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Temporomandibular Joint Disorder https://www.instituteforchronicpain.org Mon, 30 Jan 2023 18:16:54 +0000 Joomla! - Open Source Content Management en-gb Chronic Pain and Insomnia https://www.instituteforchronicpain.org/blog/item/121-24chronic-pain-and-insomnia https://www.instituteforchronicpain.org/blog/item/121-24chronic-pain-and-insomnia

Insomnia is common among people with chronic pain. It's also problematic. It typically makes your pain worse and saps your abilities to cope. Understanding and overcoming insomnia is therefore important to successfully self-manage chronic pain.

Overcoming insomnia is possible for most people with chronic pain. Like most good things in life, though, it takes some work. There are no quick fixes when it comes to overcoming insomnia. There are actually a number of steps in the process. First, it’s helpful to understand the cyclical nature of chronic pain and insomnia. Second, it’s helpful to understand something about the three basic treatment options that are available for insomnia. Third, pursue one or some combination of these options.

Understanding the cyclical nature of chronic pain and insomnia

It’s common to think of chronic pain as the sole cause of insomnia – as if it’s a one-way street from chronic pain to insomnia. In some ways, of course, it makes sense as pain does in fact make it hard to sleep at night. Pain is a function of our nervous systems and when in pain our nervous systems are reactive. Our normal physical, emotional, and cognitive responses to pain are indicative of this reactive nervous system as well: we remain tense, alarmed, and focused on the pain. None of these automatic reactions to pain are conducive to falling or remaining asleep!

From these observations about pain and its effect on sleep, it seems logical that the best thing to do is to get rid of the pain. This approach, however, is insufficient in most cases of chronic pain.

First, this approach assumes that we can get rid of chronic pain. The reality, though, is that we can’t get rid of it. This fact is one of the things we mean when we use the adjective “chronic.” The most powerful procedures and medications can only reduce chronic pain, and don’t tend to get rid of it. So, there is no way around the fact that most people with chronic pain go to bed with pain. Even if it’s reduced, pain can continue to disrupt sleep.

Second, even if there was a way to fully cure chronic pain, it still might not be sufficient to overcome insomnia once you have it. Certainly, pain can start a bout of insomnia. However, insomnia is almost invariably maintained by more factors than just pain. One common factor is anticipatory anxiety about experiencing another night of insomnia. As you experience an insufficient amount of sleep night after night, it’s almost inevitable that you’ll start to worry about not sleeping as it comes time to go to bed. The arousal associated with this worry --as a form of anxiety or nervousness – can itself prevent you from falling asleep. In other words, insomnia can come to maintain itself!

Third, anxiety of all types can cause or maintain insomnia. People with chronic pain can become anxious for any number of reasons: loss of work; how to pay the bills; people not understanding what you are going through; loss of social or recreational activities; loss of your role in the family; and so on. People with chronic pain can also have anxiety disorders unrelated to their chronic pain. All of these issues can initiate and/or maintain insomnia.

Indeed, in most people with chronic pain, insomnia has multiple contributing causes. Certainly, pain can be one of those causes, but typically it is not the only cause. Moreover, these multiple contributing causes can come to exacerbate each other, making a vicious cycle of chronic pain and insomnia.

For example, say that chronic pain initially causes insomnia in someone. Over time, the insomnia becomes further complicated by nightly bed-time anticipatory anxiety about not getting enough sleep. At some point, worry sets in about loss of work, medical bills, strained marriage, and so forth. All of these factors come to maintain the insomnia over and above the role that pain has in maintaining insomnia. This chronic lack of sleep further stresses the person’s nervous system, making the reactive nervous system even more reactive. As such, the stress of it all makes the original chronic pain worse via its effects on the nervous system. As a result, we have a vicious cycle of chronic pain causing insomnia, which, in turn, makes the chronic pain worse.

This state of affairs reduces the individual’s ability to cope with pain and any of the other life’s stressors. Chronic pain and chronic insomnia can take its toll on anyone. This decreasing ability to cope fosters a greater sense of stress, which, in turn, elicits further pain and insomnia.

Chronic pain and insomnia are therefore complex phenomena that occur in a cyclical nature.

Therapies to address these problems must reflect this complexity. It just isn’t realistic to think that there can be simple, easy or quick fix to insomnia related to chronic pain.

Therapies for insomnia related to chronic pain

Many people rely on so-called “sleeping pills” to cope with insomnia. These pills are from two classes of medications that are technically called hypnotics (e.g., zolpidem) and benzodiazepines (e.g., diazepam). While common, their use is controversial in the healthcare field.

A number of problems are associated with their use. While providing short-term relief, they do not actually cure insomnia. Upon stopping their use, insomnia typically returns and, in the case of using benzodiazepines, the insomnia typically returns worse than when you initially started the use of the medication (Longo & Johnson, 2000). Moreover, the use of hypnotics has been associated with sleep-walking and other behaviors performed while sleeping (Morganthaler & Silber, 2002). In addition, it’s generally known that both classes of medications aren’t very effective. When compared to placebo, people taking hypnotics fall asleep on average 12.8 minutes sooner and people taking benzodiazepine medications fall asleep 10 minutes sooner (Buscemi, et al., 2007). Lastly, their use reinforces subtle, yet important, beliefs about yourself and your abilities to overcome insomnia. Namely, they foster associations that insomnia is a medical problem and that you need to rely on medicines to resolve this medical problem. In other words, they serve as a nightly reminder that you can’t overcome it yourself. You remain, in a word, helpless and must rely on something external to you (i.e., the pill) to do it for you. Now, of course, no one has these thoughts on an overt basis when going to bed at night after taking these medications. But, these subtle beliefs inevitably come to mind when the prospect of reducing the use of these medications is raised. After their long-term use, people can become quite concerned about reducing their use. The prospect is almost inevitably distressing and leaves people feeling helpless to the return of insomnia. What we are really talking about, here, is a subtle form of psychological dependence – the belief that you need the “sleeping pill” in order to sleep at night.

For all these reasons, the use of hypnotics and benzodiazepines for insomnia is controversial.

Chronic pain rehabilitation providers typically prefer to use a combination of two other types of therapies. These therapies are the use of tricyclic antidepressants and cognitive behavioral therapy.

Tricyclic antidepressants are old style antidepressants that are typically no longer used for depression. They are, however, used for chronic pain and insomnia. One of them, amitriptyline, is one of the most effective pain medications available (Hauser, Wolfe, Tolle, Uceyler, & Sommer, 2012; Wong, Chung, & Wong, 2007). They are also somewhat sedating and so are used at night to aid in falling and staying asleep. They do not produce a sense of dependency as often seen in hypnotics and benzodiazepines.

Cognitive behavioral therapy for insomnia is a short-term psychotherapy, usually provided by the psychologist on the chronic pain rehabilitation team. Cognitive behavioral therapy by itself can resolve insomnia once and for all. It breaks the vicious cycles of insomnia and creates new patterns of sleeping. However, it takes a whole lot more work than taking a pill.

Cognitive behavioral therapy requires a multi-pronged effort over time on the part of the patient. It involves the following:

  • Sleep hygiene changes
  • Regular use of relaxation exercises
  • Regular mild, low impact aerobic exercise
  • Cognitive interventions in which you learn how to overcome worry, or anxious thinking
  • Cognitive interventions in which you change your conceptualization of sleep to a more accurate and healthy understanding
  • Stimulus control (i.e., breaking associations that have developed over time between being in the bedroom and being awake)
  • Sleep restriction (i.e., intentionally limiting when you lay down to sleep or remain asleep in order to develop a normal sleep-wake cycle within the 24-hour day)
  • Tapering hypnotic or benzodiazepine medication use

Cognitive behavioral therapy is generally considered the most effective treatment for insomnia (Mitchell, Gehrman, Perlis, & Umscheid, 2012; Riemann & Perlis, 2009; Smith, et al., 2002; Taylor, Schmidt-Nowara, Jessop, & Ahearn, 2010).

While cognitive behavioral therapy is hard work, it neatly fits into the established protocols of a chronic pain rehabilitation program. As we have discussed in previous posts, chronic pain rehabilitation programs are cognitive behavioral based programs that already involve engaging in regular mild aerobic exercise, regular relaxation exercises, lifestyle changes some of which overlap with fostering sleep hygiene, and cognitive interventions for managing pain which have some overlap with those for managing insomnia.

The right approach for you

Whenever you decide upon a therapy that’s best for you, it is important that you discus it with your healthcare providers and allow them to be part of the decision making process. They are working for you and should have your best interests in mind. They also have an expertise in the field as well as knowledge of you as an individual, which puts them in the best position to advise you on what’s best.

It’s also important to get advice from healthcare providers who practice in the manner that’s right for you. As discussed in a previous blog post, all pain clinics are not alike. There are chronic pain rehabilitation clinics. There are long-term opioid management clinics. There are interventional pain clinics. There are spine surgery clinics. They can all go by the name of a “pain clinic.” Some of these clinics may be more prone to recommend hypnotic or benzodiazepine medications for your insomnia. Some of these clinics, specifically clinics with chronic pain rehabilitation programs, are apt to be more prone to recommend tricyclic antidepressants and cognitive behavioral therapy for your insomnia.  

References

Buscemi, N., Vandermeer, B., Friesen, C., Bialy, L., Tubman, M., Ospina, M., Klassen, T. P., & Witmans, M. (2007). The efficacy and safety of drug treatments for chronic insomnia in adults: A meta-analysis of RCTs. Journal of General Internal Medicine, 22, 1335-1350.

Hauser, W., Wolfe, F., Tolle, T., Uceyler, N. & Sommer, C. (2012). The role of antidepressants in the management of fibromyalgia: A systematic review and meta-analysis. CNS Drugs, 26, 297-307.

Longo, L. P. & Johnson, B. (2000). Addiction: Part 1. Benzodiazepines – side effects, abuse risk and alternatives. American Family Physicians, 61, 2121-2128.

Mitchell, M. D., Gehrman, P., Perlis, M., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: A systematic review. BMC Family Practice, 13, 40.

Morganthaler, T. I. & Silber, M. H. (2002). Amnestic sleep-related eating disorder associated with zolpidem. Sleep Medicine, 3, 323-327.

Riemann, D. & Perlis, M. L. (2009). The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavior therapies. Sleep Medicine Reviews, 13, 205-214.

Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., & Buyesse, D. J. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5-11.

Taylor, D. J., Schmidt-Nowara, W., Jessop, C. A., & Ahearn, J. (2010). Sleep restriction therapy and hypnotic withdrawal versus sleep hygiene education in hypnotic using patients. Journal of Clinical Sleep Medicine, 6(2), 169-175.

Wong, M., Chung, J. W., & Wong, T. K. (2007). Effects of treatments for symptoms of painful diabetic neuropathy: A systematic review. British Medical Journal, 335, 87.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-16-2013

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Insomnia Thu, 17 Oct 2013 07:26:35 +0000
Institute for Chronic Pain - One Year Anniversary https://www.instituteforchronicpain.org/blog/item/120-23institute-for-chronic-pain-one-year-anniversary https://www.instituteforchronicpain.org/blog/item/120-23institute-for-chronic-pain-one-year-anniversary

The Institute for Chronic Pain celebrates this month its one-year anniversary of going live with our website and blog.  The Institute for Chronic Pain is an educational and public policy 'think tank' devoted to changing the culture of how chronic pain is managed. We imagine a day when the management of chronic pain is guided by the principles of empirical-based healthcare (i.e., pursuing only those treatments that research has shown to be effective). Our public face is our website and blog, where we provide academic-quality information that is accessible to patients, their families, as well as providers and third-party payers.

In this last year, our main goal was to establish the website as a leading source of information on chronic pain and its treatments, particularly chronic pain rehabilitation. In this next year, our main goal is to grow our stakeholder community. We want to be a trusted source of high quality information to patients and their families. We also want to increase our presence among the provider and third party payer communities. We expect to provide content by an increasing diversity of experts in healthcare and from academia. Outreach to third party payers will also be essential, providing information on empirically-based treatments for chronic pain.

To these ends, we ask you to become a stakeholder with us in the future of a more effective and cost-effective healthcare system for the management of chronic pain syndromes. Please like us or follow us on:

The more we learn together, the more effective our care will be as providers and consumers of chronic pain management.

In closing this celebration announcement, I'd like to re-post our first introductory blog post (in a slightly edited fashion). Originally published on October 7, 2012, it remains a fresh statement of our guiding vision. Thank you for being a stakeholder in this future.

*     *

Welcome to the Institute for Chronic Pain blog. We appreciate your interest in our organization and issues related to chronic pain management.

Changing the culture of how chronic pain is managed

Our hope with this blog is to create a community of stakeholders in the field of chronic pain management who participate in informed discussion on an array of issues related to the field. The stakeholders in this community are patients and their families, healthcare providers, third party payers, policy analysts, and society generally.

Our mission is to change the culture of how chronic pain is managed in the U. S. and other industrialized societies. Our specific goal is to make chronic pain management more effective and beneficial for the individual patient, their families and society.

It is no small task. The improvement of healthcare for chronic pain patients requires a change in the culture of how chronic pain is conceptualized and treated. Multiple, complex issues must be addressed and resolved.

  • As stakeholders, we need to acknowledge and accept that our healthcare system is expensive and largely ineffective in the treatment of chronic (non-cancer) pain.
  • As stakeholders, we need to recognize that the on-going cause of chronic pain is typically different than the acute pathology that was involved in the initial onset of pain.
  • We need to help stakeholders to understand that chronic pain syndromes are more accurately conceptualized in terms of nervous system dysregulation (e.g., central sensitization reinforced by secondary psychosocial stressors) than in terms of structural or orthopedic pathology.
  • As stakeholders, we need to recognize and accept that at present chronic pain syndromes are truly chronic and typically cannot be cured; we tend to recognize the chronicity of  other chronic conditions, such as diabetes or heart disease, but tend to forget it when it comes to chronic pain.
  • Once accepting the chronicity of chronic pain, we need to stop misleading ourselves (as both patients and providers) by thinking of pain-related interventional and surgical procedures as significantly helpful when in fact they are not.
  • As stakeholders, we need to accept that, on average, long-term opioid management for chronic pain syndromes fail to provide demonstrable reduction in pain or improvement in functioning.
  • As stakeholders, we need to accept that, even when effective for an individual case, long-term opioid management is typically not feasible to continue indefinitely, assuming a normal lifespan; so, unless terminal or elderly, most patients will have to learn how to self-manage pain at some point in their lives.
  • As stakeholders, we need to engage in a frank discussion of whether it is ethical to maintain patients on long-term opioids to the point of developing tolerance to high doses of medications, if the patients still have a long life expectancy ahead of them.
  • As stakeholders, we need to secure a change in reimbursement practices that at present privilege interventional pain management and spine surgery procedures, which are largely ineffective

The list is not exhaustive. However, it does demonstrate that the number of problems within the field of chronic pain management is expansive. It is for this reason that we use the word “culture” in the mission statement of the Institute for Chronic Pain.

To improve the health and well-being of patients with chronic pain syndromes, we need to change not just clinical practice patterns. We need to change the very culture of how we (as patients, providers and third party payers) conceptualize the nature of chronic pain and subsequently provide care for it.

In short, we need to change the paradigm that underlies chronic pain management.

Analogy to the change in our cultural understanding of cigarette smoking

Our current cultural understanding of chronic pain is like how we as a society thought of cigarette smoking forty years ago. In the last forty years or so, cigarette smoking has undergone a paradigmatic change in its cultural understanding. At one point, it was a cool thing to do that had no adverse health consequences. Smoking in public spaces, like the work site or even your healthcare provider’s office, was the norm. Now, cigarette smoking is largely considered by society as a smelly habit that is one of the leading causes of death. It’s almost even hard to imagine now what it was like when people smoked at their desks at work or in the doctor’s office.

A number of factors brought about this change in our cultural understanding. Science identified the adverse health consequences of tobacco use. The science subsequently informed the clinical practice patterns of healthcare providers. Providers began and continued to make recommendations to their patients to stop smoking. Multiple methods to quit smoking were developed and proliferated. Insurance companies started to pay for them and they continue to do so to this day.

Factors outside of the traditional healthcare system had a role too. Educational campaigns and marketing campaigns helped to change how we thought about smoking. They changed our understanding of the facts, as well as our attitudes and values about the facts. Society changed the regulations that impacted both the tobacco industry and societal norms. These regulations changed who could smoke, what they smoked, and where they smoked. Educational, marketing, and regulatory campaigns have had a profound impact on the health of people through changing how we think about smoking.

It might even be reasonable to argue that educational, marketing and regulatory campaigns have had as much if not more impact than the afore-mentioned changes in the healthcare system regarding smoking.

On the one hand, the focus of the traditional healthcare system is on the individual and as such its impact on our cultural understanding of smoking is limited. The progress of health sciences is interesting to only a select few. Changes in clinical practices, such as what gets recommended by healthcare providers, have limited effectiveness. Patients commonly fail to get persuaded by recommendations that differ from what they know. Healthcare providers too commonly fail to adhere to guidelines for recommendations that differ from what they know or were taught in school. Insurance companies and policy analysts are often slow to change their bureaucracies.

On the other hand, educational campaigns, marketing campaigns, and regulatory campaigns reach large numbers of people. They have the capacity to change our cultural understanding of health-related facts and our attitudes about those facts in ways that the individual healthcare provider simply cannot. We see it every day in commercial marketing or public service announcements. They persuade us to buy one product over another or change our attitudes about drugs. When it comes to health-related issues, such campaigns can have a profound impact on our health – even though we don’t typically think of them as part of our healthcare system per se.

All these factors have had an impact in changing the culture of how we think about smoking and what we go on to do when helping people to stop smoking.  They have been largely effective in making a profound and beneficial impact on our health.

The time has come to do the same thing in chronic pain management. We need to change the paradigm of how we think about chronic pain and what we then go on to do when treating it.

It’s here where the Institute for Chronic Pain is going to come into play. We founded the Institute to be a leading voice and propagator of paradigmatic change in the field of chronic pain management.

The management of chronic pain syndromes needs to change. The above-noted bullet items describe a number of ways the field needs to change if it is to have a demonstrable beneficial impact on the health of patients with chronic pain syndromes. The list is not exhaustive. There are more issues than those cited above that highlight a need for change:

  • We need to develop a greater sense of conventional agreement among all stakeholders as to how to best treat chronic pain, as there is little to no such agreement currently, even for common chronic pain conditions, like chronic low back or neck pain, fibromyalgia, or chronic daily headaches.
  • Among all stakeholders, we need to develop conventional agreement in how to conceptualize the nature of chronic pain, as presently there is no such agreement.
  • Given this lack of agreement, the care that patients receive is based largely on the specialist to whom they get referred and as a result care tends to be a hodge-podge mix of different therapies, even across patients with the same condition.
  • We need to acknowledge that treatment recommendations, which patients receive, are largely based on tradition and not on a careful allegiance to what science tells us is most effective.
  • We need to acknowledge that, in addition to tradition, profit motive can affect treatment recommendations in ways that fail to adhere to what science tells us is the most effective.

The Institute for Chronic Pain was founded to help change the culture of how we think about chronic pain and how we deliver care to patients with chronic pain syndromes. In short, we developed the Institute to help change the culture of how chronic pain is managed. In the process, our aim is to develop consensus among the lay public, patients, providers, third party payers, and public policy analysts as to a) how to conceptualize chronic pain and b) how to most effectively treat it.

Goals of the Institute for Chronic Pain

The Institute has set out a number of methods for achieving the resolution of these goals.

  • We provide a free health information website that provides academic-quality information which is also approachable and understandable by the lay public, patients, third party payers, and policy analysts.
  • We provide this blog through our website.
  • We promote traditional media communications on the nature of chronic pain and its most effective treatments vis-à-vis conference presentations, video presentations, academic journals and newsletters, books, and white papers.
  • We promote traditional educational and marketing campaigns to change our cultural understanding of chronic pain and how to best treat it.
  • We provide fee-based education and consultation to the lay public, patient advocacy groups, healthcare provider groups, and third party payers.
  • We maintain financial independence from pharmaceutical and medical technology industries for the on-going operations of the Institute.
  • We rigorously adhere to the principles of empirical based healthcare (i.e., using science to inform us about what works and what doesn’t work in healthcare, and using this information to guide treatment decisions).
  • We rigorously adhere to the guiding values of integrity, transparency, excellence, concern for the health and welfare of patients, and social responsibility.

Through commitment to these methodologies, the Institute plans to change how the healthcare community and its patients conceptualize and treat chronic pain.

We hope that you will join us in this endeavor. Join our community and be part of this change.

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Author: Murray J. McAllister, PsyD

Date of last modification: 10/7/2013

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) News & Recent Events Mon, 07 Oct 2013 06:53:07 +0000
September is Pain Awareness Month https://www.instituteforchronicpain.org/blog/item/119-22september-is-pain-awareness-month https://www.instituteforchronicpain.org/blog/item/119-22september-is-pain-awareness-month

September is Pain Awareness Month! It is a special month for us at the Institute for Chronic Pain (ICP). The theme of the month is one of the central goals of our mission. Specifically, our mission is to change the culture of how chronic pain is treated by promoting the theory and practice of chronic pain rehabilitation.

We raise awareness of the numerous personal, systemic, and societal issues related to chronic pain with the long-term goal of making the management of chronic pain more effective and cost-effective.

It’s no small task. Indeed, a critic might charge that we are pie-in-the-sky dreamers. However, the status quo is not acceptable.

And what is the status quo when it comes to chronic pain management? Consider these facts about the current state of affairs in the U.S.

  • The U. S. consumes 80% of all opioid medications prescribed in the world (Manchikanti & Singh, 2008).
  • The rate of spine surgery has been steadily and significantly increasing  over the last thirty years (Nilasena, Vaughn, Mori, & Lyon, 1995; Rajaee, Bae, Kanim, & Delamarter, 2012; Weinstein, et al., 2006).
  • The increase in the rate of interventional pain procedures has been described as “explosive” over the first decade of this century (Manchikanti, Pampati, Falco, & Hirsch, 2008).
  • Pain-related conditions remain the most common reason for disability and the rate of disability continues to increase (CDC, 2011).

Obviously, all this pharmacological, surgical, and interventional care is not helping.

Maybe, it is because as a society we are treating chronic pain in the wrong way. What if even the ways we think about the nature of chronic pain are wrong?

The ICP was founded and developed to resolve these issues. We attempt to foster consensus among the patients, providers, third-party payers, and public policy makers as to how to most accurately conceptualize chronic pain and how to most effectively treat it. We aim for everyone to more accurately understand that the nature of chronic pain is a biopsychosocial condition.

The leading scientific research clearly shows us that chronic pain is a nervous system condition that is biopsychosocial in nature, not an orthopedic condition (see, for examples, Apkarian, Baliki, & Geha, 2009; Baliki, et al., 2006; Chapman, Tuckett, & Song, 2008; Curatolo, Arendt-Nielsen, & Petersen-Felix, 2006; Meeus & Nijs, 2007; Woolf, 2011; Wieseler-Frank, Maier, & Watkins, 2005; Yunus, 2007).

Moreover, a large number of studies over multiple decades show consistent findings that chronic pain rehabilitation, an interdisciplinary therapy that focuses on down-regulating the nervous system, is the most effective form of chronic pain management (see, for examples, Flor, Frydrich, & Turk, 1992; Gatchel & Okifuji, 2006; Guzman, et al., 2001; Hoffman, Papas, Chatkoff, & Kerns, 2007; Turk, 2002).

At the ICP, we aim to tell the story of both these facts and do so in a way that’s credible and understandable to everyone. Thanks for supporting us!

References

Apkarian, A. V., Baliki, M. N., & Geha, P. Y. (2009). Towards a theory of chronic pain. Progress in Neurobiology, 87, (2), 81-97.

Baliki, M. N., Chialvo, D. R., Geha, P. Y., Levy, R. M., Harden, R. N., Parrish, T. B., & Apkarian, A. V. (2006). Chronic pain and the emotional brain: Specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. Journal of Neuroscience, 26, 12165-12173.

Center for Disease Control. (June 21, 2011). 47.5 million U. S. adults report a disability; arthritis remains most common cause. Retrieved September 22, 2013, from http://www.cdc.gov/features/dsadultdisabilitycauses/.Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: Reciprocal neural, endocrine and immune interactions. 

Journal of Pain, 9, 122-145. Curatolo, M., Arendt-Nielsen, L., & Petersen-Felix, S. (2006). Central hypersensitivity in chronic pain: Mechanisms and clinical implications. Physical Medicine and Rehabilitation Clinics of North America, 17, 287-302.

Flor, H., Frydrich, T., & Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49(2), 221-230.

Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Guzman, J., Esmail, R., Karjalainen, K., Malmivaara, A., Irvin, E., & Bombardier, C. (2001). Multidisciplinary rehabilitation for chronic low back pain: Systematic review. BMJ, 322(7301), 1511-1516.

Hoffman, B. M., Papas, R. K., Chatkoff, D. K., & Kerns, R. D. (2007). Meta-analysis of psychological interventions for chronic low back pain. Health Psychology, 26(1), 1-9. doi: 10.1037/0278-6133.26.1.1.

Meeus M., & Nijs, J. (2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Journal of Rheumatology, 26, 465-473.

Manchikanti, L., Pampati, V., Falco, F. J., & Hirsch, J. A. (2013). Growth of spinal interventional pain management techniques: Analysis of utilization trends and Medicare expenditures 2000 to 2008. Spine, 38(2), 157-168.

Manchikanti, L., & Singh, A. (2008). Therapeutic opioids: A ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician, 11(2suppl), S63-S88.

Nilasena, D. S., Vaughn, R. J., Mori, M. & Lyon, J. L. (1995). Surgical trends in the treatment of diseases of the lumbar spine in Utah’s Medicare population, 1984-1990. Medical Care, 33(6), 585-597.

Rajaee, S. S., Bae, H. W., Kanim, L. E., & Delamarter, R. B. (2012). Spinal fusion in the United States: Analysis of trends from 1998 to 2008. Spine, 37(1), 67-76. doi: 10.1097/BRS.0b013e31820cccfb.

Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

Weinstein, J. N., Lurie, J. D., Olson, P., Bronner, K. K., Fisher, E. S., & Morgan, T. S. (2006). United States trends and regional variations in lumbar spine surgery: 1992-2003. Spine, 31(23), 2707-2714. doi: 10:1097/01.brs.0000246132.15231.fe.

Wieseler-Frank, J., Maier, S. F., & Watkins, L. R. (2005). Immune-to-brain communication dynamically modulates pain: Physiological and pathological consequences. Brain, Behavior, & Immunity, 19, 104-111.

Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152 (3 Suppl), S2-15.

Yunus, M. B. (2007). The role of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain. Best Practice Research in Clinical Rheumatology, 21, 481-497.

 

Author: Murray J. McAllister, PsyD

Date of last update: September 23, 2013 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Pain Awareness Month Mon, 23 Sep 2013 06:52:17 +0000
Fear-Avoidance of Pain https://www.instituteforchronicpain.org/blog/item/118-21fear-avoidance-of-pain https://www.instituteforchronicpain.org/blog/item/118-21fear-avoidance-of-pain

There’s a divide between chronic pain experts and their patients that rarely gets crossed. The divide centers on the issue of fear-avoidance of pain. 

On one side of the divide, among chronic pain experts, fear-avoidance is one of the most well established facts about chronic pain and chronic pain-related disability. Over more than a decade, researchers and clinicians have extensively studied fear-avoidance and almost every month another study on it gets published in the professional journals. As such, it’s a well established fact among chronic pain experts. On the other side of the divide, it’s rare to find a chronic pain patient who has ever heard of it.

It’s a strange state of affairs that goes on between chronic pain providers and their patients. We know something important about chronic pain and chronic pain-related disability and our patients don’t know it. And yet, it goes unsaid. You’d think that everyone involved would want it shared. But, still, it doesn’t.

While I’ve never seen a study that could shed light on why the divide occurs, I have some thoughts about it. There are actually two reasons, but they go hand in hand.

First, we don’t share what we know about fear-avoidance because we aren’t very good at teaching patients (and maybe even the public) about what chronic pain is. Patients (and the public) commonly consider the sensation of pain as solely and only a physical sensation. As such, it’s thought that psychological aspects have very little to do with the sensation of pain itself. At most, the psychological aspects of pain are thought of as consequences of pain – that the distressed thoughts and moods, like fear, and the behaviors that go along with them are really just reactions to the physical sensation of pain. As chronic pain experts, though, we know that it isn’t true. While it requires and involves a physical sensation, to be sure, the experience of pain also inherently involves unpleasant and distressing thoughts, feelings, and behaviors. Any explanation of fear-avoidance requires this understanding of chronic pain – that it is more than simply and only a physical sensation. However, it is hard to communicate this notion. It’s difficult to teach patients to expand their understanding of chronic pain and incorporate its inherent cognitive, emotional, and behavioral components. Moreover, besides being hard to communicate, it has to be communicated well – with compassion and sensitivity -- in order for most patients to succeed in understanding the true nature of chronic pain. This point leads us to the second reason for the great divide between chronic pain experts and their patients.

Second, to be frank, there can be a little pushback from patients when it comes to explaining that chronic pain is more than simply a physical sensation and that it in fact involves psychological as well as medical aspects. Frank discussion of the inherent psychological aspects of chronic pain can tend to get inhibited because it opens up the possibility of critical judgment and stigma by others. It’s safer to insist that chronic pain and its related difficulties are solely and only physical because in our society it is acceptable if you struggle with a medical condition. It’s not acceptable to acknowledge that you’re psychologically struggling. Consequently, and understandably, patients can resist coming to understand how chronic pain is inherently both a medical and a psychological condition – what healthcare providers call a biopsychosocial condition.

This resistance reinforces any unwillingness of healthcare providers to bring up the notion of fear-avoidance because it assumes a foundational understanding that chronic pain is both a medical and a psychological condition. To convey the latter, though, as indicated, it’s hard work. To succeed in doing so, it requires a high level of skill on the part of healthcare providers – a degree of interpersonal compassion and sensitivity. It also involves a level of interpersonal skill on the part of the patient – the ability to develop a safe, trusting relationship in which the patient can be assured that no critical judgment will occur.

Fear-avoidance is therefore a sensitive issue, which challenges the skills of both chronic pain experts and patients, if we are to ever bring it up. We have to admit that providers have a hard time talking about it and patients tend to have a hard time hearing about it. So, we avoid the topic. It’s a bit ironic: we avoid discussions of fear-avoidance. The great divide in knowledge and understanding subsequently continues.

If you’re game to talk about it, though, I’m game. Let’s give it a try.

There’s significant benefit if we can pull this off. As chronic pain experts, we know that fear-avoidance is one of the most important factors that lead to chronic pain-related disability (Crombez, Vlaeyen, Heuts, & Lysens, 1999; Leeuw, et al., 2007; Vlaeyen & Linton, 2012). If you can learn about it, and acknowledge it when it occurs, then you can begin to challenge it and change it. It’s not an exaggeration to say that overcoming fear-avoidance is essential if you want to self-manage pain successfully. It’s really that important. So, let’s talk about it. Ready?

Fear-avoidance defined

Pain is a naturally unpleasant and distressing experience. We don’t laugh or jump up and down for joy when in pain. Rather, we cry and become alarmed. Pain captures our attention and our thoughts become concerned about it. We think about what’s causing it and how to get rid of it. Emotionally, we are alarmed and distressed. These cognitive and emotional aspects to the experience motivate us to get help, stop the pain, and avoid it again in the future.

These ways of experiencing pain and reacting to it are not chosen or the result of intentional decisions. When in pain, we don’t intentionally decide to perceive it as unpleasant or distressing, and subsequently begin to cry and emotionally become alarmed. Moreover, we don’t typically choose how we are going to think about pain and how we might make sense of it. Rather, pain just is inherently emotionally distressing and alarming. As such, even though we can tend to think of it as solely a physical sensation, we cannot wholly divorce the sensation of pain from how we perceive it, cognitively and emotionally. The cognitive and emotional distress is just part and parcel of the experience of the sensation. The whole experience also involves behaviors that are indicative of being in pain – the grimacing, verbal expressions, guarding, and the like. None of these behaviors are typically thought of as chosen behaviors. Subsequently, we might say that all these cognitive, emotional, and behavioral aspects to the experience of pain are automatic or reflexive.

Let’s take an example. Consider what happens when you burn your hand on the stove. Behaviorally, you reflexively pull your hand away and guard it. Tears might come to your eyes and you might exclaim all sorts of utterances. Cognitively, your thoughts are focused on the pain and what to do about it. Emotionally, you are upset and alarmed. Your emotional distress motivates you to act. It also motivates you to be careful next time. Later, you’ll apt to be apprehensive and take steps to avoid getting burned again.

Experts in chronic pain management call this constellation of cognitive, emotional, and behavioral components to the experience of pain, “fear-avoidance.”

Fear-avoidance is all well and good in an acute injury. It’s an adaptive and helpful response. It helps us to get better and avoid future injury.

What’s good for an acute injury, however, is not always good for chronic pain. Persistent fear-avoidance in chronic pain leads to persistent emotional distress and impairments in activities. In other words, chronic fear-avoidance is one of the most important factors that lead people with chronic pain to become disabled.

If, like the alarming nature of acute pain, chronic pain remains alarming indefinitely, then the natural reaction to pain is to always try to stop it or get rid of it. Since, though, the pain is chronic, there’s not much the typical chronic pain patient can do to stop it. Of course, there are medications and various kinds of therapies, but at best these approaches only reduce pain. It can then seem like the only thing that’s left to do is to stop doing activities that make pain worse.

If work makes your pain worse, and you struggle to tolerate it, coming home distraught by the pain night after night, then it can seem reasonable to conclude that maybe you shouldn’t go to work anymore. If the pain of sitting in the bleachers at your child’s sporting event or musical performance was too excruciating the last time you went, then you might find yourself making the tough decision to stay home tonight instead. Over time, you can come to anticipate when pain is going to become too overwhelming and consequently avoid those activities too. You end up declining invitations to the extended family reunion, the weekend trip that includes the long car ride, the outing to the amusement park, or other similar activities. All these examples are examples of fear-avoidance of pain and its associated activities.

Notice that inherent in all these examples is that pain is something that’s concerning and distressing, which then leads to not doing the activities that bring on pain. For after all, if, when doing some activity, the pain wasn’t alarming, then we’d say the pain was tolerable and we’d keep doing the activity. The pain would still be there, of course, but we’d do the activity without any concern or sense of alarm about it. In the examples above, though, the pain involved in the activities is distressing and alarming and so the activities are stopped. In the short hand of pain experts, these examples involve fear-avoidance of pain and the activities associated with pain.

What it all comes down to is that, when it comes to chronic pain-related disability, the cognitive, emotional, and behavioral aspects of the experience of pain are the most important components, not the actual physical sensation. It’s the sense of alarm that is the tipping point and stops people from doing things. Of course, the sensation plays a role, but without the sense of alarm – the cognitive and emotional ways of perceiving the sensation – the sensation itself would be tolerable and there’d be no need to avoid or otherwise stop the activity.

Now, here is where patients can start to get a little uncomfortable.

Common patient reactions to the notion of fear-avoidance

When first hearing about fear-avoidance, a common reaction among patients is something like the following: “It’s not my emotional or behavioral reactions to pain that disable me, it’s the physical pain!” The sentiment involves a concern for being judged and also being a little put off. Both sentiments are understandable.

At the end of the day, though, is it accurate and is it necessary? Would the patient be better off by coming to understand the truth about fear-avoidance and then learning how to overcome it? Let’s take a close look at these issue.

As suggested above, the point of the resistance to fear-avoidance is really two-fold, but they go hand in hand. First, it is an assertion about what pain is – that pain is a physical sensation that is wholly different from any cognitive, emotional, and behavioral factors related to pain. Second, it is an assertion that if psychological aspects of the experience of pain are acknowledged, then they open up chronic pain patients to the potential shame of stigma and the critical judgments of others. The two assertions work hand in hand because insistence on the notion that pain is solely and only a physical sensation puts it into the medical category of conditions and it is typically socially acceptable to be disabled from medical problems. But, if we acknowledge that there are psychological aspects to the pain experience, then we run the risk of putting it into the psychological category of conditions, and it just isn’t acceptable to be disabled by psychological problems.

As we said, it’s a sensitive issue.

Any response to this common patient reaction requires, not only an expert understanding of what chronic pain is, but also a deep level of compassion and sensitivity in order to convey this understanding to patients, making it okay enough for them to acknowledge and learn from.

Let’s try to show how it might just be true that the psychological aspects of the experience of pain are more important than the physical sensation, especially when it comes to chronic pain-related disability.

Consider, for the moment, two patients with chronic low back pain, Mr. Smith and Ms. Jones. Let’s further suppose that they each have the same exact degenerative changes in their lumbar spine, as evidenced by recent scans. Over the last month, each of their pain has been worsening.

Mr. Smith has been told and therefore believes that the degenerative changes in his spine are inevitably progressive. He conceptualizes his condition as that his ‘discs are degenerating.’ He believes (and may have been told) that given the degenerative nature of his condition he will likely end up in a wheelchair someday. During the last month, his pain has been worsening and he takes it as evidence of his inevitably degenerating condition. This perception of his pain is alarming. Out of this resultant fear, he responds with rest and inactivity. From his perspective, it makes all the sense in the world to rest and remain inactive. Given his understanding of his pain as the result of a fragile orthopedic condition that is inevitably getting worse, he reasons that he needs to not engage in activities as a means to prevent, or at least slow down, the degenerative process in his spine. Just as you wouldn’t walk on a broken leg, rest and not doing too much seems like the best approach for his condition. He rates his pain as intolerable.

Ms. Jones has been told that she has degenerative changes in her spine, but she has also been told it is normal for a person of her age. It was explained to her that the term ‘degenerative disc disease’ is actually a misnomer and that we now know it really isn’t degenerative or a disease. We know, for instance, that most of the time degenerative changes of the spine get better, not worse, and even in those situations where they don’t get better, they almost always stay the same. It was explained to her that chronic pain is actually a complex condition and that her pain is only partly attributable to her stable degenerative changes in spine. The overall state of her nervous system, in terms of central sensitization, and external stressors, can also play a role in maintaining her chronic pain.

Ms. Jones has taken these lessons to heart and is confident that she knows what her pain is and that it is chronic and stable. She has so fully accepted it that it no longer alarms her. She knows that reasonable activities are not going to make her stable degenerative changes worse. She’s identified for herself that if she stays home when having a bad pain day she has nothing to do but focus in on how much pain she has. As a result, her response to pain is to get up and go do something. Of course, she’s reasonable about it and she paces herself when needed. Nonetheless, she sees staying active and productive as ways to cope with pain. Because she knows her degenerative condition is stable, she reasons that the increase in pain over the last month isn’t due to a worsening of her spinal condition and subsequently looks to other reasons for the pain increase. She recognizes that the increase in pain corresponds, for instance, to the last few months of poor sleep and, sometimes, outright insomnia. She knows that her poor sleep is itself due to the stress of some recent family issues -- one of her children is going through a difficult divorce and her grandson, from another one of her children, was recently diagnosed with autism. She recognizes that her increased pain is due to the stress of these family issues and the resulting insomnia. So, she sets out to take better care of herself and manage her stress better. She notes that her pain has increased but it still remains tolerable.

Mr. Smith and Ms. Jones have the same degenerative condition and, we assume, the same physical sensation. However, how they make sense of it is very different. How they feel about it is very different. How they behaviorally cope with it is very different. Mr. Smith experiences pain through the lens of it being indicative of a threatening condition that’s inevitably going to bring about severe impairments. Ms. Jones sees her pain as indicative of a benign and stable condition. She also recognizes that she has some control over how much pain she has by managing the state of her nervous system and how much stress she has. Mr. Smith sees his pain as largely out of his control. Mr. Smith’s moods are mostly fear-based. Ms. Jones is mostly confident. Mr. Smith engages in passive coping strategies of rest and inactivity. Ms. Jones engages in active coping strategies of remaining active, productive, and often getting out of the house. Mr. Smith experiences his pain as intolerable. Ms. Jones still rates her pain as tolerable, even though it has increased over the last month.

Mr. Smith, we might say, is fear-avoidant. Ms. Jones is not.

While hypothetical, the case examples show how it is possible that the psychological components to the experience of pain can make all the difference. The physical sensation, we assume, remains constant across both individuals. However, the beliefs about the sensation, the quality of the attention given to it, the mood states that occur during the sensation, and the behavioral responses to it, all have a reciprocal affect on the quality and intensity of the overall experience of pain.

In one instance, these psychological components make the pain intolerable and impairing. In the other instance, the psychological components make the pain tolerable and she refrains from becoming disabled.

A vast array of experimental and clinical research supports our hypothetical cases. Of course, a review of the biopsychosocial nature of chronic pain is beyond the scope of this blog post. I’d refer the reader, though, to any of the numerous reviews of the matter (e.g., Bushnell, Ceko, & Low, 2013; Linton, 2000). You’ll find that beliefs, particularly beliefs of the threatening nature of pain, can influence the self-rated unpleasantness and intensity of pain (Gracely, et al., 2004). It’s well established that people rate their pain as worse when they believe it’s somehow threatening to them, than if they believe it’s benign, even when the painful stimuli is held constant across both groups. You’ll find that it is well established that pain is worse when your attention is focused on it than when your attention is distracted (Bantick, et al., 2002; Eccleston & Crombez, 1999). It’s well established that people with negative mood states will have higher pain ratings than people with more positive mood states, again, even when the painful stimuli is held constant (Tang, et al., 2008; Villemure & Bushnell, 2009; Wiech & Tracey, 2009; Wiech, Ploner, & Tracey, 2008). It’s also well established that people who engage in passive coping strategies, such as rest and inactivity, tend to have higher rates of pain and disability than those who don’t (Jensen, Turner, Romano, & Karoly, 1991; Samwel, Evers, Crul, & Kraaimaat, 2006).

In all, there’s just no getting around the fact that the nature of chronic pain is such that it has both physical and psychological aspects inherent to it. The notion that pain is solely a physical sensation that can be wholly divorced from cognitions, emotions, and behaviors is just not true. In fact, like in the case of fear-avoidance, the psychological components can make all the difference in what makes pain tolerable or not.

As chronic pain experts, we need to find a way to routinely educate patients and the public about the true biopsychosocial nature of chronic pain. We also need to be able to do it well – with compassion and sensitivity. We need to understand why patients might tend to resist what we take as established truth. It’s because of stigma. It’s because in this day and age it is still not socially acceptable to see chronic pain as a psychological condition, even if it is only in part psychological. We need to be able to develop trusting relationships where the truth can be told and discussed, and patients remain accepted and respected.

Patients too need to practice having the ego strength to acknowledge this truth and do so without shame. You don’t have to buy relief from stigma by insisting on something that’s not true – the belief that chronic pain is solely and only a physical sensation that is separable from any psychological factors. The challenge is to practice remaining confident that you are doing nothing that’s worthy of criticism. We might rightfully judge and criticize someone who lies, cheats, or steals. But, we don’t judge or criticize those who struggle to cope with any of life’s psychological problems, chronic pain included.

Indeed, if we all could overcome stigma, then healthcare providers could openly talk about the well established psychological aspects of chronic pain, such as fear-avoidance, and our patients could openly hear it. Together, we could make significant progress in helping people to learn to live well despite having chronic pain. In so doing, we could bridge the divide that has prevented us from acknowledging what we all know is true.

References

Bantick, S. J., Wise, R. G., Ploghaus, A., Clare, S., Smith, S. M., & Tracey, I. (2002). Imaging how attention modulates pain in humans using functional MRI. Brain, 125(2), 310-319.

Bushnell, M. C., Ceko, & Low, L. A. (2013). Cognitive and emotional control of pain and its disruption in chronic pain. Nature Reviews Neuroscience, 14(7), 502-511.

Crombez, G., Vlaeyen, J. W., Heuts, P. H., & Lysens, R. (1999). Pain-related fear is more disabling than pain itself: Evidence on the role pain-related fear in chronic back pain disability. Pain, 80(1), 329-339.

Eccleston, C. & Crombez, G. (1999). Pain demands attention: A cognitive-affective model of the interruptive function of pain. Psychological Bulletin, 125(3), 356-366.

Gracely, R. H., Geisser, M. E., Giesecke, T., Grant, M. A., Petzke, F., Williams, D. A., & Clauw, D. J. (2004). Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain, 127(4), 835-843.

Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: A critical review of he literature. Pain, 47(3), 249-283.

Leeuw, M. Goossens, M. E., Linton, S. J., Crombez, G., Boersma, K., & Vlaeyen, J. W. (2007). Fear-avoidance model of chronic musculoskeletal pain: Current state of scientific evidence. Journal of Behavioral Medicine, 30(1), 77-94.

Linton, S. J. (2000). A review of psychological risk factors in back and neck pain. Spine, 25(9), 1125-1156.

Samwel, H. J., Evers, A. W., Crul, B. J., & Kraaimaat, F. W. (2006). The role of helplessness, fear of pain, and passive pain-coping in chronic pain patients. Clinical Journal of Pain, 22(3), 245-251.

Tang, N. K., Salkovskis, P. M., Hodges, A., Wright, K. J., Hanna, M., & Hester, J. (2008). Effects of mood on pain responses and pain tolerance: An experimental study in chronic back pain patients. Pain, 138(2), 392-401.

Vlaeyen, J. W. & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153(6), 1144-1147.

Villemure, C. & Bushnell, M. C. (2009). Mood influences supraspinal pain processing separately from attention. Journal of Neuroscience, 29(3), 705-715.

Wiech, K., & Tracey, I. (2009). The influence of negative emotions on pain: Behavioral effects and neural mechanisms. NeuroImage, 47(3), 987-994.

Wiech, K., Ploner, M. & Tracey, I. (2008). Neurocognitive aspects of pain perception. Trends in Cognitive Sciences, 12(8), 306-313.

Author: Murray J. McAllister, PsyD

Date of last modification: 9-9-2013

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Fear Avoidance Mon, 09 Sep 2013 19:03:45 +0000
Finding Hope in Acceptance https://www.instituteforchronicpain.org/blog/item/117-20finding-hope-in-acceptance https://www.instituteforchronicpain.org/blog/item/117-20finding-hope-in-acceptance

At first thought, it might seem ridiculous to accept that your pain is chronic. When I bring it up with patients, many of them tell me, not without irritation in their voice, “I’ll never give up hope of finding someone who can fix me!” Indeed, it’s common to think that accepting the chronicity of your pain is the same thing as giving up hope that you’ll ever get better.

So, why in the world would you ever want to accept that your pain is chronic?

Contrary to what you might think, accepting that your pain is chronic is the first step in actually getting better. It opens up a whole new way of getting better, a way that takes into account the realities of your pain condition. As such, it’s a new and more realistic way to have hope.

To understand the point more clearly, let’s briefly review two different models of healthcare – two different ways that we get better when having an illness or injury. These two models are what we might call the ‘acute medical model’ and the ‘rehabilitation model.’ The latter is sometimes called the ‘self-management model.’ (For a more thorough review of these models of healthcare, click on this post here.)

Acute Medical Model

The acute medical model of healthcare is what most of us think of when we go to see a healthcare provider. When sick or injured, we go to a provider who determines what’s wrong and provides a treatment that cures us. The healthcare provider is an expert who usually knows more about the condition and the treatments than we do. The treatments themselves are usually medications or procedures that act on us. We don’t typically get better by doing things ourselves. Rather, it’s the treatments that get us better and we rely on healthcare providers to provide us with those treatments. Lastly, getting better in the acute medical model is usually thought of as getting cured. We return to our usual state of health -- how we were before we became ill or injured.

Hope of getting better within the acute medical model lies in finding the right healthcare provider who knows what’s wrong and knows how to cure you. In this model, hope lies external to you. You find it in the expertise and treatments of a healthcare provider.

Now there’s nothing wrong with the acute medical model. It’s all well and good when we have a condition for which there actually is a cure. Indeed, it’s likely the best thing to do. But, what do you do when you have a condition for which there is no cure?

Rehabilitation Model

The answer to the question, of course, isn’t to give up hope and do nothing. There’s actually a different way of getting better. It’s the rehabilitation model of care. It requires, however, redefining how to get better and even redefining what it means to get better.

In the rehabilitation model of care, the emphasis is on what you, the patient, do to get better -- not on what the healthcare provider does to get you better. Specifically, the focus is on the patient acquiring the abilities to make healthy changes, which, when done over time, have a positive impact on the chronic health condition that you have. These changes fall into two categories: a) changes in health behaviors, or what’s often referred to as lifestyle change, and b) changes in coping, or what’s often referred to as stress management. The goal of learning and engaging in these health behaviors over time is two-fold: you reduce the symptoms of the condition and you reduce the impact that the chronic health condition has on you. In other words, you get so good at self-managing the condition that it no longer is as problematic as it once was. As a consequence, you can move on with the rest of your life, engaging in the meaningful activities of life – such as work, family activities, social and recreational activities.

Notice that the rehabilitation model doesn’t promise a cure. The reason is that the conditions for which the rehabilitation model is best suited are those conditions that are chronic. They have no cure. Nonetheless, the patient does get better in very real and meaningful ways.

Notice too that hope gets redefined. It allows for having hope even when there is no cure. Finding a cure is not the only way to get better. Therefore there’s still hope. It’s just a different way to have hope, a hope that realistically takes into account the chronic nature of the condition you have, but nonetheless points to how to how you still can get better.

The conditions for which the rehabilitation model is best suited are chronic conditions, where there is no cure, such as chronic pain syndromes, diabetes, heart disease, and spinal cord injuries, among others.

Finding Hope in Acceptance

Acceptance that your pain is chronic is the first step in pursuing the rehabilitation model of care. Rehabilitation is hard work. It also takesFinding Hope in Acceptance time. You don’t do it if you think that a cure is just around the corner. Once you recognize, though, that your chronic pain really is chronic, it becomes your life-saver – or life-retriever. You start to get your life back. You learn how to self-manage your pain and you practice it to the point that you move on with the rest of your life. Your life doesn’t have to be about chronic pain.

Patients can keep their life on hold when they insist on finding hope only in a cure. They seek out appointment after appointment, attempting to find the right specialist who will know what to do to make their pain go away. Oftentimes, they seek out surgeries or interventional procedures that seem as if they might be a cure, but aren’t. Each time they seek out a new specialist, there is hope. Each time, though, it gets dashed because there really is no cure for chronic pain. Chronic pain really is chronic.

The point, here, is not a criticism of such patients. What we are describing makes sense if you think of healthcare as only the acute medical model. If we think of healthcare providers as specialists who fix us when sick or injured, it makes all the sense in the world to look for the right one who can do the job – even if you have to try one after another. It’s a hard lesson to learn when realizing that it’s only sometimes that healthcare providers act like a mechanic. A lot of the time, we have no fixes. So, again, I’m not judging when I describe patients who fail to accept that their pain is chronic.  We can all understand how it happens. They are trying to find hope in a cure.

What if, though, at the end of the day, the hope is really a false hope? It can become a vicious cycle that leads to depression and oftentimes more pain. Hope is found with each new procedure, but each procedure fails to cure the pain and so hope is dashed. If hope is defined by finding a cure, and if there really is no cure, then you are left helpless – and hopeless.

Maybe it’s best to find a new way to have hope.

You find it by accepting that chronic pain really is chronic. You accept that you are not going to get better by finding a cure. Rather, you accept that you are going to get better by learning to self-manage it. You learn how to make healthy changes in your life that, when done over time, reduce your symptoms and reduce the impact that chronic pain has on your life. You get so good at managing chronic pain that it is no longer the preoccupying problem that it once was. Your life consists of the stuff of life and chronic pain comes along for the ride, but remains in the side car.

It’s okay if you don’t know how to do it yet. Most patients have to learn how to do it. Oftentimes, I remind patients that you’re not born with the knowledge of how to self-manage pain successfully. People have to learn it. And it’s okay if you don’t know how and have to learn it.

What matters, though, is that you learn how. It’s possible to learn how to self-manage pain and do it successfully. People learn how to do it everyday in chronic pain rehabilitation programs. And you can too.

You just have to first accept that your chronic pain is really chronic.

(For more information, please see: "What is chronic pain?""Why the healthcare system refuses to accept the chronicity of chronic pain" or "What is Cognitive Behavioral Therapy for Pain?")  

Date of publication: August 26, 2013

Date of last modification: September 13, 2022

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Acceptance Mon, 26 Aug 2013 06:31:12 +0000
Memory Problems and Chronic Pain https://www.instituteforchronicpain.org/blog/item/116-19memory-problems-and-chronic-pain https://www.instituteforchronicpain.org/blog/item/116-19memory-problems-and-chronic-pain

Half jokingly, patients with chronic pain can sometimes start to wonder whether they are coming down with Alzheimer’s. They don’t seem to remember anything anymore. Besides memory problems, it can be hard to concentrate, multi-task, and find the right word to use – that experience when the word you want to use is “on the tip of your tongue.” People with fibromyalgia have even given these problems a nickname – “fibro fog” – as in when your head is in the clouds.

More professionally, we might call these problems “mild cognitive problems” or “mild cognitive deficits.” The term “cognitive,” of course, comes from the noun “cognition,” which is a catchall term for types of thinking, such as concentration, memory, multi-tasking, use of language, etc. The use of the term “mild” is not meant to minimize the extent of these problems, as patients can report them to be quite problematic. Rather, the use of the term is common among healthcare providers because it contrasts the extent of these problems with people who typically have more severe cognitive deficits, such as those with traumatic brain injuries or dementia.

So are the memory problems that seem to go along with chronic pain real? What’s the connection between chronic pain and memory problems?

Is the connection real?

Over the years, healthcare providers have asked themselves this question and scientists have put it to the test. There’s a couple of ways of going about doing it. It takes a little bit of explaining first.

One way researchers determine whether the reports of memory problems are real is to use psychological tests of memory. They test a large group of patients with chronic pain and they test a large group of people without chronic pain. Next, they compare the average scores of both groups. If the average score of the chronic pain group is significantly different (and worse) then the average score of the group without chronic pain, then they conclude that the memory problems of the chronic pain patients are real.

Another way researchers can determine whether the memory problems of chronic pain patients are real is to take studies like those described above and combine them into one super large study. They find the studies published in professional journals. They do a systematic search for all such studies and then combine them. This type of study is called “a meta-analysis.” Meta-analyses are thought to be the most valid kind of study because it combines many studies, any one of which in isolation may have produced erroneous results. In other words, in science, large studies are better, because any potential errors that can occur along the way get watered down by the large number of studies and don’t throw off the main results.

A meta-analysis on the relationship between memory problems and chronic pain is what Berryman, et al. (2013), published in this month’s issue of Pain, a leading professional journal in the field of pain management. They combined 24 studies that tested the memory abilities of people with chronic pain and compared them to the memory abilities of people without chronic pain. They found a consistent, moderate deficit in what’s called ‘working memory’ for people with chronic pain.

Working memory is the ability to hold information in mind in order to do something. It involves short-term memory, attention, and information processing. You use working memory when deciding upon doing something and setting out to do it, such as when you decide to get something from the basement. You have to hold the thing in mind while walking down into the basement and remember what it is you are looking for when you get there. You use working memory when learning to do something. You have to hold the instructions in mind while you practice it. You also use working memory when multi-tasking. You have to hold information in mind while engaging in the different activities.

In sum, Berryman, et al., (2013) found that people with chronic pain had moderately lower scores on tests of working memory when compared to the scores of people without chronic pain on the same tests. This finding is consistent with the common complaints of memory problems by chronic pain patients.

What is the connection between chronic pain and memory problems?

To understand the connection between chronic pain and memory problems or other forms of cognitive problems, we have to review a known fact that is commonly overlooked. This fact is that the experience of pain occurs because of our brain and other parts of our nervous system. Whatever the initial cause of pain, once pain becomes chronic, it becomes a nervous system problem. Different areas of the nervous system, such as in the brain and spinal cord, go through changes and these changes are responsible for the development of chronic pain.

One area of the brain that appears to go through such changes is the hippocampus (Cardoso-Cruz, Lima, & Galhardo, 2013; Mutso, et al., 2013). The hippocampus is involved in the development of central sensitization (Lamtremoliere & Woolf, 2009), depression (Campbell & MacQueen, 2004), and memory (Squire, 1992). Pain can change the hippocampus. In turn, these changes to the hippocampus can create a cascading effect on the experience of pain, leading to central sensitization, depression, and memory problems.

Much is yet to be learned from the study of chronic pain and the nervous system. The hippocampus may not be only thing that is responsible for the development of memory problems in people with chronic pain. Indeed, in all likelihood, it is not the only thing that leads to such problems. At the very least, though, it is likely a part of the connection between chronic pain and memory problems.

References

Berryman, C., Stanton, T. R., Bowering, K. J., Tabor, A., McFarlan, A., Mosely, G. L. (2013). Evidence for working memory deficits in chronic pain: A systematic review and meta-analysis. Pain, 154, 8, 1181-1196.

Campbell, S. & MacQueen, G. (2004). The role of the hippocampus in the pathophysiology of major depression. Journal of Psychiatry & Neuroscience, 29, 6, 417-428.

Cardoso-Cruz, H., Lima, D., & Galhardo, V. (2013). Impaired spatial memory performance in a rat model of neuropathic pain associated with reduced hippocampus-prefrontal cortex connectivity. Journal of Neuroscience, 33, 6, 2465-2480.

Lamtremoliere, A. & Woolf, C. J. (2009). Central sensitization: A generator of pain hypersensitivity by central neural plasticity. Journal of Pain, 10, 9, 895-926.

Mutso, A. A., Radzicki, D., Baliki, M. N., Huang, L., Banisadr, G., Centeno. M. V., Radulovic, J., Martina, M., Miller, R. J., & Apkarian, A. V. (2012). Abnormalities in hippocampal functioning with persistent pain. Journal of Neuroscience, 32, 17, 5747-5766.

Squire, L. R. (1992). Memory and the hippocampus: A synthesis from findings with rats, monkeys, and humans. Psychological Review, 99, 2, 195-231.

Date of last modification: 8-12-2013

Author: Murray J. McAllister, PsyD

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Memory Problems Mon, 12 Aug 2013 07:11:56 +0000
Why See a Psychologist for Pain? (Part 2) https://www.instituteforchronicpain.org/blog/item/115-18why-see-a-psychologist-for-pain-part-2 https://www.instituteforchronicpain.org/blog/item/115-18why-see-a-psychologist-for-pain-part-2

In the last post, we addressed the question, “Why see a psychologist for pain?” The answer is that psychologists are the experts in teaching patients how to self-manage and cope with chronic pain. Patients who see psychologists for chronic pain can learn to self-manage and cope with pain so well that they can largely come to live a normal life despite having chronic pain.  

Another way to respond to the question of “Why see a psychologist for pain?” is to look at the role of the nervous system in chronic pain and how psychologists are experts in the treatment of health problems related to the nervous system. Let’s attempt to unpack this statement.

Nervous system & chronic pain

People commonly think of chronic pain as if it is a long-lasting symptom of an injury or illness that has failed to heal. This viewpoint is mistaken. Take, for example, the notion of degenerative disc disease. It is common to think that degenerative changes of the spine are the cause of chronic back pain. However, we know that degenerative changes of the spine are only minimally correlated with pain, which means that most of what makes up the experience of pain cannot be attributed to degenerative changes of the spine (Endean, Palmer, & Coggon, 2011). Such changes of the spine are a minor ingredient, if you will, in the pie that’s chronic pain.

A more accurate understanding of chronic pain is that it is a disorder of the nervous system called central sensitization. An orthopedic injury, for example, might have initially caused a case of back pain, but now, after many months or years, the whole nervous system is involved, including the brain and spinal cord. Changes to the whole nervous system have now made the nerves at the original site of the injury highly sensitive and reactive. They are stuck, as it were, in a “hair trigger” mode that makes any little movement painful.

In the notion of central sensitization, we also see one of the central tenets of chronic pain rehabilitation: that when it comes to chronic pain, what initially caused the pain is not now the only thing that maintains pain on a chronic course. The notion captures the complexity of causal factors in chronic pain, as opposed to acute pain, which may have one cause – an injury or illness. Biological, psychological, and environmental factors are known to influence the development of central sensitization (please see the Institute’s content page on central sensitization for more details). The notion of central sensitization also explains other psychosocial aspects of chronic pain – chronic fatigue, insomnia, limited cognitive deficits such as poor concentration and short-term memory, gastrointestinal upset, anxiety, and depression (Meeus & Nijs, 2007; Wieseler-Frank, Maier, & Watkins, 2005; Yunus, 2007)

For many years, psychologists have successfully treated patients with health conditions related to the nervous system: depression, the various anxiety disorders, insomnia, irritable bowel syndrome, as well as chronic pain.

Psychological therapies for chronic pain

The Society for Clinical Psychology, which is a division of the American Psychological Association, developed task forces to compile a list of treatments that have been determined to be effective for a variety of disorders. They defined “effectiveness” as having multiple clinical trials from different researchers showing the effectiveness of a specific treatment. Not surprisingly, they have identified as effective multiple psychological treatments for mental health disorders such as depression, post-traumatic stress disorder, panic disorder, obsessive compulsive disorder, and general anxiety. However, they have also identified as effective multiple psychological therapies for health conditions. There is strong empirical support for cognitive behavioral treatments for chronic low back pain, osteoarthritis, rheumatoid arthritis, fibromyalgia, headache, and chronic pain syndromes in general. They have also identified effective psychological therapies for primary insomnia and irritable bowel syndrome. You can find information on these treatments here and here.

These therapies are effective likely because of their impact on the nervous system. Just as cognitive behavioral therapies reduce the reactivity of the nervous system in persons with post-traumatic stress disorder or panic disorder, in terms of their heightened startle response or susceptibility to panic, respectively, cognitive behavioral therapies for chronic pain disorders are likely to reduce the reactivity of the nervous system. By reducing the reactivity of the nervous system, patients come to have less pain and increased abilities to cope with the pain that remains.

References

Endean, A., Palmer, K. T., & Coggon, D. (2011). Potential of MRI findings to refine case definition for mechanical low back pain in epidemiological studies: A systematic review. Spine, 36, 160-169.

Meeus M., & Nijs, J. (2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Journal of Rheumatology, 26, 465-473.

Wieseler-Frank, J., Maier, S. F., & Watkins, L. R. (2005). Immune-to-brain communication dynamically modulates pain: Physiological and pathological consequences. Brain, Behavior, & Immunity, 19, 104-111.

Yunus, M. B. (2007). The role of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain. Best Practice Research in Clinical Rheumatology, 21, 481-497.

Date of last modification: 7-29-2013

Author: Murray J. McAllister, PsyD

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Health Psychologist Mon, 29 Jul 2013 06:55:31 +0000
Why See a Psychologist for Pain? https://www.instituteforchronicpain.org/blog/item/114-17why-see-a-psychologist-for-pain https://www.instituteforchronicpain.org/blog/item/114-17why-see-a-psychologist-for-pain

Patients can sometimes question why their physicians want them to see a psychologist for pain. The concern, of course, is that they are going to get stigmatized. They might wonder, “Doesn't my doctor not believe me?” or “Do they think it’s all in my head?” This reaction can often prevent patients with chronic pain from seeking the care of a psychologist. It is, however, unfortunate. Among all healthcare providers who specialize in the treatment of chronic pain, psychologists provide some of the most effective therapies.

Patients can fail to benefit from them when they fear stigma and fail to follow-up on recommendations to obtain psychological care.

Psychologists have a long tradition of providing chronic pain management. Psychologist were integral to the development of chronic pain rehabilitation programs thirty to forty years ago and have been either running them or working in them ever since. As described in previous posts (such as this one here), chronic pain rehabilitation programs are commonly considered among healthcare providers to be the most effective treatment option for people with chronic pain.

To get such care, though, it’s helpful to know what psychologists do when seeing patients for chronic pain. In this post, and the next, we will explore the answer to the question: Why see a psychologist for chronic pain? We will answer this question from two broad perspectives.

First, in this post, we will look at the answer from the perspective of the role of coping and self-management. Second, in the next post, we will explore the issue from another perspective. Namely, we will look at the answer from the perspective of the bodily organ system that is most responsible for chronic pain – the nervous system.

So, the quick answer to the question of why you should see a psychologist for chronic pain is the following:

  • Among all healthcare providers who treat chronic pain, psychologists are the experts in teaching patients how to cope with and self-manage pain.
  • Psychologists are experts in the treatment of nervous system problems and chronic pain is largely the result of nervous system disorders.

Let’s now look at the first answer in a little more detail. We'll look at the second one in the next post.

Self-management of pain

All experts (and most patients, by the way) agree that to successfully manage chronic pain patients must be active participants in their care. That is to say, they have to learn effective ways to cope with and self-manage pain. It’s as true of chronic pain as it of other common, chronic diseases. Most everyone would agree that patients with heart disease or diabetes wouldn’t manage their disease successfully if they themselves didn’t engage in self-management: who would argue with the importance of maintaining a healthy diet, weight loss, exercise, and stress management, among other health behaviors, in the successful management of these diseases? Similarly, most everyone accepts that patients have a role in the successful management of their chronic pain syndrome. Successful management requires the ability to self-manage and cope with pain very well. But where do chronic pain patients learn how to do it?

Patients with chronic pain seek care from many different types of providers, all of whom specialize in the management of chronic pain. However, it’s only one kind of chronic pain provider who specializes in teaching patients how to self-manage and cope with pain.

Typically, it is not spine or orthopedic surgeons. Surgeons tend to have relatively brief appointment times with their patients and they tend to focus on surgical procedures and how to aid in recovering from such procedures. Now, certainly, there may be a time and place for the care of a surgeon. The point here is not to criticize surgeons or surgery. Rather, it is simply to point out that the focus of surgeons is typically surgery, not in teaching patients how to cope with and self-manage chronic pain.

It is also typically not the role of interventional pain physicians. Their appointment times are also commonly brief and focused on providing injections and other minimally invasive procedures. The point is not a criticism. Rather, the point is that their focus lies elsewhere. It is not on spending time with patients and teaching them how to cope with pain well.

It is also typically not the provider who prescribes opioid pain medications on a long-term basis. Of course, there can be exceptions, but most such providers have relatively brief appointment times, usually around fifteen minutes. The focus of much of this time is on obtaining updates about your well-being since your last appointment and on how well the medications are working. There is not a lot of time left over for teaching, clarifying, and reviewing strategies for coping and self-management. Again, the point is not a criticism. It's simply that the focus of prescribing providers is typically on managing the medications and not on teaching patients how to self-manage pain without the medications.

All these providers typically know it too. It’s why they tend to refer chronic pain patients to pain psychologists.

So, where do you go to learn how to self-manage and cope with pain well? You go to healthcare providers who specialize in teaching patients how to do it. You go to health psychologists and you find them in chronic pain rehabilitation programs.

Health psychologists have been running chronic pain rehabilitation programs for the last thirty to forty years. You can find such programs throughout the world. Research consistently shows that they are one of the most effective treatment strategies for chronic pain (see, for example, this article here).

They are so effective because they focus on teaching patients how to self-manage and cope with pain very well. Self-management and coping very well are essential to manage chronic pain successfully.

Most patients, though, have to learn how to do it. Such learning requires appointment times that are longer than fifteen minutes or so, and more frequent than once a month or so. It also requires having a good, solid, therapeutic relationship with an expert provider who listens to you and gently coaches you over time on how to do it. You find such care with a health psychologist who works in a chronic pain rehabilitation program.

It’s possible to self-manage and cope with chronic pain very well. You just have to learn how to do it. And you learn from a health psychologist. It’s why you would see a psychologist for chronic pain.

Author: Murray J. McAllister, PsyD

Date of last modification: July 1, 2013

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Health Psychologist Mon, 01 Jul 2013 06:35:46 +0000
How People Cope with Pain Really Well: 2 https://www.instituteforchronicpain.org/blog/item/113-16how-people-cope-with-pain-really-well-2 https://www.instituteforchronicpain.org/blog/item/113-16how-people-cope-with-pain-really-well-2

In the last post, we started a discussion about how people cope with chronic pain really well. Specifically, we looked at five attributes and skills that people do when coping well with chronic pain. The point of the discussion was that it is a way to learn how to cope better. Coping with chronic pain is a set of skills like any other set of skills and you learn how to cope with pain just like you learn other skills – like learning how to knit or play the piano or play tennis.

If you wanted to learn how to play the piano really well, you would do a number of things (such as take piano lessons), but one of the most important things is that you would study those who are better than you. You would play their recordings and listen and watch how they do it. You would then try to do what they do. The same can be true with learning how to better cope with pain. With this idea in mind, we looked at five attributes and skills that people do when they cope with pain really well.

These five things were the following:

  • Being open to change and learning from others
  • Accepting that chronic pain is chronic
  • Focusing on self-management
  • Engaging in a mild, low-impact aerobic exercise on a regular basis
  • Understanding the relationship between pain and stress, and managing stress well

These are things that people do when coping really well with chronic pain.

Lets look at five more attributes and skills that make for good coping. As we do, remember one more thing from the last post. It was the discussion about how there is no shame in acknowledging that you can learn to cope with pain better. All skills, including the skills of coping, can be seen as on a spectrum for which there is no point at which you are as good as you ever will get. Rather, if you take any skill imaginable, you can always get better at doing it no matter how good you are at it. Any guitar player can get better with learning and practice – even rock and roll superstars. Any tennis player can get better too – even the pros. Similarly, anyone with chronic pain can learn to cope better -- no matter how good you are at it. So, there is no shame in acknowledging that you can learn a thing or two. You are in the same boat as everyone else. So, let’s look at five more ways to cope better with chronic pain.

1) People who cope really well don’t react to their chronic pain as if it is acute pain.

If you accidentally stepped into a hole and broke your ankle, the pain of the broken ankle would be considered acute pain. The normal reaction to such an injury would be to become alarmed, seek help, stop using the ankle, stay at home, and rest. With the pain of acute injuries, such as a broken ankle, this set of reactions would not only be normal but largely helpful. Generally, a broken ankle gets put into a brace or cast and we are told to stay off it. By doing these things, we allow the bone fracture to heal. Subsequently, the pain goes away. As such, this set of reactions to acute pain is a good thing.

However, what’s good for acute pain is not good for chronic pain. The normal sense of alarm that goes along with being in pain becomes problematic when occurring on a chronic basis. It can become any number of negative emotions, such as fear, anxiety, irritability, and even depression. The normal reaction of resting becomes problematic too when done on a chronic basis. While resting can help an acute injury, it can make chronic pain worse. Your body is made to move and if you don’t use it for too long you get stiff, achy, and sore. It's not just you. It's true for everyone of us. We also get out of shape and gain weight when we are inactive for too long. Becoming de-conditioned in these ways can make pain worse too. Staying home and resting for too long also leads to what healthcare providers call “fear-avoidance.” Fear-avoidance is the cycle of avoiding activities out of concern that the activities will increase pain. Any number of normal activities of daily life can increase pain and so it can become easy to stop doing them out of anticipation that they will cause pain. When done in response to acute pain, it might be helpful. When done on a chronic basis, it’s one of the ways pain can become disabling. Moreover, staying home and not doing your normal daily activities for too long can lead to becoming chronically bored or aimless or depressed. In all these ways, responding to chronic pain as if it is acute pain becomes problematic.

People who cope with pain really well make the transition in their understanding that their pain is no longer acute pain but chronic pain. They know what their chronic pain is and are no longer alarmed by it. They understand that chronic pain is a nervous system condition and not a long-lasting orthopedic injury. They understand that engaging in normal activities won’t make the nervous system condition worse, as it might if it was an acute orthopedic injury, like a bone fracture. Consequently, they no longer become alarmed that they will make the underlying condition worse when they do normal activities of life.

Now, of course, their pain might be worse when they do things, even if it doesn’t make the underlying nervous system condition worse. However, they recognize that not doing things makes their pain worse too. Staying home and resting doesn’t serve a useful purpose when done on a long-term basis. So, people who cope with pain well respond to their pain by saying, “I got to get up and do something!” or “I’ve got to get out of the house or else I’ll go stir-crazy!” That is to say, they react to their chronic pain in ways that are almost opposite to how you normally react to acute pain.

People who cope with pain well have gotten back into the normal activities of their lives despite the pain because the pay off is that it leads to improved coping. They are no longer bored or aimless or depressed. They are getting things done, checking things off their lists, and even having fun on occasion. Because they are doing these things, they feel productive. They feel like they are going somewhere and have a direction again to their life. Their self-esteem is on the rise. In all these ways, they are now coping better and their improved abilities to cope buffer the increased pain they may have from doing these activities.

2) People who cope with pain well pace their activities.

Having gotten back into the normal activities of life, people who cope with pain well are reasonable about how much they do. They do some things, but not everything. They break up a large activity or their entire ‘to do’ list into manageable size chunks. Referring to the story about the tortoise and hare, they might joke that their motto is “slow and steady wins the race.” That is to say, they have overcome any tendencies to engage in what psychologists call “all-or-nothing” approaches to life.

Additionally, they are reasonable about what they do, and not just how much they do. They might not expect to be able to water ski or dirt bike race. Nonetheless, they make it a point to still do a lot of fun things.

3) People who cope well with pain overcome any perfectionist or workaholic tendencies they may have had.

Perfectionists and workaholics get a lot of kudos in our society. They get a lot done and what they do they do very well. Employers love them and reward them for it. So, if you are a perfectionist or workaholic, it may have gotten you far before the onset of chronic pain. However, now that you have chronic pain, perfectionism and workaholism are problematic.

Perfectionism and workaholism are problematic in many ways. First, perfectionists and workaholics engage in “all-or-nothing” thinking and as such tend to struggle with pacing themselves. If they have a good day in terms of their pain level, they clean, not just the kitchen, but the entire house. As they do, they might say to themselves, ‘If you are going to do it, do it right or not at all.’ However, their strict adherence to perfectionistic standards leads to exacerbating their pain through over-activity. Second, their ‘do it right or not at all’ attitude lends itself to the ‘not at all’ side of the equation because they have chronic pain and the pain makes it difficult to ‘do it right.’ Not doing things leads to all the problems described above – getting out of shape, weight gain, aimlessness, and more pain. Third, once they have stopped doing things, they are prone to self-criticism. Their perfectionistic standards are hard taskmasters. When they don't live up to their standards, they get down on themselves. No one is harder on him- or herself than the perfectionist or workaholic. Such persistent self-criticism can lead to poor self-worth and depression. Fourth, perfectionism and workaholism tend to make people inflexible and poor adapters. We reviewed in our last post that one attribute of a good coper is someone who is flexible and can adapt. The ‘all-or-nothing’ thinking of the perfectionist or workaholic makes it hard to adapt and be flexible. They have difficulty finding the middle ground between their 'either-or' thinking. In all these ways, perfectionism and workaholism do not lend themselves to coping well with pain.

People who cope with pain well tend to have worked through their perfectionist and workaholic tendencies. With persistent effort and time, they have broken themselves of the habit of holding themselves accountable to perfectionistic standards. They have come to see that even before the onset of their chronic pain they never really did achieve those standards. Whatever they did, they could always find some fault or room for improvement. There was always something more on the list to do. It never really was a very good recipe for happiness. By overcoming perfectionism, they came to see that what they thought was happiness was really just temporary satisfaction. The feeling associated with a job well done lasted only as long as it took to move on to the next thing on the ‘to do’ list. And there was always more to do on the ‘to do’ list. So, people who cope with pain well have worked through these issues and no longer hold themselves to perfectionistic and workaholic standards.

4) People who cope with pain well maintain a regularly structured day.

Everyone has a routine. We typically go to bed and get up at more or less the same time each day. We typically eat our first meal in the morning, our second meal in the early afternoon, and our third meal in the late afternoon or early evening. We typically shower or bathe shortly after awakening or shortly before bed. Our typical daily chores and activities also follow a routine. We all do better when, more or less, we follow a routine.

Sometimes, of course, it’s fun to break up the routine. When we are on vacation, we enjoy the break in the routine. Right after retirement or obtaining disability, it is nice to have a break in our usual routines and many people have some fun with it.

However, if the break in the usual routine never returns to the normal routine or is never supplanted by a new routine, a couple of problematic things happen that reduce our abilities to function well in life. First, we become aimless. After awhile, we don’t know what to do with ourselves if we don’t have a focus for the day. Without a focus for our concentration and efforts, our attention tends to focus in on the problems of life. For those with chronic pain, our attention gets focused on pain and all the stressful problems associated with living a life in chronic pain. Second, we tend to start napping. Now, an occasional nap is fine, but when it starts happening everyday, it become problematic. It disrupts our nightly bedtime routines. It’s hard to fall asleep because of the nap earlier in the day. Once we start falling asleep later in the evening, we tend to start sleeping in longer and longer in the morning. In turn, this shift pushes the naptime later into the afternoon, which subsequently pushes bedtime later and later. As a result, a shift occurs in your sleep-wake cycle, sleeping more and more into the day and awake more and more at night. Chronic disruption in your sleep-wake cycle is a common cause of social isolation, aimlessness, persistent fatigue, and depression.

I often tell patients that we all need a reason to get up in the morning. We need to have some idea of what we are going to do with ourselves throughout the day. When, on a chronic basis, we don’t have any plans or routine to guide us through the day, then every moment requires a decision – “What am I going to do?” The question can become surprisingly hard to answer! It’s like when you were a kid during the last few weeks of summer vacation and you and the neighborhood kids have done everything you wanted to do; you sit around the house or backyard, staring at each other, asking, “What do you want to do? Oh, I don’t care, what do you want to do?” Back and forth it goes and boredom and aimlessness are the result. Routines serve the function of allowing us not to think so hard. We just know what we are supposed to do from one thing to the next. They keep our minds focused on getting things done, rather than becoming aimless or, worse yet, becoming focused in on all the problems of life while awake in the middle of the night when every one else is sleeping. That’s not what good coping looks like.

5) People who cope with pain well engage in a daily relaxation exercise.

Like mild aerobic exercise, a regular relaxation exercise is an essential component of successful self-management. People who cope with pain really well engage in both on a regular basis.

People commonly misunderstand the role of relaxation in pain management. They tend to think of it as something you do when experiencing a lot of pain in order to get through it. When they try it, it doesn’t work real well and so give up.

While a relaxation exercise can be done in the midst of a pain flare (think, for example, the deep breathing women learn for childbirth), relaxation for this purpose is a very difficult skill to achieve and it takes a lot of practice – more than most people are initially willing to do.

The most important reason a relaxation exercise is an effective treatment for chronic pain is that it is an intervention that targets the nervous system and reduces its reactivity over time. It’s more of a prevention type treatment than something you do in the midst of a pain flare.

Chronic pain is the result of the nervous system being stuck in a persistent state of reactivity that makes nerves highly sensitive to pain. As you know, any normal movement can be painful. Mild pressure like massage or even touch in the painful area of the body can feel painful. Of course, normal movements and massage and touch shouldn’t be painful, but they are because the nerves and the rest of the nervous system are stuck in a persistent state of reactivity, making the nerves in the painful area sensitive. It’s called central sensitization.

A daily relaxation exercise is one of many treatments for this condition. A relaxation exercise targets the nervous and relaxes it for a short period of time. After awhile, the nervous system returns to its high level of reactivity. If you do it again everyday, however, the nervous system begins to return to lower and lower levels of reactivity. As a result, you have less and less pain over time.

You are also more grounded and less stressed. As a result, you also tend to cope better.

A daily relaxation exercise is a two-fer: less pain over time and improved coping over time.

There are literally countless ways to get better at coping with pain. In this post, we reviewed five of them. We reviewed a different five ways in the last post. I intend to periodically review more ways to cope with pain on this blog.

Author: Murray J. McAllister, PsyD

Date of last modification: September 27, 2013

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Mon, 17 Jun 2013 06:40:00 +0000
Coping with Pain: How People Who Cope Really Well Do It https://www.instituteforchronicpain.org/blog/item/112-15coping-with-pain-how-people-who-cope-really-well-do-it https://www.instituteforchronicpain.org/blog/item/112-15coping-with-pain-how-people-who-cope-really-well-do-it

If you wanted to learn how to knit well, you might take a class at your community craft store. You might also get a how-to book out of the library or watch a few YouTube videos. But as you did all these things, you would also pay attention to those who already knit well and watch how they do it. You would then try to do what they do.

The same thing would be true if you wanted to learn how to play a musical instrument well or play a sport well or fish well. Say, for example, you wanted to learn how to become a better guitar player. You would probably take lessons from a teacher. You might read how-to books and watch videos on the internet. But you would also listen to how really good guitar players play. And you would try to play like them.

Why shouldn’t the same thing be true with coping with pain?

If you wanted to learn to cope with pain better than you do at present, then you likely would do a few different things. You might find teachers to teach you how (usually, when it comes to chronic pain, such teachers are called chronic pain rehabilitation providers and are found in chronic pain rehabilitation programs). You might read about how to do it (such as in blogs and self-help books). You might also watch videos on the internet (such as this one here).

Also, though, you might try to learn from those who cope with chronic pain really well. Just like learning any other skill, it is helpful to learn from those who do it well. You learn what they do and then try to do it yourself. Of course, like any skill, it takes practice and sometimes it takes a lot of practice.

Looking at coping from this perspective takes the mystery out of it. Coping with pain involves skills like any other skills. In this way, it is just like knitting, playing tennis, fishing, or playing the guitar. These activities are all a set of skills and similarly coping with pain is a set of skills. Like any other set of skills, the more you learn about how to cope and the more you practice, the better you get at it.

Skills, like coping with pain, might be thought of as occurring along a spectrum in which there is no endpoint. There is no point at which you are as good as you possibly ever will get. No matter how good you are at a particular skill, you can always get better with learning and practice. Whether you are a novice tennis player, a pretty good tennis player, or a professional, you can still get better at playing tennis. You can always hone your skills and get better with practice. The same is true with playing a musical instrument. Whether a beginner or a virtuoso, the musician can always get better with learning and practice. The same is true with coping with chronic pain. No matter where you are on the spectrum of coping with pain, you can always get better at it.

Looking at coping in this way takes the judgment out of it. You don’t have to feel bad if there is more for you to learn about how to cope with chronic pain. Everyone, no matter who you are, can learn how to cope with pain better. In reality, it’s true of coping with whatever problem you face. There is simply no endpoint at which someone knows all there is to know about how to cope with the problems they have. Let’s, then, look at what people do when they cope really well with chronic pain. Research psychologists spend a lot of time studying how people cope with adversity of any kind. Clinical and health psychologists spend a lot of time teaching patients how to overcome adversity. Based on this research and clinical experience, we might review a number of skills and attributes of people who cope well. The point here is that it is a learning process. Just like the guitar player who studies superstar guitar players by listening to them and trying to do what they do, let’s review the skills and attributes of people who cope really well with chronic pain. By doing so, you learn from them and can practice doing what they do.

As we do, try not to feel bad about yourself if you don’t do exactly what they do. Remember the point about the spectrum of coping with pain: coping is a set of skills and no matter how well (or not-so-well) you cope with chronic pain, you can always get better at it. It’s true for everyone. So, don’t feel bad if you can learn a thing or two. Everyone is in the same boat as you are. (In fact, rather than feeling bad about it, celebrate it! Isn’t it great that you can learn to cope better with pain!)

There are almost countless ways to get better at coping with chronic pain. In this post, we will review five of them. We will then review five more in the following post. The intention is for these posts to be a series that reoccurs on a periodic basis.

Skills and attributes of those who cope with chronic pain really well

1) They are open to change and learning from others.

People who cope with pain really well are open to change. They recognize that things will have to be different now that they have chronic pain. In this way, they are flexible and adaptable. They do not insist on returning to exactly how they were the day before they were injured or became ill. They recognize and accept that doing so would be impossible. Rather, they are open to new ways of living. They adapt their work positions or even seek out new employment positions that work well with their chronic pain condition. They find new social and recreational activities. If it hurts too much to stay in the bowling league, they join a cribbage league instead. They also find new ways to stay involved in their religious or civic organizations. Because they are open to change, they might still work or still have fun with their friends and family and are still engaged in their community, despite the chronic pain.

People who cope well with chronic pain are also open to learning from others. They don’t get offended or defensive or nervous when talking about how they might come to learn better ways to cope. Rather, they acknowledge that they don’t know everything there is to know about coping with pain. They also recognize that there is no shame in learning new ways. Like we did with the discussion above on the spectrum of coping, they understand that they can learn a thing or two and don’t feel bad about it.

2) People who cope really well with chronic pain accept that their pain is chronic.

Initially, it might seem counter-intuitive to accept that your pain is chronic. Understandably, many patients want to maintain hope by trying to find the right specialist who can cure them of their chronic pain. At some point, though, it’s helpful for most patients to recognize that medical management has its limits. Why? Because when your pain is truly chronic, it means that it is not curable. Chronic health conditions are conditions for which we have no cures and for which the patient will have to live with. Insistence on finding a cure long after it is reasonable to recognize that your pain as chronic becomes itself a problem. It can reduce your ability to cope because it leads to a vicious cycle of false hope in a cure that never comes followed by failed treatment and then disappointment. Hope and disappointment is a common theme as patients talk about what they have tried when attempting to cure their pain – the various medications, injections, and surgeries they have tried. If this cycle continues for too long, patients come to feel hopeless and depressed.

So, at some point, it is helpful to accept the chronicity of chronic pain. People who cope really well with chronic pain do it. They don’t spend time trying to fix what is ultimately an unfixable problem. They recognize it would be a losing battle and that it would lead to becoming hopeless and depressed.

3) Instead, people who cope really well with chronic pain focus on what they can do to manage their pain.

They seek out things that they can do to manage pain rather than looking to other people or other things to manage their pain for them. They don’t see ‘pain management’ as something that their healthcare providers do or that their medications do. Rather, they see that the lion share of it is their ability and responsibility.

They have a routine of ways to self-manage their daily level of pain. When they have a typical pain flare, they ask themselves what’s going on in their lives that might be contributing to it and then set about to resolve it. In short, they consider themselves to be primarily responsible for their health in general, not their healthcare providers.

This point is true of all people who cope well with any chronic health condition. The person who copes well with heart disease is typically one who doesn’t primarily rely on healthcare providers to manage the disease for them. Rather, one who manages heart disease well is one who quits smoking, engages in regular exercise, changes their diet, loses weight, and manages stress. Of course, they might see healthcare providers too. However, it is a matter of emphasis.

People who manage chronic health conditions well are those who primarily see their health as their responsibility and so rely on their healthcare providers less, rather more.

This emphasis on what the patient can do is called empowerment. People who cope with pain really well feel empowered and confident in self-managing their chronic pain. They know what their pain is. They are not alarmed by it. They know what to do about it. And they do it.

4) People who cope with pain really well exercise on a regular basis.

Typically, they engage in a low-impact, mild aerobic exercise at least three to four times per week. Examples are walking in a pool, walking outside or on a treadmill, riding a stationary exercise bicycle, or using a stationary arm bike. All these exercises involve a low degree of impact to the body. However, they all are aerobic, or cardiovascular, exercises. That is, they get your heart rate up.

The importance of a mild aerobic exercise is its effect on the nervous system. Following an aerobic exercise in which you get your heart rate up for a period of time, the nervous system relaxes. You feel grounded. You have a sense of well-being. It’s why people exercise to manage stress. Runners call it ‘a runner’s high.’ However, you don’t have to run in order get it. The exercises listed above will do just fine.

Why is this important and why is it helpful? It’s because chronic pain is a nervous system condition. Whatever the initial cause of your pain, if you have chronic pain, then you have a nervous system that is stuck in a persistent state of reactivity, making the nerves super-sensitive. Any little movement sets the nerves off firing pain signals to the brain. People who successfully self-manage chronic pain maintain their nervous system reactivity in the lowest possible state. One of the many ways to do this is to engage in a regular, low-impact aerobic exercise.

Following each time you engage in an aerobic exercise, your nervous system relaxes for a period of time. Of course, since you have chronic pain, it returns to a higher level of reactivity after awhile. However, if you do it again and again, on a regular basis over time, your nervous system returns to lower and lower levels of heightened reactivity. In effect, you are down-regulating the reactivity of your nervous system. As such, you have less pain and more ability to cope.

Also, regular aerobic exercise improves your mood. Again, many people exercise solely for its stress-relieving properties. When we engage in an aerobic exercise, we feel good, not only physically, but emotionally too. When you exercise on a repetitive basis, your mood gets better and better. Consequently, when your mood improves, you cope better with the chronic pain that remains.

For both of these reasons, people who cope with pain really well almost always engage in a low-impact, mild aerobic exercise on a regular basis.

(Let me make two quick notes before moving on. First, you should always check with your healthcare provider before starting an exercise routine for the first time. Chances are, they will be quite supportive of the idea. However, some people might have medical conditions that can complicate matters and for which you need specific instructions for your specific condition(s). Second, many healthcare providers continue to treat chronic pain as if it is the result of a long-lasting acute injury. They subsequently recommend stretching and core strengthening exercises. These might be helpful, especially if you are out of shape and would find walking, for instance, too difficult. However, their effectiveness for chronic pain is limited. They are best seen as a way to get you into enough shape that you could then transition to a low-impact, mild aerobic exercise. They are like a bridging exercise to get you to your goal exercise.  In and of themselves, you probably don’t want to expect a lot of improvement in pain or coping from them. Improvement comes when you are able to engage in a mild aerobic exercise over time. )

5) People who cope really well with chronic pain understand the relationship between pain and stress.

They understand that they have to keep their nervous system in check. They understand that whatever affects the nervous system also affects pain levels. Moreover, they understand that stress affects the nervous system. They subsequently use this knowledge to help them cope with pain: one of the chief ways to manage chronic pain well is to manage stress well.

People who cope with pain really well see life’s problems in terms of their stressful impact and how these stressful problems make their pain worse. They see such problems and automatically assume that the stress of them affects their pain levels. Any of life’s problem can be stressful, of course, but some examples are you and your spouse not getting along, your kid getting into trouble, a period of insomnia, getting behind on bills, or the loss of a loved one. People who are coping with pain really well take it for granted that these kinds of problems make their pain worse.

This knowledge allows them to cope with pain well in two different ways. First, they understand that their pain levels are in some ways a barometer of what else is going on in their life. They always have, of course, some baseline level of pain from the pain condition they have. However, what makes their pain wax and wane beyond the normal level of pain is how much stress they are experiencing. If their pain is through the roof one day, they ask themselves what else is going on. They subsequently identify the stressful problem and set about working on it. By resolving the problem, they reduce their pain back down to their normal level of chronic pain. In this way, managing stress is a way of managing pain. Second, by knowing the relationship between pain and stress, they don’t become alarmed when experiencing a pain flare. They don’t, for instance, think that their underlying health problem is worsening or they don’t think it is necessarily cause for seeking repeat diagnostic testing. They know what it is and can identify where it is coming from. They know that it is a stress-induced pain flare. Then, they set about trying to resolve the stressful problem and reducing the reactivity of their nervous system.

In these ways, they remain grounded, empowered, and in control. These are attributes of those who are coping with pain really well.

For more information, please see the next post in the coping with pain series.

Author: Murray J. McAllister, Psy.D.

Date of last modification: April 21, 2014

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Mon, 03 Jun 2013 06:42:35 +0000