Pain-Free Living

Dealing with Chronic Pain

By Jackson Rainer

We are a nation in pain. Pain has been identified as the most common presenting symptom for all who seek medical advice. At its best, pain is a signal that something has gone wrong and needs immediate attention. At its worst, it disables, depresses, and impairs quality of life. The degree of a person’s pain is a predictor of daily stress; it lowers feelings of mastery and effectiveness in moving though day-to-day activities. As one gentleman said, “I am an independent old cuss and don’t ever want to be told what to be told what to do. If there is one thing that I will obey, though, it’s pain.”

Everyone has intermittent aches and pains, but people with arthritis generally experience pain on a regular basis. Living with arthritis means living with pain. Arthritis Self-Management focuses on people who have been diagnosed with any form of arthritis, all of whom are tied together by the common thread of pain.

Fortunately, good research has been published in the last decade about pain and its management. The more we learn about pain, the more we learn ways to minimize it or end it. Historically, pain has been identified by its cause: injury, illness, or infection. In contemporary practice, though, pain is identified by how it affects the nervous system. To ensure that we are speaking the same language, some definitions are necessary.

Pain: The International Association for the Study of Pain’s widely used definition states that “pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Pain encompasses multiple mental and physical sensations, and each pain experience is unique to the individual. It is fully subjective—your pain cannot be felt by others, although an empathic relationship with another individual helps for pain perceptions to be understood, valued, and appreciated.

Acute or inflammatory pain: This type of pain generally comes on suddenly, as when pain is caused by a burn or sprained ankle. In the presence of injury, the body produces pro-inflammatory cytokines, which are regulatory proteins released by cells of the immune system to stimulate the nervous system and promote healing. The cause of this kind of pain can usually be diagnosed and treated. Acute, also known as inflammatory, pain is self-limiting and confined to a finite period of time and severity. When the inflammatory response does not turn itself off and persists over time, the type of pain is reclassified.

Chronic pain: This type of pain is more resistant to analgesic treatment and is widely believed to represent a disease entity. This is long-lasting pain that transforms our brains and nervous systems into hurt machines without an “off” switch. Chronic pain can also be made worse by stressful environmental or psychological factors. It’s disruptive to quality of life, since the brain is pumping out “ouch,” “ache,” and “throb” messages constantly.

There are two types of chronic pain. Dysfunctional pain is pain that comes out of nowhere. It’s triggered by the brain in the absence of obvious trauma, inflammation, or damage to the nervous system. Fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome are all examples of dysfunctional pain. Neuropathic pain is caused by damage to the nerves themselves, such as the pain resulting from a ruptured or bulging disk that causes systemic damage to nerve pathways. While this type of pain typically is thought of as an abnormality of the nervous system, particularly in the cranial or spinal system, it also can be born from viruses—for example, the chicken pox virus that causes shingles.

INTEGRATIVE CARE
Contemporary treatment for dysfunctional or neuropathic pain focuses on integrative care. This is a team-based approach that blends alternative practices with traditional Western medicine, integrating physical, psychological, and intangible concepts of body, mind, spirit, and community to support multiple theories about healing.

The goal of integrative medicine isn’t to cure a disease, but to help a person suffering from chronic pain manage and control its impact on daily living and quality of life. A patient in integrative care is asked to participate and comply with traditional medical interventions, but focus is also placed on the holistic nature of the self, i.e., the interactions of mind, body, and spirit. The term “integrative” comes from Latin roots that mean “to make whole.”

Integrative pain management care acknowledges that there is no one-size-fits-all approach to treatment. Using a multidisciplinary mix of traditional and alternative methods, various therapies and interventions from the healing arts are prescribed to treat different maladies that cause dysfunctional and neuropathic pain. Integrative care operates under the philosophy that the whole is greater than the sum of its parts. It employs an empirical process to treatment, focusing on observable evidence: The person in therapy sits at the center of the team and reports on how each treatment affects his or her pain. Each form of prescribed treatment or therapy is tailored to the individual and then closely and systematically observed for results, defined by reduction of suffering or discomfort. Treatment is matched to diagnosis, with the knowledge that what works for one may not for another. What helps is enhanced, and what is ineffective is dropped in favor of another type of intervention.

YOU ARE NOT CRAZY
One of the greatest challenges people with chronic pain face is the fact that some do not believe them. “Many people, including several of my doctors, doubt me all of the time,” one woman says. “I spend as much of my time trying to convince them that I hurt as they do trying to help me.”

Managing dysfunctional and neuropathic pain is complicated because of its subjectivity. Pain is a highly personal state, so measurement relies on what the individual says and does in response to the pain. Many psychological and social factors—attitudes, beliefs, cultural norms, moods, motivation, and personality traits—contribute to the experience, so the assessment of chronic pain is like putting together a puzzle, assembling pieces of collected information to determine a prognosis and course of treatment. In the process, pain intensity, functional capacity, mood and personality, active or passive coping styles, and medication usage are evaluated. It’s also common practice to include a behavioral analysis that includes information on psychosocial history, adverse effects of treatment, and health care utilization.

The woman mentioned above complained to her physician: “Why don’t you believe me? I know I’m irritable and short with others. I don’t feel like answering questions that just don’t seem relevant to what I need to control my pain. It just seems like you are telling me that I’m crazy.”

He replied, saying: “No, I don’t believe you are crazy. Working with you and your pain requires thinking ‘outside of the box.’ Traditional Western medicine asks me to think in straight lines—an if/then sort of thing. You come in with a symptom like a sore throat; I give you a clear-cut diagnostic test during the examination and prescribe a medication if you have strep. With pain, we have to think in circles, more like a both/and approach. It’s important to get bigger pictures and perspectives, so that’s why you are asked so many personal questions that don’t seem directly related to what treatment or intervention will be prescribed. There are more treatment options than just medications, and all of these have to be considered. I wish there was a pill that would restore you to baseline, but I’m working with you to help control your pain and take back your life with a different way of looking at what makes you hurt.”

The physician avoided the easy answer of “it’s all in your head” or “this is just stress,” because integrative pain management includes medication prescription, relaxation training, exercise, weight management and nutrition, comfort measures, and evaluations of sleep disturbance and depression.  The old-school thought “you are making this worse than it really is” is outdated and fundamentally wrong. Promising research is being done on diagnosing pain objectively using MRIs (although this is in its early stages),  but even with more accurate diagnostic tools, treatment will continue to rely on multiple interventions that are guided by patient report.

OTHER THAN MEDICATING PAIN, WHAT CAN I DO?
Active participation and shared decision-making are critical to managing pain. The most effective methods of improving pain control for individuals with arthritis have been achieved by providing self-management activities, such as exercise, education, and informed decision-making. An integrative approach to treatment will include conversations about three specific aspects that affect your ability to cope with pain:

• sensory (the intensity and quality of pain),
• affective (the emotions of pain), and
• cognitive (the thoughts associated with the pain).

Treatment providers ask patients to identify their current level of pain on a scale of 1 to 10, describing the onset, duration, and site of pain. The examination will include questions about the intensity and nature of the pain—e.g., “It is dull or throbbing?”—any exacerbating and relieving factors, such as “Does rest help?,” and the presence or absence of night pain. During these conversations, the practitioner will ask about a patient’s personal and social life, including awareness and interest in surroundings, any guarded or abnormal range of movement due to pain, changes in appetite or normal sleep patterns, and general mood and emotions. Questions of these types will be asked at all meetings and appointments with practitioners.

EXERCISE
Most people living with chronic pain are physically deconditioned because they’re reluctant to exercise and feel a need to protect themselves from additional physical injury. However, research shows that people who exercise are less likely to suffer the same degree of chronic pain as those who are sedentary, since physical activity alters the brain by releasing endorphins, chemicals that help improve mood while blocking pain signals. Exercise also strengthens muscles, which helps prevent injury and further pain. Exercise is important in weight management, and it reduces heart disease risk. Choose low- to no-impact exercise that you can attend in a group setting, which encourages motivation. Try to dedicate at least 30 minutes three times a week to strengthening and stretching physical activities. Tai chi, yoga, and water aerobics are all popular forms of gentle but effective means of exercise that help push back the pain threshold.

STRESS MANAGEMENT AND RELAXATION TRAINING
Stress increases your body’s sensitivity to pain, so learning to control the negative effects of stress may provide some relief.  The stress of chronic pain overactivates the autonomic nervous and endocrine systems, causing an increase in heart rate, blood pressure, sensory alertness, mobility, and readiness to respond. In combination, these responses are identified as a syndrome called arousal: Your body is on alert, and it responds with tense muscles and increases in heart rate, respiration, adrenal gland secretion, and blood pressure. Blood vessels in the arms and legs constrict, and you feel a fluctuation of mood. These are classic “fight or flight” responses.

As one pain patient said, “I can’t control all of the stress in my life, but I can be in charge of how I respond to it.” Lower your arousal levels, and you may lower your suffering. Track your pain level in response to daily activities. Keep a journal, and when pain occurs, assign it a name and number, such as “a 9 hot ache.” As you begin to see your patterns, make a daily priority list of tasks and allow sufficient time to accomplish them—don’t put more on your list than can be managed by the end of the day. Learn your limits and respect them.

Deep breathing and meditation can quiet the body and lower arousal, since relaxation may ease pain. Mindful relaxation can be achieved in many ways, but the easiest is through some type of meditation, a mind-body technique that teaches you to focus your attention and be aware of the flow of emotions and thoughts in your mind. All forms of meditation, from prayer to yoga, reduce pain by altering activity in four pain-producing areas in the brain.

One note of caution: Many people consider alcohol a relaxant. It is not, and it can adversely interact with pain medications and worsen sleep problems. Pain makes sleep difficult, and alcohol is known to interrupt natural sleep patterns. If you’re living with chronic pain, drinking less or abstaining from alcohol can improve your quality of life.

TO SUM UP
A Native American practice offers a wonderful lesson. The night before a hunt, the tribe would gather in a circle and hold a sacred ceremony, during which the quarry to be hunted would be given a name. The strengths, weaknesses, and characteristics of the named animal were acknowledged, appreciated, and honored. Such a tradition gave the hunters a vision that guided their path.

The same is true for chronic pain: When you name it and understand it, you take a step toward mastering it. One man calls his arthritis “my travelling companion.” Another woman laughs as she refers to her pain as “my ‘AccuBack.’ I’m better than the TV weather forecasters—I can tell when it’ll rain long before they can. My aching back lets me know.”

Encourage yourself to take personal responsibility for being accountable for your own physical and mental health. Take the time to do your own research in preparation for discussions with your health-care provider, and be ready to talk about complementary and alternative medical practices. The more knowledgeable you are, the more you stay in charge.

Last Reviewed September 15, 2015

Dr. Jackson Rainer is a board-certified clinical psychologist who practices with the Care and Counseling Center in Atlanta.

 

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