Chronic pain (2009)

Chronic pain (2009)

by Fred Lane PhD

A large Australian study (Blyth et al 2001), supported by overseas research (e.g. Tunks et al 2008 and Breivika et al 2006) suggests that about one in five adults have chronic pain. That equates to about 133 Naval Officers Club members.

The saga of diagnosing and treating chronic pain goes on. Definitions vary, but when defined as persistent pain without underlying physical cause (e.g. perceived pain in the fingers of an arm amputated at the shoulder) the psychological nature of the disorder becomes immediately apparent.

Acute pain from a surgical operation or tooth extraction should fade gradually over a few days, or a few weeks at the most. Sometimes acute pain fails to dissipate, perhaps due to insufficient analgesic drugs.

Chronic pain intrudes when acute pain fails to dissipate in a timely fashion or the pain is associated with long term morbidity, such as migraine, arthritis or degenerative joint back pain.

Chronic pain unfortunately interacts with other conditions, particularly depression and anxiety, that in turn tend to exacerbate the perception of pain. Decreased physical activity linked to the apprehension of pain is common, typically making pain worse. Then again, too much or the wrong kind of physical activity can do just as much damage. Be guided by the physical therapist in a good pain management team.

Modern research aims

Modern research finds that it is rare, but not impossible, to achieve absolute and sustained pain relief. The clinical goal nowadays is simple pain management. Once pain management is demonstrated, steady gains inevitably follow.

Another trend is that even though many new pain drugs have been developed, multidisciplinary teams (medical, psychological, chiropractic, alternative medicine, etc.) report greater success rates than the old unitary pill-popping GP or specialist approach.

tmjgfw
The hardest working joint in the body and a common site of chronic pain is the temporomandibular joint (TMJ), a hinge and gliding joint. On the upper end of the lower jaw is a condyle and its socket is the articular fossa. Between the fossa and the condyle is a flexible disk or cushion that absorbs stress and allows the condyle to move smoothly as the jaw opens and closes. TMJ disorders sometimes resist treatment and have many different causes, including hyperextension during dentistry, arthritis, osteoporosis and sudden trauma.
There are pitifully few well-trained pain specialists or multidisciplinary teams available in Australia and virtually none outside the big capital cities. Therefore, as Khazzoom (2009) asserts, some pain sufferers might have to become their own diagnostic and medication expert. This does not mean that you cut the family doctor or specialist out of the treatment process, but people with chronic pain might have to learn how to discuss their problem with their GP or specialist in a more educated, more assertive and more objective manner.

Perhaps the simplest advice is not to accept pain as inevitable, but to tell everybody, in no uncertain terms, that there is pain and that pain persists. Initially, think about demanding more analgesic medication.

Objective data record

Start a written log of the pain levels experienced at, say, 1000, 1400 and 2000 each day. Use a 1 to 9 scale, where 1 equals no pain and 9 equals unbearable agony. Log significant physical activities (including rest) over the preceding six hours.

Next, establish a reliable pain free period every day, by whatever means that works. Try medication first but alternative treatments from the table below might help. Then add one or more of the listed interventions systematically to gradually extend this pain-free period. Keep the pain log going.

Positive reinforcement

Importantly, give yourself a pat on the back when your log demonstrates improvement.
Importantly, give yourself a pat on the back when your log demonstrates improvement, and just in case you forget:
Importantly, give yourself a pat on the back when your log demonstrates improvement.

The following table, derived from Kazoom (2009) shows many of the interventions chronic pain teams use to control pain. The list is fairly comprehensive but by no means complete. For instance it does not mention self-hypnosis, transcutaneous electrical stimulation (TENS), distraction, copper bracelets, magnetic pillows or the better-researched arthritis nonprescription drug combination glucosomine and chondroitin. Kazoom also fails to mention the important kitchen and other tools devised to help those with arthritis. Rather, it is a generic list that a good pain control team will consider. It demonstrates chiefly that, as pain science presently stands, not one intervention suits everbody and that two or three or more interventions are frequently recommended before success can be claimed.

The bottom line is that whatever works (other than lying down doing nothing), use it. Essentially, gain mastery over the pain, never let it control you. Use whatever method, including powerful analgesics, to guarantee at least one designated period every day to be free of pain. Then extend that time by whatever other method that works. Head off pain by using one of the interventions below or taking analgesics before you embark on a known pain-causing activity, such as essential hard work.

Invariably, don’t forget that pat on the back once you have demonstrated success and gradually wean yourself offf the analgesics and other interventions.


Movement-Based Therapies:

Type: Physical exercises and practices.
What they help: Musculoskeletal pain, joint pain and lower-back pain.
How: By strengthening muscles supporting joints, improving alignment, and releasing endorphins.
Examples
Physical therapy: Specialised movements to strengthen weak areas of the body, often through resistance training.
Yoga: An Indian practice of meditative stretching and posing.
Pilates: A resistance regimen that strengthens core muscles.
Tai chi: A slow, flowing Chinese practice that improves balance.
Feldenkrais: A therapy that builds efficiency of movement.

Nutritional and Herbal Remedies:

Type: Food choices and dietary supplements. (Ask your doctor before using supplements.)
What they help: All chronic pain, but especially abdominal discomfort, headaches, and inflammatory conditions such as rheumatoid arthritis.
How: By boosting the body’s natural Immunity, reducing pain-causing inflammation, soothing pain,and decreasing insomnia.
Examples
Anti-inflammatory diet: A Mediterranean eating pattern high in whole grains, fresh fruits, leafy vegetables, fish, and olive oil.
Omega-3 fatty acids: Nutrients abundant in fish oil and flaxseed that reduce inflammation in the body.
Ginger: A root that inhibits pain-causing molecules
Turmeric: A spice that reduces inflammation
MSM: Methyl sulfonylmethane, a naturally occurring nutrient that helps build bone and cartilage.

Mind-Body Interactions:

Type: Using the powers of the mind to produce changes in the body.
What they help: All types of chronic pain.
How: By reducing stressful (and, hence, pain-inducing) emotions such as panic and fear, and by refocusing attention on subjects other than pain.
Examples
Meditation: Focusing the mind on something specific (such as breathing or repeating a word or phrase) to quiet it.
Guided imagery: Visualising a particular outcome or scenario with the goal of mentally changing one’s physical reality.
Biofeedback: With a special machine, becoming alert to body processes, such as muscle tightening, to learn to control them.
Relaxation: Releasing tension in the body through exercises such as controlled breathing.
Cognitive behavior therapy (CBT): teaches skills, such as guided imagery, relaxation, attribution therapy, self-talk therapy, log-keeping and selective positive reinforcement.

Energy Healing:

Type: Manipulating the electrical energy (called chi in Chinese medicine) emitted by the body’s nervous system.
What they help: Pain that lingers after an injury heals, as well as pain complicated by trauma, anxiety, or depression.
How: By relaxing the body and the mind, distracting the nervous system, producing natural painkillers, activating natural pleasure centers, and manipulating chi.
Examples
Acupuncture: The insertion of hair-thin needles into points along the body’s meridians, or energetic pathways, to stimulate the flow of energy throughout the body; proven helpful for post-surgical pain and dental pain, among other types.
Acupressure: Finger pressure applied to points along the meridians, to balance and increase the flow of energy.
Chigong: Very slow, gentle physical movements, similar to tai chi, that cleanse the body and circulate chi.
Reiki: Moving a practitioner’s hands over the energy fields of the client’s body to increase energy flow and restore balance.

Physical Manipulation:

Type: Hands-on massage or movement of painful areas.
What they help: Musculoskeletal pain, especially patterns of lower-back and neck pain; pain from muscle underuse or overuse; and pain from adhesions or scars.
How: By restoring mobility, improving circulation, decreasing blood pressure, and relieving stress.
Examples
Massage: The manipulation of tissue to relax clumps of knot­ted muscle fibre, increase circulation, and release patterns of chronic tension.
Chiropractic: Physically moving vertebrae or other joints into proper alignment, to relieve stress.
Osteopathy: Realigning vertebrae, ribs, and other joints as with chiropractic; osteopaths have training equivalent to that of medical doctors.

Lifestyle Changes:

Type: Developing healthy habits at home and work.
What they help: All types of chronic pain.
How: By strengthening the immune system and enhancing well-being, and by reframing one’s relationship to (and, thus, experience of) chronic pain.
Examples
Sleep hygiene: Creating an optimal sleep environment to get deep, restorative rest; strategies include establishing a regular sleep-and-wake schedule and minimising light and noise.
Positive work environment: Having a comfortable workspace and control over one’s activities to reduce stress and contribute to the sense of mastery over pain.
Healthy relationships: Nurturing honest and supportive friendships and family ties to ease anxiety that exacerbate pain.
Exercise: Regular activity to build strength and lower stress.


Another bottom line could be financial. Don’t rush in and end up with worse pain and an empty wallet. Do your internet research and discuss the best interventions with your GP. For a quick and dirty internet start, Google “chronic pain” then “NIH”, or go directly to http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm. There you will find easy-to-read summaries and links to important research papers.


References:

Blyth F.M, L.M. March, A.J. M. Brnabic, L.R. Jorm, M. Williamson, and M.J. Cousins. Chronic pain in Australia: a prevalence study. Pain 2001 Jan; 82 (2-3) pp127-34.
Breivika H., B.Collett, V. Ventafridda, R. Cohen, and D.Gallacher. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European journal of pain, Vol 10, May 2006, pp.287-333.
Khazzoom L. Drug-free remedies for chronic pain. AARP the magazine, Jan-Feb 2009, pp 26-30.
Tunks E.R, J. Crook, and R.Weir. Epidemiology of chronic pain with psychological comorbidity: Prevalence, risk, course, and prognosis. Canadian journal of psychiatry, Vol 53, No 4, April 2008. pp 224-44.