Gerry Gajadharsingh writes:
“ Chronic pain affects around 28 million adults in the UK, which is roughly 44% of the population. This includes pain that lasts for more than three months and can be associated with conditions like arthritis, back pain, and fibromyalgia.
Among those with chronic pain, a considerable number report that it affects their ability to work. Estimates indicate that around 10% to 20% of those with chronic pain may be off work due to their condition at any given time.
Based on these figures, if we take a conservative estimate of 10% of those with chronic pain being off work, it translates to about 4.4% of the UK population (10% of 44%).
Chronic pain leads to significant healthcare costs due to frequent medical visits, treatments, and medications.
It also affects the economy through lost workdays and decreased productivity. Many people with chronic pain either reduce their working hours or leave the workforce entirely.
Pain is experienced physically but there is a strong link between chronic pain and mental health issues, such as depression and anxiety.
The mechanism is usually through Central nervous system (CNS) sensitization and is a key concept in understanding chronic pain. It refers to the process by which the nervous system becomes more sensitive and reactive to stimuli that typically should not cause pain.
Mechanisms of CNS Sensitization
Neuroplastic Changes: CNS sensitization involves changes in the structure and function of neurons in the spinal cord and brain. These changes increase the excitability of neurons, making them more responsive to pain signals.
Enhanced Synaptic Transmission: Increased release of neurotransmitters and heightened responsiveness of receptors can amplify pain signals within the CNS. This means that normal sensory inputs can be perceived as painful (allodynia) or that pain from existing stimuli can be exaggerated (hyperalgesia).
Gene Expression Alterations: Long-term changes in the nervous system can lead to alterations in gene expression, producing more receptors and ion channels that facilitate pain transmission.
Types of Sensitization
Peripheral Sensitization: This occurs at the site of injury where local nerve endings become more sensitive. It often initiates CNS sensitization but is distinct from it.
Central Sensitization: This occurs within the spinal cord and brain. It can persist even after the initial injury has healed, contributing to chronic pain conditions.
Conditions Associated with CNS Sensitization
CNS sensitization is implicated in various chronic pain conditions, including:
Fibromyalgia: Characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas.
Chronic musculoskeletal pain
Chronic Fatigue Syndrome: Often involves persistent, unexplained fatigue along with pain.
Irritable Bowel Syndrome (IBS): Chronic gastrointestinal pain and discomfort.
Migraine: Severe headaches often accompanied by other symptoms like nausea and sensitivity to light.
Complex Regional Pain Syndrome (CRPS): Persistent, severe pain usually affecting a limb, often after an injury.
Central nervous system sensitization is a process that amplifies pain perception, making the nervous system more reactive to stimuli. It plays a crucial role in the persistence of chronic pain and requires targeted treatment strategies that address both the physical and psychological aspects of pain.
The important thing is that chronic pain often has a multifactorial ideology, that means there are often several causes to the ongoing pain. The key is exploring these multiple factors and doing your best to address them with your patient. The challenge is often that patients don’t accept the psychological component to chronic pain, with many embarking on merry-go-round of multiple clinicians and investigations to try to find the root cause of their pain, often unsuccessfully.
Pain medication (analgesics) often complicates the scenario, due to medication rebound pain, when the medication wears off the pain increases the patient takes more medication and it develops into a viscious circle. Although there’s no doubt that certain drugs such as amitriptyline and nortriptyline can be part of the mix to trying to break the vicious circle of chronic pain.
The research recently published on Medscape suggests that a single course of treatment with emotional awareness and expression therapy (EAET) was associated with a significantly greater reduction in chronic pain severity than cognitive-behavioural therapy (CBT), the current psychotherapeutic gold standard, a new study suggested.
The trial enrolled 126 veterans (92% men; 55% Black or African American) aged 60-95 years with at least 3 months of musculoskeletal pain. More than two thirds of patients had a psychiatric diagnosis, with about one third having (PTSD). Almost all had back pain, and many had pain in multiple locations.
Two thirds of the patients who received EAET reported at least a 30% reduction in pain compared with 17% of those who received CBT.
“Most people with chronic pain don’t consider psychotherapy at all,” study investigator Brandon C. Yarns, MD, a staff psychiatrist at the VA Greater Los Angeles Healthcare System, and clinical professor of health sciences at the Department of Psychiatry and Biobehavioural Sciences, UCLA Health
In the therapy, patients are asked to recall a difficult or traumatic memory, engage in experiencing how the related emotions feel in the body, express those feelings in words, and release or let them go. They are taught that the brain’s perception of pain is strongly influenced by the evasion of grief, fear, rage, or guilt, Yarns said.”
Medscape
Alicia Ault
A single course of treatment with emotional awareness and expression therapy (EAET) was associated with a significantly greater reduction in chronic pain severity than cognitive-behavioural therapy (CBT), the current psychotherapeutic gold standard, a new study suggested.
Two thirds of the patients who received EAET reported at least a 30% reduction in pain compared with 17% of those who received CBT. The randomized clinical trial also showed that individuals with depression and anxiety responded more favourably to EAET, a novel finding.
The study is one of only a few to directly compare EAET with CBT.
“Most people with chronic pain don’t consider psychotherapy at all,” study investigator Brandon C. Yarns, MD, a staff psychiatrist at the VA Greater Los Angeles Healthcare System, and clinical professor of health sciences at the Department of Psychiatry and Biobehavioural Sciences, UCLA Health, told Medscape Medical News.
Although patients were allowed to continue medication for pain and other comorbidities during the study, those who received EAET “had larger improvements in pain, depression, and anxiety,” Yarns said. “That suggests that the effect was due to the EAET.”
EAET was first used in the early 2010s. In the therapy, patients are asked to recall a difficult or traumatic memory, engage in experiencing how the related emotions feel in the body, express those feelings in words, and release or let them go. They are taught that the brain’s perception of pain is strongly influenced by the evasion of grief, fear, rage, or guilt, Yarns said.
This contrasts with CBT — considered the current gold standard for chronic pain — which teaches patients to improve the ability to tolerate pain though guided imagery, muscle relaxation, and other exercises and to adapt their thinking to change how they think about pain.
Although prior studies suggested EAET is effective in reducing pain in fibromyalgia and chronic musculoskeletal, pelvic, and head pain, most included primarily younger, female patients.
The research is the “first full-scale evaluation of EAET, to our knowledge, in a medically or psychiatrically complex, racially and ethnically diverse, older sample comprising predominantly men,” investigators wrote.
The trial enrolled 126 veterans (92% men; 55% Black or African American) aged 60-95 years with at least 3 months of musculoskeletal pain. More than two thirds of patients had a psychiatric diagnosis, with about one third having (PTSD). Almost all had back pain, and many had pain in multiple locations.
All services were delivered in-person at the US Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles. Half underwent CBT, while the other half received EAET.
Each patient had one 90-minute individual session and eight additional 90-minute group sessions.
Patients were asked to rate their pain using a 0-10 scale in the Brief Pain Inventory (BPI) before starting treatment, at the end of the nine sessions (at week 10), and 6 months after the sessions ended. Baseline BPI score for both groups was a mean of around 6.
Post-treatment, people in the EAET vs CBT group had a mean two-point reduction vs 0.60 reduction, respectively, on the BPI scale. A clinically significant reduction in pain — defined as ≥ 30% decrease — was reported in 63% of EAET patients vs 17% of CBT patients (odds ratio [OR], 21.54; P < .001).
At 6 months, the mean reduction was 1.2 for the EAET group compared with 0.25 for the CBT group, and 40% of the EAET group reported a clinically significant reduction in pain.
A little more than a third (35%) of veterans receiving EAET reported at least a 50% reduction in pain at 10 weeks compared with 7% of those receiving CBT. At 6 months, 16% of the EAET arm reported a halving of their pain.
EAET was also superior to CBT in reducing anxiety, depression, and PTSD symptoms at the 10-week mark.
More Work Needed
In an accompanying editorial, Matthias Karst, MD, PhD, a clinician with the Pain Clinic, Hannover Medical School, in Hannover, Germany, noted that EAET’s effects “are significantly superior to those of CBT in almost all dimensions, even after 6 months.”
EAET “assigns a special place to the integration of the body into the emotional experience,” he wrote.
The study demonstrated that “the evocation and expression of emotions is superior to the mere cognitive discussion of these emotions in therapy of patients with chronic pain.”
Commenting on the findings for Medscape Medical News, Traci J. Speed, MD, PhD, assistant professor of psychiatry and behavioural sciences and an attending psychiatrist of the Johns Hopkins Pain Treatment Program at Johns Hopkins University, Baltimore, called the study “ground-breaking” because it showed effectiveness in people with high rates of PTSD, anxiety, and depression.
“It is a little bit surprising how impressive the study outcomes are in terms of maintaining the effects at the end of the treatment and sustaining some of the effects on pain sensitivity even at the 6-month follow-up,” said Speed, who was not part of the study.
However, she continued, “I don’t think it changes the current standard of practice yet. CBT has decades of research and evidence that it is effective for chronic pain and that will I think continue to be the standard of care.”
Although EAET is in its infancy, chronic pain experts are interested in learning more about the therapy, Speed added.
“It blends well with the current techniques and extends the current gold standard treatment approaches,” she said. “We are starting to really appreciate the role that emotions play in pain sensitivity.”
Both Karst and Speed noted that more study is needed to determine the sustainability of treatment effects.
Yarns agreed. “We need more research on what the appropriate dose is and perhaps how one might go about personalizing that for the patient,” he said.
The study was funded by a career development award to Yarns from the VA Clinical Science Research and Development Service. Yarns reported receiving grants from the US Department of Veterans Affairs during the study. Other authors’ disclosures are in the original article. Speed reported no conflicts.