[pain] stats (or lack thereof) on causes of chronic pain

[kaberett]

One of the things I'm sure I've come across repeatedly in the books I've read so far is the idea that a very high proportion of Chronic Pain Cases are down to either back pain or headache. This is important because back pain genuinely is something that has a massive nociplastic component, especially in the lower back, that is unequivocally worth treating (despite myself I remain grudgingly impressed with the Boulder Back Pain Study; and, to be clear, I do myself have a grumbly section of lower back following an injury a few years ago that I am practising all my Theories on!).

This is an Important To Me framing device because my point is that treatments aimed purely at nociplastic pain/central sensitisation cannot be expected to work as well for people with ongoing or recurrent tissue damage/injury... but why it's worth using some of these approaches anyway, with the understanding of the actual scope of what effects to hope for or expect. Which means I'd like to know where they're GETTING those numbers from.

Book #1 is Mindfulness for Health, which on the one hand does cite sources for most of its claims (however dubious they are on even superficial inspection) and on the other very much does not cite sources for this one (p. 18 in my edition):

The biggest causes of chronic pain are back problems, arthritis, injury and headaches. Following close behind are conditions such as cancer (and its associated chemotherapy), heart disease, fibromyalgia, coeliac disease, lupus, chronic fatigue syndrome and irritable bowel syndrome.

The Way Out (p. 8 in my edition):

Back pain is the most common form of chronic pain and the leading cause of disability worldwide.

This does have two sources NOT THAT THE DUDE BOTHERS ACTUALLY PUTTING FOOTNOTE MARKERS IN, urgh, but okay, the footnote (p. 174) says:

The National Center for Health Statistics found the following rates of pain in its 2017 National Health Interview Survey:

Pain in lower back: 28 percent
Migraines or severe headaches: 15.5 percent
Pain in neck: 14.9 percent
Pain in face or jaw: 4.4 percent

National Center for Health Statistics. "Migraines and pain in neck, lower back, face, or jaw among adults 18 and over, by selected characteristics." National Health Interview Survey, 2017. Hyattsville, Maryland, 2018. Hoy, Damian, Lyn March, Peter Brooks, Fiona Blyth, Anthony Woolf, Christopher Bain, Gail Williams, et al. "The global burden of low back pain: Estimates from the Global Burden of Disease 2010 study." Annals of the Rheumatic Diseases 73, no. 6 (2014): 968--974.

See also my intense irritation with p. 29, which is a total tangent but I have been reminded of it and I Must Rant:

As I said in chapter 1, neuroplastic chronic pain is more common than structurally caused chronic pain.

How much more common? In the Boulder Back Pain Study, there were fifty subjects in the treatment group. Dr. Howard Schubiner, who specializes in pain, did a medical consultation, and I did a more general evaluation. Based on our initial assessments, as well as evidence we gathered during treatment, we found no cases of chronic back pain that we believed to be structurally caused. None!

You may be thinking, "Of course you thought everyone had neuroplastic pain. You specialize in neuroplastic pain. When all you have is a hammer, everything looks like a nail." Well, my hypothetically skeptical friend, that couldn't be further from the truth. We went into the study expecting some of the patients to have structurally induced pain. But to our surprise, we didn't find evidence of a single case. Even patients who had significant findings on X-rays or MRIs ended up having neuroplastic pain. We know this because Pain Reprocessing Therapy successfully eliminated their pain.

[...]

The Boulder study focused on back pain, but it mirrors my experiences treating people with every form of pain. In most cases, pain caused by a physical problem will not become chronic. It will heal or respond to medical treatment. Most chronic pain is neuroplastic pain.

However, I am by no means an absolutist. Some patients do have structurally caused chronic pain. You never want to assume that your pain is neuroplastic without sufficient evidence. It's important to be thorough. I've included an appendix in the back of the book -- it's a guide to help you determine whether your pain is neuroplastic or caused by a physical problem in your body.

"Most chronic pain is neuroplastic pain" does have a citation (p. 180, also patronising):

This article is long and technical but has some good information about neuroplastic pain in various parts of the body. (Note: instead of "neuroplastic pain," the author uses the term "central sensitization," but it's the same phenomenon. "Central sensitization" refers to the idea that the central nervous system has learned to be too sensitive to pain.) Woolf, Clifford J. "Central sensitization: Implications for the diagnosis and treatment of pain." Pain 152, no. 3 (2011): S2--S15.

I know that even after everything you just read, it can be challenging to accept that you have neuroplastic pain. It's hard to let go of the idea that your pain is caused by a physical problem in your body. Chapter 4 can help you embrace this new perspective (which is why chapter 4 is called "Embracing a New Perspective").

As previously noted, I'd have more patience for this dude if he didn't routinely forget the existence of women, but the fact that he does inclines me to give particularly short shrift to the sections of the Quiz in the Appendix headed "pain originated without injury", "symptoms are inconsistent" (including cyclical/time-dependent pain), "large number of symptoms" ("Having three or four unrelated conditions is extremely unlikely. A single underlying cause--neuroplastic pain--is a far more plausible explanation." BRO HAVE YOU HEARD OF COMORBIDITIES), "symptoms spread or move", "triggers that have nothing to do with your body" (like "time of day" or "weather"; "these are all just conditioned responses"), "delayed pain", "lack of physical diagnosis": to so much of this my response is "BRO HAVE YOU EVEN HEARD OF ENDOMETRIOSIS" with a side of "that is literally in the diagnostic criteria for plantar fasciitis". (Yes, the things he's trying to get at are not entirely without merit... but calling a bunch of these things "clear signs of neuroplastic pain", without qualification, is exactly the kind of bullshit that I Am Writing In Reaction To.

But also, you know, a couple of references to follow up. Which is something.

(OH RIGHT I just found another fucking thing that makes me want to scream about this book, courtesy of my notes: "To eliminate neuroplastic pain, we need to accept that there's no physical problem in the body." NO THE FUCK WE DON'T AND, ALSO, THE LIMITS OF YOUR PERSPECTIVE ARE ACTIVELY SABOTAGING YOUR STATED LIFE GOALS. HTH, HAND

In keeping with being one of the books that has thus far annoyed me least, the closest Monty Lyman gets to claiming that most chronic pain is back pain is (p. 95):

... Let's take long-term back pain, for example. It's incredibly common in the West; it's the largest cause of work-related absence and something the majority of us experience at some point in our lives¹⁹.

Footnote 19, p. 251:

Andersson, G. B., 'Epidemiological features of chronic low-back pain', The Lancet, 354(9178), 1999, pp.581--5

... aaaaaaand it is now definitely past bedtime so I'll finish Revisiting Books tomorrow. (My notes on Explain Pain, consistent with it being generally competent, are that it doesn't go anywhere near talking about what The Most Common Forms Of Chronic Pain are; might have a quick flip through when I'm next in the same place as my copy. Also couldn't find anything in Touch. Will be revisiting the current book, Ouch!, in the morning...)

Comments

[redbird]

Yeah, there's a huge difference between "back pain is the most common form of chronic pain"--logically, _something_ must be most common--and "most chronic pain is back pain."

[davidgillon]

We went into the study expecting some of the patients to have structurally induced pain. But to our surprise, we didn't find evidence of a single case.

Colour me unconvinced. Was he looking for back injuries, back injuries and spinal anomalies, or did he also include skeletal anomalies and injuries outside of the back such as leg length discrepancies? Because as soon as I started using crutches, and therefore limping less, there was a significant down shift in my pain levels.

[vass]

I seem to remember reading somewhere that some of the plot decisions in House MD were driven by the pain Hugh Laurie was in from having to limp when playing House.

[davidgillon]

Haven't seen that for House, but I do remember they decided to fix Kerry Weaver's (Laura Innes') hip in ER because a decade of limping for her role was messing up her hip and back for real.

[lilysea]

(see icon)

to so much of this my response is "BRO HAVE YOU EVEN HEARD OF ENDOMETRIOSIS"

Yes, I was reading this post and before I even got to you mentioning endometriosis, I was like

"HE'S FORGETTING ABOUT ENDOMETRIOSIS"

I don't have endo, but I know a lot of people both in person and online who do - spend any time in chronic illness/chronic pain communities and you'll meet lots of people with endo.

And given that endo takes an average of 7 years to get diagnosed (and sometimes 10 to 15 years to get diagnosed], lots of people with endo would have "no diagnosed cause" for their pain.

[cesy]

Oof those are some leaps of logic.

[vass]

Even patients who had significant findings on X-rays or MRIs ended up having neuroplastic pain. We know this because Pain Reprocessing Therapy successfully eliminated their pain.

?????

Or the Pain Reprocessing Therapy had an effect on other kinds of pain? Or its main benefit is changing how much pain patients report, not how much pain they're in?

I haven't read the study, but is he arguing both that this specific treatment is effective for neuroplastic pain and also that you can identify neuroplastic pain based on whether someone responds to treatment?

In which case, if someone doesn't respond to treatment, is that "unfortunately it's not 100% effective for everyone with neuroplastic pain" or "their pain must not be neuroplastic after all", or is it "this patient is not trying hard enough and/or their problem is their refusal to accept that there's nothing really wrong with them"?

[davidgillon]

Yeah, it's definitely circular reasoning that leapt out at me when I read the quote.

[azurelunatic]

I'd like to give that guy in particular some endometriosis.