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PRIVACY / DISCLAIMER https://www.instituteforchronicpain.org Sat, 04 Feb 2023 01:51:01 +0000 Joomla! - Open Source Content Management en-gb COVID-19 and Chronic Pain: Challenges and Opportunities https://www.instituteforchronicpain.org/blog/item/219-covid-19-and-chronic-pain-challenges-and-opportunities https://www.instituteforchronicpain.org/blog/item/219-covid-19-and-chronic-pain-challenges-and-opportunities

The COVID-19 pandemic continues to impact the world with deaths in the hundreds of thousands and countless more having become ill. To reduce the risk of contagion and death, areas around the world maintain self-quarantining practices and have been doing so now for multiple months.

Sheltering-in-place, or self- quarantining, presents both challenges and opportunities for everyone, including those with persistent, or chronic, pain.

Challenges

While the COVID-19 pandemic presents multiple challenges to everyone, one of the most important of these challenges to those with chronic pain are the potential for vulnerabilities to developing serious complications if becoming ill with COVID-19. The coronavirus, which is the virus that causes COVID-19, leads to a wide range of symptoms for those who become infected. Some people don’t have any symptoms at all. Still others have mild to moderate degrees of symptoms. Still others have critical, life-threatening symptoms. These latter people with COVID-19 tend to become hospitalized and may even die.

The Centers for Disease Control (CDC) keep statistics on cases of COVID-19 worldwide and initially found that those who are most prone to Photo by Allie Smith courtesy of Unsplashdeveloping critical, life-threatening forms of the illness are the elderly and those with certain pre-existing health conditions (April 3, 2020). Health conditions that are present at the time when another, unrelated health condition develops are called comorbid conditions. These conditions are high blood pressure (otherwise known as hypertension), high cholesterol (otherwise known as hyperlipidemia), diabetes, and chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD) and asthma.

In the United States, the CDC later found that African-Americans also have a greater risk of developing serious, life-threatening illness from COVID-19 (April 14, 2020). Indeed, in some states the majority of those who have died from COVID-19 are African-Americans, even though this group of people only makes up a minority of the population. While the cause(s) for this discrepancy is unknown at present, speculation is that the above-mentioned comorbidities as well as social and economic causes of poor health are the most likely culprits (Yancy, 2020).

It’s noteworthy that chronic pain syndromes are not one of the comorbidities that make people prone to critical, life-threatening progressions of COVID-19. With that said, however, the comorbidities listed above can occur in those with persistent pain. As such, it is important to take the threat of COVID-19 infection seriously for anyone with persistent pain whose health is additionally compromised by conditions such as heart disease, diabetes, COPD or asthma.

To reduce your risk of infection, it is important to follow the common guidelines advocated widely by governmental and healthcare institutions. Most everyone knows of them by now, but they bear repetition.

  • Stay home as much as possible.
  • Engage in distancing at least six feet, or 2 meters, (or more) from others, particularly when in public.
  • Wear a mask when out in public or at home if you’re ill.
  • Wear a mask if you are taking care of someone who is ill with COVID-19.
  • Wash your hands often and for at least 20 seconds with soapy water, or use a hand sanitizer that is made up of at least 60% alcohol.
  • Cover your cough or sneeze with your arm or a tissue.
  • Don’t touch your eyes or face.
  • Wash and disinfect common surfaces.

The CDC has a good webpage with more information here on this topic.

Opportunities

It may also be an opportunity for all of us to do what we can to become as healthy as possible. It’s all too easy for anyone of us to focus on the dangers of the illness, the disruptions of sheltering-in-place, and the economic stresses that are occurring as well. With all these problems, it’s easy to seek comfort in comfort foods, sleeping in late and staying up late, binge-watching TV, web surfing aimlessly for hours, or drinking alcohol (or using other drugs) more than you should. It’s all understandable, of course, so we shouldn’t judge ourselves or others when engaging in these behaviors, but when we do them we end up becoming unhealthier at a time when we need to be as healthy as possible.

Most of us while sheltering-in-place tend to have extra time on our hands and we could use this time to start a healthy behavior that we’ve always known we probably should do, but have never really gotten around to doing. As such, we could spend our extra time on ways to foster our health and overall well-being.

Maybe we could work at cooking from scratch more often, looking up some recipes and spending more time in the kitchen. We may come to enjoy cooking when done for pleasure as a pastime. We would also subsequently eat less processed foods and likely more fruits and vegetables. In doing so, we might even lose a bit of weight. In all, we might develop an enjoyable past time that is safe to do because we are also at home, while also eating healthier and possibly even losing some weight.

We could also start a gentle exercise routine.* Initially, it could be something quite modest, without rigor. You could use the motto of 'anything is better than nothing’ and so perhaps it is just walking a circle or two in your house or down to your mailbox and back. With time, you could extend it to walks outside each day or every other day. You could use the same approach if you have access to a treadmill, stationary bike, or other similar equipment. Notice it is gentle, yet something more than just stretching. It’s something that gets your heart rate up. It's a gentle or mild aerobic exercise and it makes us healthier when done over time.

We could get outside more often (while maintaining social distance) and spend time in green spaces.* Many parks remain open. Our grandmothers used to tell us to ‘go outside’ when we were kids because they knew it was good for us and they were right. Being among rocks and trees, with birds and scurrying little critters, and breathing fresh air improves our well-being. This link is a nice article that reviews the science proving that our grandmothers were right all along.

We could also do a stress management technique for a few minutes each day, such as diaphragmatic breathing, progressive muscle relaxation,Photo by Madison Lavern courtesy of Unsplash meditation, yoga, or tai chi. Any of these contemplative practices are ways to develop the skill sets of calming yourself down and focusing your attention. We don’t tend to think of the abilities to calm yourself down and stay focused on things as skills that can be learned, but they are. They are like learning to play a sport or a musical instrument – the more you practice, the better you get at them. Simlarly, a contemplative practice like those listed above take practice to get good at them. With practice, however, you won’t have to resign yourself to being stressed and scattered. Instead, you could get good at becoming calm and focused. These skills sets can positively affect our health and well-being.

Any of these healthy behaviors bring about a greater sense of well-being, but are also apt to reduce factors associated with many of the comorbid conditions listed above that are associated with severity of COVID-19. They help to reduce blood pressure, lower cholesterol, reduce inflammation, lose weight, and lower blood sugars. They may even improve the functioning of the immune system.

Conclusion

Living and staying safe in the time of COVID-19 with its resultant economic uncertainties presents many challenges. It’s normal to be scared in the presence of danger. Sheltering-in-place, or self-quarantining, can also lead to persistent boredom and aimlessness. In response, it is common to seek comfort that temporarily provides relief, but in the end is actually unhealthy.

Now is the time, when we need to be as healthy as we can to fight off potential infection, to take active steps to improve our health. It’s a time to reset our priorities and stop putting off doing those things that we always knew we should do, but haven’t gotten around to it. Now, more than ever, is the time to become as healthy as possible.

*Please always follow the advice of your healthcare providers when starting a gentle exercise routine or going outside. Their recommendations should always supercede the informational content of this site. You may have unique aspects to your health that cannot be represented accurately with general, educational information as found on this site. Please also see Terms and Conditions of Use.

References

Centers for Disease Control (CDC), (April 3, 2020). Retrieved on April 20, 2020, fromhttps://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Centers for Disease Control (CDC), (April 14, 2020). Retrieved on April 20, 2020, fromhttps://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/

Guan, W., Liang, W., Zhao, Y., et al. (2020). Comorbidity and its impact on 1590 patients with COVID-19 in China: A nationwide analysis. European Respiratory Journal, 55(4), 2000547. doi: 10.1138/139930003.00547-2020

Yancy, C. W. (2020). COVID-19 and African-Americans. JAMA, published online. doi: 10.1001/jama.2020.6548

Date of publication: April 23, 2020

Date of last modification: April 23, 2020

About the author: Dr. Murray J. McAllister is the editor at 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 and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on pain that is approachable to patients and their families.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) News & Recent Events Wed, 22 Apr 2020 18:35:03 +0000
Adopting an Attitude that You're Healthy despite having Chronic Pain: Coping with Pain Series https://www.instituteforchronicpain.org/blog/item/214-adopting-an-attitude-that-you-re-healthy-despite-having-chronic-pain-coping-with-pain-series https://www.instituteforchronicpain.org/blog/item/214-adopting-an-attitude-that-you-re-healthy-despite-having-chronic-pain-coping-with-pain-series

Chronic pain rehabilitation programs are a traditional and effective treatment for chronic pain. Such programs are based on cognitive-behavioral principles that aim to change how you experience pain. By doing so, chronic pain rehabilitation programs help you to a) reduce pain and b) return to meaningful life activities even though some level of pain may persist. In other words, by participating in chronic pain rehabilitation, you change your relationship to chronic pain. You no longer perceive pain as an alarming and disabling condition, but develop the know-how to understand your pain as a benign condition that no longer needs to disrupt or prevent your daily life activities.

Wouldn’t it be good to become so competent at dealing with persistent pain that you no longer are disabled by it?

Pain would continue to occur, of course, but it would now be occurring in the background of your day-to-day life. The reasonable activities of life, like work and family activities, would become what occupies your time and attention, not pain. Again, wouldn’t it be good to learn how to do it?

Everyday, people with moderate to severe chronic pain learn to do it in chronic pain rehabilitation programs across the world.

There are countless strategies for coping better with pain, which can be learned in chronic pain rehabilitation programs. One strategy, which has been taught ever since there have been such programs, is to adopt an attitude that you remain a healthy person even though you have chronic pain. By assuming this attitude, you come to change your understanding of how you should relate to chronic, or persistent, pain.

Do you remain a healthy person when having persistent pain?

Like many questions in life, the answer to the above question depends on whom you ask. There may or may not be a universally correct answer for all people across all conditions and all situations. Pragmatically, however, the answer is important because it can determine how well you cope with persistent pain.

Many people with persistent pain consider themselves injured or ill. It’s common, for instance, for those with chronic low back or neck pain to think of themselves as injured. Another possibility is that individuals with such pain might have been told they have degenerative disc disease and as such they consider themselves to have a disease of the spine. Still others might consider migraine headache (aka, “sick headache”) or fibromyalgia as an illness. In all these scenarios of thinking of pain as the result of injury or illness, the implication is that you are unhealthy.

Indeed, this way of understanding pain goes hand in hand with seeking healthcare for it. It’s what sick or injured people do. You go to the doctor in order to get better. In this light, pain medications are often thought of as “medicine”.

It can also lead those who conceptualize chronic pain in this manner to engage in other behaviors associated with injury or illness, such as stopping life activities, staying home from work, and resting. It’s what injured or sick people do to get healthier, right?

Together, these beliefs and behaviors make up what’s called the sick role. They are the normal ways of understanding yourself as injured or ill and therefore what you do when you think of yourself in this manner.

Is there really any other way of thinking about it?Healthy Person Exercising

For many, this way of relating to chronic pain doesn’t involve a choice. It’s just how they experience pain. The presence of pain is simply and necessarily a sign of injury or illness for which there is nothing you can do but stay home and remain inactive. It’s never questioned and when it is, such questioning is perceived as invalidating or stigmatizing the reality of the pain as it is experienced.

This way of experiencing pain is apparent when people express such beliefs as “I can’t work” or “I can’t go to my kids ball game this afternoon” or “I have to take pain medicines.” For them, the presence of pain requires certain behaviors like staying home and resting or taking pain medicines. Open discussion of other possible ways of reacting to pain is perceived with skepticism at best and as invalidating or stigmatizing at worst. “You just don’t understand,” they might say. There really is nothing else they might do in the presence of pain, for its very experience requires that one must stay home, rest or take pain medicines. It’s just how it is.

What we are trying to articulate is the underlying conceptual framework or categories through which people experience pain.

Or, more specifically, we’re trying to articulate the conceptual lens through which some people experience pain (see also, Jensen, et al, 1999).

Do all people experience persistent pain in this manner?

While the above noted ways of experiencing pain are common, they are not universal to all people with chronic pain. We know, for instance, from empirical research but also from everyday experience, that some people with moderate to severe pain don’t take opioid pain medicines or don’t perceive themselves as disabled and so remain at work (see, for example, this article here).

For them, the presence of pain doesn’t rise to any level of urgency that requires action. It’s experienced as inconvenient or bothersome, but largely normal. “It’s just what happens when you get old” or “My migraines are a barometer that tells me I’m not taking care of myself very well” or “I heard that back pain is just something we have because early humans stood up on two feet” or “Doesn’t everybody have back pain?” Notice the lack of alarm or urgency with which these people experience pain. They have pain, but there’s no need to do anything about it. They accept it as normal. They don’t enjoy it, of course, but neither are they distressed by it. Pain is something we have and it's accepted as a bothersome fact of life that we put up with.

One way in which people experience pain in this manner is that they don’t understand pain as a health problem. In other words, pain lies outside of the conceptual categories of health or disease or injury. For them, knees and hips and backs and stomachs and necks and heads hurt because that’s how we’re made. It just comes with the territory of playing sports or getting older or getting stressed. It’s the given. It’s not abnormal. It’s normal.

This conceptual lens through which they perceive pain has for them no bearing on whether they are healthy or not. They might, for instance, consider themselves healthy even though they have to mind their persistent knee pain because of the sports they play. Indeed, the presence of chronic pain can sometimes serve as the cause of maintaining a healthy lifestyle. “I have a desk job and so when I sit all the time my back tends to hurt a lot and so it makes me insistent that I block my lunch hour so that I can walk everyday.” “I’m prone to migraines, almost everyone in my family gets them, and so I really have to stay on top of my stress and get regular exercise.”

Notice in these scenarios that pain isn’t understood as in itself an injury or illness. Rather, it’s due to playing sports or sitting too much or getting older or having too much stress. These ways of understanding pain don’t lead to illness behaviors such as staying home or resting or taking pain medicines. Indeed, it just might never occur to them that they should respond to their pain by staying home or taking pain medicine.

To learn to cope better, you have to be open to learning how

What we are trying to do in this discussion of contrasting experiences of pain is to articulate the underlying conceptual frameworks with which people understand pain. Pain is a complex subjective experience and we are attempting to make apparent the possible differences in the subjectivity of these experiences. Pain may be a universally human sensation, but it is subjectively experienced differently by different people in part because different people perceive pain through different conceptual frameworks.

For some, the sensation falls into the categories of injury or illness and poor health. From this way of understanding and perceiving pain, pain is an abnormal sensation that requires actions that sick or injured people do: seeking the advice of healthcare providers, getting tests and medical procedures, staying home from work, resting and taking medicines.

For still others, the sensation of pain falls into different conceptual categories, such as a sign of a hard fought sports game or getting really good work outs or getting older or sitting too much or having too much stress. From these ways of experiencing the sensation, there’s no sense of urgency to do something about it. It’s because they are understood as normal experiences.

The observation of these differences involves no intention to stigmatize. There are times, of course, when pain is due to injury or illness. Acute pain, for instance, is commonly the result of an acute injury or illness. So, it is not inherently wrong to conceptualize pain within the frameworks of injury or illness.

Not all pain, however, falls into these categories and it is sometimes in the best interest of those with chronic, or persistent, pain to begin to understand their pain differently.

It’s possible to learn how to experience pain differently. You have to be open to learning and it helps if you can learn from teachers or coaches within a non-judgmental or stigma-free environment. People with moderate to severe chronic pain learn everyday in chronic pain rehabilitation programs across the world.

Adopting an attitude that you remain healthy despite persistent pain

More often than not, if you see healthcare providers for chronic pain, they will encourage you to remain active, use the painful body part, exercise, manage your stress, stay at work, and try not to take opioid pain medications. Sound familiar? Despite these common recommendations, there’s often little instruction as to how to do these things when actually having pain. In fact, it almost seems impossible because the presence of pain seems to demand that you rest, guard or stay off the painful body part, stay home and take pain medicines. So impossible, it seems, that maybe they don’t really get how much pain you have or otherwise they wouldn’t recommend doing things that you know you can’t do.

With the discussion above, however, we can now begin to articulate how you might actually go about engaging in these recommendations, despite how impossible it might seem at first. It starts with adopting an attitude that you are healthy even though you have chronic pain.

Begin by reflecting on this essay. Consider the possibility that understanding your chronic pain as a long-lasting injury or illness leads naturally to behaviors that healthcare providers recommend against doing: staying home from work, resting, guarding the painful body part, taking pain medicines. This combination of beliefs, perceptions and behaviors lead to what we call identifying with the sick role. It puts you in a dependent role to your healthcare providers, on whom you rely to make you better. It also often puts you in a dependent role to family members, on whom you rely to take up the slack of what you can’t do. However, healthcare providers don’t have many effective ways to make you better, short of helping you to engage in the above recommendations. Reliance on family can foster guilt in you or increased stress and conflict with them. So, in all, experiencing pain through the lens of the sick role doesn’t typically amount to much improvement and sometimes it can even make your overall situation in life worse.

Maybe, then, it’s time to re-think how you think about pain.

Once you decide that it is in your interest to be open to learning new ways to respond to pain, then practice thinking of yourself as a healthy person with persistent pain. Recognize that healthy people have pain, even persistent, or chronic, pain. Low back pain, for instance, is by far the most common form of chronic pain and to manage it well you have to engage in behaviors that healthy people do – stay active, remain at work, use your back, get regular exercise, manage your stress, and maintain a healthy weight.

To adopt the attitude that you remain healthy despite having persistent pain, it helps to recognize that persistent pain is common. A third or more of the population has persistent pain. As we age, pain becomes increasingly more common (Fayaz, et al., 2016). It isn’t, therefore, abnormal to have chronic pain.

From this understanding, the occurrence of persistent back, neck, joint or head pain doesn’t have to be cause for alarm. It’s not signaling a state of urgency. Pain can be accepted as a fact of life. Many of us, as we get older, have a harder time keeping weight off. This biological condition isn’t a pathological condition of illness, but rather just something that is accepted. Most forms of chronic pain can be considered in a similar light – not something that is a pathological condition of illness or injury, but just something that tends to happen. It may occur because of sedentary lifestyles or sports activities or age or stress or maybe we don't even question why because it happens to so many of us. From this way of understanding it, pain isn’t abnormal and it's not alarming, but just bothersome.

This way of experiencing pain seems considerably more preferable than experiencing it as an abnormal and alarming event for which valued life activities must be given up. Rather, pain is something for which you stay active. Motion is lotion, as the old saying goes. Experiencing it this way, pain persists, but occurs in the background of daily life in which you stay active, remain at work, get regular exercise, manage your stress, maintain a healthy weight, and otherwise engage in the healthy behaviors of the healthy person you are.

Now that’s what really good pain management looks like.

References

Fayaz, A, Croft, P., Langford, R M., & Jones, G. T. (2016). Prevalence of chronic pain in the UK: A systematic review and meta-analysis of general population studies. BMJ Open, 6, e010364. doi: 10.1136/bmjopen-2015-010364

Jensen, M. A., Romano, J. M., Turner, J. A., Good, A., Wald, L. H. (1999). Patient beliefs predict patient functioning: Further support for a cognitive-behavioral model of chronic pain. Pain, 81(1-2), 95-104. doi: 10.1016/S0304-3959(99)00005-6

Date of publication: October 7, 2018

Date of last modification: October 7, 2018

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) Coping Sun, 07 Oct 2018 20:12:55 +0000
What is Chronic Pain? https://www.instituteforchronicpain.org/privacy-policy/item/200-what-is-chronic-pain https://www.instituteforchronicpain.org/privacy-policy/item/200-what-is-chronic-pain What is Chronic Pain?

Patients and healthcare providers commonly think of pain as a symptom of an underlying injury or illness. Say, for example, you hurt your low back while lifting. Perhaps, you’ve injured a muscle or ligament, or perhaps it’s an injury to the spine, like a disc bulge or herniation. Either way, you now have pain and the pain is the symptom of the injury. The same might be true for any health condition that causes pain, particularly when it first starts.

Acute pain defined

We call this type of pain acute pain.  Acute pain has two characteristics. First, just as described, acute pain is a symptom of an underlying health condition. Second, its duration is

Patients and healthcare providers commonly think of pain as a symptom of an underlying injury or illness. Say, for example, you hurt your low back while lifting. Perhaps, you’ve injured a muscle or ligament, or perhaps it’s an injury to the spine, like a disc bulge or herniation. Either way, you now have pain and the pain is the symptom of the injury. The same might be true for any health condition that causes pain, particularly when it first starts.

Chronic pain is not long-lasting acute pain

Sometimes pain doesn’t go away. It can last for longer than six months. In fact, it can last for years. In these situations, there is a tendency among patients and some healthcare providers to continue to see the pain as a symptom of the underlying health condition that started it. They think of chronic pain as simply the long-lasting pain of an injury or illness that hasn’t yet healed.

This line of thinking leads to getting a lot of healthcare. Surgeries, injections, and other interventional procedures are common attempts to reduce pain by focusing on the underlying condition that started the pain. The typical chronic pain patient has had any number of such procedures and therapies.

These procedures and therapies aren’t very effective. At best, they tend to provide temporary reductions in pain. Studies of healthcare expenditures show that in the last twenty years the rates of pain-related surgeries, injections and narcotic pain medications are at an all time high. At the same time, applications for pain-related disability are also at an all time high.1 Obviously, these procedures and therapies don’t work so well.

The truth is, once pain is chronic, it’s pretty hard to stop, particularly if the focus of care is to try to fix the underlying injury or illness that started it all.

The reason is that chronic pain is something more than the pain of a health condition that hasn’t healed. The importance of this point is hard to underestimate.

Chronic pain defined

Chronic pain has two characteristics that are different from acute pain. First, chronic pain lasts longer than six months. Second, and most importantly, chronic pain is pain that occurs in addition to the pain of the original health condition. In fact, the original, underlying condition may or may not have healed. It doesn’t really matter. Chronic pain is pain that has become independent of the underlying injury or illness that started it all.

Once pain has become chronic, attempts to fix the underlying injury or illness that started it tend to fail to reduce pain. The mistake that patients and some healthcare providers make is to think that chronic pain is just a long-lasting version of acute pain. However, chronic pain is pain that has taken on a life of its own. Chronic pain is pain that is occurring over and above any pain that may or may not occur from the underlying injury or illness that started it. As such, attempts to cure the original health condition commonly miss the mark.

Cause of chronic pain

What then is the cause of chronic pain? To answer this question, we need to understand some facts about the nervous system.

Whatever its initial cause, pain is a function of the nervous system. Say you injure your low back. Nerves around the site of the injury detect it and sends signals that travel on a highway of nerves from the injury to the spinal cord and up to the brain. Once they get to the brain, the brain processes the signals and they register as pain in the low back. The whole highway, from the nerves in the low back to the brain, is the nervous system.

At the same time as the signals travel from the injury to the brain, the whole nervous system becomes reactive. Like a fire detector in a building sounding the alarm in response to fire, the nervous system sets off the alarm bells when in pain. Our muscles become tense. We guard and grimace. We cry and are emotionally alarmed. The nervous system controls all these reactions. We can think of it as the whole nervous system going into red alert.

This reactivity of the nervous system is all well and good when it comes to acute pain. It helps us to know that something is wrong. Becoming alarmed, we protect against further injury and seek help. Once the original injury or illness heals, everything about the nervous system usually comes back to normal.

In some people, however, the nervous system can stay in a persistent state of reactivity even upon healing of the original acute injury or illness. The whole nervous system becomes more and more reactive in a process called wind-up. This reactivity of the nervous system comes to maintain pain in a vicious cycle, over and above the pain of the original condition that started it all. The end state of this process is a highly reactive nervous system called central sensitization.

The hallmarks of central sensitization are increasingly widespread pain and increasingly intense pain. Suppose you have an injury to your neck and come to have chronic neck pain. In this process, central sensitization develops independdnelty of whether the initial injury heals.  Subsequently, you develop pain in your shoulders and upper back as well as tension headaches in adition to neck pain. The pain may become so intense that even touch can hurt.

Other problems occur as well with central sensitization. Since the nervous system also controls our emotional lives, a highly reactive nervous system leads to anxiety and irritability, poor sleep, fatigue, and eventually depression. These psychological problems are secondarily stressful. The stress adds to the reactivity of the nervous system, making the pain worse.

The upshot of it all is that chronic pain develops from acute pain but becomes an altogether different type of pain, which we call chronic pain, by way of central sensitization and is not the result of a long-lasting injury or illness.

Central sensitization can occur with all acute pain conditions. It can occur with spine-related acute injuries, whiplash injuries, tension headaches, migraine headaches, rheumatoid arthritis, osteoarthritis, and endometriosis. It can occur with injuries from a motor vehicle accident or following surgeries.

The importance of treating the nervous system in chronic pain

Chronic pain is thus categorically different from acute pain. It’s not just that it lasts longer. It’s that the whole nervous system is involved, maintaining the chronicity of the pain, over and above whatever pain that might continue, if any, from the original health condition that started it.

Earlier, we commented on the frequent failure of surgeries, injections, and other interventional procedures to permanently reduce pain. From here, we can see why. They are attempts to fix the injury or condition that started it all. The original condition, however, is typically not what’s responsible for maintaining pain on a chronic course. That is to say, the treatments fail because none of them address the most important cause of chronic pain – central sensitization.

The only treatment that fully addresses central sensitization is chronic pain rehabilitation.

References

1. Brook, M. I., Deyo, R. A., Mirza, S. K., Turner, J. A., Comstock, B. A., Hollingworth, W., & Sullivan S. D. (2008). Expenditures and health status among adults with back and neck problems. Journal of the American Medical Association, 299, 656-664.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) What is Chronic Pain Thu, 20 Apr 2017 16:47:15 +0000
How to Get Better When Pain is Chronic https://www.instituteforchronicpain.org/blog/item/171-74how-to-get-better-when-pain-is-chronic https://www.instituteforchronicpain.org/blog/item/171-74how-to-get-better-when-pain-is-chronic How to Get Better When Pain is Chronic

In the last post, we began to introduce a broad definition of coping, as one’s subjective experience, or reaction, to a problem. In this post, let’s expand on this definition and explain how coming to cope better with a problem is a process of coming to experience the problem in a different and better way.

Coping is how we subjectively experience a problem

In our society, when having a problem, we tend to focus on the problem itself, its characteristics and how they do or don’t lend themselves to resolving the problem. In so doing, we put our focus and energy towards fixing or getting rid of the problem. This way of thinking about the problem is all well and good. It likely lends itself to our society’s successes in developing technological solutions to many of the great problems that we have faced.

As an example of this tendency to focus on problems and fixing them, we need only to look to the problem of pain and how we tend to focus on it, and how we try to get rid of it or otherwise reduce it. Knees and hips can now be replaced and we have a large assortment of different medications that can reduce pain and sometimes get rid of it entirely.

However, instead of focusing primarily on the problems itself, we might also bring our attention to the unique characteristics of each individual with the problem and how they understand it, feel about it, perceive it, and how they behave in regards to it. In effect, we might focus on the characteristics of each person and how these characteristics influence the way individuals experience the problem.

For wherever there is an objective problem in the world, there are also perceiving subjects who have the problem.

We typically call the ways that people experience problems “coping.” It’s something that usually we only direct our attention to when we can’t come up with a solution, or fix, to a problem itself. Nonetheless, it comes in handy in such situations because it offers a way to still get better even if there is no fix to the problem. Namely, we get better at coping with the problem: we can become less distraught by the problem or less impaired by the problem.

In this regard, in returning to our pain example above, we might focus not so much on how to get rid of pain, but how to get better at coping with pain. This change in the approach to getting better may come in handy when pain is truly chronic and you’ve already tried every reasonable procedure and medication without any significant benefit. In such a situation, you focus not so much on how to reduce pain, but on how to increase coping.

In doing so, you can come to learn to tolerate pain that at present is intolerable. You might even get so good at coping that you do more than simply tolerate it – you might get so good at coping that the pain goes from something that is the central focus of your life to something that occurs in the background of your life. It becomes a problem, in other words, that’s not very problematic.

Moreover, you can do such a thing without ever reducing pain itself. It can all occur by changing how you experience, or cope with, pain.

It may sound too good to be true.

How coping better makes problems less problematic

It’s important to recognize that people who cope well with a problem tend to experience the problem as less significant or severe than those who don’t cope well with the problem. In other words, when we aren’t coping well, we tend to perceive or judge the problem that we face as more problematic than those who cope well with it. For example, if you had taken a speech class and had actually given many speeches before in the past, you might find the prospect of giving a speech to a packed auditorium as less problematic than someone without your level of expertise and practice. You might find it quite tolerable, in fact possibly even not problematic at all – something in the category of “Well, it was no big deal.” However, another individual, who faces the challenge of giving the exact same speech to the exact same auditorium, might find it overwhelming, paralyzing or intolerable. This individual might judge the problem as one of the hardest things he has ever done in his life.

Objectively, it’s the exact same problem, but the two people subjectively experience it in very different ways. We might say, in such cases, that the differences lie in how well the individuals cope with the problem of giving a speech to a packed auditorium.

How well we cope depends, of course, on how significant the problem is. Big or complicated problems are more difficult to deal with than small or simple problems. Most people will find talking to a group of two or thee people easier than an auditorium of two or three hundred. Nonetheless, how well we cope with problems is also dependent on other things too.

Notably, it’s dependent on certain characteristics of the person who is coping with the problem. If one knows a lot about the problem and is actually an expert on the topic, then typically that person copes better than someone who doesn’t know as much about the problem. Or, if someone has experienced the problem before or expects the problem to occur, then that person often copes better than the individual who has never encountered the problem before or someone who is taken by surprise by the problem. Confidence plays a role here too. Someone who knows a lot about the problem and is well-versed or well-practiced with dealing with the problem tends to be more confident and that confidence aids in coping better. Someone who lacks such confidence tends to be more alarmed or even distraught, which makes for more difficulty in coping. In any of these cases, the subjective experiences of the problem are different for the different people, even if the problem was objectively the same problem.

We could go on indefinitely about the subjective characteristics of the coper, which play a role in how well the individual deals with a problem. We might make a list of subjective characteristics that determine, in part, how well one copes:

  • Degree of knowledge or expertise about the problem
  • How one conceptualizes the problem
  • Degree of accurate information that one has about the problem
  • How much one has practiced overcoming the problem
  • Other attitudes about the problem
  • Degree of confidence in facing the challenge
  • Degree of attention directed on the problem
  • How one feels about the problem
  • What one’s mood is at the time of encountering the problem (e.g., whether one is calm or irritable, depressed or anxious)
  • How much sleep one has had in the past few days prior to encountering the problem
  • How many other problems one is experiencing at the time of encountering a new problem
  • What one goes on to do about the problem (behaviorally)
  • Degree of loving support one has in facing the problem

There are literally countless aspects of the coper that determines, in part, how well one experiences, or copes with, a problem. Some of these characteristics lend themselves to better coping and some lend themselves to worse coping.

Getting better by getting better at coping

So, think about this simple fact: if you have a problem that can’t be entirely fixed, you could still get better by setting out in a concerted effort to get better at coping with it. You could, in effect, obtain training at having the problem and get so good at it that having the problem becomes less and less problematic. It could become, for example, something that occurs in the background of your day-to-day activities, but for the most part you’ve moved on and focus on the meaningful activities of your life. Indeed, there is simply no end to how good one can get in coping with a problem, even a problem that can’t be entirely fixed, like chronic pain.

Photo by Tim Marshall 450x300Here is where true hope lies. Even when your pain is chronic, you can get so good at coping with it that living with chronic pain is no longer a distressing or impairing problem. Alternatively, you can get so good at coping with it that it no longer requires opioids to manage it and so you can move on with the rest of your life.

Usually, this level of advanced coping requires a concerted effort of training, done over time, and typically with a team of healthcare providers who coach you and support you throughout the process. Traditionally, patients find such support and training in chronic pain rehabilitation clinics. Such clinics are a type of pain clinic that involve an interdisciplinary team of healthcare providers (consisting of at least pain psychologists, medical providers, and physical therapists, but oftentimes other kinds of providers as well) who work with patients over an extended period of time in the pursuit of not so much reducing pain, but improving the patient’s coping. Such clinics are not new, but have been around since at least the early 1970’s and as a result they have about four decades of published research proving their effectiveness (see, for example, these meta-analytic studies and literature reviews: Chou, et al., 2007; Flor, Frydrich, & Turk,1992; Gatchel & Okifuji, 2006; Neusch, et al., 2013; Turk, 2002).

When talk of the possibility of coping better feels like a criticism

Sometimes, when healthcare providers like me talk in these ways, it feels to patients with chronic pain like a judgment. It feels like blame. It feels like you’re being told there’s something wrong with you -- that you aren’t coping well enough.

Oftentimes, when patients have people in their lives who judge them or stigmatize them for how they have been coping, they can come to hear their healthcare provider talking about the benefits of learning to cope better as a similar criticism.

In such cases, patients can come to refuse the recommendation to participate in chronic pain rehabilitation. The hopeful message that there is a traditional and scientifically proven treatment that helps patients to learn to cope better with pain can be met with quick and sometimes sharp rebuttals. Common examples are the following:

  • The provider must be insensitive.
  • The provider must not know what he or she is talking about (i.e. the provider is incompetent).
  • The provider doesn’t (or won’t) recognize that I’m coping as well as humanly possible given the amount of pain I have.
  • The provider must not have chronic pain or otherwise he or she would understand.
  • The provider must not believe me that I have real pain.
  • The provider is just out to make money and so wants me to go to yet another treatment from which he or she will profit.
  • The provider just wants me to get off opioid medications.

Obviously, talk of how to learn to cope better is a sensitive topic. It’s as if the same words can engender almost two opposite interpretations. The healthcare provider intends it to be a hopeful message – you can get better by undergoing extensive training over time and as a result come to cope better with a condition that is incurable. The patient, however, can hear it as an insensitive criticism of how the patient isn’t coping well right now.

Importance of trusting your healthcare provider

In such situations, what can make the difference is having a good, therapeutic relationship with your healthcare provider. If you know your provider and trust him or her, then you know that your provider isn’t just being mean or insensitive or ignorant of what’s it like to have pain or out to make money off you. Instead, you know that your provider has your best interest at heart.

References

Chou, R., Amir, Q., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.

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

Neusch, E., Hauser, W., Bernardy, K., Barth, J. & Juni, P. (2013). Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: Network meta-analysis. Annals of the Rheumatic Diseases, 72, 955-962

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

Author: Murray J. McAllister, PsyD

Date of last modification: September 11, 2016

About the author: Dr. McAllister is the editor 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 Sun, 11 Sep 2016 17:52:53 +0000
The Biopsychosocial Nature of Pain https://www.instituteforchronicpain.org/blog/item/156-59the-biopsychosocial-nature-of-pain https://www.instituteforchronicpain.org/blog/item/156-59the-biopsychosocial-nature-of-pain

Contexts matter. The same joke might go over in very different ways, depending on whether it’s told by a comedian in front of an audience at a comedy club or told by an applicant in the middle of a job interview. An action done over and over again might be considered in one context an admirable example of perseverance in the face of adversity, whereas in another context it might be considered an exercise in futility.

Contexts matter in health too. The onset of a health condition might have two very different trajectories based on the contexts in which its onset occurs. Take, for example, a flu infection. It might be a nuisance for someone who is otherwise healthy, whereas the same infection might be disastrous for an elderly person or for a person whose immune system has been compromised due to undergoing chemotherapy. The overall presentation of flu in these cases is different because of the context. They each share a common precipitating cause – the influenza virus, but their illness is manifested differently due to the contexts that they don’t share.

In this light, we have to acknowledge the importance of context as a cause of health problems. In the common influenza examples described above, the context plays just as an important causal role as the influenza virus itself. Indeed, it’s the context that determines whether the flu will be either a nuisance or life threatening. In other words, the particularities of the person who has the health condition – the host, if you will -- have a causal influence on the overall ways that the condition presents.

Moreover, it’s hard to imagine a health condition that occurs in isolation of the person who has it. As such, we must acknowledge that health conditions almost always have multiple causes – the precipitating event and how it interacts with the particularities of the person who has it and experiences it.

The common reductionistic view of health conditions

In our society, we tend to forget this simple fact about health. We tend to equate a health condition with a single precipitating cause and explain the differences across people who have the same condition by asserting differences in the severity of the precipitating cause. So, in the influenza example above, we tend to explain differences in severity of illness by asserting that one person’s influenza infection (i.e., the precipitating cause) must be due to a more virulent strain than another person’s flu infection.

As a society, we take this stance all the time in chronic pain management. We assume that people with high levels of pain and disability always must have had more severe precipitating injuries than those who have less pain and disability. Of course, sometimes it is true. Someone who breaks her neck in a motor vehicle accident may result in a high level of pain and disability.

Reductionism leads to stigma

Yet, not everyone with pain, perhaps not even a majority, fit neatly into this simple equation that differences in pain and disability are always explainable by differences in the precipitating event or cause.

It’s not uncommon for people to have excruciating pain and severe disability from moderate injuries, such as a fall from a ladder or stairs, or mild injuries such as a muscle strain from lifting something or simply bending over to pick something light off the floor. It’s even common for people to have severe pain and impairment without a precipitating injury or illness at all.

These people don’t fit into our common assumption that severity of pain and disability must always correspond with severity of precipitating injury or illness. Unfortunately, what happens to these people is that they get stigmatized. Others invalidate them by doubting the legitimacy of their pain and disability. “All you did was to bend over and pick up your hammer off the ground,” they might say, “How can you have so much pain that you can’t work?”

But what if there is a rational explanation for their pain and disability?

Chronic pain is multifactorial

We need to recognize that pain is more complicated than we tend to think it is. There is always more than one factor that initially causes pain and always more than one factor that maintains pain on a chronic course. A good place to start to recognize these facts are in the context in which precipitating causes occur.

In healthcare, we tend to categorize the contexts in which health conditions occur in three ways. They are biological, psychological and social contexts.

The 'bio-' in the biopsychosocial

The biological contexts are the health of the person in terms of his or her bodily systems – the nervous system, the endocrine or immune systems, for instance. In the cases above, we described two people with the same precipitating event, an influenza infection, and saw how in one person the flu was a minor illness and in another it became a life-threatening illness because of differences in their immune systems. Whether healthy or compromised, the immune systems of each have an influence on the overall presentation of the illness. Indeed, in the case of the person with the compromised immune system, it is equal in importance to the precipitating cause of the influenza infection itself: it’s what makes the infection life threatening.

Similarly, the health of a person plays a role in the onset and chronic maintenance of pain. We know, for instance, that certain conditionsImage by Britta Preusse courtesy of Unsplash make the onset of pain more likely or the transition from acute pain to chronic pain more likely. Obesity is an example. Those who are obese are more likely to develop low back pain (Shiri, et al., 2009), hip and knee pain (Andersen, et al., 2003). Oftentimes, the cause of their low back, hip or knee pain gets attributed to osteoarthritis, but osteoarthritis isn’t necessarily a discrete illness. It’s typically considered overall wear and tear that comes with age, or in the case of those who are obese, the extra weight that those joints must bear. Thus, obesity can be a cause of a new episode of pain.

The overall health of the nervous system also plays a role in the development of chronic pain. We know that people who have been subjected to prolonged stress are more likely to develop a new episode of pain and develop chronic pain once pain occurs. Examples are people who have experienced trauma or who are depressed or anxious or experiencing other life stressors (Croft, et al., 1995; Linton & Bergbom, 2011; McBeth, et al., 2007; Pincus, et al., 2002; Raphael & Widom, 2011). It’s not because they are any more accident-prone or illness-prone. Injury or illness, we might say, is an equal opportunity event. Rather, it’s that nervous systems under prolonged stress tend to have lower thresholds for stimuli to provoke pain and tend to become increasingly sensitive once a new episode of pain occurs.

Obviously, there are countless facets about the overall health of people that can play causal roles in either the development of pain or in the transition from acute to chronic pain. These biological factors provide a context in which a precipitating event, such as a painful injury or illness, occurs and they influence how the pain of the precipitating event is manifested.

The 'psycho'- in the biopsychosocial

The psychological contexts are the psychological conditions and stressors that impact the nervous system, as well as health beliefs and behaviors that might impact the experience of pain and how people react to pain once becoming injured or ill. As suggested above, those who have struggled with trauma, anxiety or depression are at greater risk for developing pain and especially transitioning from acute to chronic pain once having an acute injury or illness. In other words, the state of the nervous system at the time of the acute injury or illness, especially when it’s under prolonged stress, can have a causal role in the development of subsequent chronic pain. In this way, we can rightly say that anxiety and depression can be one of the many multifactorial causes of chronic pain.

Indeed, in people who subsequently develop chronic pain, it’s actually quite common to have experienced trauma, anxiety and/or depression prior to the acute onset of pain (Knaster, et al., 2012; Magni, et al., 1994) and these emotional disorders interact synergistically with biological causes of pain to heighten the overall experience of pain (Domnick, Blyth, & Nicholas, 2012). These factors can tip the scale, as it were, to transition acute pain into chronic pain, following a precipitating painful injury or illness.

Other psychological factors, besides emotions, can exercise a causal role in the development of pain and chronic pain. Beliefs about pain and prior learning about pain can influence how pain is experienced and what we go on to do about it once having it (Arnstein, et al., 1999; Edwards, et al., 2011; Linton, Buer, Vlaeyen, & Hellsing, 2000; Nahit, et al., 2003). Some beliefs about pain and what we are supposed to do about it are helpful. They can reduce the intensity of pain or promote healing or recovery in the case of acute pain. They can also promote coping well with pain and remaining active in the case of chronic pain. Some beliefs, however, are not so helpful and can lead people to inadvertently experience more pain or do things that don’t promote recovery or good coping. Examples are catastrophizing, fear-avoidance beliefs, and engaging in illness behaviors (e.g., persistent resting and activity avoidance).

There are countless more psychological factors that can influence how pain and disability are manifested. Nonetheless, the point here is to recognize that the context in which pain occurs has an influence. It has a causal role – even if it’s not the initial or precipitating cause – in how we experience pain and what we go on to do about it once becoming injured or ill.

The ‘social’ in the biopsychosocial

The social contexts are those social conditions and stressors that can impact the nervous system or otherwise affect the trajectory of people’s health. These aspects widen the context further, beyond the biological and psychological make-up of the individual. They involve the make-up of the individual’s surroundings in terms of their relationships and social resources. We know that these factors too have a causal influence on health, pain included.

To illustrate the point, let’s take an all-too-common example that occurs within our field of chronic pain management. Suppose you see a woman who has chronic daily headache. Outside your clinic, she’s been treated for many years with medications and interventional pain procedures. She tells you that she’s been told she has cervicogenic headache, which means that her headache is thought to be due to structural problems in the cervical spine (i.e., neck). On MRI, she does in fact have modest degenerative changes, but these findings are common in people of her age. As such, we might consider this way of understanding her pain as a biomedical conceptualization. You, however, are a provider who understands chronic pain from a biopsychosocial conceptualization and so you ask, in your initial evaluation, about her psychological health as well as about her relationships, home life, financial stressors, and about where she lives in the community. At first, she’s a little taken aback. No one, she tells you, has asked about such things, at least not in the depth that you go into. She also doesn’t understand, she says, what all of this has to do with her pain. With budding trust, however, she begins to tell you that she has been involved in a domestically violent relationship for many years.

Might it not be reasonable to suppose that the persistent stress of physical, emotional and sexual violence plays a causal role in her headache pain? How could it not? Such prolonged stress would have to adversely affect her nervous system and thereby exacerbate her chronic pain. Even if, as has happened to her, we adequately treated any ‘cervicogenic’ aspects of her pain, wouldn’t it be insufficient to adequately manage her pain? We have to address the social causes of her pain condition as well.

Domestically abusive relationships are not the only type of persistently stressful relationship that can affect the trajectory of chronic pain. Care-taking relationships are also chronically stressful: care-taking an elderly parent with dementia, care-taking a spouse with cancer or a spouse disabled by a stroke, care-taking a child with special needs. Chronic marital conflict, short of domestic abuse, might be another. The absence of relationships can also be a chronic stressor in the form of loneliness that can influence the development of pain (Jaremka, et al., 2013).

These chronic social stressors affect the nervous system, likely making it more sensitive to stimuli, and thereby exacerbating pain, as well as sapping the ability of such people to cope with the pain that they experience. As such, social stressors have a causal influence on pain, even if they are not the initial precipitating cause.

We also know that poverty and living in dangerous neighborhoods can affect overall health as well the onset of pain and its chronicity (Gooseby, 2013; Ulirsch, et al., 2014). These social-based stressors adversely affect the nervous system and thereby adversely affect pain levels as well.

We know too that lack of access to adequate healthcare affects the trajectory of pain once having an acute injury or illness. Lack of insurance or being underinsured can often lead to emergency room based care or other stop-gap measures that are poorly suited for chronic conditions. Lack of availability of effective chronic pain management, even for those with adequate insurance coverage, can also play a role (Prunuske, et al., 2014). For example, the most effective form of chronic pain management, interdisciplinary chronic pain rehabilitation programs, is not widely available in the United States (Schatman, 2012). As such, many people with chronic pain simply do not have ready access to them and so must rely on less effective means to manage their pain. These social factors thus influence the pain levels of an individual’s condition.

Conclusion

Like all health conditions, pain is multifactorial. Meaning, multiple factors go into causing pain and maintaining it on a chronic basis. In our society and healthcare system, we tend towards understanding pain in reductionistic terms – understanding pain as solely the result of the event that precipitated it – an injury or illness. This reductionistic understanding leads to the belief that severity of pain and disability is solely the result of the precipitating event. So, if pain and disability are severe, there must have been a severe injury or illness. Most people’s pain or chronic pain, though, simply don’t fit neatly into this reductionistic model. They can have high levels of pain and disability in the absence of severe injuries or illnesses. As a result, they often get stigmatized: others doubt the legitimacy of their pain and disability. However, there is a rational explanation for these people’s pain and disability. Their pain, as with all people’s pain, is not solely caused by the precipitating event that started it all. Pain is multifactorial: there are multiple causal influences to pain in terms of the overall contexts in which injuries and illnesses occur. The biological, psychological, and social health of these contexts play a part in the onset and chronic maintenance of pain. These causes provide a rational, accurate and legitimate explanation for how pain and chronic pain become manifested in individuals.

(For more advanced study of the biopsychosocial nature of chronic pain, please see Gatchel, et al., (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581-624. doi: 10/1037/0033-2909.133.4.581)

References

Andersen, R. E., Crespo, C. J., Bartlett, S. J., Barthon, J. M., & Fontaine, K. R. (2003). Relationship between body weight gain and significant knee, hip and back pain in older Americans. Obesity Research, 11(10), 1159-1162.

Arnstein, P., Caudill, M., Mandle, C. L., Norris, A., & Beasley, R. (1999). Self-efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain, 80(3), 483-491.

Croft, P. R., Papageorgiou, A. C., Ferry, S., Thomas, E., Jayson, M. I., & Silman, A. J. (1995). Psychologic distress and low back pain: Evidence from a prospective study in the general population. Spine, 20(24), 2731-2737.

Domnick, C. H., Blyth, F. M., & Nicholas, M. K. (2012). Unpacking the burden: Understanding the relationships between chronic pain and comorbidity in the general population. Pain, 153, 293-304.

Edwards, R. R., Cahalan, C., Mensing, G., Smith, M., & Haythornwaite, J. A. (2011). Pain, catastrophizing, and depression in rheumatic diseases. Nature Reviews Rheumatology, 7, 216-224. doi: 10.1038/nrrheum.2011.2

Gooseby, B. J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Heath and Social Behavior, 54(1), 75-91.

Jaremka, L. M., Fagundes, C. P., Glaser, R., Bennett, J. M., Malarkey, W. B., & Kiecolt-Glaser, J. K. (2013). Loneliness predicts pain, depression, and fatigue: Understanding the role of immune dysregulation. Psychoneuroimmunology, 38(8), 1310-1317.

Knaster, P., Karlsson, H., Estlander, A., & Kalso, E. (2012). Psychiatric disorders as assessed with SCID in chronic pain: The anxiety disorders precede the onset of pain. General Hospital Psychiatry, 34(1), 46-52.

Linton, S. J & Bergbom, S. (2011). Understanding the link between depression and pain. Scandinavian Journal of Pain, 2(2), 47-54.

Linton, S. J., Buer, N., Vlaeyen, J., & Hellsing, A. (2000). Are fear-avoidance beliefs related to inception of an episode of back pain? A prospective study. Psychology & Health, 14(6), 1051-1059.

Magni, C., Moreschi, C., Rigatti-Luchini, S., & Merskey, H. (1994). Prospective study on the relationship between depressive symptoms and chronic musculoskeletal pain. Pain, 56(3), 289-297.

McBeth, J., Silman, A. J., Gupta, A., Chiu, Y. H., Morriss, R., Dickens, C., King, Y., & Macfarlane, G. J. (2007). Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain: Findings of a population-based prospective cohort study. Arthritis & Rheumatism, 56, 360-371.

Nahit, E. S., Hunt, I. M., Lunt, M., Dunn, G., Silman, A. J., & Macfarlane, G. J. (2003). Effects of psychosocial and individual psychological factors on the onset of musculoskeletal pain: Common and site-specific effects. Annals of Rheumatic Disease, 62, 755-760.

Pincus, T., Burton, A. K., Vogel, S. , & Field, A. P. (2002). A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine, 27(5), E109-E120.

Prunuske, J. P., St. Hill, C. A., Hager, K. D., Lemieux, A. M., Swanoski, M. T., Anderson, G. T., & Lutfiyya, M. N. (2014). Opioid prescribing patterns for non-malignant chronic pain for rural versus non-rural US adults: A population-based study using 2010 NAMCS data. BMC, 14, 563.

Raphael, K. G. & Widom, C. S. (2011). Post-traumatic stress disorder moderates the relation between childhood victimization and pain 30 years later. Pain, 152(1), 163-169. Doi: 10.1016/j.pain.2010.10.014

Schatman, M. E. (2012). Interdisciplinary chronic pain management: International perspectives. IASP Pain Clinical Update, 20(7).

Shiri, R., Karppinen, J., Leino-Arjas, P., Soloviev, S., & Viikari-Juntura, E. (2009). The association between obesity and low back pain: A meta-analysis. American Journal of Epidemiology, 171(2), 135-154. doi: 10-1093/aje/kwp356

Ulirsch, J.C., Weaver, M. A., Bortsov, A. V… & Mclean, S. A. (2014). No man is an island: Living in a disadvantaged neighborhood influences chronic pain development after motor vehicle collision. Pain, 155(10), 2116-2123. Doi: 10.1016/j.pain.2014.07.025

Date of publication: 3-1-2015

Date of last modification: 3-21-2021

Author: Murray J. McAllister, PsyD, LP 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Biopsychosocial Sun, 01 Mar 2015 19:03:24 +0000
What is your relationship to chronic pain? https://www.instituteforchronicpain.org/blog/item/135-38what-is-your-relationship-to-chronic-pain https://www.instituteforchronicpain.org/blog/item/135-38what-is-your-relationship-to-chronic-pain

What is your relationship to your chronic pain? At first thought, it seems like an odd question. But, if we stop to reflect on it, couldn’t we have a relationship to pain? Don’t you already have one?

The Merriam-Webster Dictionary (n.d.) defines the word ‘relationship’ as “the way in which two or more people, groups, countries, etc., talk to, behave toward, and deal with each other.” We usually think about relationships as applying to people, such as our spouses, children, family, or enemies, but we also have relationships to non-human beings, such as God and pets, and even inanimate things, such as our work, our children's schools, our own alma maters, our country, or nature. We also have relationships to things that are somewhere in between, such as our bodies. Might we not have a relationship to chronic pain?

Let’s look at a number of different possible relationships to chronic pain. We’ll simply try to take an inventory of different relationships without judging whether they are good or bad or better or worse than any of the others. Our only goals for taking this inventory are to see how people relate to chronic pain and to see how different people relate to chronic pain differently.

Chronic pain as something that we must get rid of

In the acute medical model of healthcare, we often treat pain as something that we must get rid of. It’s a bad thing. It’s so bad, in fact, that we might unquestionably go to great lengths and almost all costs to get rid of it. As healthcare providers and as patients, we try one therapy after another, one procedure after another, and one medication after another.

All this healthcare hardly ever requires justification: our relationship to pain is such that it is something, which is assumedly bad -- so bad, in fact, that we must get rid of it.

Chronic pain as something that we fight againstImage by Raj courtesy of Unsplash

Indeed, pain is something that we declare war on. For after all, it is often thought of as fighting us. It’s stabbing, piercing, jolting, burning, and pounding. It’s like hand-to-hand combat, but it’s our hand, or arm, or leg, or neck or low back that’s fighting us. Our bodies have turned against us and the pain is insidious and relentless. It’s taken our life away. Our relationship to pain in such instances is one of fighting and war. Like any people under siege, we vow to maintain hope by never giving up the fight.

Chronic pain as something that imprisons us

Patients commonly tell me that they wish the painful part of their body could just be cut off. When you think about it, there’s something very primitive about this wish. It brings connotations of what an animal might do when caught in a steel jaw trap: it chews its limb off.

Pain can indeed capture our attention and ensnare us. We might find ourselves entertaining doing most anything in order to become pain-free. Our relationship to pain at such times is one of having been taken prisoner. Having lost our abilities to move about freely, we have to stay at home and rest day after day. Our sentence: house arrest.

Chronic pain as a mechanical problem that requires a fix

We can also think of pain as a mechanical problem for which there must be some type of fix. Both providers and patients can relate to pain in this way. Spine surgeons and interventional pain physicians commonly conceptualize back pain as ‘mechanical back pain.’ A common explanation for sciatica is that a disc in the low back has ‘slipped’ or ‘ruptured’ and is now ‘pinching’ the nerve that extends down the leg. It brings connotations of a car engine part slipping out of place or breaking altogether and is now pinching some important cable or hose. In a procedure called a ‘discectomy,’ a spine surgeon attempts to free the pinched nerve by scraping away the part of the disc that’s impinging the nerve. Interventional pain physicians attempt to temporarily reduce the inflammation around the ‘pinched’ nerve with epidural steroid injections. They might also attempt to temporarily deaden the nerve altogether with a rhizotomy (i.e., a radiofrequency neuroablation procedure, or what is called a ‘nerve burning’ procedure).

Chronic pain as something that is the result of a long-lasting injury

We can also relate to chronic pain as something that is the result of a long-lasting injury. In conditions that are acute, such as a bone fracture, pain occurs and we think of it as the result of the underlying acute injury. In such cases, we tend to react to the pain by staying home and resting. Commonly, people think of and react to chronic pain in similar ways. Even if it has been years since the onset of the initial injury that started the pain, we can think of the original condition as remaining unhealed (or even getting worse) and continuing to cause the chronic pain.

As such, we might remain concerned about making the underlying injury worse and engage in behaviors that we think will prevent harm. Similar to what we might do with acute injuries, we might stay home and rest. We also avoid activities that we think have a chance of making the underlying injury worse. In these ways, we tend to think of the pain that occurs with activities as a sign that we are in fact making the underlying problem worse.

Chronic pain as an illness

Sometimes, people with chronic pain think of themselves as ill. Their relationship to pain is one of illness even in cases of chronic pain that started with an injury or had no identifiable cause. They hear explanations for back pain, such as ‘degenerative disc disease,’ and understandably think of themselves as having a disease. People with headaches too can often refer to themselves as 'being ill with a headache.' Conceptualizations of chronic pain as an illness naturally lead to the above behaviors that we do when ill: we stay home and rest. Frequently, pain relievers subsequently get referred to as ‘medicines,’ a term that has connotations of something one takes to cure an illness.

Chronic pain as something that is alarming

In all the above ways of relating to pain, there is a common element: it’s that chronic pain is alarming. Whether it is war or imprisonment or a mechanical problem or an injury or illness, pain is an object of concern. It’s not only bad; it is bad enough to do something about it. In other words, it impels us to act like a fire alarm. Such alarms are emotionally distressing. We become concerned and aroused with some degree of fear. We can also cry when in pain. We don’t jump up and down for joy. Rather, we are emotionally distressed while in pain. As such, pain is alarming.

Differing relationships to chronic pain

As is clear, different people can have different relationships to chronic pain and an individual might have different relationships to his or her pain at different times in life. Moreover, this inventory of possible relationships is not exhaustive. There are more relationships that we could describe.

The point is important to remember because when you are in one of these relationships to pain they seem obviously accurate to the situation at hand. It’s hard, for instance, to recognize that it is just one perspective that you might take on pain when you are in one of these relationships. It can be hard to understand how someone might have a different relationship to his or her chronic pain. For instance, one might say, “Of course, you are going fight against the pain… Who wouldn’t?” The relationship to pain as alarming and something that must be gotten rid of seems so obviously true. What the inventory makes clear, though, is that each relationship is but one perspective and that it is possible to have different perspectives that you can take on your pain.

Are there other relationships to chronic pain? Ones that are very different than the above?

Sometimes people with chronic pain have none of the above relationships to pain and are, in fact, not very alarmed by their chronic pain. Rather than fighting against it, they have made peace with it. They are no longer alarmed by it and instead have learned to live with it.

Some people with chronic pain treat their pain like a noisy neighbor next door or in the apartment above. They once tried to get the neighbors to quiet down, but were unsuccessful and so have come to accept that they must learn to live with them. While the neighbors are still noisy, they no longer allow the neighbors to occupy too much of their time and attention. They still hear their neighbors but they then move on with the rest of their day.

Many people with chronic pain have a similar relationship to their pain. They are no longer alarmed by their pain. It’s there, but they realize that there’s not much they can do about it. So, ‘why fight it?’ they might ask. Instead, they move on with their day and get busy with other things. Of course, they would rather not have it, if they had a choice. But, they recognize that they don’t and so accept it. Part of acceptance is that they are just not that alarmed by pain anymore.

Their relationships to chronic pain involve understanding pain as something that is not alarming. They see chronic pain as part of life – the bad, along with the good, that we just have to put up with.

Now, what might that look like?

Chronic pain as a stable condition

Some people with chronic pain see their pain as a stable condition that doesn’t have any bearing on whether they are healthy or not. They might think of it or refer to it as ‘my old war injury’ or ‘my trick knee’ or ‘my old high school football injury’ or ‘my bad back’ or the like. The connotation in these ways of thinking about pain is that chronic pain is an old condition that isn’t going anywhere. That is to say, it’s stable and not going to get much better or much worse. In its familiarity, there’s not much cause for concern. While they may have seen a healthcare provider initially, a long time ago, there’s no need now to get it checked out. They know what it is and know that it is stable.

Notice too that people like who I’m describing tend not to view chronic pain as a health problem. They don’t see themselves as ill or unhealthy or in need of healthcare because of it. It’s a condition that they put up with. We all have things about our bodies that we don’t like or are bothersome, but we don’t feel any strong need to do anything about it because they are not indicators of an illness or poor health. Sometimes, it can be really big things, such as an old spinal cord injury that led to a paralysis. We don’t consider people in wheelchairs as ill. Paralysis is a stable condition that you live with. It is not an indicator of illness. Some people with chronic pain might see chronic pain in a similar way – it’s a stable condition that doesn’t lead to considering oneself as ill or unhealthy or in need of healthcare.

In these ways, they relate to chronic pain in ways that have taken the sense of alarm out of being in pain. As such, it makes it easier to put up with and they move on with their lives. The ‘bad back’ or the ‘trick knee’ or ‘the old war injury’ comes along for the ride, of course, but it is relegated to the background of their life. It is not a daily cause for much concern.

Chronic pain as part of growing old

Some people with chronic pain relate to their pain as something that just happens to most of us at some point in life. [They are not too far from the truth, in this regard. Anywhere between 20-30% of the general population has chronic pain and the percentages increase as we get older (Andersson, 1999; Manchikanti, et al., 2009; Toblin, et al., 2011.)] In this way, it’s not cause for much concern. It’s not unusual or startling. It’s an expected part of life and so it is not especially alarming. “Things are gonna hurt,” they might say with a certain amount of acceptance. Now, they might do things to manage pain, such as staying active, exercising, pacing themselves, and not doing any one thing for too long of a time. At the end of the day, though, they accept it and have made a place for it in their life.

Chronic pain as a broken check-engine light

A common cognitive behavioral intervention in chronic pain rehabilitation is to teach patients to relate to their chronic pain as a broken dashboard check-engine light. It goes something like the following. Acute pain is like a working check-engine light. When it comes on, it signals or warns us that something is wrong in the engine. As a result, we become mildly alarmed, pull over, and bring the car to the mechanic.

Acute pain has a similar function. It’s a danger signal that warns us that something is wrong in the body. As result, we become alarmed, stop what we are doing (i.e., pull over, as it were), and go see a healthcare provider.

Chronic pain is like a check-engine light that’s broken and remains stuck in the on-position. It doesn’t serve any useful function. The nerves are chronically reactive but they are not signaling any corresponding problem in the body (i.e., engine). Even if it is signaling some underlying problem, there isn’t much you can do about it. So, the check-engine light – the chronic pain – remains lit.

What if you had a check-engine light that remained lit up, but your mechanic says that, while there is a problem in the engine, its basically not fixable. He adds that as long as you drive reasonably, such as not driving a hundred miles an hour, it’s safe to drive. He concludes that you should just ignore the check-engine light and learn to drive with it on. You don’t have to become alarmed by it, pull over or bring the car in every time it comes on or remains on. Now, you are no longer alarmed by it and you know that the car is safe to drive as long as you are reasonable about it. After awhile, you may not notice it as much. The check-engine light remains on, but it doesn't capture your attention as much any more.

Similarly, for most people with chronic pain, it’s safe to keep living life and engage in your normal activities as long as you are reasonable about what you do. With such reassurance from your healthcare provider, you can learn to ignore the pain, relegate it to the background, and not be concerned by it. You don’t have to pull over, as it were, and seek healthcare. You’ve had it checked out and your providers tell you that you should stay active.

The metaphor of the check-engine light takes the alarm out of pain. You still have it. The light is still on when you look at your dashboard, but it is not cause for alarm. So, you keep driving, or living life, engaged in your normal activities, as long as you are reasonable about it.

Some people with chronic pain relate to their pain as if it is a check-engine light that is broken. It provides no useful information. So, they keep living life despite it.

Chronic pain as something you get up and get out of the house for

As we described above, some people with chronic pain relate to pain as an injury or an illness and as such they react to pain as something for which they should stay home and rest. Other people with chronic pain, however, relate to their pain in almost the exact opposite way. When they have a bad pain day, they think to themselves, ‘I got to get up and get out of the house and go do something!’ They tend to think that, if they don’t get out of the house and get busy, all they’ll do is think about how much pain they’re in and how hard life is. In other words, they know they don’t cope very well when they don’t stay actively engaged in the activities of life. As such, they do the exact opposite of those who stay and rest: they get up and get out of the house!

This relationship to pain tends to involve continuing to work despite having chronic pain. For people who relate to pain in this manner, work is not something that one does after they get pain adequately managed; instead, work is a form of pain management. Work helps them to cope with pain. It allows them to get out of the house, structure their day, be involved with others, feel productive, feel good about themselves, and reduces financial stress. All these things buffer their pain by helping them to cope and all of it makes up for any added pain that they may have by being active. Contrariwise, they think that staying home and resting makes them not cope very well. It gets too depressing, for instance, if they don’t have anything else besides pain to hold their attention. They end up feeling unproductive and socially isolated.

Chronic pain as a barometer of what else is going on in life

Some people with chronic pain see their pain as a barometer for what’s happening in their life and how well they are managing it. While they might recognize that they will always have some baseline level of pain due to the medical aspects of their condition, they also understand that the overt fluctuations of pain – whether for the better or worse – are due to how well they are managing the stress in their lives. For instance, they notice that they are having more frequent headaches recently. Rather than understanding it as progression of an illness, they identify that the more frequent headaches are due to the stress of their recent insomnia. Maybe, they notice that their low back pain is worse in the last week. Rather than understanding the increase in pain as the result of ‘degenerating’ discs, they identify that they have been overly busy at work for the last few weeks and as a result they have fallen out of their usual mild aerobic exercise routine.

Understanding fluctuations of chronic pain as reflective of the stress in one’s life allows for people to then do something about it. They work on their insomnia or the workload at work. In other words, they take steps to manage their stress better.

Their relationship to pain is one that involves seeing fluctuations of pain as providing important information. It is not to be dreaded. They don’t feel vulnerable to pain as something that seems to come and go out of nowhere. Rather, they feel empowered by the important information that fluctuations of pain provide them. It allows them to know what they are doing works when their pain reduces or what they need to work on when their pain increases. They know that on most occasions there is a reason for the fluctuation of pain and it involves how well they are managing the stress of their lives. In other words, the relate to chronic pain as a barometer of what's going on in their lives.

Different relationships to chronic pain for different people

As our short inventory reveals, people relate to chronic pain in different ways. Each relationship to chronic pain can feel like the truth. They each seem obviously accurate to the situation at hand. It’s important, however, to recognize that it is possible to relate to chronic pain in very different ways. You don’t have to be stuck in any one particular relationship.

I’ll leave it to the reader to reflect on your personal relationship to chronic pain. You might see yourself in one of the relationships in the inventory above. Or maybe you have an altogether different one. Maybe you could comment on this post and describe it for us. I’ll also leave it to you to consider whether your particular relationship is the most accurate understanding of pain and the one that’s best for you. It may be. However, it might not be.

It is therefore important to reflect on your particular relationship to chronic pain and whether you might change it if it’s not working for you. If you feel stuck, it’s possible to change your relationship to pain. It likely will take some work on your part. It may even require the assistance of some chronic pain rehabilitation providers or a full-fledged chronic pain rehabilitation program. But, it is possible to do. You can change your relationship to chronic pain.

References

Andersson, G. B. (1999). Epidemiological features of chronic low-back pain. Lancet, 354, 581-585.

Manchikanti, L., Singh, V., Datta S., Cohen S. P., & Hirsch, J. A. (2009). Comprehensive review of epidemiology, scope, and impact of spinal pain. Pain Physician, 12, E35-70.

Relationship. (n.d.). In Merriam-Webster Dictionary. Retrieved from http://www.merriam-webster.com/dictionary/relationship

Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152, 1249-1255.

Author: Murray J. McAllister, PsyD

Date of publication: 8-2-2014

ate of last modification: 11-14-2021

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Relationship to Pain Sat, 08 Feb 2014 09:28:28 +0000
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
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
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
Your Doctor Says That You Have Chronic Pain: What Does That Mean? https://www.instituteforchronicpain.org/blog/item/107-10your-doctor-says-that-you-have-chronic-pain-what-does-that-mean https://www.instituteforchronicpain.org/blog/item/107-10your-doctor-says-that-you-have-chronic-pain-what-does-that-mean

Your injury was many months ago. You initially saw your primary care provider who sent you to a pain clinic. The provider at the pain clinic who evaluated you may have been a surgeon who told you to come back after you have gone to the interventional pain provider and physical therapist. You subsequently underwent evaluations and started care with each of these providers. You had this procedure and that procedure. You went to physical therapy. You did it all in the hopes that they would find the source of the pain and fix it. None of it really worked, though.

At best, some of them were helpful for a few days or weeks but pain seemed to always return to the level it was previously. So, you decided to go back to the surgeon. You underwent a surgery and followed it up with more physical therapy. Perhaps, you had to go through a revision of the surgery a few months later. Maybe the surgery or surgeries didn’t help. Maybe, your pain was worse afterwards. Or, maybe it helped for a few months, but again the pain returned. Then, you go to another pain clinic and the provider there tells you that you have chronic pain.

What does that mean?

Frequently, definitions of chronic pain characterize it as pain that lasts longer than three or six months and then leave it at that. While the timeframe is accurate, this definition leaves out a whole lot. There’s more to chronic pain than just the time frame. Let’s look at what more there is and come back to the timeframe in a bit.

The understanding that your pain is chronic signals a change in what your providers think is the primary cause of your pain. When pain is chronic, the source of your pain is no longer the initial injury that started the pain. Rather, if your pain is chronic, then the source of pain has become the nervous system. It’s no longer an orthopedic problem, but a nervous system problem.

What happens is that, once having an injury and coming to have pain, the nervous system can change. It can become stuck in a persistent state of reactivity. Over time, the nervous system becomes so sensitive that any little movement hurts. Leaning over hurts. Standing back up hurts. Sitting down and getting up from a chair hurt. Walking hurts and so on. These simple, everyday movements shouldn’t be painful; but they are. They are painful because the nervous system has become stuck in a persistent state of reactivity. This state of reactivity has led the nerves in the area of your initial injury and the corresponding nerves in the spinal cord and brain to become so sensitive that simple, everyday movements hurt.

Patients often come to think that these movements are painful because the initial orthopedic injury, such as to the spine, has made their spine permanently fragile. Along the way, they may have been told that they have degenerative disc disease. This way of making sense of the pain naturally leads you to think that you have a disease that is inevitably going to deteriorate your spine, making it more and more fragile. As such, it’s natural to think that simple, everyday movements hurt because the spine is so fragile.

Over the last several years, however, basic science has studied how commonly degenerative changes of the spine occur in people with chronic back and neck pain as well as how commonly degenerative changes occur in people without back or neck pain. It turns out that degenerative changes of the spine are as common, if not more common, in people without spine-related pain. Basic science has also tracked the natural outcomes of degenerative changes of the spine over many years. It turns out that most of the time degenerative changes get better. Sometimes, they stay the same, but they typically don't get worse.

With such research, we now know that “degenerative disc disease” is a misnomer. That is to say, it is a misleading term. Degenerative changes of the spine are neither a disease nor are they inevitably going to get worse. Now, I’ll save the details and references for another post, because the issue of degenerative disc disease is such a big topic. For now, you can visit the content page on degenerative disc disease at the Institute’s web page.

Suffice it to say that it is not accurate to think of “chronic pain” as a long-lasting acute injury, such as an orthopedic condition of the spine. The initial injury that started the pain may have long since healed. Rather, chronic pain is a nervous system condition whereby the nervous system is stuck in a persistent state of reactivity that has made the nerves highly sensitive. As such, simple, everyday movements hurt.

Besides the term “chronic pain,” researchers and providers call this condition “central sensitization.” The nerves at the site of the injury, say, for example, your low back, are part of the peripheral nervous system. These nerves send chemical information, what we might call a ‘pain signal,’ to the spinal cord and from there the signal takes an elevator up to the brain, where there, it registers as pain in the low back. The spinal cord and brain make up the central nervous system. With chronic pain, the peripheral nerves at the site of your pain, for example, your low back, and the central nervous system have become stuck in a persistent state of reactivity that leads them to react like a ‘hair trigger.’ Any little movement can set them off.

Often, with chronic pain, the site of pain is also sensitive to touch or pressure. Pushing on the area causes pain. A simple bump is likely to cause more pain than it should, were it not for the nervous system’s reactivity and sensitivity. Sometimes, in more severe cases, simple touch can hurt.

Patients with chronic pain are not making this stuff up. It’s really happening and it is real pain. What’s happening is that the nervous system problem is maintaining the pain.

So, when your provider tells you that you have chronic pain, it means that he or she no longer sees your condition as primarily an orthopedic problem, but a nervous system problem. The timeframe of three to six months is important because the pain of most acute injuries subsides after this number of months. Sometimes, of course, pain continues and becomes chronic. In these cases, as described above, the nervous system reorganizes and becomes sensitized. In this way, the pain of an acute injury transitions to the pain of central sensitization, or chronic pain.

So, your provider tells you that you have chronic pain. Now what? Just as your pain has transitioned from acute pain to chronic pain, you must transition your treatment strategies. Under your provider’s direction, you will likely do two broad categories of things. First, you will likely stop undergoing orthopedic treatments, such as spinal injections, surgeries, and physical therapies that are geared towards resolving an injury. Second, you will start obtaining treatments for the nervous system problem that you now have. There are a number of them that are proven effective. What are these?

Before listing these treatments, a brief caveat is in order. A number of treatments are proven effective, but “effective” does not mean curative. We do not have any cures for chronic pain. This fact brings us to another important part of the definition of “chronic pain.” Chronic pain is chronic. The word “chronic” itself means that it will last indefinitely. It doesn’t mean terminal. You won’t die from it. Rather, what it means is that it is not fixable and it is something you will likely have for the rest of your natural life.

Nonetheless, there are a number of treatments that are effective in the sense that they have all been shown in research to either reduce pain or improve functioning or reduce the need for on-going healthcare services, including the use of opioid medications. The known effective treatments for chronic pain are the following:

  • Cognitive behavioral therapy
  • Relaxation exercises, including mindfulness-based therapies
  • Mild aerobic exercise, including pool therapy
  • Anti-epileptic medications
  • Antidepressant medications, particularly tricyclic antidepressants
  • When done altogether in a coordinated fashion, these therapies are called a chronic pain rehabilitation program

The common denominator of all these therapies is that they target the nervous system and reduce its reactivity over time. All of them have multiple clinical trials showing their effectiveness.

Recently, a few clinical trials of yoga and tai chi have been published showing that these too are effective. It seems reasonable given their quieting effect on the nervous system. However, because of the insufficient number of studies, I think it is too soon to draw firm conclusions. My guess, though, is that more studies will come in time and that these therapies will also some day firmly be established as effective. Many chronic pain rehabilitation programs already incorporate them.

Author: Murray J. McAllister, PsyD

Date of last modification: March 18, 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) Pain Clinic Mon, 18 Mar 2013 06:00:21 +0000