From the outside looking in

One of the most difficult group of patients I have in my practice are the chronic pain patients. These people suffer from chronic pain, usually its in the lower back but for some it's in the neck, shoulders, hips or elsewhere. For joints we can usually refer them for surgery, but for non specific back pain we need to apply a multimodal approach to therapy.

The research on chronic pain reveals that certain people are more susceptible to it than others. These are people who catastrophise, and don't believe it when the doctor tells them the pain will get better. They leap on every symptom to reinforce their belief that their pain is getting worse, and seek continual investigations and escalating amounts of analgesia, develop protective movements and postures to avoid pain, reduce their activity levels to avoid pain, and suffer more for it.

The research shows that this group of people can be identified early on, and health practitioners can implement strategies to prevent some of these patients from spiralling into the chronic pain nightmare. A nightmare where no amount of multiple pharmacy makes much difference, where they are incapable of getting gainful employment, and where deaths occur as a result of overdosing on prescription medications.

Prevention starts with health practitioners taking a good history and examination and using evidence based guidelines to screen out any risk factors that suggest a serious cause for the pain. These are cancer, or significant nerve impingement necessitating surgery. All other causes of back pain do not require imaging at all, regardless of the injury. I am excluding acute trauma from this group as these patients aren't going to be walking in to my practice.

The reason imaging should be avoided is it's simply unreliable. Grab 20 people off the street, image their backs and then ask if they have any back pain. There will be no correlation between their symptoms and what their back looks like. A person with a normal Xray might have regular episodes of back pain, whilst a person with an Xray full of degenerative changes might have never had a day of pain in their life. Grab 100 people, same result. So it just doesn't give you guidance at all.

But for the catastrophising patient, it starts their journey of seeking a cause. Non specific lower back pain is called that for a reason, no-one knows the cause of it. But it does exist. And it causes a hell of a lot of suffering.

We know that acute pain and chronic pain are two different beasts. Acute pain is there to prevent you injuring yourself further, to notify you that your appendix is about to burst, or that the fire is burning you. Chronic pain isn't notifying your brain that there is real and present danger, because the danger, or whatever triggered the pain in the first place, is well and truly gone.

However, the chronic pain sufferer believes that they need to protect their painful part from further injury, so they develop intricate posturing and movements that they believe protect them. In fact these "protective postures" do the opposite, they make the pain worse, so in an attempt to reduce the pain they overcompensate even further, reducing their activity more and more, and thus the spiralling down occurs.

Managing chronic pain patients starts with trying to prevent the next one. By not imaging unnecessarily, by informing patients that their acute injury will improve spontaneously over a few weeks, that they return to normal activity as soon as possible. It also involves screening for those high risk patients (yes we have a tool to work out whether you're a loony or not!) and keeping a closer eye on them, perhaps by referring them for physiotherapy to ensure they don't develop those protective behaviours.

Once you've got a patient with chronic pain, which is roughly pain for more than 6 weeks, then one needs to assess them for which approaches are needed to stop the spiral. A holistic approach is needed, and one of the hardest things is getting patients to understand the role that their own mental state plays in chronic pain. A patient may hear "it's all in your head" when the doctor may not be saying that at all, but trying to explain the way one's mental state contributes to one's pain. It is not an accident that depression and chronic pain coexist side by side.

The role of exercise in recovery is crucial. This works in two ways. Firstly, avoidance of protective behaviours, because these just cause more pain through stiffness and incorrect posturing overburdening the wrong muscle groups. And secondly, because when we move normally our other nerve fibres responsible for touch and position sense provide a feedback mechanism to our pain nerve fibres telling them there is no danger and to shut the fuck up.

The role of analgesia is questionable. I've prescribed my fair share of seriously strong pain killers over the years and I'm yet to be convinced that they make one iota of difference. The way patients talk to me about how the analgesia works for them is really text book behaviour for catastrophising individuals. They believe their life will be unbearable without the medication, so they need to keep taking it. I think if they weren't on the medication their pain would be the same, although there's some evidence suggesting that their pain may actually be improved. Some chronic pain specialists I've talked to have countless stories of huge improvements, even resolution, once analgesia has been ceased. But try convincing patients of that.

Working on their psychological state, preferably through the services of a psychologist experienced in chronic pain management, and on their movement with an experienced physiotherapist can reduce the suffering for these patients. For some, they can get out of the cycle of despair, but for others, especially those who choose only to rely on medication and unproven therapies like spinal injections, I never see improvement.

Which gets me back to me, and why I am discussing my work on my blog when I don't normally. The reason is because I have found myself starting to fall into the chronic pain spiral.

It's not a secret that I've had my bouts of depression over the years and that I was going through a pretty rough patch around December/ January. My holiday in Japan, despite my injury, really lifted my mood, but the protracted pain and the refusal for the pain to resolve within my expected time frame has begun to take its toll. I too am wondering if this pain will ever go away.

I have days when I am so stiff and sore that I just curl up in bed and don't go to work. I reduce my activity, because it hurts to do it. I am not, BTW, popping pills. They really don't make a difference.

This morning, having taken the morning off due to pain, kept warm under the doona until 10 and then gotten up and gone through my specific exercises for the day (a mixture of pilates and core strengthening, flexibility and leg strengthening exercises for my ski trip) I suddenly reached an epiphany.

I was doing exactly what my chronic pain patients do.

Avoiding.

It was time to stop.

Funnily enough, by the time I had done all those exercises I was hot and sweaty and the pain and stiffness was considerably less than it had been for the previous 3 or 4 days.

My physio has very pointedly said that I can't injure myself again unless I fall directly onto my derriere. This is his way of saying the danger has passed. Although he was the one putting the brakes on my activity levels early on in my recovery I think he may be a little frustrated at my current lack of activity. I blame it all on the delay in my new bike arriving. What should have taken a week took almost 4, so it is only in the last 2 weeks that I have begun cycling again.

It's a great lesson for me, because it helps me understand what's going on in my patients' heads. I get it, I just don't choose to take that path, because I darn well know where it leads.

Nowhere!

The story of my back

I've been struggling with finishing off the Japan blog posts because I need to edit a whole bunch of photos before I can publish them. And the problem is that I can't sit at a desk long enough to do it because I have gone and injured my back.

A week or so before I left for holidays I had a huge weekend in the garden, repairing the upper chook run, digging and carting soil, and laying a whole trailer load of horse manure on the garden. Typical things you do just before a holiday...

My back was quite sore the week after, so I took daily anti-inflammatory medication, and by the end of the week I was feeling better. I jumped on a plane and headed to Japan.

When I arrived I did a lot of to-ing and fro-ing at Narita airport, dragging my bag around, up and down elevators etc whilst I was trying to sort out my money situation. Then I took a shuttle bus to my hotel and slept the night.

The next day I was fine, travelled back to the airport to meet the gang, sat around for a few hours then we all manhandled our luggage through a few train stations, up and down stairs and elevators, shoved into and out of trains, and even up onto luggage racks. Though I don't think I personally did the latter.

The next day I had a sore leg and thigh. Not too bad, but a little sore. I went skiing, and after two runs on my brand new skis turning in the soft new snow on the edge of a couple of piste runs, I agreed to join the group heading into the trees to ski a pristine, untouched lift line. In retrospect, this was probably a really dumb move given I had new skis and am not that experienced in thick powder.

First I did an accidental ejection out of my skis, due to the DIN bindings being too loose for the conditions. This probably exacerbated my sore back, and was quite hard to get back into my bindings as the snow was thigh deep. Then I crashed on my way down and had to dig my skis out, then I did it again. I can't even think now, how much that must have strained my back. Then I continued to ski, in pain, on piste, for most of the day. I am nothing if not a stubborn warrior.

By the evening I was in extreme pain, which only worsened over the next few days, taking me maybe four days before I could stand fairly upright. So I went skiing again.

When we moved north to Appi Kogen Milan very kindly helped move my bag for me, and I continued to ski. On the second day at Appi Kogen my one attempt off piste was a disaster, as I struggled to move forward enough to initiate a turn, and the legs felt too weak to support my weight. It was a disaster and I retired in tears. Not the first lot I've shed either...

As we moved further north the pain improved. Most of my pain was in my groin and thigh, akin to a sharp burning pain like when you reach your anaerobic limit, say cycling up a hill in low gears. But there was also pain around the knee and shin. I tried various back exercises, which seemed to help a little, and had some shiatsu massage. The only time I was pain free was in a hot bath. I adored those onsens...

In Kyoto I continued to have pain, and only took pain killers intermittently. Since I've been home I haven't been taking anything, mainly so I can monitor where the pain is going or moving to as I do the exercises prescribed by my physiotherapist.

As it turns out I have injured my nerves at the L3 level, causing femoral nerve impingement and wasting of my vastus medialis (the muscle on the inside of the thigh). My physio calmly informed me today that if it wasn't improving he'd suggest I seek surgery.  In other words, I really fucked my back up.

The good news is that it is improving, but I now realise it's going to be a slower road to recovery than  I envisaged. After all, it has now been five weeks, so I am entering chronic pain territory. Of course I expect to make a full recovery, but I realise now I need to be patient. Luckily, I have a lot of sick leave entitlements so there is no financial imperative to return to work. I am getting a wee bit bored though, as I am limited in what I can do.

I am walking every day, not far, but enough to keep active, and doing a bunch of mobilising and strengthening exercises. The pain is beginning to localise to my back, which is where it should be, which means today, after my physio session, I've been in more pain than I've been for a week. I just may have to resort to medication to get to sleep.

The Kyoto posts should be up soon, hopefully...