Untangling chronic pain: Inside WashU Medicine’s holistic approach

Prick your finger and it hurts—simple cause, simple response. But for millions of people living with chronic pain, pain is anything but straightforward. It persists without a visible cause, defying easy diagnosis or treatment. At the WashU Medicine Pain Center, physicians and specialists say understanding pain as a complex interaction between the brain, nervous system, and body is key to helping patients whose symptoms don’t show up on scans—but are no less real.

“When treating patients with pain we always think about five different tools: medications, injections or procedures, physical therapy, pain psychology, and surgical considerations,” says Dr. Lara Crock, an anesthesiologist and fellowship-trained pain management physician at the center. “Not every tool is relevant to every patient in pain, but this is the framework we use when evaluating patients.”

Crock and colleagues from disciplines including physical therapy, pharmacology, radiology, surgery, and clinical psychology communicate regularly about complex pain cases, using a variety of tools to address patients’ needs. Diagnosis begins with imaging and lab tests to determine if an obvious injury or condition is causing a patient’s pain. 

In the case of nociplastic pain–or pain that occurs without obvious tissue damage–diagnosis requires an understanding of different types and causes of pain. “It’s tricky because often there isn’t really anything that shows up on imaging in the area that aligns with the pain presentation, but sensitization of the central nervous system can happen both at the level of the spinal cord and some of the central processing areas of the brain. It’s not just one part of the brain that does pain,” says Corey Woldenberg, a physical therapist with WashU Medicine Physical Therapy in the Pain Center. Patients who have chronic back pain, for instance, may not show a specific injury on an MRI, but the pain is real. The question is: Where in the central nervous system are the pain signals coming from?

In some cases, the nervous system almost becomes programmed to send ongoing pain signals even after an injury has healed. Woldenberg compares it to the type of muscle memory used to play an instrument. “Research would suggest that the body can create a habit where the neural networks that were triggered during a pain experience can be triggered by something else and still create a pain cascade.” A pain psychologist at the center, Sarah Buday, refers to this as “synaptic efficiency,” adding that “nerves that fire together wire together, creating long-term changes.” 

To begin untangling the complexities of chronic pain cases, center clinicians collaborate in formal weekly conferences and informal communications regarding patients who may benefit from more than one type of treatment. “Even if their images show that there’s a problem, we treat the whole person,” Crock says. That involves helping patients learn how they can take responsibility for their own healing, even when they’re afraid of making the pain worse. 

For instance, a patient may see Crock for an initial treatment, such as an injection. The patient also visits Woldenberg to learn how to reincorporate movement into daily life and become less fearful of making an injury worse or causing a new injury. And Buday may help the patient better learn to cope with pain through Pain Reprocessing Therapy, which helps individuals manage pain through cognitive techniques. 

Crock credits Dr. Robert Swarm, a WashU pain management specialist, with bringing the multidisciplinary approach to his creation of the center during his more than three decades of practice in St. Louis. “It does take time and effort on both the patient and provider sides, but all of us here to listen and talk and help figure out how we can best help,” Crock says. “I tell patients every day that I’m going to do everything possible to help you feel better, but you’re going to have have to help yourself as well–we’re going to work together.”