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May 22

Personalized Treatments

Updated: May 28



The importance of personalized treatment for pain

One of the things that really intrigues me about pain (and health in general) is the incredible amount of variation in treatment responses between people.


Some people get complete temporary pain relief from spinal manipulations while it flare’s up someone else’s pain. One person gets complete relief from a corticosteroid injection while it does very little for the next. For one person surgery is the answer while for the next it successful surgery seems to have made little difference.


This is even more interesting when you look at the research, where a lot of commonly used treatments for pain either do not outperform sham treatment or only outperform it by little margins (Gibson et al., 2019)(Oliveira et al., 2020)(Williams et al., 2012)(Geneen et al., 2017)(Birkinshaw et al., 2023)(Rubinstein et al., 2011)(Vickers et al., 2012)(Aiyer et al., 2020)(Surace et al., 2020)(Colquhoun et al., 2013)(Korakakasis et al., 2018)(Furlan et al., 2015)


So why do we see so much variation in effectiveness between people? A simple explanation for this is the fact that pain is a unique experience. A person's pain can be impacted by numerous factors which can then further impact each other. Some factors that can contribute to pain directly or indirectly include:


  • Pain mechanism: nociceptive, neuropathic or nociplastic

  • Central and/or peripheral sensitisation

  • An underlying disease process or ongoing lesion

  • Inflammation

  • Age

  • Genetics

  • Comorbidities (other health conditions)

  • Lifestyle (exercise, physical activity, diet)

  • Medications or previous treatment (e.g., chemotherapy)

  • Fear avoidance

  • Catastrophization

  • Chronic stress and major stressors

  • Heightened emotions

  • Unhelpful beliefs around pain

  • Mood/Depression

  • Anxiety

  • PTSD

  • Adverse childhood experience

  • Other major life trauma/abuse

  • Previous pain memories

  • Appraisal of your pain (how you interpret it)

  • Pain memories

  • Previous injury or surgery

  • Gender

  • Financial stress

  • Education level

  • Social support


And the list goes on. There are also still likely numerous other factors that contribute to pain that have not been explored.


Hopefully the above shows that one person's pain will never be the same as another. Hopefully it also highlights that treatment for pain also requires a personalized approach and not a standardized cookie cutter approach based on your diagnosis alone.


If you have tried different treatments and they have not seemed to have worked for you, this is not your fault! It is also not likely your healthcare provider's fault! You may however, need a different approach and potentially a team of healthcare professionals that have more knowledge and training in persistent pain then the average healthcare professional. Indeed a multi-disciplinary approach is the gold standard and leads to the best results for chronic pain.


Think of it as building a house, you will likely need a plumber. However, he/she is unlikely to be able to do the electrical wiring, earth works, or bricklaying. The same goes for chronic pain treatment. A doctor is not able to address psychosocial factors, physical functioning, need for work related intervention, etc. He/she needs a team to assist.


Yes, it is costly to see a number of different healthcare professionals at once. However, it could be

cheaper in the long run.





References


  1. Aiyer, R., Noori, S. A., Chang, K. V., Jung, B., Rasheed, A., Bansal, N., Ottestad, E., & Gulati, A. (2020). Therapeutic Ultrasound for Chronic Pain Management in Joints: A Systematic Review. Pain medicine (Malden, Mass.), 21(7), 1437–1448. https://doi.org/10.1093/pm/pnz102

  2. Birkinshaw, H., Friedrich, C. M., Cole, P., Eccleston, C., Serfaty, M., Stewart, G., White, S., Moore, R. A., Phillippo, D., & Pincus, T. (2023). Antidepressants for pain management in adults with chronic pain: a network meta-analysis. The Cochrane database of systematic reviews, 5(5), CD014682. https://doi.org/10.1002/14651858.CD014682.pub2

  3. Colquhoun, D., & Novella, S. P. (2013). Acupuncture is theatrical placebo. Anesth Analg, 116(6), 1360-1363. https://doi.org/10.1213/ANE.0b013e31828f2d5e

  4. Furlan, A. D., Giraldo, M., Baskwill, A., Irvin, E., & Imamura, M. (2015). Massage for low-back pain. The Cochrane database of systematic reviews, 2015(9), CD001929. https://doi.org/10.1002/14651858.CD001929.pub3

  5. Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. The Cochrane database of systematic reviews, 4(4), CD011279. https://doi.org/10.1002/14651858.CD011279.pub3

  6. Gibson, W., Wand, B. M., Meads, C., Catley, M. J., & O'Connell, N. E. (2019). Transcutaneous electrical nerve stimulation (TENS) for chronic pain - an overview of Cochrane Reviews. The Cochrane database of systematic reviews, 2(2), CD011890. https://doi.org/10.1002/14651858.CD011890.pub2

  7. Korakakis, V., Whiteley, R., Tzavara, A., & Malliaropoulos, N. (2018). The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. British journal of sports medicine, 52(6), 387–407. https://doi.org/10.1136/bjsports-2016-097347

  8. Oliveira, C. B., Maher, C. G., Ferreira, M. L., Hancock, M. J., Oliveira, V. C., McLachlan, A. J., Koes, B. W., Ferreira, P. H., Cohen, S. P., & Pinto, R. Z. (2020). Epidural corticosteroid injections for lumbosacral radicular pain. The Cochrane database of systematic reviews, 4(4), CD013577. https://doi.org/10.1002/14651858.CD013577

  9. Rubinstein, S. M., van Middelkoop, M., Assendelft, W. J., de Boer, M. R., & van Tulder, M. W. (2011). Spinal manipulative therapy for chronic low-back pain. The Cochrane database of systematic reviews, (2), CD008112. https://doi.org/10.1002/14651858.CD008112.pub2

  10. Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Foster, N. E., Sherman, K. J., Witt, C. M., Linde, K., & Acupuncture Trialists' Collaboration (2012). Acupuncture for chronic pain: individual patient data meta-analysis. Archives of internal medicine, 172(19), 1444–1453. https://doi.org/10.1001/archinternmed.2012.3654

  11. Williams, A. C., Eccleston, C., & Morley, S. (2012). Psychological therapies for the management of chronic pain (excluding headache) in adults. The Cochrane database of systematic reviews, 11(11), CD007407. https://doi.org/10.1002/14651858.CD007407.pub3





This blog was written by Samuel Bulten


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