The International Association for the Study of Pain defines pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (Merskey and Bogduk 1994, 209) and defines persistent pain as pain on most days or every day in the past six months. It is important to note that pain and tissue damage do not always correlate, and the longer a person experiences pain, the weaker the correlation. It is very possible to have tissue damage without experiencing pain and it is also possible to experience pain when there is no apparent tissue damage (Crofford 2015). Nearly every condition we assume to be a sign of dysfunction (poor posture, tightness, weakness, degeneration) can exist in people without the presence of pain. Pain can tell us that there is a problem that needs to be addressed, but it rarely tells us what the problem is, where it is, or how bad it is. Population-based estimates of persistent pain among U.S. adults range from 11% to 40%, meaning that a lot of people are in pain for a lot of time (Interagency Pain Research Coordinating Committee 2016).
Persistent pain is often correlated with depression, fear, rumination, and worries about injury. Recent studies have provided incontrovertible evidence that psychiatric disorders and other psychosocial factors can influence both the development of persistent pain conditions and the response to treatment. In a study by Polatin and colleagues (1993), 77% of patients with persistent lower back pain met lifetime criteria, and 59% demonstrated current symptoms for at least one psychiatric diagnosis, with the most common being depression, substance abuse, and anxiety disorders. Notably, more than 50% of those with depression and more than 90% of patients with substance abuse or an anxiety disorder experienced symptoms from these psychiatric disorders before the onset of lower back pain. Most, but not all, studies have shown untreated psychopathology to negatively affect lower back pain treatment outcomes (Fayad et al. 2004). This does not mean that pain is all in one’s head. It means that there is often a strong link between experiencing pain and one’s mental resilience. Neugebauer and colleagues (2004) reported that neuroplastic changes were shown in the amygdalae in persistent pain. It is thought that the amygdalae play an important role in the emotional–effective dimension of pain (Neugebauer 2015).
The Biopsychosocial Model
Social factors have also been demonstrated to have an impact on persistent pain. These include return-to-work issues, catastrophizing, poor role models, codependency behavior, inadequate coping mechanisms, and attitudes, beliefs, and expectations (Seres 2003). Catastrophizing is a cognitive process whereby a person exhibits an exaggerated notion of negativity, assuming the worst outcomes and interpreting even minor problems as major calamities (Biggs, Meulders, and Vlaeyen 2016). Pain could be thought of as all of life’s stressors (physical, social, psychological, and spiritual) exceeding our perceived ability to withstand or adapt to these. To optimize outcomes, the identification and treatment of associated psychosocial issues is of paramount importance. This is best accomplished via a multidisciplinary approach and using the biopsychosocial model, which was first presented by Engel in 1977. The biopsychosocial model (figure 2.8) is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care (Borrell-Carrió, Suchman, and Epstein 2004).
It is important for us all to realize that experiencing some pain at different stages in our lives is a normal part of being human. It is our response to the pain that tends to be most significant. Often understanding and acknowledging pain can be desensitizing.
Can yoga help to manage persistent pain? A systematic review and meta-analysis of mindfulness meditation for persistent pain by Hilton, Hempel, and colleagues (2017) concluded that there was low-quality evidence that mindfulness meditation is associated with a small decrease in pain compared with all types of controls in 30 trials. Statistically significant effects were also found for depression symptoms and quality of life. The authors recommended that additional well-designed, rigorous, and large-scale trials are needed to decisively provide estimates of the efficacy of mindfulness meditation for chronic pain. A systematic review and meta-analysis of yoga for lower back pain by Cramer, Lauche, Haller, and Dobos (2013) reported that there was strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness of yoga for chronic low back pain in the most important patient-centered outcomes. A systematic review of randomized controlled trials looking at the effects of yoga on chronic neck pain (Kim 2016) concluded that there was evidence from the three trials showing that yoga may be beneficial for chronic neck pain.
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References:
Biggs, E., A. Meulders, and J. Vlaeyen. 2016. “The Neuroscience of Pain and Fear.” In Neuroscience of Pain, Stress, and Emotion, edited by M. al’Absi and M. Arve Flaten. 148-162. Cambridge, MA: Academic Press.
Borrell-Carrió, F., A. Suchman, and R. Epstein. 2004. “The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry.” Annals of Family Medicine 2 (6): 576-582.
Cramer, H., R. Lauche, H. Haller, and G. Dobos. 2013. “A Systematic Review and Meta-Analysis of Yoga for Low Back Pain.” The Clinical Journal of Pain 29 (5): 450-460.
Crofford, L. 2015. “Chronic Pain: Where the Body Meets the Brain.” Transactions of the American Clinical and Climatological Association 126:167-183.
Engel, G. 1977. “The Need for a New Medical Model: A Challenge for Biomedicine.” Science 196 (4286): 129-136.
Fayad, F., M. Lefevre-Colau, S. Poiraudeau, and J. Fermanian. 2004. “Chronicity, Recurrence, and Return to Work in Low Back Pain: Common Prognostic Factors.” Annales de Réadaptation et de Médecine Physique 47:179-189.
Hilton, L., S. Hempel, B.A. Ewing, E. Apaydin, L. Xenakis, S. Newberry, B. Colaiaco, A. Ruelaz Maher, R.M. Shanman, M.E. Sorbero, and M.A. Maglione. 2017. “Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-Analysis.” Annals of Behavioral Medicine 51 (2): 199-213.
Interagency Pain Research Coordinating Committee. 2016. National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain. Washington, DC: U.S. Department of Health and Human Services, National Institutes of Health.
Kim, S. 2016. “Effects of Yoga on Chronic Neck Pain: A Systematic Review of Randomized Controlled Trials.” Journal of Physical Therapy Science 28 (7): 2171-2174.
Merskey, H., and N. Bogduk. 1994. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2nd ed. Seattle: International Association for the Study of Pain (IASP) Press.
Neugebauer, V. 2015. “Amygdala Pain Mechanisms.” Handbook of Experimental Pharmacology 227:261-284.
Neugebauer, V., W. Li, G. Bird, and J. Han. 2004. “The Amygdala and Persistent Pain.” The Neuroscientist 10 (3): 221-234.
Polatin, P., R. Kinney, R. Gatchel, E. Lillo, and T. Mayer. 1993. “Psychiatric Illness and Chronic Low-Back Pain. The Mind and Spine: Which Goes First?” Spine 18:66-71.
Seres, J. 2003. “Evaluating the Complex Chronic Pain Patient.” Neurosurgery Clinics of North America 14:339-352.