in my practice. And this is my challenge to anyone who says that
they think that a certain person is imagining their pain: Focus on a part of your body where
you don’t have any pain let’s say the tip of your nose or your elbow. Now try to imagine that you have pain there.
And I want you to imagine that you are creating pain in that part of the
body for the next 3 days and I guarantee that you will fail. You will fail in your ability to
create a pain in your body by imagining that it is there. So, I dismiss the idea of imagined
This leaves us with a couple of other options. Number one is that a person is being
disingenuous and they are pretending that they have a pain that they don’t. This has been
suggested by various sources claiming that the people may have ulterior motives for pretending
that a pain persists whether it’s a workers compensation claim or whether it’s a motor vehicle
accident that’s being litigated. Perhaps they are getting time off work as long as they are
in pain and so on. I think this phenomenon does exist but it is rare. In these cases it
becomes quite obvious to the therapist after a short time that a person is not being honest.
I think it is foolish to try to explain all chronic pain in terms of ulterior motive. The other view is that the practitioner just doesn’t have enough knowledge about the different
factors that can be affecting somebody’s experience in order to know what to do about it.
In this case, the patient is being completely honest and the health care professional has the
deficit. It is a very difficult thing to admit as therapists but if we don’t we risk blaming
the patient and actually contributing to their pain experience. We certainly don’t want to do
that. So again, I think it’s a very small percentage of chronic pain patients that are
seeking an ulterior motive and for the ones that I cannot help I assume that it is the lack
of my knowledge and my expertise that is not enabling me to help this person and that I must
take the steps to try to improve my base of knowledge to be able to help more people in that
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Q: Do all people experience pain the same way? Why can you have 2 individuals who sustain the same injury, one of them recovers quickly and the other one ends up with chronic pain?
That’s an excellent question and the answer is that obviously people do not experience pain
the same way and people do not recover from pain in the same way. And I think this is where
we have to go into the detail of tissue healing and pain.
In an ideal world we would have an injury and initially we may have quite a lot of pain and then as the tissue heals we would
have less and less and finally when the tissue is completely healed we would have no pain.
In this case, pain diminishes as tissue healing increases. However, things do not always
work out in this way and in some cases we have tissue healing yet pain increasing or pain
persisting. And we normally associate the presence of pain with tissue damage and the
absence of pain with tissue healing or healed tissue. Yet, what the research has found is
that this is not actually what happens. This is why someone may say something like, “I don’t
understand it… I fell on my knee 2 years ago and it still hasn’t healed” and what they mean
is that because they are still experiencing pain in the knee they are just assuming that it
In fact what has happened here is that the knee has become sensitized in some
Sensitization can occur at the tissue level, nerve level or brain/spinal cord level.
I’ll give you an example of each: Peripheral sensitivity would be a muscle that is painful to
touch after a bruise or sunburned skin on your shoulders when someone comes around and slaps
you. Nerves can make an area more sensitive by growing more “ion channels” which are little
gaps along the nerve which help transmit the signals to the brain. The third kind of
sensitivity is central sensitivity and the way occurs because all pain is ultimately
interpreted in the brain.
No brain, no pain and that’s the bottom line. And the brain
devotes brain space to different parts of your body. Generally, the parts of the body that
have a lot of function and a lot of usefulness in our survival like our hands, eyes and
mouths have a lot more brain space devoted to them. The mouth for example is used for speech,
eating, breathing and expression and therefore has a lot more brain space devoted to it
than the shin. But in any case if the brain decides that it needs more information from
a particular part of the body it can devote more brain space to it thereby sensitizing it
to all sorts of signals. A good example of this is someone who has become blind and learns
how to read Braille.
It is not that their fingers suddenly become more sensitive to little
bumps on a piece of paper. They have sensitized their fingers centrally. Unfortunately,
going back to our advanced testing techniques, the MRI doesn’t take any of this into account.
There is no place on the MRI that says “yes, the bone in your arm has healed nicely
however we can see that it has been sensitized by your brain.
Your brain has given more space to this area and that’s why you are still feeling pain there”. back to top
Q: Which treatments and techniques that you’ve been using can offer the most relief for chronic pain?
I think that ultimately what I do that translates into relief from chronic pain is that I
take into account as many contributing factors as I can for a particular individual. I then
use a wide variety of techniques (some peripheral, some neural and some central) that aim to
reduce or eliminate those factors. I think that it’s the overall combination of tailoring a
treatment to an individual that gives the best effect. I also maintain a constant dialogue
with the patient as to which approaches are helping and which are not. People sometimes say
“Oh, I’m sorry…that didn’t help” to which I say, “Don’t be sorry because I need your honest
feedback to know that we’re going in the right direction”. If a certain technique is not
helping we need to abandon it and try a different strategy.
One of the approaches that I use incorporates the autonomic nervous system in the treatment of chronic pain and it is a
technique that really focuses on whole body, central mechanism as opposed to peripherals.
And when it does work it works extremely effectively. I have seen some dramatic results in
patients who have been to exceptional ‘peripheral’ therapists with little or no improvement.
In these cases a series of breathing exercises may be the most effective intervention. back to top
Q: Can you name some of the techniques that you use?
Sure. I’m trained as a manual therapist. I have experience with a lot of manual therapy
techniques, be it joint mobilizations, Paris manipulations, Mulligan mobilizations with
movement, Travell trigger point releases, myofascial releases, Butler neuro-mobilizations
and so on. I also do cardiac coherence for autonomic nervous system rebalancing, primal
reflex release technique and then some of the body mapping treatment techniques. back to top
Q: Is there anything that the chronic patients themselves can do to help with the pain, such as stress reduction, diet or any other technique?
Yes and I try to emphasize to my patients how many factors are under their control.
Sleep deprivation is a good example. Although some people may need more specialized intervention
when it comes to sleep, a lot of us inflict our own sleep deprivation by watching television
in bed or letting the dogs sleep in the bed with us.
Improving nutrition and increasing general health and fitness may all serve to eliminate factors that contribute to the pain
experience. More specifically, a lot of the techniques that I do can be done by the patients
themselves and my goal is to teach them how to do their own treatment. Any technique that I
find to be effective I will teach the patient how to do the self-applied version. This way
they have a tool wherever they are that they can use to reduce or eliminate their pain and
that provides them with a sense of control….something often missing when dealing with chronic
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