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Four Perspectives: Chronic Pain and Inflammation Part 1

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Four Perspectives: Chronic Pain and Inflammation Part 1

Chronic pain affects more that 3.6 million Australians and is a leading cause of disability Up to 68% of people who suffer from chronic pain are of working age, with 40% of those retiring early due to this pain. It is ubiquitous in our current health landscape and is a difficult task to manage without the tools and knowledge in understanding both the mechanisms of action and the symptoms surrounding chronic pain and inflammation, alongside managing your patient’s preconceptions, expectations and results on their pain journey. 

Professor Lesley Braun is joined by our four Ambassadors to gain their four modality-specific perspectives on chronic pain and inflammation. In part one Dr. Adrian Lopresti describes the bi-directional relationship between chronic pain and mental health. Emma Sutherland helps us understand the fragility of these patient’s and how to skilfully work with them. Lisa Costa-Bir’s naturopathic perspective brings us back to square one – Tolle causam – where she focuses on understanding the root cause, and Dr. Michelle Woolhouse takes us through the role of inflammation and the markers she uses to when treating patients who are chronically inflamed and in pain. 


Covered in this episode

[00:50] Welcoming the Ambassadors and introducing today’s topic
[03:25] Understanding the purpose and origins of pain
[05:59] Timeframes for resolving acute and chronic pain
[08:08] Neuropathic pain and why it’s different
[09:11] understanding pain from a naturopathic perspective
[10:32] When pain presents in other ways
[13:46] How to talk to the patient who has tried everything but is still in pain
[15:30] Connections between pain perception and mental health
[18:08] Effects of pain on anxiety and lifestyle
[20:49] The role of inflammation in pain
[24:08] pathology and functional testing
[28:40] resolving inflammation vs reducing inflammation
[30:12] Risks associated with untreated pain and inflammation
[32:27] Exploring stigmas of pain and unseen chronic conditions
[36:07] Loneliness is connected to poor health and increased inflammation 
[38:12] Reframing  our perceptions of pain
[40:44] Thanking the ambassadors and closing remarks

Key takeaways

  • Defining pain: it’s an unpleasant sensory event, associated with emotion and can occur with tissue damage or the potential of tissue damage.  
  • Acute VS chronic pain. Acute pain occurs and resolves quickly through the natural process of healing and local damage can be repaired to return the damaged tissue to normal function. Chronic pain, on the other hand, is typically pain persisting for 3 months or more. Local damage may be present but there are also structural changes within the brain and nervous system which has significant effects on one’s perception of pain.  
  • Understanding and addressing the umbrella of associated symptoms that can sit alongside chronic pain (beyond the pain itself), are pivotal to your patient’s health than just the pain itself. 
  • Watch out for patients who have normalised chronic pain, where they’ve “learnt to live with it”, and may not be coming to you for pain. If it’s something that interferes with daily life, has an impact on mental health, they have a perpetual fear of undertaking everyday tasks because it worsens their pain –investigating chronic pain and inflammation deserves attention. 
  • Emotional support is foundational to treating chronic pain and inflammation. These patients are not only treatment fatigued but may also feel stigmatised. They have an increased risk of depression and anxiety and may socially isolate themselves- all of which exacerbate the perception of pain. 
  • Lifestyle factors that have major impacts on pain perception are sleep and diet. Breaking the cycle of poor sleep supports resolution of many of the dysregulated aspects of the nervous when chronic pain and inflammation are present. Additionally, an anti-inflammatory diet not only helps to reduce exposure to triggering compounds but also provides the body with the necessary nutrients to calm and heal. 
  • Tracking anti-inflammatory markers and using motivational techniques can aid treatment and support it moving in the right direction. Ferritin, C-reactive protein, hsCRP, ESR, cholesterol, uric acid and LFT’s can be markers for managing chronic inflammation.  
  • Not only do biomarkers motivate change but words also have therapeutic power – retrospective reflection with patients on their symptoms and comparing these to their current symptoms (no matter how small an improvement) also supports with improving health. 
  • A major barrier to patients managing chronic pain is cost – target not only the symptoms and the root cause but also focus on cost-effectiveness. 

Research and additional resources

National Pain Week Survey Results 2022 (Chronic Pain Australia)
Research: Chronic pain and suicide risk: A comprehensive review (Progress in Neuro-Psychopharmacology and Biological Psychiatry, 2018)
Research: Altered physical pain processing in different psychiatric conditions (Neuroscience & Biobehavioral Reviews, 2022)
Research: Good Sleep Quality Improves the Relationship Between Pain and Depression Among Individuals With Chronic Pain (Front. Psychol., 2021)
Research: Chronic opioid use and complication risks in women with endometriosis: A cohort study in US administrative claims (Pharmacoepidemiol Drug Saf., 2021)

Scales and Questionnaires  

Depression, Anxiety and Stress Scale (DAAS-21)
The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
Pain Catastrophising Scale
Pain Self-Efficacy Questionnaire


Lesley: Hi. This is FX Medicine, bringing you the latest in evidence-based, integrative, functional, and complementary medicine. 

I begin today by acknowledging the traditional custodians of the land on which we gather and pay my respects to their elders, past and present. I extend that respect to Aboriginal and Torres Strait Islander peoples here today and wherever you are listening from. 

I'm Professor Lesley Braun, Director of Blackmores Institute and editor-in-chief of FX Medicine. Welcome to part one of our two-part series on chronic pain and inflammation.

Today, I'm going to be talking with our four FX Medicine ambassadors, Dr. Adrian Lopresti, who's going to offer his thoughts as a psychologist and a renowned herbal medicine researcher; Emma Sutherland, who brings an important naturopathic understanding of pain and inflammation; Lisa Costa-Bir, who's going to add her naturopathic views as well on acute and chronic inflammation; and finally, Dr. Michelle Woolhouse, who brings in perspectives from an integrative GP. 

Hi, everybody.

Emma: Hi, Lesley.

Michelle: Hello, Lesley.

Lisa: Hi, Lesley. Hi, everyone.

Adrian: Hi, Lesley.

Lesley: So, the focus of this discussion is on chronic pain and associated inflammation. And the reason for this is because chronic pain affects more than 3.6 million Australians. It is a leading cause of disability, and we know from the research that up to 68% of people who suffer with chronic pain are of working age, with a whopping 40% of people with chronic pain retire early because of that pain. 

To do this enormous topic justice, we are going to break this topic down into a two-part series. So, in part one, we are going to focus on the landscape of pain and inflammation, identify why it's important to understand all these different perspectives so that we can start to put in place a better understanding and, ideally, a holistic approach forward. And in part two, we are going to dive deeper into some of the more common conditions associated with pain and inflammation, but also discuss management using natural medicines to both reduce and resolve pain and inflammation. We're also going to be discussing the emerging concept of resolving inflammation, not just reducing inflammation, which is very much a move away from the way that we've often been looking at things.

In 2020, a staggering $49.74 billion were lost due to reduced productivity, and these statistics don't even speak about its impact on an individual's mental health and well-being, as well as obviously their family and workplace.

First of all, I'm going to start talking to Michelle. Good morning, Michelle.

Michelle: Good morning.

Lesley: Now, we know not all pain is the same. Can you tell us a bit about the different types of pain? What's the purpose of pain, if it provides any purpose at all, and what are the underlying mechanisms in the body that result in pain?

Michelle: So, pain is essentially a part of the human condition. There's not one human life that hasn't experienced pain. And it's really important to start with the definition of pain. So, it's an unpleasant sensory and emotional experience associated with actual or potential tissue damage. And it's really important to understand that pain is both a sensory and an emotional experience because that actually dictates how we approach pain. So, it originates in the nerve receptors, called nociceptors, in and under the skin. And they're located also in tendons and ligaments and bone and all throughout the body, even in the viscera as well. So, it is influenced by a complex interaction of behavioural and environmental and biological and societal factors as well. So, it's a really complex experience for the human being.

And you can get acute pain and chronic pain. So acute pain comes on quickly and is often resolved quickly through the natural healing processes of the body, whereas chronic pain is actually... It's been studied a lot over the last decade in a really new and exciting way now that we know a lot more about neuroplasticity. Chronic pain actually causes structural changes within the brain. And that's really important because the perception of pain then becomes a maladaptive experience. And that's really different to acute pain, and so, therefore, has a really different approach.

We can also break down pain into where it's located in the body. So, you can have things like visceral pain. And visceral pain is obviously associated in the midline where the viscera is. But visceral pain's different because it's actually really quite vague and it's not exact. When you injure an ankle or you roll an ankle, the pain is located to the injury, where in visceral pain, it's actually quite vague and can transfer into different parts. And so it's a lot more, I guess, slippery to diagnose, whereas something like a structural somatic pain like a rolled ankle is a lot more localised. So, that's a little bit about how we define and how we break down pain as a general rule.

Lesley: So, Michelle, I know you talked about acute and chronic pain. Can you give us a timeframe? For example, with acute pain, it comes on quickly. How quickly would we expect it to resolve compared to chronic pain?

Michelle: Yeah, it's a really good question. It depends on where it is and what the actual injury is, but they define it as what is expected to be normal healing time. So, for example, let's bring it back to, say, a rolled ankle or a broken bone, there's a certain time period that that occurs over. So, let's say a swollen ankle or a really significant strain takes about six weeks. And so you would be starting to get into a chronic pain process if that wasn't healed by about the three-month mark. Likewise, with a bone, that would take a little bit longer. So, chronic pain would be associated after the expected time period of that healing would occur. And let's say you had a simpler injury, so a ligament strain, for example, or a mild strain, then acute pain would, say, be within the three-week mark, and then post that would end up being more unusual and outside the parameters of what we would expect healing to be. 

But always, in medicine, we use the three-month mark. There usually is a lot of healing that goes on within that acute phase into that first 12 weeks of the injury or the event, and then any time after that would be considered chronic.

Lesley: Great. So, I'm assuming acute pain might also be a headache or a migraine, which are just acute episodes. They start, they stop, and that's the end of it.

Michelle: Yeah, absolutely. And things like abdominal pain or an episode of irritable bowel syndrome or gallstones. There's a lot of ways that the body expresses pain and a lot of reasons for why the body will express pain. But essentially, pain is a symbol to stop and take heed and listen to the body. And I think that's really important because we live in a community that tends to... We minimise things like that and we tend to push on, so there's a lot of aspects of "Just take a painkiller and keep pushing on," whereas I think if we can change that to really respond to pain and really listen to pain, we can get a lot from it.

Lesley: Michelle, I've also heard about neuropathic pain, which seems like a completely different beast again, and people really complain. This is a hard one. Can you tell us a bit about that?

Michelle: Yeah. Neuropathic pain is probably considered to be the most severe of pain, and it occurs when there's a sensitivity or a damage to the nerve endings. And people experience it differently. So, it's often a very, very emotionally debilitating pain. It's often a throbbing, can be a sharp pain, but it's often unrelenting. And it's different from the other pain. It's less understood almost and it can be very difficult to treat because of that hypersensitivity of the nerve endings. And it often takes a longer time to calm down just because the nervous system and the nerves actually heal much more slowly as opposed to, say, tendons and soft tissues.

Lesley: Yeah. That makes a lot of sense actually. When you talk to people with neuropathic pain, it really does seem very debilitating and it lasts a long time. 

I want to ask, Lisa, from a naturopath's perspective of pain, because I'm assuming you'd have people coming in with lots of different things, and chronic pain and inflammation might be a feature of that, how do we understand this from that perspective?

Lisa: Sure. So, naturopathically, we see pain as a disturbance of the patient's vital force. And even though disturbance could be seen as a negative thing, as Michelle was saying, pain and inflammation are really a sign, a means of communication by the body that something's not quite right and we need to understand those underlying drivers a little bit better. So, if we go back to the naturopathic principle of tolle causam, treat and identify the underlying cause, that's what naturopathy is all about when it comes to pain and inflammation.

Yes, like allopathic medicine, we are going to manage the symptoms and the pain, but we also want to really understand where it's coming from and the things that have contributed. So, for example, if someone comes in and they've got a chronic menstrual migraine, yes, I'm going to probably suggest pain relief throughout the cycle where it's hitting, but I'm also going to be looking at diet, lifestyle, stress, and all the other things that could be contributing to that pain and inflammation and that chronic migraine.

Lesley: Look, it makes a lot of sense to me that you're wanting to help people with these symptoms so they feel better quickly, they feel better, but to really get to the bottom of it is that long-term approach, isn't it?

Lisa: Yes, definitely.

Lesley: Yeah. Great. Thank you. 

Now, Michelle, from a GP's perspective, how would a patient with chronic pain show up? What would you be seeing? What would you look for? What are they telling you, and what are those signs and symptoms that tell you, "Yeah, this is a chronic pain situation. I need to look at it differently?"

Michelle: Yeah, it's a good question. People will often come, and sometimes they don't even present with chronic pain, they might come for another different reason, but in fact, they've normalised their chronic pain as something that they've lived with. 

Let's take the thing of lower back pain. That's probably one of the most common causes of chronic pain. And what happens is it's a very cyclical experience and it often interferes with their mental health and their activities of daily living. So, chronic pain is something that people generally live with, but it affects their general functioning on such a huge level. It's very difficult to live with chronic pain, and it has a physiological effect on the body.

So, they present often with a sense of lacking apathy and motivation because the chronic pain tends to wear their mental state down. They may present with depression. And obviously, they talk about the pain and the limitations that they experience from that. But often, chronic pain comes alongside fear as well. So, this is often fear that if they continue to do their activities of daily living, that they're actually making the causation of the pain worse. And there's a lot of confusion and shame around chronic pain because it's an invisible symptom for lots of other people. And people experience it like, "Well, how come you don't get better? I had a sore back and mine's better and now I'm doing everything else. Why can't you get better?"

And things like chronic pain, like you mentioned migraine before, that's often debilitating. And endometriosis, it's very cyclical, particularly if the migraine is associated with the menstrual cycle. So, they might be every month or every second month getting a debilitating pain experience. And that is very emotional and very socially unaccepted in many ways, and that creates a complication on the actual pain experience itself.

Lesley: Look, thanks for that. It's interesting that you mentioned that people with chronic pain don't always know they've got that. I was at a yoga retreat talking to one of the lovely ladies over there, and she was telling me how she didn't realise she had chronic pain over a period of time. She just started drinking more alcohol, and she was using that. And she didn't realise that, in fact, underlying all of that was chronic pain. And it wasn't until she went to her GP, because her drinking was getting a little bit out of control, that the GP picked up that actually it was chronic pain. And once she had that managed, so many things fell into place for her, and she just hadn't recognised it, and like you say, started to just live with it and thought, "Well, that's just my normal," as opposed to the fact it doesn't need to be your normal either.

Michelle: Yeah, absolutely right. You see it all the time. People normalise difficult situations when they feel disempowered. They don't know what to do. It's become a chronic cycle for them. And that's a challenge to the clinician to really inspire them and motivate them, but also to support them very gently in their experience out of that particular phase or problem that they've got.

Lesley: Yeah. I want to ask Emma, in your naturopathic practice, you're also very busy. I'm sure you see people who've been everywhere and tried everything, and what do you do? How do you talk to them about it? How do you understand that?

Emma: Look, I think in naturopathic practice, we do tend to see patients where their chronicity is even more extended because they've often seen so many practitioners before they've come to see us. And they might have spent hours and hours researching as well. They're quite savvy often on what's going on in their body because of the duration of their pain. But we've also got to understand that these patients are often treatment fatigued and they're very vulnerable. And so by the time they actually get to us, there is a level of fragility about them, physically, mentally, emotionally, that we really have to be aware of. And the importance of us really collaborating well and getting that safety net in place for them is absolutely critical in order for them to heal in the long term. So, I think our position in that is really important.

Lesley: I think it also lends to what Michelle was talking about, how for some people with chronic pain, there can be almost a little bit of a shame associated with it, that how come they haven't gotten better? They've done all the right things, they've seen all the right people, and it's still not working.

Emma: Yeah. And when they see us, they're hopeful that we can help them, of course, but they're also very fearful because of the treatment failure that they've had to experience. So, being able to inspire hope in them but being realistic is a fine line that we have to be very aware of as well.

Lesley: Yes. Now, I wanted to talk to Adrian because Adrian's been doing a lot of research in the area, but before we go into anything like that, I want to talk a bit more about the link between the mind and the body, because I know there's been a lot of work done on perception and pain and then how that manifests in the body and that whole cycle in there. And I can only imagine that with chronic pain it'd have to influence a person's mental health, it would be affecting their sleep, I'd assume, their mood, all of these things. So, Adrian, can you tell us a little bit about that effect of mindset and attitude on pain and also all the things that come with that?

Adrian: Yeah, certainly, Lesley. There's fascinating research about the relationship between pain and perception and mental health. And really, the research shows that there's a bidirectional relationship between chronic pain and mental health, for example. So, we know that having chronic pain increases your risk of developing depression and anxiety. And the reverse also occurs that having depression or anxiety, for example, will then impact on how you perceive chronic pain. So, we know that people who have chronic pain, some of the research shows that chronic pain is associated with 80% increased risk of depression and it's associated with an almost 90% increased risk of recent suicide attempts. So, really affects how people feel and their emotional coping. So, obviously, chronic pain decreases a lot your quality of life, it decreases your work function, you're more likely to utilise healthcare, and so forth.

So, that's really important, that chronic pain then has an impact on our mental functioning, but also our mental functioning also affects how we feel from a chronic pain perspective. So, certainly, if we are depressed or anxious, there's a greater increase of pain reports, and how we interpret pain is different. And there's also research around something called pain catastrophising. So, people who have depression or anxiety have an increased risk of being pain catastrophisers. And basically, what that means is where they have magnified the pain, they're associated with more rumination or obsessive thinking about the pain, they have more helplessness about the pain.
So, that's really important for practitioners just to be aware that if they're seeing somebody, are they a pain catastrophiser? And then maybe that really needs to be targeted as part of the intervention because somebody who's high on pain catastrophising, it's a prognostic factor for how they cope over time. So, I encourage people to really think about that. And there's a questionnaire called the Pain Catastrophising Questionnaire that's such a simple 13-item questionnaire that people can give to people to just really assess where they are from a pain catastrophising point of view.

Lesley: That's fascinating. I can only imagine that if you're not sleeping well, your mood's getting affected, you've got the chronic pain issues, that ultimately, like you say, you become less productive, that starts to affect your self-worth as well, and then you've got this catastrophising of pain, which would probably become all consuming. What would that look like, Adrian?

Adrian: Yeah, there's the constant...you're waking up, you're constantly thinking about the pain, you're worried about whether it's ever going to get better, and your prediction is you're not sure...obviously, you're not sure. When it comes to chronic pain, you don't know when it's going to get better. And with somebody with anxiety, for example, uncertainty is something that actually feeds anxiety. So, when you have something that you're just uncertain about, it's been six months now and the pain's still there, then that just feeds the anxiety. Then it leads to a whole range of behaviours. Do they then go onto Dr. Google and search what's going on? Do they go onto forums with chronic pain sufferers? And then there's a whole bunch of people there who are probably pain catastrophisers. So, talking to people on these forums might then feed the pain catastrophising.

And then you've just got the sense that even when you're feeling anxious and stressed, that impacts on how you feel the pain, and in actual fact, the pain becomes worse. The reality is that having anxiety impacts on centres in the brain that are also associated with pain. And so that then also exacerbates things. And then you've got your whole range of other behaviours that are linked with depression and anxiety like less engagement in pleasurable activities. So, you have stopped doing that and now you're again focusing on the pain. You socialise less, your diet might change and you might eat more inflammatory foods, then that also exacerbates the pain. So, as I said, there's that bidirectional relationship.

And then when you look at sleep, that's another factor that's going on. And obviously, if you have pain, you're more likely to have disturbances in your sleep. But also, the other occurs is if your sleep is poor, it's going to affect your pain. And some of the research actually shows that basically, yes, chronic pain affects your sleep, but actually, the reverse is actually worse, that sleep affects pain more than pain affects sleep.

Lesley: Wow.

Adrian: So, again, when we're seeing somebody, what is their sleep like? And maybe part of the intervention for chronic pain management is working on their sleep.

Lesley: That's so interesting because what you've just described is I guess this cycle that just keeps feeding off each other. And where do you intercept? What parts of the cycle do you intercept at to start breaking it down? And I think sleep, I mean, we know sleep is a mental health superpower really in so many ways, but it seems for pain as well. 

Emma, to get on top of this, to try and break this cycle, let's just dive a little deeper into what's happening within the tissues and in the body. Can you tell us about the role of inflammation? And obviously, we're talking about inflammation in relation to chronic pain. I know it can be beneficial sometimes, but it can also be unproductive. Can you tell us a bit about that? And what are those cardinal signs of inflammation which might be useful, might not be useful, in chronic inflammation?

Emma: Yeah, this is really interesting, Lesley, because I think, no matter what's caused the pain, whether it's an infection, an injury, an autoimmune response, you've got a release of pro-inflammatory cytokines, and that results in the five cardinal signs of inflammation. And this type of inflammation is beneficial. It's a critical part of the healing process.

So, first, we have pain, as Michelle mentioned. Those inflammatory chemicals stimulate the nerve endings causing those areas to feel more sensitive. Next, you've got heat coming in due to the increased blood flow to the area. Then there's redness which occurs as the blood vessels dilate. And then swelling and oedema results from fluid that accumulates in the area as the leukocytes and macrophages are recruited in this inflammatory process. So, the swelling additionally presses on the nerves which exacerbates the pain sensations. And then, finally, there can be a loss of function completely. So, this situation of pain and redness, heat, swelling, loss of function is a protective mechanism and, ultimately, it aims to heal that acute injury or infection. And that kind of inflammation is fast, it's heightened, and it's acute. 

But conversely, when is pain unproductive? Well, in chronic inflammation, which, on the other hand, it's much slower, it's more insidious, and I feel very underestimated by us as clinicians and the patients themselves. If that initial inflammatory response isn't turned off, then healthy cells can start to become collateral damage. And in these cases, instead of moving in, healing the problem, and returning to normal, the inflammation persists over time. And we see this in conditions like rheumatoid arthritis, asthma, inflammatory bowel disease.

And we also think of this concept of chronic metabolic inflammation, or metaflammation, which is that low-grade chronic systemic inflammation. And I think of it as the opposite of acute inflammation. And this is the kind of inflammation we see with non-alcoholic fatty liver disease, with diabetes and cardiovascular disease. So, there are many drivers for this type of chronic inflammation. The most common can be our diet. High intake of fats, sugars, alcohol, that are very common in the Australian diet. Our gut microbiota can also be skewed towards a more pro-inflammatory profile. And also, our state of Omega-3s. Where are we with that? All of these factors can drive that chronic inflammation.

Lesley: It sounds like there's a lot of factors at play here. And I really found it very interesting how you talked about how there are points where inflammation is actually very important to help with the healing process, but gone too far, left unchecked, you get all that collateral damage of tissues that were never involved.

Emma: Exactly. That's right.

Lesley: Michelle, when a patient comes to see you and you understand that they might have chronic pain and inflammation, obviously, you take a history, they explain their symptoms to you, but are there actual tests that you can use, whether they're subjective/objective tests to help you understand where a patient is and possibly even track their progress over time?

Michelle: Great question because, wouldn't it be fabulous if we could just have one test that tested for it and then watch it get better? But it's a little bit more complicated than that, and it also depends upon the underlying cause of the pain. What I think a lot of patients fail to recognise is the role of the anti-inflammatory markers that we can look for within the body. And often, they don't rise that high in chronic inflammation. Certainly, in acute inflammation, they do rise. If you've got an acute process going on, something like a pneumonia or a significant injury, an inflammatory bowel disease process, you are going to see a rise in things like ferritin and C-reactive protein and the ESR. And they can rise quite significantly.

So, for example, in a pneumonia, you can see the CRP being 300, even I've seen it at 800 and 1200 over time. So, that's a dramatic impact on the body, and you can see the body is inflaming in which to protect itself. But in chronic inflammation, we don't see so much of a rise. We now have a test called High-sensitive-CRP, which we can see it rise a little bit more subtly in chronic inflammation. We can watch that decrease over time. But the amounts of inflammation that you see is not as much as we would like. It's not as simple as that.

But certainly, testing for ESR, CRP, ferritin can be important. And then obviously testing for the underlying causes that may be at play. So, looking at the digestive health, or if it's an abdominal problem, you may need a CT or an ultrasound which to elucidate what is actually going on. Certainly, other things like cholesterol and uric acid and liver function tests can also indicate, in a very subtle way, some of the underlying drivers that may be at play. And so they can be fantastic tests to look at long-term over time.

And just picking up on Emma's point on the metabolic inflammation, looking at the health of the metabolism can be critical to look at chronic inflammatory responses. But then there's also even beyond testing is actually looking at the conditioning of the body. So, how much fat people have got, abdominal and visceral fat, even waist circumference, blood pressure, they can be really great keys in which to look at overall health long term. So, testing them pre and post-intervention can sometimes be great to watch the markers of health come back as you work to decrease chronic inflammation. 

Lesley: And Michelle, are there any validated surveys? Because, for example, I'm thinking about what Adrian said before about how chronic pain can affect mood. And we know there's a lot of validated surveys that can pick up mood changes over time. Is there something similar in chronic pain?

Michelle: I don't use one per se, but certainly looking at the other mental health aspects or overall health aspects. So, the DASS looks at depression, anxiety, and stress overall. That can be a really good one. You can also look at validated questionnaires about quality of life and well-being. So, that can often be impacted by chronic inflammation and chronic pain as well. So, looking broadly at your patient and what they're experiencing and how they're living their life.

What I'll often do is rather than validated questionnaires, is really look at full history and doing a full examination. We'll sometimes go back to those original consultations and use the person's exact language, as in, "I can't do this and I can't do that. And it's constant and it's all the time." And then when you play that back to them, they're like, "Oh, it's actually not as constant," and, "Oh, I can do that." And that can be a nice personalised way of reflecting back to them the benefits that they've experienced when they engage in treatment and, hopefully, get better from the treatment they're receiving.

Lesley: I'd imagine those quality of life indicators, so, there's one thing to assess for pain and inflammation, but how does it affect their daily life? Can they still do what they want to do? So, those quals would be really helpful in rounding that out, and I think they're used a bit in naturopathic practice as well just to round out the picture.

Now, Lisa, we've all been taught about the importance of inflammation and reducing inflammation when it's not useful and not beneficial, but there's been an emerging focus and some more research coming through on the resolution of inflammation. And this is really interesting because resolving inflammation compared to reducing inflammation is a really different way of looking at things. Can you tell us a bit more about that?

Lisa: It is different, and I think, as practitioners, when we think we are reducing inflammation and we're implementing anti-inflammatory protocols with diet and supplements and things like that, we assume that we are going to be resolving inflammation when we are reducing it. But actually, they are two distinct things. So, when we see problems with resolving inflammation, we see that the person gets stuck in this chronic pain cycle, and this can happen where the pathways involved with reducing inflammation become blunted and then the inflammation is not actually being resolved.

Lesley: Okay. And in practice, I'm assuming that you'd look at them a little bit differently, too?

Lisa: Yes. So, typically, I think we've all had the patient where they've got a chronic pain condition, such as a rheumatoid arthritis, and we are doing all the anti-inflammatory things and they're getting better, but it's not actually resolving. And so that's when we want to start implementing different things that assist with resolution of that inflammation.

Lesley: Right. I know, in part two, we're going to talk a lot more about what they are. Fabulous. 

Okay. Emma, so we've talked about chronic pain and inflammation that lasts a long time, it seems to affect people's ability to live the life they want. What are those risks associated with untreated pain and inflammation?

Emma: They're incredibly shocking. As you said, 3.6 million Australians suffer from chronic pain. There's robust evidence that people with chronic pain are at least twice as likely to report suicidal behaviours. I want to just draw down and look at a study. This was absolutely fascinating. It was conducted by Chronic Pain Australia, and it really demonstrates that, unfortunately, there continues to be a lack of awareness surrounding the issues associated with chronic pain. And up to 75% of the respondents said that cost, so finances, really prevent them from accessing health professionals and specialists. So, for one, there's actually the financial cost, which is huge.

And another one to think about is that that same survey found that 22% of respondents were forced to reduce their opioid dosage due to the 2020 Opioid Reforms. They're a good thing, but in other ways, patients have really suffered. So, 29% of respondents said their GPs had put them on antidepressants instead, 11% on sedatives as a substitute for their pain relief. And when you're looking at a 2021 paper on chronic opioid use in women with endometriosis, it concluded that women with endo were four times higher risk for opioid use compared to women without endometriosis. So, I think we have many issues related to chronic pain, financial, emotional, addictions. I think, yeah, we are really underestimating how impactful this is.

Lesley: First of all, that number is shocking in itself, just how many people are dealing with this, and obviously their family will be affected as well, their workplace. So, it's affecting millions of people. But the other thing that I thought was interesting is when you talked about underdosing. And whatever it is, if you're not taking a therapeutic dose, you are actually wasting your time and your money. And so underdosing is worse. You think it's working, but it's just doing nothing. It's wasting your time. That's really important and quite shocking actually.

Michelle, I've heard that...and, in fact, you mentioned this earlier, the stigma about pain and inflammation and how some people feel like they've dropped the ball or something is really wrong with them because they didn't resolve their pain like say their friend did who had something similar. Do you see much of that? And what do you tell people?

Michelle: Oh, I see it all the time. I think stigma is a huge issue in medicine across the board in many, many ways for most chronic diseases or mental health issue or chronic pain because there's a lot of invisibility in it. And it's very real and it's very significant in people's lives, yet, as a society, we don't accept it as real. And it does lead to, the other hosts have mentioned, too, poor self-esteem, poor sleep, underemployment or unemployment. And that has huge impacts, you mentioned, too, Lesley, on sense of self and self-worth.

And I think what is really important to understand here is that the risk of developing chronic pain is higher in people with a trauma history. And whether that's a significant trauma from a motor vehicle accident or event such as a major disaster, natural disaster, or an abusive childhood, or something like that in the past is that you are much more at risk of developing chronic pain, and even you are more at risk of having a motor vehicle accident as well, which is interesting because it comes full circle.

And then there's a stigma around opioid medication. Because if we don't dose effectively, we are wasting our time and money. But also, sometimes the dosing required to manage the chronic pain, in fact, impacts mental functioning as well and the ability to develop relationships and cognitive processing and mental clarity. And so there's a stigma around about that as well. So, it just is a chicken and the egg. And then often, sometimes, too, the stigma around often with chronic pain, we get weight gain and inability to exercise and to be active and support our metabolic health in a different fashion. And so that leads to body image issues and the problems associated with obesity that go along with that and deconditioning.

And so I see it a lot, and I think Adrian mentioned it too, is looking at ways in which we can take a holistic view to chronic pain. So, there's often looking at the underlying drivers of it, but supporting somebody's mental resilience and looking at explaining people's propensities and skillset as a way of encouraging responsibility rather than blame. And so we don't want to add to that stigma and that blaming aspect of that chronic pain. Rather, we want to offer an explanation of that so people can feel empowered by developing new skill sets with regards to chronic pain. And that seems to be where the research is heading because of the neuro-structural changes that occur through chronic pain at a brain level. And so we want to really target the nervous system, almost to befriend it, so that we can develop new skill sets to manage chronic pain long term.

Lesley: It's interesting when I hear you speak about this, about the stigma about pain and inflammation or the fact that people don't tend to recognise and understand it, hide it, it reminds me a lot of mental health. If you can't see it, people don't recognise it, they may not take it seriously. For some people, there's still a stigma. It seems to fall into a similar category. And so that's why I found what Adrian said earlier very interesting about how there's such a crossover over time.

But I'm going to shift to talk to Lisa now because we've mentioned the holistic approach, and I think this is where we're all heading. We know there's no silver bullet here. We've described how it is complex. So, taking a holistic approach, looking at lifestyle factors, obviously dietary factors that are going to help a person who might be out of balance in all of those ways is going to be important. And I think the other thing is just thinking about that  mental health link and loneliness, and people almost taking themselves out of society for all of these different reasons because they can't, they won't, they don't want to, for all of these other things that we've talked about. Can you share with us also that potential role of loneliness, which falls into that lifestyle factor which could probably, well, I would imagine have a big impact?

Lisa: Absolutely. Well, we know that loneliness is associated with poorer health outcomes. And we know, based on the research, that people that feel lonely and socially isolated, they actually have higher levels of inflammation, so high levels of tumour necrosis factor-alpha, interleukin-6, than people who feel...

Lesley: Connected.

Lisa: ...they're connected. Exactly. So, essentially, what happens is that feeling lonely is a stress response, really. You are going to see release of stress hormones. And we know that the immune cells have receptors for stress hormones on them. So, when we're in that fight or flight all the time and feeling lonely, the immune cells actually change and increase inflammation in that way. We also see that loneliness, or the perception of loneliness, decreases expression of anti-inflammatory genes and upregulates expression of genes that increase inflammation. So, it's very, very interesting. And I think as practitioners, we do need to ask patients about their social support, how they're feeling about life. Because we know that people can have lots of friends and have lots of connections but not necessarily feel connected and supported.

Lesley: That is fascinating. So, feeling lonely has an effect on what happens with your genes.

Lisa: Yes. It's so interesting.

Lesley: And the fact that there's a link, it's been proven, that they're connected.

Lisa: Yeah.

Lesley: Well, we're going to have to move to Adrian now, okay, as our psychologist. There's been a lot of work taken to reframe pain. I remember starting to hear about the reframing of pain as being almost one of the therapies that can be very helpful for people. So, Adrian, can you tell us a bit more about the role of reframing?

Adrian: Yeah, certainly. All of us have mentioned that how we perceive the pain is going to affect the impact the pain has on us. And the reality is that, for some people, they perceive pain differently to others. Even if I think about myself, and this is acute pain, but if I go to the gym and I can't walk the next day, I see that pain as a very positive thing. I'm in pain, it's hurting, I can't walk, but I see that as a very positive thing.

Lesley: Yeah. You worked hard, didn't you?

Adrian: Exactly.

Lesley: You worked hard.

Adrian: However, if I go to the dentist, I don't see that pain as very positive, unfortunately, even though it might be quite therapeutic in the long term. So, how we perceive pain, really important. And if we can help people change the way they view the pain... But we need to be very careful about how we do that because, obviously, we don't want to dismiss the pain. We need to be very empathic, and all those factors are really, really important in how we do it. But I mentioned earlier about pain catastrophising. So, that's a perception. So, if we can modify how they view that pain from a catastrophising point of view, that's going to have a really positive impact. The pain won't feel as bad if that's the case.

So, there's research around self-efficacy. So, our self-efficacy is our confidence in managing a specific situation. So, we have our pain self-efficacy. And if somebody has low confidence in their ability to manage their pain or to cope with their pain, the pain is going to get worse. So, we might need to ask them about their confidence in managing that pain and then, again, help them change their self-efficacy or their confidence around doing that.
And I keep bringing up questionnaires, but I've talked about the Pain Catastrophising Questionnaire. There is also the Pain Self-Efficacy Questionnaire that you can give people to assess their self-efficacy. So, there's a whole range of factors that we've got to consider. And there's also that balance between, when it comes to pain, a balance between acceptance of the pain — that doesn't mean liking it, that means accepting that's what it is, and change. So, it's making sure that people have that right balance between acceptance versus change. And if the balance is not appropriate, then that again will affect pain and the perception and its impact on our life and our likelihood of recovering over time, and all those different factors that are important.

Lesley: Thanks, Adrian. 

Look, we've covered a lot of ground today. We've talked a bit about what is pain, acute pain and chronic pain, and all the different types. We've very much heard about the role of the mind and the body being linked in so many ways and how it can amplify, not just the perception of pain, but also even from a genetic perspective, and inflammatory markers. We've talked a little bit about how you might test for that, so looking at quality of life as well as a whole lot of biomarkers as well. And also how we've got GPs and naturopaths and even psychologists working with people with chronic pain, all to put together this really complex puzzle in a way that's going to make a difference and get people off that cycle, which seems to be very difficult.

So, I want to thank everyone today. That was part one of our two-part series on chronic pain and inflammation. In the second part of this series, we're going to take a closer look at the research around treatment options for common conditions associated with pain and inflammation, and those natural medicines, diet and lifestyle treatments, and therapies that can support the reduction and resolution of chronic inflammation and pain. So, be sure to join us for part two. Thank you, everybody.

Michelle: Thanks, Lesley.

Adrian: Thanks.

Emma: Thanks.

Lisa: Thanks, Lesley.

Lesley: Thanks, everyone, for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website. I'm Professor Lesley Braun, and thanks for joining us. We'll see you next time.


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