I Am Being Told That My Pain Is Subjective, That It Is Unprovable, And Therefore I Cannot Be Compensated. If This Is So Subjective And Mild, Why Can’t I Function?
Pain is subjective by definition, but chronic pain leaves objective marks. Structural MRI in chronic low back pain shows gray matter loss in the brainstem and somatosensory cortex. That loss tracks pain intensity. And adequate treatment reverses it.
I have been asked the question above hundreds of times, in one form or another. Patients ask it. Attorneys ask it. Insurers ask it. The reality is that pain symptoms are subjective by definition. They are, after all, symptoms, like the symptoms a person might have after a stroke. Showing objective evidence of pain takes costly testing of the central nervous system. That testing is not the standard of care. Outside a research setting, it would be considered medically unnecessary. But the research has already been done, and it is easy to find. Chronic back pain is one of the most frequent causes of permanent impairment in people under age 65. Yet it is treated as a subjective symptom. Third-party insurers often brush it off as unprovable and demand “objective” evidence of disability. The reality is that chronic pain is associated with less brain gray matter and weaker thinking ability. Both can be reversed with appropriate and adequate treatment. Evidence suggests that pain turns chronic through cortical reorganization, the brain rewiring itself. That is an objective, functional change in the brain (neuroplasticity). Structural MRI of the brain in people with chronic low back pain documents a significant drop in gray matter in the brainstem and the somatosensory cortex. The drop grows as pain gets stronger. Oddly, gray matter grows on both sides in the basal ganglia and in the left thalamus, the pain transmission centers. That growth also tracks stronger pain. These data support the hypothesis that ongoing pain signals (nociception) are associated with cortical and subcortical reorganization of the brain at a structural level. That may play an important role in how pain becomes chronic. The data also support the hypothesis that the thalamic pain processing center grows in size and function. Appropriate and adequate treatment of chronic pain reverses many of these functional and structural brain abnormalities. It restores gray matter in the brainstem and the somatosensory cortex.
Our physician-directed physiotherapy program is built the same way. Every visit is recorded at the time with clock times, settings and the patient’s signature, and progress is measured with the same questionnaire at the start and at each re-check.
Frequently asked questions
Why is pain so subjective?
Pain is a symptom, and symptoms are subjective by definition, the same way the symptoms after a stroke are. Only the person in pain feels it directly. That is why third-party insurers call chronic pain unprovable and demand “objective” evidence of disability. They do this even though chronic back pain is one of the most frequent causes of permanent impairment in people under age 65.
Is there objective evidence of chronic pain?
Yes. Structural MRI studies of people with chronic low back pain show less gray matter in the brainstem and the somatosensory cortex. The loss grows as pain intensity rises. Gray matter in the basal ganglia and the left thalamus, the pain transmission centers, increases as pain intensity rises. These are measurable changes in the structure of the brain, not a matter of opinion.
Can the brain changes from chronic pain be reversed?
Yes. Appropriate and adequate treatment of chronic pain reverses many of its functional and structural brain abnormalities. It restores gray matter in the brainstem and the somatosensory cortex. Chronic pain is also tied to weaker thinking ability, and that can be reversed with adequate treatment too. Treating the pain is treating the brain that the pain has reshaped.
Why don’t doctors order brain scans to prove pain?
Documenting objective evidence of pain takes costly testing of the central nervous system. That testing is not the standard of care. Outside a research setting, it would be considered medically unnecessary. The research has already been done, and it is easy to find. It shows the gray matter changes that chronic pain produces in the brainstem, the somatosensory cortex and the thalamus.
For additional information
http://www.painjournalonline.com/article/S0304-3959(06)00255-7/abstract Affective components and intensity of pain correlate with structural differences in gray matter in chronic back pain patients, T. Schmidt-Wilcke, et al. PAIN Volume 125, Issue 1 , Pages 89-97, November 2006 http://www.jneurosci.org/content/31/20/7540.abstract Effective Treatment of Chronic Low Back Pain in Humans Reverses Abnormal Brain Anatomy and Function David A. Seminowicz, et al. The Journal of Neuroscience, 18 May 2011, 31(20): 7540-7550; doi: 10.1523/JNEUROSCI.5280-10.2011
Medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP — Board Certified in Anesthesiology, Pain Medicine, Interventional Pain Management, Addiction Medicine, and Obesity Medicine.
