Case Management Focus: David Hanscom — Chronic Pain is Solvable

Sarasota, FL (WorkersCompensation.com) -- Patients with chronic pain are challenges to all members of the healthcare team as well as the employer and the especially, the injured worker and their families. In this article, I asked Dr. David Hanscom who has dedicated his career to helping people (patients and caregivers) as well as all members of the healthcare team learn how to break loose from the grip of chronic mental and physical pain – with and without surgery.

Anne: Dr. Hanscom, can you help us understand chronic pain?

Dr. Hanscom: Chronic pain is a problem caused by neuroplastic changes in the brain. Chronic pain is defined as a state of continued suffering, sustained long after the initial inciting injury has healed. In terms of learning and memory one could recast this definition as: Chronic pain is a persistence of the memory of pain and/or the inability to extinguish the memory of pain evoked by an initial inciting injury.

Anne: Can you put this in a more understandable manner?

Dr. Hanscom: Yes, in other words, the ongoing pain becomes connected with more and more life events and the pain circuits are reinforced with repetition. It does not matter whether the onset of pain was acute or insidious or if there is an identifiable cause. For example, acute low back pain that becomes chronic shifts from the nociceptive pain centers to the emotional regions between six to 12 months. It has also been demonstrated that lack of sleep CAUSES chronic low back pain.

Anne: How can chronic pain be treated?

Dr. Hanscom: There are multiple studies documenting the neurophysiological nature of chronic pain. But the medical world continues to treat chronic pain from a structural perspective. In fact, there is a term, MUS (Medically Unexplained Symptoms). Nothing could be further from the truth. When we are trapped by any circumstance, especially pain, your body responds with threat physiology. This includes increased metabolism (catabolic state), effects of the sympathetic nervous system (increased heart rate, respirations, sweating, agitation, blood pressure), switching to excitatory neurotransmitters, and diffuse inflammation. When this threat state is sustained, people develop symptoms, illness, and disease. So, a better term would be MES (medically explained symptoms). Everything is wrong as your body struggles to return to a resting state, and it can’t.

Anne: How does the ‘system’ impact chronic pain?

Workers' comp compounds the situation in that people are trapped in the system, not receiving timely or adequate care, and pressed to return to work. They can feel truly trapped. In addition, the system does not want to cover “mental health” services as it leads to what many refer to as opening a hornet’s nest, even if the symptoms can be proved that the problem is related to the workers compensation injury. That is a problem in that mental pain is the result of the same process of being trapped. The data shows that anxiety,4 depression,5 bipolar,6 OCD,7 and schizophrenia6 are all inflammatory physiological states; not primarily psychological. In fact, you cannot treat physical symptoms without calming down the nervous system. Looking at the patient holistically is something that case manager do well and understand all of these issues are tied together.

Anne: What are some of the successes we are seeing in the treatment of chronic pain?

Dr. Hanscom: Successfully treating chronic pain involves several steps. It is a complex problem that we keep treating simplistically.

The first one is awareness of:
- The nature of chronic pain
- The principles behind the solutions
- Defining the patient’s specific problem – structural causes should always be ruled out.

The second one is that all aspects of it must be treated simultaneously and all of them count. It is like fighting a forest fire. Random simplistic treatments can’t and don’t work. The categories of variables to be addressed are:
- Sleep
- Medication stabilization
- Exercise/ conditioning/ physical modalities
- Life outlook – anger, anxiety, depression, reconnecting with family and society
- Calming exercises – breath work, mindfulness, massage, acupuncture

Finally, since every person is infinitely unique, he or she must take control of their care.
- Pain education
- Processing anger to come out of the blame/ victim mode.
- Moving forward into the life that they want.

Anne: What are some solutions?

Dr. Hanscom: Unfortunately, with few exceptions, mainstream medicine is on an ongoing trajectory of treating chronic disease as a structural problem, hence the term, MUS. The first step in addressing problems is understanding ALL aspects. We are not taking the time to listen and are just treating symptoms. At the root of all chronic disease is that life circumstances are processed by the nervous system and translated into physiological changes, that create symptoms, illness, and disease. Treating only symptoms is ineffective and futile.

There is a term, “Dynamic Healing” that understands the interaction between your stresses and coping skills. Treatment involves teaching you to process stress in a manner that has less impact on your nervous system, increases the resiliency of the patient, and uses strategies to directly lower threat physiology. Symptoms are addressed to keep the patient comfortable while they heal.

Medical care is getting worse. Doctors are not given time to talk to or listen to their patients and more risky and expensive procedures are being performed that often cause harm. People (Patients) are going to have to take charge of their own care, and it is extremely unfortunate it must be this way because those with chronic pain are not in a position to advocate for themselves. Much, if not most, of medicine continues to ignore the data around the nature of chronic disease. You should be able to trust your doctor at the deepest level. It is not that they don’t have the best of intentions, but we are not trained with the correct paradigm, and are often penalized for taking too much time with our patients.

Anne: Thanks, Dr. Hanscom. Your work is really helping to educate people (patients and caregivers as well as the all members of the healthcare team). Please share some resources where we can learn more so we can improve the care of patients with chronic pain.

Solutions

There are many options available to the public that have evolved in response to a better understanding of the common links to chronic disease. Here are my resources: https://backincontrol.com/resources-2/. My Book, Back in Control: A Surgeon’s Roadmap Out of Chronic Pain, reflects my personal 15-experience suffering and then escaping from the grip of chronic pain.

As I shared my insights with my patients, it became clear that an action plan was need. The DOC Journey computer-based course and the app present two sequences of learning strategies to help yourself out of The Abyss of chronic pain. I have watched hundreds of patients heal.

There are also other options available, as more clinicians are learning about the core nature of chronic mental and physical pain. This is link to some clinicians I am familiar with, and it is by no means exhaustive: https://backincontrol.com/resources/clinical-resources/.

Going Forward

Thank you for reading this article. I hope you have a new perspective on how we can help our patients avoid the pitfalls that lead to chronic pain or for those who are in the morass of being a patient with chronic pain and learn some tips that help them become comfortable with a new normal. There is more hope than you might think.

I hope you will check out many of the links embedded in this article as well as the references that are included below. If you would like to reach out to Dr. Hanscom feel free to email him at dnhanscom@gmail.com

References

Apkarian, A.V. (2008). Pain perception in relation to emotional learning. CurrOpin Neurobiol, 18(4), 464-468.
Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain 2013;136(Pt 9):2751–2768.
Agmon M and Armon D. Increased Insomnia Symptoms Predict the Onset of Back Pain among Employed Adults. PLoS ONE 9(8): e103591. doi:10. 1371/journal.pone.0103591
Teed AR, Feinstein JS, Puhl M, Lapidus RC, Upshaw V, Kuplicki RT, et al. Association of Generalized Anxiety Disorder With Autonomic Hypersensitivity and Blunted Ventromedial Prefrontal Cortex Activity During Peripheral Adrenergic Stimulation: A Randomized Clinical Trial. JAMA Psychiatry. 2022 Apr 1;79(4):323–32.
Kappelmann N, Arloth J, Georgakis MK, Czamara D, Rost N, Ligthart S, et al. Dissecting the Association Between Inflammation, Metabolic Dysregulation, and Specific Depressive Symptoms: A Genetic Correlation and 2-Sample Mendelian Randomization Study. JAMA Psychiatry. 2021 Feb 1;78(2):161–70.
Outcalt SD, Kroenke K, Krebs EE, Chumbler NR, Wu J, Yu Z, et al. Chronic pain and comorbid mental health condition. 2015 Jun 1;38:535–43.
Renna ME, O’Toole MS, Spaeth PE, Lekander M, Mennin DS. The association between anxiety, traumatic stress, and obsessive-compulsive disorders and chronic inflammation: A systematic review and meta-analysis. Depress Anxiety. 2018 Nov;35(11):1081–94.
Corsi-Zuelli FM das G, Brognara F, Quirino GF da S, Hiroki CH, Fais RS, Del-Ben CM, et al. Neuroimmune Interactions in Schizophrenia: Focus on Vagus Nerve Stimulation and Activation of the Alpha-7 Nicotinic Acetylcholine Receptor. Front Immunol. 2017;8:618.

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