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The treatment of chronic pain depends on the practitioner you ask, their educational model, and realistically their payment model. Some treatments have efficacy, some don’t, and some only treat one of the pain dysfunction’s anatomic sites.  Here are three evidence-based principles aimed to improve those suffering from ongoing pain presentations. 

 

Here is excerpt from Dr. Steele’s lecture on chronic pain.

Classify the Type of Pain

  1. Nociceptive pain is intermittent and sharp provoked by movement or mechanical aggravation.

Acute tissue injury may result in inflammation, but therapy for nociceptive pain is often mechanical—manual therapy, manipulation, and progressive loading rehabilitation strategies.

  1. Neuropathic pain typically originates from a known peripheral or central nervous system lesion. Symptoms are neuroanatomically congruent and often described as burning, shooting, or pricking.

Treatment often includes ruling out red flags, finding positions or directions of relief, and nerve mobilization techniques.

  1. Centralized pain typically demonstrates a diffuse or variable non-anatomic distribution with disproportionate symptoms to the stimuli’ severity.

Management of centralized pain must include multifactorial therapy, sometimes requiring a change in patient habits, beliefs, education, injections, diet, manipulation, medication, etc.

Modifying Pain from the Top Down

The patient’s thoughts and words are equally as important as yours. Displaying confidence in the diagnosis and treatment strategy may be of equal effectiveness to the actual therapy. A recent paper in Medicine and Science in Sports and Exercise (2020) demonstrated that exercise might increase or decrease pain severity based solely on the WORDS you use. Providing NEGATIVE pre-exercise information resulted in HYPERalgesia after the prescribed exercise. (1)

Words matter. Stay confident and optimistic in the patient education you use in this patient population.

Surgery is Rarely the Answer

“A previous review from our group showed that only half of common orthopaedic (surgical procedures) have been subjected to randomised trials comparing them to not performing them, and that many of the trials that have been performed show that surgery is not superior to the alternative.” (2)

“One review of general surgical inpatient practice found that 24% of decision making was based on RCT evidence, while 71% of patients had decision making based on other non-RCT “convincing evidence.” (2) 

“We conclude that many common surgical procedures performed for musculoskeletal conditions causing chronic pain have not been subjected to randomised trials comparing them to not performing the procedure. Based on the observation that when such studies have been performed, only 14% (on average) showed a statistically significant and clinically important benefit to surgery.” (2)

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References
  1. Vaegter HB, Thinggaard P, Madsen CH, Hasenbring M, Thorlund JB. Power of Words: Influence of Preexercise Information on Hypoalgesia after Exercise-Randomized Controlled Trial. Medicine and Science in Sports and Exercise. 2020 May 1. Link
  2. Harris IA, Sidhu V, Mittal R, Adie S. Surgery for chronic musculoskeletal pain: the question of evidence. Pain. 2020 Sep 1;161:S95-103. Link

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