Reframing the experience of pain, sometimes using apps, is one of the emerging holistic treatments often proving better than the traditional approach to chronic pain. By Nicky Pellegrino.
Giresh Kanji knows a lot about bad backs. He has been a musculoskeletal pain specialist for almost 20 years and has treated many injured and sore people over that time at practices in Wellington and Auckland. So, when he had an accident at the gym – Kanji was crushed by the 200kg he was leg-pressing – he knew exactly what he was facing.
Prior to that, he had been highly active, kayaking most days, playing hockey, cycling and crafting wooden furniture in his spare time. Now he was among the one in five New Zealanders suffering from persistent pain.
"I experienced back pain every day for two years," he says. "The pain was a six or seven out of 10, with pins and needles down the leg. And I was waking at 2am with severe pain."
As he searched for ways to ease his discomfort, Kanji started re-examining everything he understood about lower-back pain. He went through hundreds of medical articles to find the best way forward. In the process, he has developed a philosophy about the management of chronic pain that is focused not so much on the brain – as with most other modern approaches – but on the site of the initial damage.
Surgery should be used only as a last resort for spinal problems, he maintains. He's also wary of giving steroid injections for lower-back pain, advocating the more conservative option of decompression therapy (traction), instead.
The brain is a key player when it comes to pain. The body is full of millions of sensors whose job is to keep scanning for damage and let the brain know by triggering an electrical signal that travels to it through the nerves and up the spinal cord. The brain produces pain as a result. The way most painkilling drugs work is by interfering with those signals. Neuromodulation devices such as Tens (transcutaneous electrical nerve stimulation) machines operate on the similar principle of trying to scramble signals. Although this may be helpful in the short term, Kanji argues that fooling our brains isn't constructive over time. Instead, we need to focus on the basics of biomechanics.
"Pressure has a lot to do with pain," he says. "So if we reduce pressure, then maybe we can reduce pain."
The bones of the body are separated by what he describes as washers – discs in the spine and cartilage in the joints. When these washers are damaged, they become potential pain generators – up to 70 per cent of lower-back pain, for instance, is caused by problems with the discs. Loading up those discs by lifting something heavy or simply sitting still for too long (or even worse, leaning forwards over a screen) creates pressure. That leads to pain, and further deterioration, and then more pain.
"When someone with back pain lies down and they feel better, that's because they've unloaded the discs in their spine," says Kanji.
A scan of his spine showed that several of his discs were 80 per cent narrowed, putting pressure on the vertebrae. "I knew those discs needed to last me another 30 or 40 years. They weren't going to regenerate, so I needed to prevent them narrowing any more."
Having come across multiple trials that showed traction could reduce pain, Kanji invested in an inversion table and, two or three times a day, he hung at a 35- to 45- degree angle for five minutes or so.
"Over six months, my pain gradually got better. My pain has been absent for six years and I don't wake at night any more."
Kanji also bought a recliner chair and spends a lot of his relaxation time in it, watching TV or reading. Regretfully, he let go of his old hobbies, as they placed pressure on his spine.
"The best mechanism to reduce musculoskeletal pain is activity modification," he says. "So I sold my kayaks, sold the road bike, the rimu came out of the garage and I stopped a lot of the building work I used to do. Now I go to the gym four or five times a week to stay fit, but avoid any activity that loads my spine, so no dead lifts or squats, and no sitting too long with heavy weights."
Another scan six years down the track showed that Kanji's discs hadn't narrowed any further. Unloading his spine had not only reduced pain but also prevented the problem getting worse. He now takes the same behaviour-modification approach with patients, and finds most are willing to give it a go.
"I would counsel at least one or two patients a week, if not daily, about moving to an apartment from a lifestyle block," he says. "I don't sugar-coat things. I'm treating them for the rest of their lives, preserving their spines and reducing their pain for however many decades they have. Obviously, it depends on the state of the spine. If you don't have much disc narrowing, then you don't have to take such drastic measures, perhaps."
Chronic pain is defined as anything that goes on longer than three months. Recently, Kanji has been involved with the launch of an app, Pain Guru, to help people identify the source of their problem and deal with it more effectively. It can be difficult to locate pain generators in the lower back, as very often the pain volume builds and spreads away from the damaged site, reaching down the leg or upwards. Another complicating factor is that there can be more than one source.
"There are four major causes of lower-back pain," says Kanji. "The discs, the facet joints, the sacroiliac and the hip joints. Sometimes, people can have all four causes. For far too long we have purported a singular explanation for low-back pain such as, 'It's all in your muscles or discs,' and this has produced much confusion for patients."
With his patients, he uses MRI scans to take a detailed image of the spine and identify any injuries or wear and tear. Putting that information together with their symptoms and how they tend to load their joints, he is able to pinpoint what is going wrong and decide how best to manage it.
"MRI is extremely useful," says Kanji. "It gives you a warrant of fitness, a snapshot of your spine at a certain age so you can now learn to do what you need to for the rest of your life to preserve it. I take a very long-term view. If you're 50, how do you want to be when you're 80 or 90?"
For most spinal problems, surgery should be a last resort, says Kanji. Often it will solve a problem only in the short term and one surgery can end up leading to another.
"If you have disc problems on multiple levels, spinal-fusion surgery is unlikely to help. The remainder of the levels will become more painful in the future as they experience more pressure over time."
And although steroid injections are a common treatment for many forms of lower-back pain, the benefits are temporary and Kanji hardly ever offers them to patients these days – although he says there's a financial incentive to do so – because he is convinced that traction is a better option.
"Many health professionals dealing with back pain don't understand the role of pressure," he says.
Inversion therapy to decompress the spine and reduce pain is gentle, non-invasive and safe so long as you are free of medical conditions such as high blood pressure, heart disease or glaucoma. However, although there are plenty of anecdotal reports to say that it helps, the science behind it so far is mixed. There has been research to show it reduces the need for surgery in some people with thin, weak discs, but a 2013 Cochrane review found it no more effective than other approaches such as physiotherapy or exercise.
Sometimes, no matter what you do at the site of pain generation, chronic pain doesn't lessen. Even after an injury has healed, it continues because the nerves have become oversensitive and are sending warning signals to the brain without the sensors telling them to – like an alarm that keeps going off long after the danger has passed. The brain assumes there is an ongoing threat, so keeps on producing pain as a protective response. Eventually, the body is conditioned to feel pain. It becomes its new normal. This affects sleep, energy levels and the immune system and, not surprisingly for many, it also leads to anxiety and depression.
Mind over matter
Jim Barr's pain had been worsening over the course of a year. When acupuncture and osteopathy made no difference, he went for an MRI and it showed that a piece of bone on his spine had calcified and was pressing against a nerve.
"It was very debilitating," says the 74-year-old Wellingtonian. "I couldn't walk, couldn't lift things and it was painful enough to put me on the floor at times."
He had surgery to remove the bone spur and followed that with physiotherapy, but the pain persisted, continuing to make day-to-day life difficult. Then Barr came across the idea that how you think about your pain can change the way it feels. He chatted to a few people, did some reading and taught himself techniques to help his brain learn there was no need to keep creating pain sensations.
Some of what Barr did was visualisation-based. Rather than focusing on his pain, he would distract himself by thinking about his surgery, how it had been a success and how any residual pain would soon be going away.
"I stopped scanning my body for pain all the time, stopped thinking about it, accepted it was there," he says. "It had a dramatic effect. The pain has gone now, but even when it was there, it didn't feel like it mattered as much. Today, I walked up and down Brooklyn Hill. It was about 5000 steps, and I haven't been able to do that for a year. I had no pain from beginning to end."
The non-drug approach that Barr self-taught is the direction pain science has been heading for some time now. It is not that pain is "all in the mind", it's more that the brain is a tool that can be used to help control it.
There are various causes of persistent pain. Lower-back problems, arthritis, nerve damage, fibromyalgia and post-surgical pain are among the leaders. Using medications for the long haul is problematic both because of harmful side effects and the fact they tend not to help enough, anyway.
Pain's many pieces
Pain scientists now look at pain much like a pie or pizza, with lots of different pieces, and at specialist centres they take a multi-disciplinary approach, bringing together a range of clinicians – including occupational therapists, psychologists and physiotherapists – to help patients manage symptoms and regain quality of life.
Unfortunately, there are more people with chronic pain than there are pain centres and specialists. Accessing this sort of labour-intensive holistic treatment can be difficult and Māori, in particular, are struggling to get help despite having the highest rates of chronic pain.
Hemakumar Devan is a research fellow at the University of Otago and a physiotherapist at the Wellington Regional Pain Management Service. His focus is on making pain treatment more accessible. Partly, this means developing online tools for those who are stuck on waiting lists. A clinician-supported app called iSelf-help is being trialled. It is made up of 12 modules with short videos and animations, along with interactive sessions with a clinician and a peer-support person, so patients can learn about the mechanisms of pain and discover techniques such as cognitive reframing to alter the way they think about it.
"Pain is incredibly attention-seeking," says Devan. "When we teach these concepts to patients, they say, 'So, I have to work against my own body's response to overcome this?' The brain is so powerful, some of these responses are happening at a subconscious level, but the conscious brain is a problem solver and with training, it can help over time."
Pain is such a complex sensory response that even memories can fuel it. Australian pain researcher Lorimer Moseley tells a story about a patient who was a baker and had a hand amputated after it became trapped in an industrial bread maker. Afterwards, just the scent of fresh bread could trigger a bout of "phantom limb" pain. His solution was to stuff tissues up his nostrils and slowly expose himself to the smell until it no longer had that power to bring on a pain response.
"People have different strategies," says Devan. "Distraction is a good one, but anything that will take the attention away from the pain – hypnosis, mindfulness, music, art, work – is helpful."
Of course, learning how to move safely is also important. Some people tend to do more on pain-free days and then will pay for it afterwards. "We call this the boom/bust phenomenon and try to encourage patients to keep moving but avoid that crash," Devan says.
He is helping to set up a pain clinic at Kōkiri Marae in Lower Hutt and has been working with Māori to tailor an approach that will work there. He also hopes to adapt some of the resources that have been created for the app to set up a public-education website and to share the iSelf-help programme among other district health boards and physicians.
"Pain can't be fixed completely," he says. "It's hard for people to accept that. But there are so many tools they can try to help them lead the best possible life despite chronic pain."