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How does chronic pain develop ?
  • A Biopsychosocial Explanation for the development of chronic pain
  • Jane’s Story
Unfortunately, Jane’s story is typical of people developing fibromyalgia and other chronic pain syndromes. It illustrates how a simple injury can become a debilitating pain syndrome when physical (or biological factors), such as an injury, combine with psychological and social factors to create a complex situation for the person in pain. It helps us understand why physical treatments like physiotherapy and chiropractic cannot provide a cure for chronic pain. A bio-psycho-social explanation takes these three factors into account and we will explore them in this section. Read Jane’s story and then come back here to look at the way these factors interact.

Once pain has become chronic these factors both cause the pain, and become a consequence of the pain. The diagram below shows how this works.
Most people who have pain for a long time get worried, frustrated, and depressed. These are psychological factors and the body reacts to these with muscle tension and spasm. Movement and activity hurt and therefore, the person in pain does less and less. As well as this, chronic pain has all sorts of social consequences. It can affect your relationships with your partner/spouse , your family, your friends and relationships at work. You can be involved in conflict around compensation resulting in conciliation and/or litigation. Not surprisingly, the more disruption to your life, the more severe your chronic pain becomes. Once this cycle has started it isn’t possible to say what factors are the cause, and what factors are the consequence of the pain.

You can read more about the cycle of chronic pain in posters. There is a poster called the “Chronic Pain Cycle” in the set of four posters.

Jane’s Story
Jane had a car accident on the way to work. As she waited to turn right, a car hit her from the rear causing considerable damage. She was running late and knew how much work was waiting for her when she arrived at work. Her mind was on the coming day, thinking about all the documents in her in-tray that she had to deal with to have the tray emptied by the end of the day. She hadn’t seen the car and, visibly shaking, she got out to inspect the damage. She knew that she had to get to work and, after organizing the tow truck, she got in a taxi and went to work. Even though her neck was sore she thought that she would be better after a cup of tea and a panadol.

When she woke up next morning she could barely move, and reluctantly, she rang in sick. She thought that she had better have things checked out and went to see her local doctor that afternoon. He told her that she had whiplash and that she should rest for a couple of days. He also said to go and see the physiotherapist if it wasn’t better in a few days. She returned to work after these days off and struggled on valiantly. Jane was very conscientious and nothing stood in the way of her work. She prided herself on being an efficient and capable secretary. She would do whatever needed to be done and her boss could rely on her to do more than anyone else in the office. She had been with the company for 10 years and had an outstanding reputation.

By the end of the week the pain was worse and she found it difficult to get comfortable in bed. She had to do something, and therefore, she rang the physiotherapist for an appointment. The physiotherapist said it was important to mobilize the spine and started pressing on different parts of her neck to assess the situation. She said the problem was at C5-6 and possibly C6-7. Jane was asked to attend 3 times weekly to have her neck mobilized. She was told to come daily if it got worse.

When Jane arrived home from work she was a wreck. The family had to take over. Her elder daughter, who was 15, cooked the dinner and her husband took over most of the household chores. Her 10 year old son helped where he could. After weeks of this, the family started to complain. Jane’s daughter was studying for exams and Jane felt guilty about not doing her share of the household chores.

She had been back to the doctor and he took X-rays. These revealed degenerative changes in the neck and he said that this was the reason that it was taking time to heal. There was the possibility of a pinched nerve and if things didn’t improve, he would send her for further tests.

Meantime the physiotherapist kept working on the neck saying that it could take time. Jane braced herself for each visit because the pressure on the spine hurt. She thought that this must be doing some good, after all the physiotherapist was the expert. Jane was reluctant to say that it hurt because the physiotherapist was doing her best.

The family was relying on her income because her husband had recently set himself up in business and his income was unpredictable. She knew that she had to keep working.

The months went by and Jane’s life changed. She had always been very active and now all she could do was go to work and come home and go to bed. She had not been one for relaxing and had kept herself busy all the time. She felt like she was letting everyone down. She began to worry because the treatment didn’t seem to be providing pain relief; some days she felt some relief for an hour or so after treatment but other days it seemed to make it worse. She continued to attend 2 or 3 times weekly. What was causing all this pain? After all it was only a muscle strain. Perhaps the doctor wasn’t telling her something. She was beginning to feel pain up into the back of her head and down the right arm. The worst pain was between her shoulder blades and sometimes it even hurt lower down her back.As the weeks went by Jane started to feel alarmed and returned to the doctor. The masseur she had started to see said that there must be a problem that hadn’t been identified.

Her doctor sent her to a surgeon and he ordered an MRI. This revealed some abnormality at C6-7 and he said that they would consider operating if the pain didn’t subside. He asked her to come back in 6 months and in the meantime she should learn to live with it. He said these injuries could take up to 10 years to heal.

Over this 6 months, Jane stopped seeing the physiotherapist and started chiropractic treatment with a chiropractor her friend had recommended. She continued her twice weekly visits. The surgeon had said to try hydrotherapy and she added this to the chiropractic and massage. She had appointments every night after work. The hydrotherapy seemed to aggravate the problem and she stopped it after 6 sessions. Jane’s world continued to fall apart. She wasn’t coping at work, her concentration and memory seemed to be affected. Her boss was beginning to lose patience because she kept having to take days off. Finally, Jane burst into tears at work and had to go home.

She returned to the doctor who said she would need time off work. He said that she probably couldn’t return to keyboard work as this was obviously aggravating the problem. Now she had to apply for compensation payments to cover her salary. This seemed the last straw for Jane who had been the person everyone could rely on no matter what.

The surgeon gave her a 50/50 chance of success with the surgery and said that operating at one level may not solve the problem because there were changes at several levels. Jane had no idea what to do and no idea what was really wrong with her. The surgeon suggested wearing a collar to eliminate movement. This was just the opposite of what the physiotherapist had been doing; mobilizing the spine.

Her doctor suggested what she feared most. He thought she should see a psychologist. Now she knew it really must be in her head. He said that nothing else had worked and this was all that was left. He was always busy and didn’t have time to talk to her, and therefore, reluctantly, she began seeing a psychologist who treated her anxiety and depression. The psychologist was very sympathetic and listened to her story encouraging her to express her feelings. Jane realized that the psychologist didn’t have any solutions either but at least she listened. Her appointments were once a week and she talked about her fears and frustrations. This seemed to help a bit.

Two years after the accident Jane was still having chiropractic treatment and massage and she had been seeing the psychologist for a year. Nothing was really changing except that Jane had attempted a return to work, 5 days a week for 5 hours. She had lost all her confidence and the pain was so strong that she had to give up her attempt at returning to work. Her employer said that there was no longer a position for her in the company. Jane was devastated after all those years of dedicated service; they didn’t care and neither did anyone else.

Jane had no choice but to see a solicitor because the family could not survive on her husband’s income. She had growing concerns about her capacity to work in the future as she wasn’t trained to do anything else. At first her weekly wage had been reduced and was then withdrawn. Not long afterwards payment for treatment was stopped and she was left without any support. Jane could not understand what had happened and she was feeling hurt, disappointed and even bitter. Life seemed to be without meaning or purpose.
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