Is this issue in the tissues?
Chronic pain affects up to half of the UK adult population; an estimated 28 million people according to studies. In fact, about 50% of all GP appointments are for some kind of musculoskeletal pain.
In my clinic, many of the patients that we see are visiting us for chronic or long-term low back pain. Many patients tell me they’ve ‘already been to everyone else and we’re the last person who might be able to help’. Thanks, no pressure!
Most of the time they’ve been given multiple physical explanations for their pain, ranging from having one leg longer to the other to their pelvis being ‘out of place’, whatever that means!
Unfortunately, none of these explanations stand up to scrutiny when we look for the science behind them. It turns out that leg length differences occur naturally in up to 95% of the population, and even if it was a problem, studies have found that we don’t have a reliable way to test for it anyway.
For a long time now, patients have been led to believe that the ‘issue is in the tissues’ and that they just need the “correct” test or scan to find it. But we actually now know that the longer that you have had pain for, the less likely this is to be true.
Tissue injury vs chronic pain
When we injure a tissue, almost every time the damage will heal in 12 weeks. This means that any pain after then is not tied directly to tissue injury. Rather, it is tied to a malfunctioning internal alarm system.
Musculoskeletal pain itself is not an indicator of injury and rather an alarm to alert you to a potential problem. This makes perfect sense – you want to know about a problem before it occurs, not once it’s too late.
However, chronic pain is different. Chronic pain is when the alarm has been turned on and then not been able to turn off again once the tissue has healed. Think about it like a malfunctioning tyre pressure sensor or a smoke alarm that goes off when steam from the bathroom hits it. It’s a well-functioning system but has become far too sensitive.
We can actually get the opposite problem too, where we experience tissue injury but not get any pain at all – ever noticed a bruise you don’t remember getting?
Job and lifestyle factors
We don’t really know what turns short term acute pain into long term chronic pain. But we know that people who have very high levels of pain at onset or pain elsewhere on their body are more likely to get long term problems. We also know that people who are most likely to get pain for the first time are individuals with a physically demanding job, other physical or mental health problems, smokers and people who are obese.
None of these reasons can be specifically categorised as an ‘issue in the tissue’. This means that if you’re going to make real forward steps in managing chronic pain then we need to look beyond the patient’s physical structure. In fact, it’s well established within research that psychosocial factors, like depression and work dissatisfaction, are more strongly correlated with low back pain than biological factors.
This doesn’t mean that there isn’t anything happening in the tissues. We know that people with chronic low back pain have increased core muscle activity compared to people without back pain and that chronic inflammation can cause irritation of nerve endings that can further add to back pain.
Despite our vast wealth of ever-increasing knowledge, we continue to look for the single structural cause of pain. We would be better served if we take a step back and look at the patient as a whole person, instead of continually looking for the ethereal ‘issue in the tissues’.
To read Rob Bailey’s latest column in the Diss Express please click here.
