In the next installment of our Chronic Pain Series, we are discussing pain’s effect on a patient’s psychology. The emotional and cognitive impact chronic pain can have is astonishing and truly complicates the rehabilitation process, yet many medical providers do not address it. Why? Reasons can vary from simply lack of knowledge and understanding, provider laziness, lack of time, or simply avoidance due to the sensitivity of speaking about someone’s emotional and mental health. As physical rehab specialists, I feel it’s a conversation we should be comfortable having with our chronic pain patients. In order to have this conversation, we must be educated on pain’s psychological effects, and that is the intent of this article: to provide an overview of the pain-psych relationship.
A great article detailing this topic is “Psychological Processing in Chronic Pain: A Neural Systems Approach” by Simons et al., published in Neuroscience and Biobehavior Reviews in February 2014 (p. 61-78). This serves as my primary reference for this post. You can find the article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3944001/.
When discussing the brain’s response to chronic pain, there are two primary pathways to remember: 1) pain can trigger a series of neurological events, starting with the initial sensory input, that can lead to altered mental states; and 2) previous psychological impact can increase risk of chronic pain and chronic pain’s effects (i.e. previous trauma, addiction, PTSD, etc.). Basically, pain not only concerns the anatomical area of perceived pain but also impacts a person’s psyche, and pain’s psychological impact can be complicated by their history. Realizing and educating patients on these points has been helpful for me as they become more aware of why they may be more agitated, anxious, depressed, etc., especially in the military population where many come from broken homes and/or deal with combat-related PTSD.
The human body is phenomenal at adapting to new environments and stressors. Usually adaptations are beneficial, such as those obtained through strength training. However, sometimes our body’s adaptations can be detrimental to our health and performance. For example, we lose joint and tissue mobility when we become deskbound for eight hours per day, five days per week. Maladaptions also occur in response to pain through peripheral and/or central sensitization. Examples include allodynia (painful response to normally non-painful stimulus) and hyperalgesia (increased pain sensation and sensitivity). This centralization of pain, where a painful stimulus progresses to chronic pain, then negatively impacts non-sensory neuro processes (memory, motivation, mood, cognition, etc.), increases suicide risk, and decreases normal pain inhibition (body’s pain nerves become more excitatory and sensitive to stimulus).
Most of us know, whether as a provider, trainer, or through personal experience, pain can impact multiple physiological processes to include the cardiovascular, neuronal, immunologic, and endocrine systems. The body’s ability to keep these systems stable when encountering stressors is called allostasis. It’s been shown persistent pain can lead to allostatic load, or a compromise to the body’s allostasis. Additionally, persistent pain alters normal psychological processes like perception, emotion, cognition, and motivation.
We can specifically peek at chronic pain’s effects on these different psychological processes. For example, pain has been shown to diminish cognition and attention by interfering with the brain’s natural neuronal connections. Perception has also been shown to be altered in chronic pain patients. Not only do they have a changed perception regarding pain itself, but they oftentimes develop altered perceptions of their external environment and have diminished interoception (one’s own awareness of internal physiological health and processes). Additionally, chronic pain can negatively impact a person’s emotions (depression, anger, etc.) as well as motivation, learning, and memory.
In my opinion, perhaps the largest psychological effect chronic pain can have on an individual’s day to day routine is through fear learning and avoidance behaviors. Pain, which is a perceived threat by the body, can trigger fear in the moment of a painful stimulus as our psychological and physiological systems process and react to the event. Due to the complexity of pain perception and the brain’s way to connect experiences, fear can then be easily connected to a once non-painful neutral experience. An athlete injuring their back deadlifting is an excellent example. For this athlete, the short-term adaption and fear of flexion may be beneficial to protect injured tissues and allow for proper healing. However, there is now a potential internal connection for this person correlating bending over and pain, especially if picking up an object off the floor. Being injured by a 300-pound deadlift has now caused our athlete disability as they are fearful to pick up a laundry basket or their 20-pound child. The fear promotes movement avoidance which only perpetuates the problem. Overcoming fear’s impact is challenging and will be discussed in a future post.
Lastly, let’s review some potential risk factors that have been associated with chronic pain which may lead to altered psychological processing, as per the Simons et al article. It is important to be familiar with these as a medical provider, coach, or trainer as you work with an individual who recently sustained an injury. First, women tend to have higher rates of chronic pain. This may be due to the physiological differences between men and women or may simply be perceived as women tend to be more open and willing to seek care than men. History of prior physical or psychological trauma is another, regardless if it is similar or not to the current pain. The trauma can be a repetitive related issue (i.e. multiple knee surgeries) or can be unrelated (i.e. history of being abused and neglected). Either way, the risk for chronic pain increases. Lower levels of socioeconomic status and education have been correlated with increased rates of chronic pain. This may be due to higher rates of other comorbidities (obesity, diabetes, heart disease, etc.), decreased health-related understanding/education, and healthcare availability. Other risk factors include a poor social system (lack of support from friends and family) and catastrophizing (tendency to magnify the negative).
As you can see, chronic pain is complex and involves much more than just the perceived pain. The take home message here is to understand the impact pain has on an individual’s psychology. Knowing this information and being able to educate the patient can have tremendous impact on the rehabilitation process, especially if the patient is fixated on an anatomical pathology (i.e. disc bulge). Additionally, it’s critical to know when to refer a mental health specialist. As rehab specialists, we should know enough about other health domains that can impact recovery (nutrition, mental health, sleep, etc.) but know when to punt them to a specialist.
In future posts in this chronic pain series, we will discuss ways to mitigate and manage chronic pain. I hope this has been as useful for you as it has been for me diving into this material!
Thanks for reading.
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