The Complex Chronic Pain Client - and the Claim of Malingering

Next clinical trial in Perth, Western Australia, March 2020 – click here to learn more.

Jacqui (not her actual name) was a 42-year-old mother of 2 boys with developmental issues, a baby girl and a husband who was frequently working away from the home. She had been thrown sideways by a forklift at work some 2 years previously and had been in agonising pain in her neck and back, together with almost daily migraines, ever since. This was even though her injuries had long healed and no pathology had been identified which could cause her pain. She couldn’t work, struggled to function, and her relationships and ability to parent were severely affected.

Jacqui sat in our office looking like a poster girl for deadening pain and fatigue, thoroughly defeated. She wore her agony in her eyes.

Jacqui was one of 1.5 billion people worldwide suffering from non-malignant chronic pain without sufficient explanatory pathology. 1.5 billion.

She was also one of many people the CEO of a major insurer claimed were “malingerers” because he could see from his own data that the majority of workers compensation chronic pain claimants were not getting better. And even though claim numbers were decreasing, he could also see that the value of those claims had more than doubled in the past 11 years.

But perhaps we can partly empathise with this misguided and shabby insult of “malingerer” because when we review the literature on current chronic pain treatments, including the newer “multi-disciplinary” or “comprehensive” programs, and including all of the pharmacological, physical, surgical and psychological approaches currently in use, we find that exactly none are significantly better than placebo for the overwhelming majority of people.

The mystery deepens when we see that the MRIs and x-rays of chronic pain patients do not differ from those of the general population who do not have pain, even when we add elite athletes to that mix. Existence of old damage or “wear and tear” does not correlate with pain.

In fact it turns out that surgery for chronic pain makes no difference either. Comparing real surgery with sham surgery (where an incision is made but no procedure takes place) we see that both surgical and sham surgical groups have the same results in terms of no change, improvement, or worsening of pain.

Wrong Understanding of Non-malignant Chronic Pain Without Explanatory Pathology

Up until recently it was believed that not much, if anything, could be done for chronic pain, but that people could be helped to have a better quality of life in spite of the pain. Some health professionals have claimed that “pain education” where the person is taught that the pain does not correlate with damage, will reduce their pain, or that if we prevent people from “catastrophising” their suffering will be reduced.

Neither of these approaches have any evidence of efficacy when it comes to reducing pain.

Some therapists have claimed that graded exercise programs can help lower some people’s pain level, however no study to date has shown that special exercise programs are in any way superior to taking a brief leisurely stroll each day, or taking up an active hobby such as writing, painting, or playing an instrument.

Fortunately, more and more we see a different direction for understanding and treatment of this type of pain. It’s common now to hear scientists and health professionals explain this type of pain as “a brain problem” but very few fully appreciate that this “brain problem” has two aspects, both of which must be addressed, and none seem to understand how that treatment should look.

Aspect 1 - Conditioned Pain – Present in 100% of Cases

The key part of our treatment of Jacqui was the identification of conditioned stimuli which were giving rise to chronic pain signalling. In some clients this may be quite simple, but not in Jacqui’s case. Jacqui had thoughts, perceptions, metaphors, and beliefs about her pain which consistently and persistently accompanied her experience of pain. She also had specific movements which were associated with the pain. So she had a varied array of conditioned responses which required extinction.

Typically psychologists will try to apply a variation of CBT, or mindfulness in order to try to get the client thinking in a different way. Research shows us that this can temporarily help in a very small way with mood but has no effect on the pain. (And we also see that none of these types of psychological treatment are superior to taking a walk, listening to music, reading a book, or other pleasant activity.) These old psychological approaches do not extinguish conditioned responses.

Thorough extinction requires accurate and simultaneous activation and disruption of the reconsolidation phase of a precise conditioned response, and this is a critical part of treatment for chronic pain regardless of the simplicity or complexity of presentation. In fact this is a critical part of treatment for any amygdala-mediated disorder or problem.

Aspect 2 - The Hyper-sensitive Nervous System – Should Always Be Explored to Determine Relevance

It is well recognised that some people with this type of chronic pain react more extremely to stimuli than other people. In this case we will not be completely successful with treatment if we do not fully address comorbidity, as well as lifestyle issues which detract from health and wellbeing such as sleep dysfunction (extremely common amongst pain sufferers for obvious reasons) nutrition/hydration, activity levels, relationships, stress and even past trauma.

I think most readers of this article would agree that these problems are also very prevalent in the wider community and I’ve even heard claims (usually from workers compensation executives unfortunately but understandably) that because non-pain sufferers also have these issues it shouldn’t be necessary to go “digging into the past” in order to help chronic pain clients for that reason.

I counter that by saying that having a hyper-sensitive nervous system is an extremely common human condition, is not the client’s fault, and if it were not for the accident, or the surgery, or other event, they still would not have chronic pain.

The undeniable fact of the matter is that the workers compensation client with chronic pain deserves to have comprehensive treatment that works, and attempting to get people to change their perception, attitude, or behaviour despite the pain is both inhumane, a waste of limited resources, and is leading to unnecessary increases in health costs and costs to all stakeholders. We must attend to all aspects of the pain if we are to deliver the most efficacious, cost-effective treatment, and relieve the person of their pain.

Not Like a Bull in a China Shop

So back to Jacqui. In 2 years prior to seeing us she had co-operated with every doctor appointment, every physio appointment, and every psychological appointment. Her rehab team had treated her with dignity and kindness. But nevertheless she felt judged for her inability to get better, and believed that she was looked down on as a liar by old work colleagues, family and friends. She had the pressure of very limited income, the pressure of raising 3 children largely alone, the disapproval of (it seemed to her) everyone around her even her nearest and dearest, and deep depression.

There she sat in front of us, a picture of utter despair. How humane, how intelligent would it have been to say, “right, let’s see if we can switch off that pain right now” and aggressively try to dig out and extinguish all her direct triggers to pain signalling? Not very. That would have been treating Jacqui like a lab rat and would have made things worse for her, not better. This is someone who required and deserved gentleness, as well as time to build trust.

After listening to Jacqui’s story we explained that there are two planks to treatment and that while we’d like to see if we could reduce the pain even a little at the beginning, we thought it might be more helpful to her if we could reduce her stress first, and got her (somewhat skeptical) agreement to that as she admitted feeling immensely burdened.

We helped her to sort out some major stresses she was having with her children’s school, and supported her to do a very gentle walk for just 10 minutes a day, combined with some extremely gentle (non-tensioned) turning of her head and shoulders (on the basis of noting that she held herself very tightly as a natural response to the pain). The turning movements were accompanied by brisk brushing of fingertips of one hand over the back of the other hand, alternating. (This is just one example of an SDR disruption technique.)

These changes were accompanied by a complete and immediate cessation of the migraines and Jacqui began to have some hope that maybe she could become pain free after all.

During this time we asked Jacqui to keep notes in relation to all her thoughts about her pain and indeed about her life. And rather than challenging these, or asking her in any way to change these, we began to use SDR Therapy to extinguish the conditioned response to these.

Over six weeks we continued to work on those two planks of treatment, directly switching off pain signalling, and decreasing Jacqui’s stress level to allow her nervous system to return to homeostasis. We were all rewarded when at the end of six weeks Jacqui smoothly arose from her chair at the end of the session and exclaimed in shock “I don’t remember the last time I could just stand up like that – I would’ve been on the floor in pain”.

Jacqui is now in the maintenance phase of treatment and her pain has largely gone. She is able to return to work, and she is able to parent to the great standard she has as a mother.

Note: if we had restricted our treatment to this second aspect only, we may have reduced Jacqui’s pain but not eliminated it to any significant level. We also may have risked increasing sensitisation rather than reducing it.

Some People Are Not So Complex

Peter had fallen from a height at work and despite medication, physiotherapy and psychological support was still left with residual pain that prevented him from going back to his role. With no complicating stressors, extinction of conditioned responses was all that was required, and this was completed in one session.

Julia had had surgery for cancer 12 months previously and despite complete healing still had pain in her shoulder and arm. She was completely and permanently free of pain in one session.

Courses for Horses

So these are some examples of extremes in the treatment of non-malignant chronic pain without sufficient explanatory pathology. There are the people who present with extremely simple etiology, and people who present with incredibly complex etiology, and we need to respond appropriately.

If we can switch off the pain signalling, and support the person to restore homeostasis of the nervous system, we will in most cases eliminate or drastically reduce their pain relatively quickly.

The Lesson

We need to courageously accept that current treatments are not working, and that it is madness (not to mention extremely wasteful of limited resources) to keep using them, or in the case of comprehensive or multi-disciplinary programs just combine more useless treatments more often and at even greater expense.

It is time for a completely different approach.

Please see www.sdrtherapy.org for more information, including on our next clinical trial in Perth, Western Australia. There is also a free introductory training program online.