Thoughts on pain management and the cost of care

John Bonica, M.D. a world renowned anesthesiologist at the University of Washington in Seattle was the individual most responsible for the creation of a new specialty, Pain Medicine. In 1977 The American Pain Society was founded and became the United States national chapter in the International Association for the Study of Pain. Complicated difficult to treat pain patients were usually not successfully treated by a physician representing one medical discipline and thus the multi-disciplinary pain treatment model was created.

It was understood that belief systems about the patients’ pain such as –“having pain means I am harming myself “ resulting in the avoidance of activities that produce discomfort and eventually eliminating many important activities in the patients life with resulting deconditioning, depression, pain drug use, dollars spent and ultimately disability. Pain becomes the focus of life and the more it is pondered the worse it feels. Multi-disciplinary teams composed of a pain management physician, psychiatrist, psychologist, social worker, occupational therapist, physical therapist and pain team nurses provide weeks of intensive full day treatment programs with remarkable success in restoring function to patients disabled with persistent pain.

There is an organization called Cochrane Collaborations that reviews various medical treatments to determine if they have been adequately studied and the results of the studies indicate that they are effective, ineffective or undetermined. Almost all of the treatments for back pain have been found to be neither ineffective or effective, meaning the evidence is out and more and better studies are needed- but multi-disciplinary pain centers have consistently been found to be effective for the treatment of chronic back pain. In the early 1990s there were more than a hundred pain centers certified by the Commission on Accreditation of Rehabilitation Facilities and despite the success of multi-disciplinary programs , close to half of them are no longer operating.

One reason for the closing of many centers was the pull back by insurance carriers for payments for non-interventional pain treatment services. Doing a procedure seemed to be considered more valid and worthy of payment than a non-invasive service even if it was effective in reducing pain, improving function and lowering future cost of care. Today some of the best pain centers cannot survive by depending on insurance payments and are forced to charge their patients large out of pocket sums in order to remain in operation. Some of these insurance carriers that will not pay for comprehensive pain centers will routinely pay for procedures of questionable effectiveness.

Please refer back to the past two blogs to find the background material for todays blog. Although the number of CARF approved pain centers in the US halved, the number of outpatient pain centers mushroomed. The services provided however focused on two areas:

  1. Medication management
  2. Nerve blocks and other invasive procedures.

Although many patients could be helped with one or both of these approaches, many patients in need of physical therapy and psychological services that were integrated with the overall treatment plan, would no longer receive optimal treatment. Reimbursement would be the driver of care rather than the needs of the patient. Centers could not stay in business and provide care that insurance companies would not cover. The shift toward procedures became an accepted standard of care and new organizations of pain physicians were formed whose membership focused predominantly on invasive procedures.

The cost of services for the treatment of back and neck pain, now with many less comprehensive multi-disciplinary centers, has nonetheless continued to rise at an alarming rate . Some of the increased cost is because of more numerous and complicated surgeries  . The bottom line is that we are spending more money each year on neck and back pain in the US, approximately the same as we spend on Cancer, and not getting good results.


Through the ages various explanations have been offered to explain the cause and how to treat it.  But it wasn’t until the 19th century that the spine and the nervous system were seen as the fundamental source of back pain. The idea that the cause of back pain was some injury or irritation in the bones and nerves of the spine was adopted by the medical community and this notion has persisted up to the present. With this in mind, recommending bed rest made sense-so bed rest became a standard treatment through most of the 20th century.  Some savvy physicians recommended staying active, but their opinion was drowned out by the bed rest proponents. If you have an injury it can take weeks to heal, and therefore it was common to have patients with back pain lie in bed, often in a hospital, sometimes without even getting up to go to the bathroom, for two or more weeks. It was only at the end of the 20th century, that the medical community recognized two facts:1. Back pain was usually not from any obvious injury. 2. Prolonged bed rest was not only not helpful, it was damaging. So patients with typical back pain began to be encouraged to remain active and to return to work as quickly as possible.

When x-rays were introduced, doctors could see the joints in the spine and the pelvis, and began to suggest that this is where the pain originated.  New phrases, such as “my sacroiliac is out” and I have a “bout of lumbago”, creeped into our conversations.  In the 1920s and 30s a variety of new creative surgeries were tried including fusing the sacroiliac joint, fusing the joint between the lumbar section of the spine and the sacrum and cutting out parts of the spinal column, all of which didn’t solve the problem and rapidly became unpopular. Some bad ideas with dreadful consequences don’t go away easily, and some physicians have reintroduced sacroiliac fusion. The joints that don’t look pretty on x-ray or now with MRI/CT scanning, although not undergoing surgery, still remain as targets for injections in pain centers.

The first report of spine surgery to remove a herniated disc to treat pain radiating down the leg (sciatica) was in 1934 and in 1935 the same operation was suggested as a treatment for back pain as well. The disc pressing on a nerve to cause pain shooting down the leg and the surgery to remove the part of the disc and bone in the spine to relieve the pressure on the nerve made sense and surgery for sciatica sometimes is indicated and successful. But looking to the disc as the cause of back without leg pain proved to be the foundation of the mistaken notion that the disc was the fundamental cause of most low back pain. This concept has led to needless surgeries, exorbitant costs and tragic suffering. Over the next twenty years surgery on the disc became one of the most common operations done by neurosurgeons.

The disc was not the reason for most back pain and many of the surgeries that were done were failures with patients experiencing no change or even worse back pain. The number of unsuccessful back surgeries was so high that a new diagnosis was created, something unique in all of medicine, “Failed Back Surgery Syndrome” , also known as “Post-laminectomy Syndrome”, referring to the part of the vertebra, the lamina, that is cut away to remove pressure from the disc. The surgeon was no longer the unquestioned authority as the answer to back pain. Many clinicians, including orthopedic and neurosurgeons, recognized that the problem of back pain was more complex than a problem in the discs and that many factors including emotions, job issues and physical conditioning, all contributed to the experience of back pain.

In the 1970s a new movement to understand pain in general, with back pain as a major focus, was spawned through the efforts of John Bonica, M.D. and his colleagues. More on Pain Treatment Centers next time.


Opioid Induced Hyperalgesia (OIH)

Patients who receive high, escalating doses of opioids (for example: morphine or oxycodone) may experience an increase in pain as a result of their medication.  This phenomenon, called Opioid Induced Hyperalgesia (OIH), is different than developing a tolerance to medication in several waysPain pills blog-Norman Marcus Pain Institute-blog

  • The nature of the pain is different than the pain for which the opioid was originally prescribed.  Often, pain becomes more diffuse, or widespread.
  • The location of the pain is different than the pain for which the opioid was originally prescribed, and often extends to more locations.
  • The quality of the pain is different than the original pain.  For example, the patient may experience allodynia, a condition in which normal sensation, such as touch, becomes painful.
  • Pain sensitivity can increase
  • Pain tolerance decreases
  • Whereas patients who have developed opioid tolerance may have transient relief from additional opioids, patients with OIH will have an increase in pain from additional opioids.[1]

Theoretical explanations for OIH include the roles of microglia and mast cells.  Though the mechanism by which this occurs isn’t fully understood yet, use of ultra low-dose Naltrexone has been reported to be effective in decreasing opioid side effects and facilitating reductions in dose. It is clear that long-term maintenance on opioids can do more harm than good for some patients.  Therefore, it may be wise to periodically attempt to decrease the amount of opioids to see if this either results in no increase or an actual decrease in pain.

[1] Lee, Marion, Sanford Silverman, Hans Hansen, Vikram Patel, and Laxmaiah Manchikanti. “A Comprehensive Review of Opioid-Induced Hyperalgesia.” Pain Physician Journal (2011): n. pag. Print.


Pain relief following a motor vehicle accident

Dean was a 41-year-old, married executive when he was involved in a motor vehicle accident where his car was totally wrecked. X-rays revealed no fractures. Over the next five years he experienced progressively increasing aching and tightness in his low back which sometimes radiated into his buttocks and down into both legs to the soles of his feet. He also reported pain in his neck and shoulders, which was made worse by bending over.

Therapeutic exercises, medications, psychotherapy, epidural steroids and nerve blocks were given without success. Radiofrequency lesioning of nerves innervating the facet joints in his cervical and lumbar spines provided six months of minor relief.

His pain became unbearable and he attempted suicide twice. When he consulted me five years after the accident, he was no longer working and rarely left his house. Physical examination revealed 16 muscles that appeared to be a source of pain. He lived out of state so his treatment was not continuous. Over the course of 4 months, he received muscle-tendon injections to each muscle identified followed by 3 days of a physical therapy protocol after each injection which included teaching Dean an exercise program that had been given at the YMCA . No muscle was re-injected. His pain was eliminated. Four years later, he continues to contact us to let us know he is still pain free and working as a corporate executive.



The Cinderella Hypothesis

Cinderella syndrome-Norman Marcus Pain Institute-blogThe Cinderella Hypothesis postulates that damage to the muscles can occur when the muscle fibers which are activated first are also the last to deactivate. Like Cinderella, they are always working, and not given adequate amounts of time to recover. These damaged muscle fibers can be a source of pain.

Low intensity, continuous activation of the fibers can be initiated consciously, for example while typing, or subconsciously, due to tension. Some studies have found that damage to the muscles can occur in as little as 30 minutes during continuous typing.

Though continuous activation without release does not happen for all patients during low intensity, sustained activity, the Cinderella Hypothesis presents a compelling case for taking breaks throughout the work day to participate in some brief stretching, which may help relax and lengthen the muscles.



Back pain relief achieved when soft tissue was addressed

Oliver is an 84-year-old publisher who came to see me for pain in the middle of his low back, which sometimes radiated to his right hip and down his right thigh.  He described this pain as an intermittent aching, stabbing, shooting sensation, made worse by sitting for more than 30 minutes, standing for more than 15 minutes, and walking.  His pain made it difficult for him to stand erect.  Though his pain began 8 years before he came to see me, it was exacerbated by an automobile accident 5 years prior to treatment.  He had been to a physical therapist and a neurologist, and was diagnosed with postpolio syndrome.  Imaging studies revealed severe degenerative changes throughout the lumbar spine.Back Pain

His physical examination revealed that although he had adequate strength in his trunk and no trigger points, his hamstrings were very tight and he had atrophied muscles in his lower extremities. I suggested that he learn the exercises that were created at the Columbia University School of Medicine in the early 1960s by my mentor Hans Kraus.  These exercises were later given at the YMCA to over 300,000 people with an 80% success rate in diminishing or eliminating low back pain.  The exercises are created to produce relaxation, limbering, stretching and strengthening of key postural muscles.  Oliver also began to gradually increase the amount of walking he did each day until he reached 2-3 miles.

By addressing the deconditioned muscles in his legs, buttocks and low back, Oliver was able to find relief for the discomfort in his low back, and stand erect.  Even with a diagnosis of Post-polio syndrome and  imaging studies showing degenerative changes in his spine, Oliver found relief when the soft tissue component of his pain was addressed.


Failed Back Surgery Syndrome

Anna is a 40 year old married woman, who had been on bed rest for approximately 3 years because of her pain. After a spinal fusion, discectomy, facet blocks and physical therapy, she was still having severe pain in her low back. Another surgery was suggested.

When I examined Anna, I identified and treated 5 muscles in her low back and buttocks (lumbar paraspinals and piriformis on both sides and the left gluteus medius). Each muscle was treated with an injection technique that addresses the muscle attachments and tissue and followed with a 3 day physical therapy protocol. She was taught an exercise program, developed at the Columbia University School of Medicine in 1960 and given to 300,000 participants at the YMCA, to help keep her muscles relaxed, limber and strong. With significant relief in her pain, she traveled to Asia a few months following treatment, began working part-time, and now 5 years later still reports being able to enjoy her life again.

Failed Back Surgery Syndrome is often thought to be amenable only to palliative interventions such as Spinal Cord Stimulation or chronic administration of opioids. Anna had muscle related pain that had not been considered as a possible cause of her ongoing post-operative pain. We will be posting other patient histories where persistent pain was caused by overlooked painful muscles.



Physical Examinations Result in Better Outcomes for Back Pain

Donna, a 43 year old married mother with a one year old son saw me for evaluation of severe low back and buttock pain. Her MRIs showed a disc herniation at L4-5 and moderate-to-severe spinal stenosis at the same level. She received physical therapy, 3 epidural steroids and chiropractic treatments with transient or no pain relief. Her orthopedic surgeon told her that since all conservative measures were already done the only option was spine surgery. He felt a fusion should be done.

My soft tissue examination identified 3 areas in her low back (the Quadratus Lumborum on both sides, and the right Gluteus Maximus) as possible sources of her pain. Each was treated with an injection technique that emphasizes placement of the needle into the muscle’s tendinous and bony attachments and the tissue along the course of the muscle from the origin to the insertion. A 3 day post-injection physical therapy protocol followed each injection session. Donna was taught all 21 exercises in my low back exercise program and experienced complete relief in less than a month after starting treatment. She returned to the gym, ran a half marathon and on follow up 5 years after treatment, was still pain free, hiking, biking, and post from NMPI

I believe that patients like Donna who receive spine surgery will frequently be found as Failed Back Surgery Syndrome cases.

Imaging findings often do not provide an accurate explanation for your pain. Addressing the imaging diagnosis without an examination to identify possible specific sources of muscle pain may lead to treatments that are at best inadequate and at worst damaging.


A step care model for pain management is often the best choice

James was a 67-year-old, married entrepreneur with bilateral thigh and calf pain that prevented him from walking for more than one block on a flat surface or sitting for more than 30 minutes. He couldn’t leave his house for a walk and was unable to sit in a restaurant. His pain was 7/10.  I evaluated him after he had undergone 2 lumbar spine fusions, epidural steroid and trigger point injections, all without pain relief.  His history revealed that after a fall he developed lower back and leg pain. An MRI found spinal stenosis and degenerative spondylolisthesis.  He had  a spinal fusion, which provided 2 months of relief before all of his symptoms returned.  He tried trigger point injections and epidural steroids, and then a second spinal fusion – all of which provided no lasting relief.Norman Marcus Pain Institute-back-pain

When James came to see me, he was offered an indwelling morphine pump or a spinal cord stimulator.

His primary complaint was a constant burning and pulling sensation in his thighs, and a pain that shot down the back of his leg to his heels. On examination, I discovered James was deconditioned: he had decreased range of motion in his back and hips due to stiffness, and showed weakness in his abdominals and back extensor muscles.  James’ physical examination also revealed 4 muscles that were likely contributing to his pain:  the right and left gluteus maximus, the tensor fasciae latae, and the vastus lateralis.  He received muscle-tendon injections to each muscle, and following each procedure,  3 days of a structured physical therapy protocol.

Soon after receiving all injections and learning all 21 exercises, he was walking easily on the street, eating in restaurants, and was able to travel to Vietnam and China with his wife.

His imaging findings of stenosis and spondylolisthesis existed before his fall and did not produce symptoms. He only had back and leg pain after his fall. It would have made sense to consider that soft tissue injury was a reasonable possible source of his pain prior to embarking on costly, interventions with considerable downside risks. I am suggesting that a step care model would have been a better option for James and for all of our patients with back pain (simple and cheap before complicated and expensive).


Over 90% of spine MRIs are interpreted as abnormal.

Fusion x64 TIFF FileNearly all individuals experience degenerative changes in the spine as they age, with nearly 20% of the population exhibiting disc herniations without any symptoms or pain by the age of 50(1).  This means that even though your X-ray or MRI shows an abnormality, it doesn’t mean that this is what is causing your pain.  Though imaging studies can be valuable tools, they are not equipped to show the nuances of the muscles and soft tissue.

In 2001, a study(2) of more than twenty thousand patients at outpatient medical clinics in the United States found that sprains and strains of muscles and other soft tissue accounted for 70-80% of all back pain.  Since muscles play such a large role in pain, and imaging studies cannot give us enough information about the state of the muscles, a thorough physical examination is necessary to evaluate the soft tissue as a source of pain.

Even if you are diagnosed with a separate condition, like spinal stenosis or fibromyalgia, if soft tissue has not been examined not only for tenderness or spasm but in addition as a source of pain, it is possible that muscles are contributing to your pain.  Over the next few blogs, I will talk about different patients who came to me with a variety of diagnoses that were thought to be the cause of their pain, who were able to reduce or eliminate their pain by treating their muscles.



1 Zimmerman, Robert D. “A Review of Utilization of Diagnostic Imaging in the Evaluation of Patients with Back Pain: The When and What of Back Pain Imaging.” Journal of Back and Musculoskeletal Rehabilitation 8 (1997): 125-33. Print.

2 Weinstein, Deyo NEJM



Impairment vs. Disability

Impairment is the clinical term for a loss of function due to pain or injury.  Being unable to lift more than 10 lbs because of low back pain is an example of impairment.  Disability is closely related to impairment, but is distinct because it involves choice.  Though your impairment may not allow you to lift heavy objects you may still able to sit at a desk. You can take on a job in which lifting isn’t necessary.  In this view, though you are impaired, you are not disabled for a desk job.Norman Marcus Pain Institute-blog-Nov19

I once met a young woman who was employed as a secretary working the switchboard at a rehabilitation center.  She was quadriplegic (paralyzed in her arms and legs), and operated the switchboard and her wheelchair by blowing through a tube. She had help in the morning getting ready to go to work and during the day for meals and personal needs. She worked 9-5, 5 days a week.  Though this young woman was 100% impaired, and could have easily made the choice to be permanently and totally disabled, she chose to work.  She was fortunate to be able to have a job that would accommodate her impairment. Even if that is not possible, her story highlights the fact that impairment does not have to equate to disability.  Though you may be impaired, you can still participate in your life in many different capacities– whether that be through employment, engaging with loved ones, taking up a hobby, or other activities that bring fulfillment.


Pain Relief – Is it Enough?

For people suffering chronic pain, pain intensity is not the only factor that should be considered when treating the patient. Many assume that once the pain is reduced, the patient will go back to living their normal life. However, this is often not the case.Physical Therapy Session

Many chronic pain patients have decreased muscle flexibility and strength, and in addition psychological problems (Schofferman, 2006). Therefore, multi-disciplinary rehabilitation may be an important part of their treatment.

Successful treatment may be reflected as much by improvement in function as in reduction in pain intensity. The capacity for increased activity allows a pain patient to do things otherwise prevented by pain. A patient who was unable to work due to his severe low back pain could after treatment, despite persistent pain,  sit, stand, and walk for longer periods of time. He returned to work to a desk job. Despite residual pain the treatment was still considered successful by the patient because he was able to return to work.


Use of statins may be cause of weakness in legs

Norman Marcus Pain Institute-blog-Nov12I have a friend who has been complaining of weakness in his legs. He has a history of high cholesterol and has been on statins.

He was seen by a spine surgeon and after an MRI showed spinal stenosis, decompressive surgery was suggested. His internist recommended stopping the statin since it can cause leg pain and weakness. Two weeks after the statin was stopped his weakness went away.

Overreliance on imaging studies could result in unnecessary surgeries as in this case. As many as 90% of adult patients who have had MRIs of the lumbosacral spine have spinal “abnormalities”. Just because we find something on imaging doesn’t mean it is the cause of the pain.


Patients feeling stigmatized for experiencing pain

Many chronic pain patients report frustration with the attitudes they face from friends, family, and health care practitioners.  Most often, patients report feeling stigmatized for experiencing pain that doesn’t have a readily identifiable cause.

Pain can have a variety of causes, and there is currently no set standard for diagnosing and treating chronic pain.  This lack of standard creates a confusing and frustrating experience for the patient, and a puzzling case for physicians.  For some, a lack of known etiology causes the patient to place blame on themselves, when in fact, the lack of knowledge is a result of the limits of medical knowledge ( Dr Norman Marcus-blog-Nov12

Blaming oneself can have destructive consequences, including avoiding getting necessary professional help and actively participating in rehabilitation(  A strong social support base can reduce feelings of stigmatization and improve coping (  Support groups for pain patients can be effective in developing coping skills for depressive symptoms that are frequently experienced in patients living with pain, and boosting self-appraised problem-solving confidence (


Some thoughts about the Affordable Health Care Act

You may have read or heard on the news about the new healthcare laws being put into place.  I have met many people who have said that they have no idea what will happen, so I thought I would provide some information. I am not an expert, nor am I placing an opinion on it. Any or all of this can change tomorrow, so before making any decisions consult your HR administrator, insurance broker, or whoever handles your health insurance needs.

As of January 1, 2014, you will be required to have health insurance. If you do not have health insurance, you will be fined a specific amount (based on your income) every year until you get coverage. The fines increase every year.  However, there are exceptions to this rule, including hardship exemptions, for which you can apply.

Many plans are changing because they don’t meet the minimum requirements set by the law. This may mean that your policy may change as of January 1, 2014. Even if it doesn’t apply to your needs and desires, the new standards require inclusion of items like prescription drugs, maternity leave, and pediatric dental care. Although pre-existing healthcare conditions will no longer be a reason for denying coverage or charging higher premiums, there are a few exceptions to this rule.

For more information, please visit



Increased risk of neck pain from extensive computer use

There has been an increase in the number of hours we sit in front of a computer for leisure and work. Does your job require you to stare at a computer for hours at a time? One study found that workers sitting for 95% of the day, and/or worked with their neck at 20˚ or more in flexion for more than 70% of their working time, had a significantly increased risk of neck pain  (

An ergonomically designed workstation would help reduce the strain on your muscles. Here are a few suggestions:neck pain-NMPI blog

  • Place your monitor so you are looking at it straight ahead or down at no more than a 15˚ angle.
  • The monitor should be 18-24 inches away.
  • The angle of your elbows when typing on the keyboard should be > 90 degrees.
  • An ergonomic mouse or keyboard may also help.
  • A laptop is always non-ergonomic; because the monitor and keyboard cannot be separated one or the other is in the wrong position.  If you always use a laptop think about getting an auxiliary keyboard.
  • Footrests should be used if your feet do not rest flat on the floor.
  • If you use a phone frequently get a headset so you will not have to hold the handset to your ear.

Aside from these changes, you may also consider doing limbering activities such as small stretches throughout the day – shrug your shoulders a few times, move your arms above your head, or get up and walk around your chair.


Obesity and pain show a strong relationship

health-weight-pain_management-Norman Marcus Pain InstituteStudies have shown that obese patients have more problems with musculoskeletal pain than the general population (  Obesity and pain show a strong relationship even when insulin resistance, inflammation, and pain-related comorbidities are accounted for (

A study of 215 fibromyalgia (FMS) patients found that obese patients had greater pain sensitivity, poorer sleep quality, and reduced physical strength and flexibility (  If you are in pain and overweight, losing weight may help reduce your symptoms.  Though this can be achieved through simply taking in fewer calories than you expend, studies have shown that diet and exercise are significantly more effective together than either intervention alone (

Adjusting your lifestyle doesn’t have to be drastic!  Start by making healthy swaps in your diet: try replacing white bread with whole wheat bread, or try using olive oil or canola oil instead of butter.  Pick up a fruit or vegetable that you wouldn’t normally buy and figure out ways to incorporate it into your meals for the week.

Exercise habits can evolve with a little time and effort.  If you normally walk five blocks in one day, see if you can increase that to six or seven.  Though weight training can be beneficial in building muscle strength and bone density, aerobic exercise is more likely to be helpful if your goal is weight loss.  Simply increasing your physical activity and making smarter food choices can help you lose weight and decrease your pain.


Fear may be the greatest predictor of disability status

Last week, we discussed some of the psychological components of pain, and the potent effect emotion and attitude can have on the day-to-day management of your pain.  Many patients coping with chronic pain experience kinesiophobia, an irrational fear of reinjuring oneself or exacerbating pain by participating in physical activity.

One study of patients with foot and ankle pain found that out of movement-related fear, pain intensity, and range of motion deficit, fear was by far the greatest predictor of disability status (  Clearly, fear of movement plays an important role in the quality of life of patients living with pain.Dr. Norman Marcus-disability status

Managing pain more successfully as reflected in continuing to work and be involved in life  is associated with less fear than those with lower levels of functioning when all other metrics are also considered.  A review of seven studies which examined patients with chronic musculoskeletal pain who chose to continue working found that these patients were significantly more likely to have low scores for both emotional distress and perceived disability (

Treatments that address both the physical and emotional aspects of pain can produce better outcomes.  A study of 130 patients who had undergone a spinal fusion found that patients who participated in a rehabilitation program that included cognitive-behavioral therapy to address  kinesiophobia and catastrophizing as well therapeutic exercise faired significantly better than those who participated in a program consisting only of therapeutic exercise.  The psychological intervention was found to reduce dysfunctional thoughts and enhance quality of life for up to one year after treatment ended (

It is apparent that attitude – especially beliefs about movement – impacts the quality of life for patients in pain.  Those who maintain a positive outlook and a healthy perspective on movement, though not necessarily reporting reduced levels of pain, do show an increase in function.


Norman Marcus Pain Institute-mood and painSeveral different variables have been studied: Catastrophizing, depression, kinesiophobia, and self-efficacy.

Catastrophizing is a type of dysfunctional thought in which the patient exaggerates the severity of a situation. Examples of catastrophizing are thoughts like “I can’t take it!” “What did I do to deserve this?” “What’s the use?”  “I might as well be dead!” One study of patients entering a multidisciplinary pain treatment center found that the extent to which a patient catastrophized was a better predictor of disability status than pain intensity (  A separate study of fibromyalgia patients found that pain catastrophizing was correlated with an increase in brain activity in areas related to attention to pain, anticipation of pain, and motor control (  This suggests that catastrophizing affects the intensity with which patients perceive pain.

Depression and chronic pain often coexist.  Both conditions can markedly affect a patient’s health, motivation, and overall quality of life.  Patients with depression often experience feelings of helplessness, fatigue, and hopelessness – all feelings which can impair treatment outcome.  Depression and pain are also linked biologically through 2 common pathways:  the serotonergic and noradrenergic systems (  The neurotransmitters serotonin and norepinephrine modulate pain transmission and also play key roles in the development of depression.  Therefore, treatments that target these neurotransmitters, such as tricyclic antidepressants, and SNRIs (serotonin/norepinephrine reuptake inhibitors) can be helpful for both conditions (

Kinesiophobia is fear of movement based on the belief that activity will result in re-injury or exacerbation of pain. Hi kinesiophobia scales result in less activity and interfere in effective rehabilitation (  Depression often co-exists with kinesiophobia.

Self-efficacy in the context of chronic pain refers to confidence in one’s ability to cope and function despite persistent pain.   A study of patients with an acute whiplash injury found that patients with less belief in their ability to manage their life in the face of pain were significantly more likely to have their injury develop into a chronic condition (  A separate study of 45 low back pain patients found that higher self-efficacy predicted better overall functioning and decreased levels of pain at 6 month follow-up (

Psychological factors play an important role in evaluating and treating pain.  When usual treatment is not progressing well, assessment and treatment of emotional factors may help the patient succeed in finding pain relief.


One of our colleagues, Ronnie Gonzalez, a bereavement counselor, sent us a comment about her clients, who often felt physical pain while struggling with the loss of a loved one.

Very often, emotional stress and negative thoughts can manifest physically as tension in the muscles, which is one of the most common causes of pain. Constant exposure to stressors can cause the development of musculoskeletal pain in even healthy individuals (, and is therefore considered a risk factor associated with the onset of pain.

fMRI (functional magnetic resonance imaging) studies of pain patients demonstrate that negative thoughts can excite areas of the brain associated with pain perceptions and intensify the sensation of pain. Studies have shown that painful muscles which are tense, especially during times of stress, can stay contracted and tight even after the stress or negative feelings are long gone. This causes the body to be more susceptible to pain.

Breathing and stress are also linked. When we suppress our feelings, we generally hold our breath. Depriving our muscles of oxygen will cause it to hurt. The advice of taking deep breaths when we’re stressed or anxious is not unfounded.

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