Chronic complaints

Chronic complaints occur when complaints last longer than about 3 months and no clear explanatory physical cause is (anymore) found. In chronic pain, the pain seems to have lost its original warning function and to lead a life of its own. A number of additional problems then arise. The approach becomes more complex.

The biopsychosocial model

To get some insight into what happens the biopsychosocial model is used. In contrast to the medical model, where only physical causes of the complaint are sought, the biopsychosocial model looks further:

A-bio: there are (still) physical factors that play a significant role in the maintainment of complaints. Example 1: someone with diabetes has delayed wound healing so that complaints can continue for longer after an accident. Example 2: someone in whom a number of spinal vertebrae are surgically fixed will have a higher load on the adjacent vertebrae, as a result of which they can be overloaded. Example 3: an athlete who continues despite signals of overtraining will no longer recover from the (normal) damage incurred in his sport.

B-psycho: how someone is and deals with the complaints (= behavior) can be decisive for maintaining complaints. Example 4: someone has back pain and is afraid to move the back because he thinks that is harmful. The result, however, is that ultimately the back can be loaded less, which makes the person more vulnerable and will develop complaints on load sooner. Example 5: someone with a lot of pain will try to avoid the pain by moving around (= assuming different behavior). The original problem gets in the background and is not resolved. The longer these adjustments there are, the more it is stuck/anchored in the person himself, and the more difficult it becomes to turn this back. Example 6: scientific research shows that persons with a strong perfectionist attitude and/or are very sensitive to stress situations more easily develop chronic complaints than others.

C-social: the total context in which the person is placed can be an maintaining factor for the complaints. Example 7: if someone can no longer participate in social activities such as work, sport or meetings for a long time, then he or she will become more isolated, then there will be less distraction, and then there will be less incentive to remain active. Example 8: Long-term complaints can also lead to resignation, so that there are no more initiatives to change the situation. Example 9: In search of improvement, the person can walk from therapist to therapist, where different explanations for the complaints pass, a lot of tinkering is done, much extra examination is done. The attention may then be too much on the complaints themselves and a possible physical cause (you see, something is found ...).

The role of memory: the brain changes

Every event that a person experiences is stored in his/her memory. The pain that has been experienced is also saved. When in the future something reminds of this pain, it can be felt again. The activity of this part of the memory can become stronger if the same pain is experienced more often, or if it takes longer as in the case of chronic pain.

When 'pain' stimuli are received more often or more severely or for a longer period of time, the brain circuits for pain sensation and pain experience become more strongly activated and tightened, making it seem as if the pain will lead a life of its own. A form of hypersensitivity arises.

Sensitization and hypersensitivity: the spinal cord changes

Apart from the fact that the brain changes with pain, the nervous system in the spinal cord also changes with continuous stimulation. The nerve cells that receive the 'pain' stimuli become more sensitive when the stimuli come in more violently, more often and for a longer period of time. As a result, a normal stimulus can ultimately become a painful experience.

Therapy

It will be clear that the approach to chronic pain complaints can be complex. Solutions are not known for all of the above processes. The approach to chronic complaints requires a multidisciplinary approach because of the multitude of factors that play a role. This means that different care providers can be called in such as a rehabilitation doctor, ergonomist, physiotherapist, psychologist, social worker, and so on. Unfortunately, there are no well-developed therapies for changing memory and sensitization. The role of medicines seems to be limited, but often necessary.

In practice for musculoskeletal medicine, physical examination remains important, also with chronic complaints. On the one hand there can still be physical factors that can be a maintaining factor. On the other hand, factors can also be excluded with good examination. In addition, it is also assessed and, if necessary, signaled that important issues play a role in psychosocial matters. However, the treatment of these factors does not belong to the field of competence of the practice.

References

Engel GL. The need for a new medical model. Science 1977 (196), 129-136.
LaMotte RH, et al. Neurogenic hyperalgesia: psychophysical studies of underlying mechanisms. J Neurophysiol 1991;66:190-211.
Wilgen CP van, Keizer D. Het sensitisatiemodel: een methode om een patiënt uit te leggen wat chronische pijn is. Ned Tijdschr Geneeskd. 2004;148:2535-8.