Persistent Chronic Pain with Iyad Salloum

Mark: Hi, it's Mark from TLR. I'm here with Iyad Salloum of Insync Physio in Burnaby. He's the clinical director there, and we're going to talk about something that is a bit of a phantom really, persistent chronic pain. So can you actually have pain when the injuries were healed? 

Iyad: Yeah, that's a very good question, Mark. So persistent pain or chronic pain as some people call it is such an interesting and kind of broad term, right? Cause it describes like basically anybody who's had pain over a longer period of time, longer than three to six months. Depends on which definition you read. 

But I think the biggest thing I wanted to kind of clarify here is, what we know about pain now and the pain science has been growing every year, is that you don't necessarily need tissue damage to have pain. And that having tissue damage isn't enough to have pain. So those two things are quite interesting because historically we've always learned while you bumped your head, it's going to hurt.

It's because you just bumped it or you bruised the bone or you bruise the muscle or something like that. What we know now, pain is a large kind of protective response from our nervous system. And it makes sense right? So like historically speaking, if I broke my foot, I would want to rest it to the bones can heal. So that's what pain kind of access as a nice reminder for ourselves. 

But there are also cases where let's say, I don't know if you've ever broken a bone, but when you're in a cast after the first week or two, it stops hurting, but the bone is still healing. So the bone is still broken. So that's a great example of how you can have still a bit of tissue damage and it doesn't hurt anymore. Other cases are things like where you have a very minor stimulus that should hurt maybe only a little bit, but then it gets kind of magnified to such a bigger thing. And that's usually what we think of as a response, when a nervous system. 

So our nervous system is a great kind of computer in a way. It's a great processor. So every time we get a stimulus from our periphery or from anywhere, even from our internal organs, we can either choose to amplify it or kind of quiet it down. So one of the things I like to think of is that pain isn't always proportional to tissue damage. Could example paper cuts on your finger hurts so much more than somebody punching you in the shoulder.

Even though I would argue that the punch has a lot more potential to damage that. So what we see in the clinics sometimes is people who've had low back pain from a year ago. They go for a follow-up MRI or x-ray and nothing is there and it almost makes them more kind of confused and maybe sometimes angry because they're like, I swear it hurts. And then they get told a really kind of, I'd say a bad answer, which is that, oh, it's all in your head. Which is not really reasonable to kind of explain this, it's almost oversimplifying the science. You know, like all the pain is in the head cause our brain is the one thing the manufacturer's this thing.

So just saying that it's a bit kind of disrespectful and maybe a bit kind of to downplay their response. But basically what we ended up seeing there is that sometimes your nervous system learns to overprotect. So think of a car alarm, that now it goes off when the fly lands on it, instead of when you actually have a break in. So that's kind of what ends up happening in these cases.

Mark: So any ideas on possible causes other than just, Hey, you know, it's how we're wired. Some people are more wired to be sensitive to pain or in context, like some people, you know, maybe they feel it more than their teeth. 

Iyad: That's a great question. We think there's tons of causes actually. So one of them, we think definitely there's genetic components, but then some of it is learned, right. And then some of it is also centred around how our own beliefs and how our kind of expectations of things are. So for example, if you expect something to hurt. It can hurt more.

We have some interesting studies where they just flash lights a red light with warm water and the blue light with cold water. And then people get given the same kind of stimulus, which is the same temperature water with different lights and they report different stimuli. So that's a great example of how your nervous system can just modulator these things.

So some people, we don't know why specifically, this person goes down the persistent pain pathway, some people don't. But we have actually some decent data, that up to one in four can go down that way where the pain kind of lasts a little longer than you'd want it to. And when there's no more need to protect.

And the way we think of this now is based on our understanding is if you have more danger signals, in everything. And I'm talking about stress or sleep or diet, just general health lack of activity or too much activity. So this is the interesting one, where if you almost avoid too much you can actually become very sensitized to that movement or to that touch or to that whatever thing you're trying to avoid. 

Or there's the person who never really allows things to take their course and just tries to push a bit too hard. And then what happens is our nervous system goes through a response for it, they're like. I guess in layman's terms would be like, I don't think this guy's getting it. I'm going to need to crack this pain level up a bit more so that, you know, they can kind of pay a bit more attention to me and allow me to recover. But the problem is you kind of get stuck in this kind of cycle and in either way where you're either avoiding too much or you're pushing too much into it. And you're kind of none the wiser in that case. 

So treating those cases is very interesting because the, I guess the first thing we try to do and we have some excellent therapists at Burnaby, like Elizabeth, our physio has worked extensively in this area. You kind of want to take a big inventory of the person's health in a way.

You look at everything from their habits, to their diet and their sleep to their activity, to their own beliefs. And yeah, the physio is not going to be a counsellor, a dietician and a therapist at the same time. But what they ended up doing is you've identified these issues and then you can kind of get them the help they need based on working with the team.

And that's kind of what the most successful pain programs we'll do is we'll kind of integrate a good team response, but then fundamentally it seems still that movement still pretty important. You know, so we kind of help people move. Sometimes it's just move differently so that they don't do the same repeated strategy. And sometimes it's just to move. Cause some people just don't do that enough after they've been injured. And that's a cause of that kind of going down that chronic route. 

Mark: So, if you need to get moving again, you've chilled out. You've meditated your way. You've seen the therapist, you've done all the other steps and you still hurting, maybe you need to move a little more. Get a physiotherapist to help you, insyncphysio.com. You can book an appointment there, or you can call them in Burnaby, 604-298-4878 or in Vancouver on Cambie, 604-566-9716. Get in and get some help and get moving again. It will help with your pain. Thanks Iyad. 

Iyad: Thanks Mark.