A Pathways Approach to Chronic Pain

  • Angele McGrady
  • Donald Moss


Chronic pain is a major cause of human suffering and impairment in function, affecting not only individuals, but also families, productivity in the workplace and society. Selected mechanisms involved in the transformation of acute pain into chronic debilitating pain are discussed. Two cases, one of a patient with chronic migraine and another case of a sufferer of back pain are presented in detail. The multi-level Pathways Model is applied to each case. The patient with migraine had a history of sexual abuse and met criteria for major depressive disorder. The example chosen for low back pain is that of a married man whose wife is emotionally and physically ill. He is stuck in past memories of a highly successful period of his life when he was a high school star athlete. Both patients were able to reduce pain, but perhaps even more importantly, they acquired healthier lifestyle behaviors, learned coping skills, and lessened symptoms of anxiety and depression. Although the interventions did not cure their pain, their suffering from chronic pain decreased and their ability to function in their personal world improved.


Chronic pain Migraines Back pain Adverse life events Central and peripheral sensitization Pathways Model 


  1. Andrasik, F., Lipchik, G. L., McCrory, D. C., & Wittrock, D. A. (2005). Outcome measurement in behavioral headache research: Headache parameters and psychosocial outcomes. Headache, 45, 429–437.CrossRefGoogle Scholar
  2. Apkarian, A. V. (2008). Pain perception in relation to emotional learning. Current Opinion in Neurobiology, 18, 464–468.CrossRefGoogle Scholar
  3. Becker, S., Gandhi, W., Kwan, S., Ahmed, A. K., & Schweinhardt, P. (2015). Doubling your payoff: Winning pain relief engages endogenous pain inhibition. eNeuro, 2(4), pii: ENEURO.0029-15.2015.
  4. Bernstein, D. A., Carlson, S. R., & Schmidt, J. E. (2007). Progressive relaxation: Abbreviated methods. In P. M. Lehrer, R. L. Woolfolk, & W. E. Sime (Eds.), Principles and practice of stress management (3rd ed., pp. 88–124). New York: Guilford Press.Google Scholar
  5. Borsook, D., Linnman, C., Faria, V., Strassman, A. M., Becerra, L., & Elman, I. (2016). Reward deficiency and anti-reward in pain chronification. Neuroscience and Biobehavioral Reviews, 68, 282–297.CrossRefGoogle Scholar
  6. Cacioppo, J. T., Hawkley, L. C., & Thisted, R. A. (2010). Perceived social isolation makes me sad: Five year cross-lagged analyses of loneliness and depressive symptomatology in the Chicago Health, Aging, and Social Relations Study. Psychology and Aging, 25, 453–463.CrossRefGoogle Scholar
  7. Chiesa, A., & Serretti, A. (2011). Mindfulness-based interventions for chronic pain: A systematic review of the evidence (structured abstract). Journal of Alternative and Complementary Medicine, 17(1), 83–93.CrossRefGoogle Scholar
  8. Christiansen, J., Larsen, F. B., & Lasgaard, M. (2016). Do stress, health behavior, and sleep mediate the association between loneliness and adverse health conditions among older people? Social Science and Medicine, 152, 80–86. CrossRefPubMedGoogle Scholar
  9. Davis, M., Eshelman, E. R., & McKay, M. (2008). The relaxation and stress reduction workbook. Oakland, CA: New Harbinger Publications, Inc..Google Scholar
  10. Dodick, D., & Freitag, G. (2006). Evidence-based understanding of medication-overuse headache: Clinical implications. Headache, 46(Supp 4), S202–S211.CrossRefGoogle Scholar
  11. Eccleston, C., Palermo, T. M., Williams, A. C., Lewandowski, H. A., Morley, S., Fisher, E., et al. (2014). Psychological therapies for the management of chronic and recurrent pain in children and adolescents (review). Cochrane Database of Systematic Reviews, 5.
  12. Elman, I., & Borsook, D. (2016). Common brain mechanisms of chronic pain and addiction. Neuron, 89, 11–36.CrossRefGoogle Scholar
  13. Geneen, L. J., Moore, R., 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. Cochrane Database of Systematic Reviews, (4). Google Scholar
  14. Griffin, G., Tudiver, F., & Grant, W. (2002). Do NSAIDs help in acute or chronic low back pain. American Family Physician, 65(7), 1319–1322.PubMedGoogle Scholar
  15. Hassett, A. L., & Finan, P. H. (2016). The role of resilience in the clinical management of chronic pain. Current Pain and Headache Reports, 20(6), 39.CrossRefGoogle Scholar
  16. Hayden, J., van Tulder, M. W., Malmivaara, A., & Koes, B. W. (2005). Exercise therapy for treatment of non-specific low back pain. Cochrane Database of Systematic Reviews, 3.
  17. Injections and Implants for Back Pain Relief. (2017). Resource document. Arthritis Foundation. Retrieved June 20, 2017, from
  18. Juang, K. D., & Yang, C. Y. (2014). Psychiatric comorbidity of chronic daily headache: Focus on traumatic experiences in childhood, post-traumatic stress disorder and suicidality. Current Pain and Headache Reports, 18(4), 405.CrossRefGoogle Scholar
  19. Kalichman, L. L., Li, L., Kim, D. H., Guermazi, A., Berkin, V., O’Donnell, C. J., et al. (2008). Facet joint osteoarthritis and low back pain in the community-based population. Spine, 33(23), 2560–2565.CrossRefGoogle Scholar
  20. Kurina, L. M., Knutson, K. L., Hawkley, L. C., Cacioppo, J. T., Lauderdale, D. S., & Ober, C. (2011). Loneliness is associated with sleep fragmentation in a communal society. Sleep, 34(11), 1519–1526. CrossRefPubMedPubMedCentralGoogle Scholar
  21. Lewinnek, G. E., & Warfield, C. A. (1986). Facet joint degeneration as a cause of low back pain. Clinical Orthopaedics and Related Research, 213, 216–222.Google Scholar
  22. Lu, C., Yang, T., Zhao, H., Zhang, M., Meng, F., Fu, H., et al. (2016). Insular cortex is critical for the perception, modulation, and chronification of pain. Neuroscience Bulletin, 32(2), 191–201.CrossRefGoogle Scholar
  23. Lumley, M. A., Cohen, J. L., Borszoz, G. S., Cano, A., Radcliffe, A. M., Porter, L. S., et al. (2011). Pain and emotion: A biopsychosocial review of recent research. Journal of Clinical Psychology, 67(9), 942–968.CrossRefGoogle Scholar
  24. Martin, P. R. (2016). Stress and primary headache: Review of the research and clinical management. Current Pain and Headache Reports, 20(7), 45.CrossRefGoogle Scholar
  25. McCraty, R. (2002). Heart rhythm coherence—An emerging area of biofeedback. Biofeedback, 30, 23–25.Google Scholar
  26. McKenzie, R. (2011). Treat your own back (9th ed.). Raumati Beach, New Zealand: Spinal Publications New Zealand Ltd.Google Scholar
  27. Mehling, W. E., Hamel, K. A., Acree, M., Byl, N., & Hecht, F. M. (2005). Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Alternative Therapies, 11(4), 44–52.Google Scholar
  28. Moldofsky, H. (2014). Pain and insomnia: What every clinician should know. Retrieved August 31, 2014, from
  29. Monticone, M., Cedraschi, C., Ambrosini, E., Rocca, B., Fiorentini, R., Restelli, M., et al. (2015). Cognitive-behavioural treatment for subacute and chronic neck pain. (review). Cochrane Database of Systematic Reviews, 5.
  30. Murray, K. A., O’Neal, K., & Weisz, M. (2015). Dietary suggestions for migraine prevention. American Journal of Health-System Pharmacy, 72, 519–521.CrossRefGoogle Scholar
  31. National Institutes of Health. (2011). Chronic pain: Symptoms, diagnosis, and treatment. NIH Medline Plus, 6(1), 5–6. Retrieved from
  32. Navratilova, E., Atcherley, C. W., & Porreca, F. (2015). Brain circuits encoding reward from pain relief. Trends in Neurosciences, 38, 741–750.CrossRefGoogle Scholar
  33. Norton, P. J., & Asmundson, G. (2004). Anxiety sensitivity, fear, and avoidance behavior in headache pain. Pain, 111(1–2), 218–223.CrossRefGoogle Scholar
  34. Penzien, D. B., Irby, M. B., Smitherman, T. A., Rains, J. C., & Houle, T. T. (2015). Well-established and empirically supported behavioral treatments for migraine. Current Pain and Headache Reports, 19(7), 34.CrossRefGoogle Scholar
  35. Prince, P. B., Rapoport, A. M., Sheftell, F. D., Tepper, S. J., & Bigal, M. E. (2004). The effect of weather on headache. Headache, 44(6), 596–602.CrossRefGoogle Scholar
  36. Purves, D., Augustine, G. J., Fitzpatrick, D., Hall, W. C., LaMantia, A., & White, L. E. (2012). Neurosciences (5th ed.). Sunderland, MA: Sinauer Associates.Google Scholar
  37. Shea, A., Walsh, C., MacMillan, H., & Steiner, M. (2004). Child maltreatment and HPA axis dysregulation: Relationship to major depressive disorder and posttraumatic stress disorder in females. Psychoneuroendocrinology, 30, 162–178.CrossRefGoogle Scholar
  38. Smith, J. C. (2007). The psychology of relaxation. In P. M. Lehrer, R. L. Woolfolk, & W. E. Sime (Eds.), Principles and practice of stress management (3rd ed., pp. 16–37). New York: Guilford Press.Google Scholar
  39. Stetler, C., & Miller, G. E. (2011). Depression and hypothalamic-pituitary-adrenal activation: A quantitative summary of four decades of research. Psychosomatic Medicine, 73(2), 114–126.CrossRefGoogle Scholar
  40. Tietjen, G. E. (2016). Childhood maltreatment and headache disorders. Current Pain and Headache Reports, 20(4), 26.CrossRefGoogle Scholar
  41. Tietjen, G. E., Herial, N. A., Hardgrove, J., Utley, C., & White, L. (2007). Migraine comorbidity constellations. Headache, 47(6), 876–877.CrossRefGoogle Scholar
  42. Tietjen, G. E., Khubchandani, J., Ghosh, S., Bhattacharjee, S., & Kleinfelder, J. (2012). Headache symptoms and indoor environmental parameters: Results from the EPA BASE study. Annals of Indian Academy of Neurology, 15(Supp 1), 595–599.Google Scholar
  43. Vachon-Presseau, E., Centeno, M. V., Ren, W., Berger, S. E., Tetreault, P., Ghantous, M., et al. (2016). The emotional brain as a predictor and amplifier of chronic pain. Journal of Dental Research, 95(6), 605–612.CrossRefGoogle Scholar
  44. Van Voorhees, E., & Scarpa, A. (2004). The effects of child maltreatment on the hypothalamic-pituitary-adrenal axis. Trauma, Violence, & Abuse, 5(4), 333–352.CrossRefGoogle Scholar
  45. Voscopoulos, C., & Lema, M. (2010). When does acute pain become chronic? British Journal of Anaesthesia, 105(S1, i69–i85.CrossRefGoogle Scholar
  46. Vreeburg, S. A., Hoogendijk, W. J., van Pelt, J., Derijk, R. H., Verhagen, J. C., van Dyck, R., et al. (2009). Major depressive disorder and hypothalamic-pituitary-adrenal axis activity. Archives of General Psychiatry, 66(6), 617–626.CrossRefGoogle Scholar
  47. Wittrock, D. A., & Foraker, S. L. (2001). Tension-type headache and stressful events: The role of selective memory in the reporting of stressors. Headache, 41, 482–493.CrossRefGoogle Scholar
  48. Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152(3 Suppl), S2–S15.CrossRefGoogle Scholar
  49. Yaqub, F. (2015). Pain in the USA: States of suffering. The Lancet, 386(9996), 839.CrossRefGoogle Scholar
  50. Yu, S. P., & Hunter, D. J. (2015). Managing osteoarthritis. Australian Prescriber, 38(4), 115–119.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Angele McGrady
    • 1
  • Donald Moss
    • 2
  1. 1.Department of PsychiatryUniversity of ToledoToledoUSA
  2. 2.College of Integrative Medicine and Health SciencesSaybrook UniversityOaklandUSA

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