Because I suffer from chronic pain, I sometimes surprise people by telling them that my pain has no physical cause. It's a mind-body thing, I say, related to stress and emotions. To many, this sounds like admitting that we are a little crazy. And when I up the ante by suggesting that they, too, have probably had this kind of pain, some become openly angry and interpret my words to mean that their pain is “all in their head.”
All of which makes a new study published in the Journal of Pain very important. It offers strong evidence that the overwhelming majority of cases of chronic back and neck pain (among the most common chronic pain complaints) come from the mind, even though most diagnoses cite a physical cause, such as bulging discs or bone spurs.
In the new study, doctors evaluated 222 consecutive patients with pain at an orthopedic care clinic in Louisiana—everyone who showed up, as long as they could complete a questionnaire. Only 12% showed evidence of a structural problem at the root of their pain. Eighty-eight percent, on the other hand, had what researchers call “primary pain,” which refers to symptoms generated by neural circuits in the brain rather than by “structural” damage to the body.
Based on this and previous research, the authors believe that a process in the brain initiates nonstructural pain. The sensations could be residual pain from a bodily injury that healed but did not notify the brain. Or the brain may have generated pain in the absence of any injury, perhaps in an effort to protect patients from emotional wounds by occupying their attention with physical sensations.
The role of the brain and emotions in the production of pain has been known for a long time and has been validated by neuroimaging showing that the brain processes physical pain and emotional distress in the same regions. Observational studies indicate that people feel more pain when they receive negative emotional stimuli. And additional research has shown that therapeutic interventions that help patients understand and reinterpret their pain can significantly reduce symptoms. The theory is that pain is a danger signal, so as we feel safer and less threatened, our nervous system comes out of fight or flight mode and stops emitting pain signals.
As a result, scientists now believe that all The pain is essentially brain pain. The idea is that just as the brain generates sensory experiences such as vision and hearing, it also generates pain by consulting our memories, expectations and emotions, as well as any physical information that our nerves can sense, and generates pain when it determines that we are under pressure. . threat. While our nerves detect sensations, it is the brain that decides whether we will experience them as pain.
The implications for healthcare are profound. Chronic pain is one of the main reasons people seek medical care. More than 1.5 billion people worldwide suffer from chronic pain, including 50 to 100 million Americans. For the most part, these patients spend billions of dollars on physical treatments. If the cause is not physical, money is wasted and suffering only increases.
And not only are we failing to relieve pain, we are creating dangerous side effects including the opioid crisis, as well as surgeries that may be unnecessary and leave patients worse off.
Of course, sometimes chronic pain has a physical cause, and distinguishing between when it does and when it doesn't is crucial. To address this key challenge, researchers at the Louisiana clinic devised an exclusion/inclusion diagnostic method that should be adopted everywhere.
The process begins with a thorough examination of the patient and a review of scans to rule out physical causes of the pain. There is a nuance: the fact that an abnormality (for example, a flattened disc in the back) appears on a scan is not necessarily the cause of the pain. As the study explains, research repeatedly shows that most people without pain shows similar abnormalities. In other words, doctors diagnosing the source of chronic pain must be aware of the poor correlation between scary scans and pain.
The registration process further clarifies whether a patient has structural or mind-body pain. It consists of taking a detailed history of the patient's pain. and life. Doctors need to know if previous treatments that should have resolved structural causes have failed; whether treatments associated with a placebo response produced relief; whether a patient's history contains significant stress or adversity; if they have other ailments associated with mind-body causes (headaches, bowel and bladder conditions, fibromyalgia, chronic fatigue, tendonitis and more may have such associations). And they need to know if the pain is inconsistent: if it moves through the body or comes and goes; Is it triggered by biologically irrelevant stimuli such as weather, smells or sounds? These variables do not correspond well with the structural causes.
The process may seem a little subjective, and it is. But no more than any other diagnostic approach. Medicine is not an exact science and doctors must act based on imperfect information. “We work with probabilities,” said Dr. Howard Schubiner, principal investigator of the Louisiana study and clinical professor at Michigan State University's College of Human Medicine. Using the careful criteria developed for the study offers as well-founded a basis for action as anything else: “When there is strong evidence using these criteria, a doctor can be confident that what he is seeing is a mind-body problem.” “.
The existing medical paradigm assumes a physical cause for most chronic pain. The Louisiana study's findings suggest that this is often incorrect.
Fortunately, my pain has greatly improved after years of pain education and good therapy helped my brain control my nervous system. Everyone deserves access to this new paradigm of pain. And that requires ending the stigma that is still associated with mind-body symptoms and understanding them as a universal human condition, not as a bunch of people who are a little crazy.
Nathaniel Frank is the director of the What We Know Project at the Center for the Study of Inequality at Cornell University. He is writing a book on mind-body pain to be published by Mayo Clinic Press.
