A Closer Look at the Etiology of Chronic Pain

When a patient comes into your clinic with a chief complaint of chronic pain, maybe your first thought is to treat the case using an orthopedic approach, using motor points or dry needling, anchoring with distal points for systemic effect; or perhaps you diagnose them with some form of bi syndrome and use TCM theory and herbs in your treatment method. Maybe you ascertain that excess dampness is causing joint arthralgia or the chronic low back pain is attributable to yang xu.

There are arguably many viable approaches to treatment. As the old saying goes, “yi bing, tong zhi; tong bing, yi zhi” – different diseases, same treatment; same disease, different treatments.

In your intake, you likely inquire about the physiologic systems covered in the 10 Questions, document “OLDCARTS” [Onset, Location, Duration, Character, Aggravating/Relieving factors, Timing, and Severity] as related to their complaint of pain, and perhaps even include orthopedic tests in your assessment.

But would you ask this patient about their emotional state and their satisfaction level with their family, personal and professional relationships, noting any temporal correlation between emotional shifts and onset of symptoms? Patients often aren’t aware of the relationship between their physical and emotional states, and may not think to offer these details unless prompted.

“Physical Pain” Is Never Just Physical; It’s Also Emotional

The identification of the Seven Emotions as etiological factors of disease in Chinese medicine dates back to the Huang Di Nei Jing. Western medicine is embracing this interrelationship and has coined the term psychogenic pain to describe the presentation of pain that would otherwise appear idiopathic.

Research shows that multiple parts of the brain process pain, including the prefrontal cortex (attentional and executive processes), the cerebral cortex (thoughts, beliefs), and the limbic system – your brain’s emotion center. In fact, neuroscience demonstrates that negative emotions like anxiety, stress, depression, and anger amplify pain; while relaxation, happiness, joy, and gratitude can reduce it.

Chronic psychogenic pain can be felt anywhere in the body, and may vary in location and intensity; although it most commonly presents as headache, muscle aches, abdominal pain, or back pain. Western medical diagnoses include chronic pain syndrome, fibromyalgia, and psychogenic pain disorder.

Patients with depression often present with a complex set of overlapping symptoms, including emotional and physical complaints, and have significantly more medically inexplicable somatic symptoms than nondepressed patients.If you’ve overlooked asking about your patient’s emotional state because you were focused on their many physical complaints, you would not be alone.

Primary care physicians fail to accurately diagnose at least 50% of patients with major depression, and at least two studies have shown that patients with depression who present with physical symptoms such as pain are particularly likely to receive an inaccurate diagnosis.¹

Treat the Root, Not the Branch

While acute pain signals danger of harm – a broken bone in need of repair, a dangerous concussion requiring rest, an infected cut requiring attention, chronic pain is the result of a sensitive false alarm, akin to a car alarm sounding in the absence of a burglar. After weeks and months of pain, the nervous system can become so sensitive that the sensation of pain, while very real, is no longer a reliable indicator of damage or inflammation.

If we don’t accurately assess the chronicity and etiology of our patient’s condition, we may be missing the root for the branch in our treatment approach. A large longitudinal cohort study has shown that depressive symptoms predict future episodes of low back pain, neck-shoulder pain, and musculoskeletal symptoms compared to patients without depressive symptoms at baseline.⁶

Another study showed that low back pain is more than twice as likely to be reported by individuals with depressive symptoms compared to those without depressive symptoms.³

The Value of Our Medicine

Fortunately, acupuncture has proven to be effective in treating chronic pain-related depression,^4-5,12 chronic pain¹¹ and fibromyalgia.^2,8-10,13 A meta-analysis of randomized clinical trials showed that acupuncture was as effective as psychiatric medication for alleviating chronic pain-related depression; and that acupuncture combined with drug therapy was more effective than drug therapy alone.¹²

So, the next time you have a patient with chronic low back pain, instead of defaulting to the urinary bladder channel or an orthopedic approach, consider focusing on the du mai, which helps to strengthen the mind and the spine, while tonifying kidney and heart yang. It also has the function of nourishing the brain, which, in conjunction with the heart, has been considered by many Chinese doctors to be the seat of the shen.

SI 3, UB 62, Du 24, Du 20, Du 14, and Ren 15 is a great point combination for the depressed patient with back pain or migratory pain along the posterior aspect of the body.⁷

The yin qiao mai and yang qiao mai both go to the brain and greatly influence its function, making them excellent approaches for any psychogenic pain. Additionally, the yang qiao mai is an extension of the urinary bladder channel. Therefore, symptoms of the UB channel can be treated using points on the yang qiao mai.

Alternatively, consider the connecting channels. A deficiency in the kidney luo will present with low back pain (the channel runs through the lumbar vertebrae), while irritability and depression are signs of excess. SP 21 is a highly effective point for migratory chronic pain. An excess in the great luo of the spleen presents with general aches and pains throughout the body.

Do the seemingly unrelated symptoms present in a manner consistent with paired yin and yang organs? Perhaps the root lies in the divergent channels.

Lastly, ghost points and Window of the Sky points can be added to treatments to deepen the connection to the spirit level. “Yi bing, tong zhi; tong bing, yi zhi.” Whatever approach you choose, let us not forget that our medicine is based on treating the root of the disease.

References

1. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med, 2003;163(20):2433–2445.
2. Bastos JL, Pires ED, Silva ML, et al. Effect of acupuncture at tender points for the management of fibromyalgia syndrome: a case series. J Acu Merid Studies, 2013;6(3):163-168.
3. Croft PR, Papageorgiou AC, Ferry S, et al. Psychologic distress and low back pain. Evidence from a prospective study in the general population. Spine, 1995;20(24):2731–2737.
4. Fan L, Fu W, Chen Z, et al. Curative effect of acupuncture on quality of life in patients with depression: a clinical randomized single-blind placebo-controlled study. J Trad Chinese Med, 2016;36(2):151-159.
5. Hopton A, Eldred J, MacPherson H. Patients’ experiences of acupuncture and counselling for depression and comorbid pain: a qualitative study nested within a randomised controlled trial. BMJ Open, 2014;4(6):e005144.
6. Leino P, Magni G. Depressive and distress symptoms as predictors of low back pain, neck-shoulder pain, and other musculoskeletal morbidity: a 10-year follow-up of metal industry employees. Pain, 1993;53(1):89-94.
7. Maciocia G. The Channels of Acupuncture. China: Churchill Livingstone, 2006.
8. Mist SD, Jones KD. Randomized controlled trial of acupuncture for women with fibromyalgia: group acupuncture with traditional Chinese medicine diagnosis-based point selection. Pain Med, 2018;19(9):1862-1871.
9. Targino RA, Imamura M, Kaziyama HH, et al. A randomized controlled trial of acupuncture added to usual treatment for fibromyalgia. J Rehabil Med, 2008;40(7):582-588.
10. Uğurlu FG, Sezer N, Aktekin L, et al. The effects of acupuncture versus sham acupuncture in the treatment of fibromyalgia: a randomized controlled clinical trial. The effects of acupuncture versus sham acupuncture in the treatment of fibromyalgia: a randomized controlled clinical trial. Acta Reumatol Port, 2017;42(1):32-37.
11. Vickers AJ, Vertosick EA Lewith G, et al. Acupuncture for chronic pain: update of an individual patient data meta-analysis. J Pain, 2018;19(5):455-474.
12. You J, Li H, Xie D, et al. Acupuncture for chronic pain-related depression: a systematic review and meta-analysis. Pain Res Management, 2021: 6617075.
13. Zhang XC, Chen H, Xu WT, et al. Acupuncture therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. J Pain Res, 2019;12:527-542.