The Impact of PTSD on Chronic Pain & Function

And What a Pain Specialist Can Do About It

Imagine being locked in your own head, vividly reliving one, or maybe several traumatic experiences over and over again. Hearing the sounds, feeling your heart race, and seeing the visions of what happened. Feeling the fear, the anger, the frustration, the despair. Imagine being too ashamed to tell anyone what you’re experiencing, not sure if, or how, or who to ask for help. You lose sleep, you can’t focus. You try to push through it, but sometimes it’s so overwhelming. For some, you go into a dark room, and try to quiet all stimulation. For others, darkness is a trigger, so you avoid it, avoiding sleep, avoiding complete quiet. Trying to run from your own head. But you can’t, because it’s with you all the time.

As a pain physician, I’ve taken care of many patients with post-traumatic stress disorder (PTSD). It is almost never the first thing they bring to me as a complaint, but I can see it, and how it affects them. The sitting quietly, eyes darting around the room. The wringing of the hands and fingers. The loss of hope. The fear of doing things that may otherwise help them regain their function or return to something related to their traumatic event(s). 

When I dive deeper, ask them a few questions, not about their pain, but about their experiences, it comes out.

They look at me, sometimes with shame in their eyes, silently apologizing for not being “strong enough”, for not “getting over it”, for being trapped by these recurrent feelings and visions, and sounds…all of it.

PTSD can occur after any major traumatic experience, or a combination of them. I have cared for individuals whose PTSD started after being involved in a car accident. Others who experienced medical trauma, either themselves, or someone they loved. And of course, my Veterans and military heroes, who in the process of serving their country saw and experienced unspeakable trauma. Many of these individuals have had their symptoms minimized, and some of them dismissed. But they can’t ignore them. Those symptoms are with them every day.

There is a scientific survey that I use to assess the severity of PTSD symptoms in individuals who have clearly struggled with functioning because of it. It’s called the PTSD Checklist for DSM-5 (PCL-5). This survey describes “a list of twenty problems that people sometimes have in response to a very stressful experience,” and asks respondents to indicate how much they have been bothered by that problem in the last month. The problems range from “repeated disturbing memories of the stressful experience”, to “Taking too many risks, or doing things that can cause you harm.” Individuals completing the form indicate how often in the past month they experienced these symptoms, ranging from not at all (0) to extremely often (4). 

According to the guide to Using the PCL-5 checklist , a score of “31-33 or higher suggests the patient may benefit from PTSD treatment.” Yet, here’s the thing: many of my patients with PTSD symptoms have never been officially evaluated for PTSD or the severity of their PTSD. So they have not been offered treatment. 

So why is an anesthesiologist and pain specialist talking about PTSD? 

Well, there are a couple of reasons. 

First, and most importantly, my focus is on restoring function to those who have been limited by their pain. This includes addressing anything, in addition to their physiologic or anatomic cause of pain that could be limiting their function. So when I see someone who may have back or neck pain from a car accident, but is unable to leave their house to come to treatment, or to participate in physical therapy, because of the severity of their flashbacks every time they see a car, then I know that just treating their physical pain alone will not get them their function back. Second, as an interventional pain specialist, I can safely perform procedures that can impact the body's stress-response system in a way that a counselor or psychiatrist may not be able to. Furthermore there is a specific type of procedure, called a Stellate Ganglion Block, that can be a game-changer for patients with moderate to severe PTSD. 

Let me explain.

The stellate ganglion is a bundle of nerves in the neck that is part of your sympathetic nervous system, the nervous system that manages your “fight or flight” response. It helps control and regulate things such as heart rate, blood pressure, breathing, sweating, and blood flow to your muscles. It does this by sending signals to your brain, heart, and lungs, among other areas, to modify how these organs are functioning in the moment. In some instances, such as with PTSD, this stellate ganglion can be overactive, not turning off once the actual threat is no longer present. In these instances, we can use a procedure called a stellate ganglion block to chemically shut down the stellate ganglion temporarily and allow it to reset itself. I usually describe this as flipping a breaker switch whenever you have a flickering light in your home. Sometimes you just have to reset the circuit for the light to function properly. 

I have performed this procedure on countless individuals with severe PTSD, who have not seen relief with traditional treatment options (counseling or medication). The results consistently amaze me. Performing the stellate ganglion block procedure saw a dramatic change in patients suffering from PTSD, many of their PCL-5 scores going from high 50s and 60s to low teens or even single digits. Patients were able to return to doing things they once avoided because of their PTSD, such as driving again after a horrible car accident or having a full night’s rest. There was remarkable improvement and the possibility to return to normalcy after just one procedure when nothing else has helped.

These dramatic reductions in symptoms and score, coupled with improved function, are why I fight to keep access to these procedures for my patients who need them. Chronic pain and PTSD are often deeply intertwined. If we ignore the psychological barriers that limit a patient’s ability to function, we risk overlooking a major part of their suffering. Restoring function requires treating the whole person, not just the physical symptoms.