Why Does Surgery Not Work for Chronic Pain?



When it comes to pain, surgery is often not the answer. I frequently see surgery lead to more pain.


Yes, in many cases surgery is appropriate. It can be a lifesaving intervention. With respect to pain, however, the answer is not clear-cut.


Let’s start with chronic pain.


A 2019 research study pooled data from 25 research trials that assessed the effectiveness of surgery for chronic pain. They concluded, “there is little evidence for the specific efficacy beyond sham for invasive procedures in chronic pain.”


Translation?


If improvements in pain are noted after surgery, it is likely a placebo effect.


Pain is complex and tissue damage is only a piece of the puzzle. When working with patients, I look beyond the physical portion of pain and assessing the psychosocial components. I am not saying pain is ‘all in the head’, rather, I am saying we cannot separate the mind from the body and only treat one.


Fear, anxiety, and a history of painful events can worsen symptoms. Comorbidities such as obesity and diabetes can worsen the pain experience and blunt the effectiveness of treatment. Simply repairing a proposed source of pain from an MRI does not solve the root cause.


I have lost count of the number of patients who have been misled, believing surgery would “fix” the problem and their pain would be gone forever. Pain is not that simple. We cannot only treat one part of the body; the mind must be treated as well. Taking it a step further, treating the damaged part of the body is can often be done without surgery.


Torn ACLs, rotator cuff muscles, and labrums showing on MRIs are immediately met with surgical preparations. Yet, research shows ACL, rotator cuff, and hip labral tears all can be successfully managed conservatively.


This is not to say ACL repairs should be grouped with limb amputations for an infected cut or bloodletting with leeches. The treatment is neither outdated nor pseudoscience. Rather, the commonly accepted belief that surgery is needed to repair damage should be questioned.


Your surgery is scheduled, and you are eager to get it over with. You have been instructed on the post-operative process, including the need for rehabilitation. Your surgeon explains that following the surgery, you will need physical therapy to restore strength and mobility. This is absolutely true, but what if you can make that rehab process smoother and quicker?


I’m not here to sell a magic copper-filled garment or ab belts claiming to rapidly build muscle, I am talking about prehabilitation.


Now that I have planted a seed of doubt regarding the necessity of some surgeries — again many surgeries are vital and life-saving — let’s look at some factors not considered when facing the prospects of going under the knife.


Do you Prehab?

Prehabilitation, or prehab for short, is participating in exercises to build muscle, endurance, strength, and power prior to surgery.


You are building your foundation prior to the rigors of surgery. Loss of muscle, endurance, strength, and power are unavoidable following surgery. The severity depends on the surgery.


A knee meniscectomy — ofter referred to as a knee scope when part or all of the meniscus is removed— may be minimal as you are able to resume some level of activity almost immediately following surgery. You will decondition some, but the activity will minimize loss of muscle, known as atrophy.


One of the strategies used to minimize the negative effects of surgery is rehabilitation. The effects of rehabilitation are mixed.


No amount of exercise will prevent muscle loss after surgery, but rehabilitation does more than build strength, or, at least it should.


Improving strength and muscle size are typically the primary goals, as they expedite early post-op progression. An area that needs more emphasis is building self-efficacy and addressing pain.


Surgery Does Not Address Fear of Movement

Pain catastrophizing (feelings of helplessness and excessive magnification of thoughts and feelings toward pain), poor pain-coping strategies, and kinesiophobia (fear of movement) are common in patients receiving a total joint replacement.


Research suggests psychosocial health plays a large role in determining the success of post-operative care.


Patients with high levels of kinesiophobia and pain catastrophizing are less active. Low levels of self-efficacy diminish a patient’s confidence in completing rehabilitation tasks, particularly those that involvements pain-inducing movements.


Self-efficacy can be defined as “how well one can execute courses of action required to deal with prospective situations.” As you can imagine, this is vital for anyone rehabilitating from surgery.


This study compared the pre-operative presentation of patients with and without elevated hip pain three months following a total hip replacement. The study assessed self-reported function and psychosocial health.


More than one-third of the participants reported anxiety or depression. Indicators of poor psychosocial health were present in nearly half of the participants.


Participants with elevated postoperative pain at rest had worse pre-operative psychosocial health and function compared to those without. Participants with elevated postoperative pain during activity had worse pre-operative psychosocial health, however, they did not have worse pre-operative function.


Pre-operative self-efficacy explained more than one-third of the variance in both elevated postoperative pain at rest and during activity.


What does all this mean?


Surgery does not cut away our fears, anxiety, and self-doubt. Personalized treatment centered around movement is needed for that.


In rehabilitation, a physical therapist can address a patient’s beliefs about pain and movement prior to surgery, which can positively influence activity level and participation in rehabilitation after surgery.


If you are planning to pursue surgery for pain, speak with your doctor about your activity level.


Pain is complex and movement is almost always beneficial. Learning how to improve your activity and address pain can improve your surgery and rehabilitation experience.


Before concluding surgery is a foregone conclusion for your pain, seek alternative opinions. If surgery is the best option for you, seek a physical therapist prior to the operation date. They can help you better understand pain and build a personalized approach to activity.