Why does acute pain sometimes become chronic? A new answer to an old question

Despite the fact that chronic pain and its associated disability is a tragedy for the patient and society, we know surprisingly little about the process of chronification. Indeed, most investigations to date examine those already suffering chronic pain.

A few are longitudinal in nature, but typically examine the effect of a variable measured at one time point, on chronic pain at a much later time point. Thus, neither the cross sectional or the longitudinal design unravels the process by which chronic pain and disability develop. This is unfortunate, as vital knowledge that may be the key to prevention is still hidden in the riddles of chronic pain. Moreover, we currently have a difficult time explaining why one patient may develop disability while another. does not, even though they appear to have similar injuries.

Indeed, some patients may develop disability with seemingly small injuries while others continue to function despite considerable injury and pain. The aim of this presentation is to take a fresh look at the process of developing chronic disability in light of recent research findings.

The latest findings in physiological research have provided a new background for viewing the development of chronic disability. This data suggests a strong interaction between the nervous system and behavior. Consequently, processes such as sensitization may enhance development, but are also related to cognitive and behavioral changes that the patient may exhibit.

Psychological research has underscored the role of emotional, cognitive, and behavioral factors in pain and disability. It is now clear that such factors are related to chronic disability. However, the question remains as to how and when these variables operate. For example, while fear-avoidance may be relevant for certain patients, we do not know whether it is important for all patients. Further, we do not know whether fear-avoidance plays its most important role early in the acute phase or whether it has most impact later on.

A new view has emerged that underscores the individual dynamic process involved as a pain problem progresses from acute to the persistent stage. This approach stresses the inter-relationship between physiological, cognitive, emotional and behavioral aspects, as they occur in the environment. Thus, the patient's experience is a key to understanding development as well as to obtaining behavioral changes in treatment. This fresh approach will be presented and reviewed to stimulate improved approaches to early interventions. Further, some implications and examples for clinical practice will be presented.