does chronic pain develop ?
- A Biopsychosocial Explanation for the development
of chronic pain
- Janes Story
Unfortunately, Janes 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 Janes 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
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
relationships with your partner/spouse , your family, your
friends and relationships at work. You can be involved in
compensation resulting in conciliation and/or litigation. Not
surprisingly, the more disruption to your life, the more
your chronic pain becomes. Once this cycle has started it isnt
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 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 hadnt
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 wasnt
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
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. Janes 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 didnt 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
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 Janes 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 didnt 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
all this pain? After all it was only a muscle strain. Perhaps the
doctor wasnt telling her something. She was beginning to
feel pain up into the back of her head and down the right arm.
pain was between her shoulder blades and sometimes it even hurt
lower down her back.As the weeks went by Jane started to feel
and returned to the doctor. The masseur she had started to see
said that there must be a problem that hadnt 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
if the pain didnt 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.
Janes world continued to fall apart. She wasnt coping
at work, her concentration and memory seemed to be affected. Her
boss was beginning to lose patience because she kept having to
days off. Finally, Jane burst into tears at work and had to go
She returned to the doctor who said she would need time off work.
He said that she probably couldnt 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
straw for Jane who had been the person everyone could rely on no
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
He was always busy and didnt 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 didnt have any solutions
either but at least she listened. Her appointments were once a
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
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
longer a position for her in the company. Jane was devastated after
all those years of dedicated service; they didnt care and
neither did anyone else.
Jane had no choice but to see a solicitor because the family could
not survive on her husbands income. She had growing concerns
about her capacity to work in the future as she wasnt trained
to do anything else. At first her weekly wage had been reduced
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.