Reversing pain, one smarter goal at a time.
Chronic pain is a terrible thing. It affects one in five adults, and it is defined as constant pain for at least 6 months. Is it possible to eliminate chronic pain?
I have been a chronic pain specialist since 1996 and I have seen all kinds of people with a multitude of chronic pain conditions. When people ask me “Doctor, will this pain go away?” my answer is “It depends”.
First, let me explain how pain becomes chronic, then we can talk about reversing it.
Pain starts with an insult, an injury or a trauma. It generates an electrical impulse that travels through peripheral nerves to the spinal cord. In the spinal cord, it connects to another neuron that brings the electrical impulse to the thalamus, the processing centre of the brain. From the thalamus, it sends messages to various parts of the brain that include areas to localize the injury, areas of emotions and memory.
The brain and spinal cord will activate the inner pharmacist and send powerful painkillers and anti-inflammatories to fix the problem. If this process works as expected, then the injury is healed, the pain signals stop and the whole system returns to the original sentinel state. However, there are circumstances when this cycle ends but the body does not return to its original state. When this happens multiple times, the person will report that they always have some “residual pain”. They are never pain-free. It is like each acute pain is adding more pain to the system, and they just keep adding, adding, until the person cannot concentrate, sleep or do anything, they are always in pain. The person tells me, “There is no single minute of the day that I am not in pain. I am in constant pain, every day”.
For the majority of people, this process takes years to fully develop, but for some, it may take weeks. This phenomenon is called central sensitization. Some factors predispose a person to develop chronic pain sensitization quicker than others, adverse childhood experiences, smoking, lack of physical activity, poor sleep habits, all contribute to a worse prognosis.
These individuals end up in pain clinics, and ideally, they will see a multidisciplinary pain clinic where there are professionals specialized in pain medications, mind-body therapies, modalities, manual therapies and movement. These are the essential 5 Ms of chronic pain management. Some pain clinics also offer injections and nerve blocks, however, these are mostly indicated when there is no central sensitization, and the problem is localized to a specific body part, such as a lumbar disk herniation or osteoarthritis of the hip joint.
When we talk about pain management, it implies that there is no cure, that we are not aiming at eliminating or treating the pain, we are just managing it. Why can’t we treat and remove chronic pain sensitization once for all? The answer is that we need to revert the pain system to the original state as it was before, we need to treat the pain system and eliminate the sensitization that occurred over many years. Keep in mind that 100% reversal might not be possible, as there are neuroplastic changes in the nerve system that are ingrained in the hippocampus, the area that stores memory in our brain.
Reverting pain is better than managing pain. Revert means to go back in this process and undo certain pathways that lead to the chronification of pain. Reverting pain takes time, effort and consistency. The multidisciplinary pain team will give the person all the tools necessary to revert the process, but it is up to the person to use them.
A pawn with a SMART goal
The person needs to know where they are going in their journey to revert chronic pain.
One reason that I see many patients failing and abandoning this process is when they do not set goals for their treatment journey. A person without goals will arrive nowhere. If the person does not see results, they abandon the practice. If the person has an unrealistic goal for treatment, they may expect that their pain will disappear completely in a couple of weeks, or that taking the painkillers will eliminate their pain. And because multiple attempts to some sort of treatment for their pain have failed, they get discouraged and depressed. Then, their lives go down on a spiral that is very dangerous. They relied mostly on passive modalities like taking pills and receiving manual therapy. They don’t want to engage in physical activity, movement or exercise because that makes their pain feel worse (anyone who starts using some muscles after a long period of inactivity will feel muscle soreness). This downward spiral leads to unhealthy behaviours like poor sleep hygiene, eating junk food, binge drinking, smoking cigarettes and cannabis, using more pills, less socializing, dropping from school and work, and end up locked in their home watching TV or browsing the internet for the rest of their lives.
It is impossible to coach an athlete that doesn’t know their goals. It is very frustrating to guide a child who doesn’t know what they want to become when they grow up. It is impossible to arrive at a destination if you don’t know the name of the place you are going to.
A chronic pain patient without smart goals is like a pawn in the middle of a game without instructions.
A patient with chronic pain must set smarter goals to revert the pain sensitization. When I say smarter goals I am using an acronym that stands for:
S: specific, strategic and significant
M: measurable, meaningful and motivational
A: attainable, achievable and adjustable
R: relevant, realistic and results
T: time-relevant, tractable and tangible
E: evaluable
R: readjustable and rewarding
This is an example of SMART goal related to weight loss: The person has severe knee osteoarthritis and the doctor said they need to lose 50 pounds. The non-smart goal looks something like this: “I’ll lose 50 pounds”. The person that sets a SMARTER goal will say “I will lose 2 pounds per week for the next 4 weeks. I’ll stop eating any kind of bread, pasta or white rice. I’ll replace them with grains, nuts and steamed vegetables. Once I lose 8 to 10 pounds I will evaluate if I am able to lose more pounds per week. I will celebrate by rewarding myself with a piece of dark chocolate”.
Here is another example related to exercising: The person has shoulder pain due to tendinitis and the physiotherapist said they need to do exercises. The non-smart goal looks like this: “I’ll sign up to a gym and go every day for 1 hour”. The person that sets a SMARTER goal will say: “The first week I will do a home-based exercise routinefor 10 minutes every day, then I will increase to two sets of 10 minutes per day on the second week, and then to 3 sets of 10 minutes daily on the third week. Then, I will increase to 4 sets of 10 minutes per day but only 4 days per week, and I will rest 3 days per week. If this goes well, then I will sign up for a gym membership”.
An example of SMART goal related to sleep routine: The person has insomnia, poor sleep quality, wakes up tired and takes long naps during the day. The psychologist recommends the person improve their sleep habits. The person sets a SMARTER goal: “I will go to bed every day at the same time, and I will set the alarm 8 hours later to wake up every morning at the same time. I will reduce the duration of naps during the day from 90 minutes to 30 minutes. Once I achieve this goal for 1 month, I will start a second goal to reduce the amount of blue light that I receive during the day”
When the person knows where they are going, it is easier for them to arrive there and to know when they arrived. It is important to remember that these are life changes. Just because they arrived there, it doesn’t mean they stop repeating these behaviours. They need to continue with these new habits that helped them work towards their goals to prevent flare-ups.
“No goal is too small”
It is important to celebrate small achievements. I recommend they keep a journal of their goals, so they can see progress being made in the right direction. Once they achieve a goal, they can move to the next goal. Or, they can have multiple goals at the same time, at different stages.
So, when I answer “It depends”, it is because the answer depends on the person that has pain if they are committed to learning how to revert their chronic pain by developing new daily habits and setting smarter goals. It is possible to revert it. Science has progressed and we already know what works and what doesn’t. I have seen many people reverting the course of chronic pain and achieving a better quality of life, one SMARTER goal at a time.
This article is not intended to give you medical advice. Please talk to your physician or healthcare professional if you have any health issues. If you leave a comment about your own medical condition, I will not be able to provide you medical advice. But, please, leave a comment if you feel that this article has helped you to learn something new.
This article is available as a YouTube video on my channel: https://youtu.be/QbhQczd5QbU
I would like to thank Virginia McIntyre for reviewing the script of this article and making excellent suggestions to improve its content.
