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Pain is inevitable suffering is optional

20 Dec

Pain is inevitable

Pain can be defined as a highly unpleasant physical sensation caused by illness or injury but can also be defined as mental suffering or distress.

Pain accounts for a substantial number of reasons for patient consulting with a doctor We know that 27% of patients attend with a musculoskeletal problem most of whom will describe an element of pain. There are also those who will complain of pain associated with their chest, abdomen or head of another part of the body. It can be localised or more generalised and can be referred from a site where the cause of pain originates. It is estimated that > 10 million people have persistent pain.

The following video attempts to give an understanding of pain

I have always been interested and puzzled about the concept and the complexities of persistent or chronic pain and how it manifests itself in people of all ages. It is one of the reasons why I took up acupuncture and studied Traditional Chinese Medicine(TCM) in an attempt to treat pain with something other than tablets, capsules or applications as well as develop a deeper understanding of pain and how it can be treated.

Pain words

Pain can be described using many adjectives such as shooting, burning, stinging, stabbing, throbbing and pricking but these all not only describe the unpleasant sensation but have association with a frightening experience. Hence, with pain there is usually a feeling of fear or emotion of some kind. I attended two lectures a few years ago; one was from an eminent American psychiatrist talking about the neurophysiology of depression and how depression could present with pain such as back pain, chronic abdominal pain or headaches and how these pains could be treated with antidepressants medication. The second lecture was from a Swedish neurophysiologist who impressed us by drawing intricate nerve pathways to demonstrate how acupuncture worked bug also by treating pain this could treat depression.

Many years ago it seemed appropriate that when I carried out intricate procedures on very premature babies that because I assumed that it must be painful, it was remarked by nursing staff that when I made the effort to talk reassuringly and stroke them the procedure went more smoothly but analgesia was never routinely given.

Premature baby
It was not until 2010 that research showed that premature babies do perceive pain and are now given analgesia routinely when procedures are performed. Infact premature babies are sensitised to pain by intensive care treatments they receive after birth, a study in 2010 suggested. Tests showed that pre-term infants that have spent at least 40 days in hospital feel pain more acutely than healthy newborns. From this study it was suggested that better pain relief should be given to premature babies under intensive care to prevent them becoming pain-sensitive. Brain activity comparing full-term babies and premature babies was seen when both sets of babies were gently touched on the heel and showed no difference, suggesting that the sensitisation of pre-term babies is specific to pain. This is important, since the sense of touch is triggered by being held or cuddled. It implies that premature babies can benefit from a mother’s touch as much as normal infants.

I remember a child coming to surgery with his mother in floods of tears and when I asked ‘What’s the matter?” He said” A lion bit my ear!” Clearly he felt the sensation of pain but expressed a terrifying fear of how it had occurred. Pain from an acute ear infection is probably for many children their first experience of severe pain and not only do they need pain relief but they need comfort and reassurance.

My personal experience of severe pain was when I was admitted with renal colic as a medical student and realising it was ‘for real’ not one of those pains that all medical students have as they study every speciality. I remember being petrified wondering, imagining what it was and although it was thoughtful to put me in a sideward I felt abandoned and desperate wondering if anyone realised how much pain I was suffering. I was given intramuscular pain relief, which gave me florid hallucinations of Monty Python feet descending on me and those around me changing in form in seconds. I was violently vomiting and terrified and this lasted several days. Then a very gentle doctor sat by my bed explained exactly what was happening and how the stone was working its way out of my system and if not it would be removed surgically next morning. He also listened to the effects I described( this drug has subsequently been taken out of use) changed the medication and then said in a gentle kind manner that if I felt distressed he was prepared to come and see me anytime. The pain instantly became more tolerable and I was able to cope much better feeling less fearful and knew it was happening. Much to the consultants chagrin, as he had come especially early to perform the surgery, about 10 minute before surgery I passed the stone! I never saw the kind doctor again but he taught me what was meant by bedside manner and what being a doctor was really all about – having the knowledge but combined with the gift of being able to allay fear by giving the time when it is needed.

Several cases of severe pain puzzled me for years and interestingly all were in severely mentally ill patients.
The first case was a gentleman who walked into A&E looking pale, cold and clammy holding his fist against his chest but not complaining of any pain despite being asked several times. A routine ECG was performed, at that time performed on all patients >50 yrs and this showed a massive hear attack across the anterior part of his heart.

The second case was of a gentleman again walking into A&E vomiting copious amounts of brown fluid clutching his distended, rigid abdomen but showing no history of pain and on palpating his abdomen no complaints of pain but X-ray corfirmed an obstruction with perforation and emergency surgery revealed widespread peritonitis.

The third case was that of a gentleman who had had a severe mental breakdown whilst working in the City as an analyst and had been treated for skin cancer and was attending a follow up appointment and it was found that he had spinal bone metastases. The day prior to being seen he had walked 7 miles on a country ramble, sadly a week later of widespread metastatic cancer.

The final case I would like to mention was that of a lady who I had been seeing in surgery regularly and knew she had a diagnosis of severe dissociative disorder,which had been the result of years of abuse in her childhood and early teens. Dissociative disorder is a condition whereby your sense of reality and who you are, which depends on your feelings, thoughts, sensations, perceptions and memories becomes ‘disconnected’ from each other, and doesn’t register in your conscious mind. Your sense of identity, your memories, and the way you see yourself and the world around you will change. This is what happens when you dissociate. It’s as if your mind is not in your body; as if you are looking at yourself from a distance; like looking at a stranger. She had been developing swelling of her joints which looked as if they should be painful but she denied severe pain and the distribution of the joint problem was typical of rheumatoid arthritis. I performed the relevant blood tests which came back extremely high supportive of the diagnosis of rheumatoid arthritis . After consultation with the rheumatologist she was seen and given high doses of intramuscular steroids. She then had to have surgery to her cervical spine as she was at serious risk of becoming paralysed from the neck down due to extensive disease in this area. She has been on many powerful drugs for rheumatoid arthritis but is now taking regular injections of an immunosuppressant treatment called adalimumab (Humira) which is a Tumour necrosis factor-alpha inhibitors (TNF-alpha inhibitors) – the human body produces tumor necrosis factor-alpha (TNF-alpha). TNF-alpha is an inflammatory substance. TNF-alpha inhibitors are used for the reduction of pain, morning stiffness and swollen or tender joints. These drugs are only used in exceptional cases of Rheumatoid Arthritis.

Pain can be helpful in diagnosing a problem. Without pain, you might seriously harm yourself without knowing it, or you might not realize you have a medical problem that needs treatment as in the case of those mentally ill patients. I realise many people are brought up not to make a fuss about pain but it is important that the symptoms of pain are shared with your doctor and necessary investigations are done, as treating an underlying cause can often cure the pain. However, sometimes pain goes on for weeks, months or even years. This is called chronic pain and it has been found that a pain cycle evolves as shown below:-

Pain cycle

Sometimes chronic pain is due to an ongoing cause but sometimes the cause is unknown and usually there is a psychological element to a greater or lesser extent. The pain may occur because the brain can’t make enough endorphins. These are chemicals that shut down pain signals. Or, pain signals continue after an injury has healed. In some cases, increased pain sensitivity makes even minor injuries very painful.

image

The British Pain Society is the largest multidisciplinary professional organisation in the field of pain within the UK.

Our membership comprises doctors, nurses, physiotherapists, scientists, psychologists, occupational therapists and other healthcare professionals actively engaged in the diagnosis and treatment of pain and in pain research for the benefit of patients.
It has published several publications which can be easily downloaded
http://www.britishpainsociety.org/patient_publications.htm

  • Managing pain effectively using ‘Over the Counter’ (OTC) Medicines (2010)
  • Understanding and Managing Pain (2010)
  • Help the Aged – Pain in Older People: Reflections and Experiences from an older person’s persepctive (2008)
  • Opioids for persistent pain: information for patients (2010)
  • Managing Cancer Pain – information for patients (2010)

It is very important to communicate how your pain effects you describing it carefully , what you do to ease it and what makes it worse and how intense it is using a scale as below:-

Pain scale

It is useful to keep a diary either using a calendar or using an App
This helps to communicate progress that is being made and how it is affecting daily life.

Pain can be classified into several categories:-

Nociceptive Pain:

Nociceptive pain is believed to be caused by the ongoing activation of pain receptors in either the surface or deep tissues of the body. There are two types: “somatic” pain and ” visceral” pain.
image
“Somatic” pain is caused by injury to skin, muscles, bone, joint, and connective tissues. Deep somatic pain is usually described as dull or aching, and localized in one area. Somatic pain from injury to the skin or the tissues just below it often is sharper and may have a burning or pricking quality.

Somatic pain often involves inflammation of injured tissue. Although inflammation is a normal response of the body to injury, and is essential for healing, inflammation that does not disappear with time can result in a chronically painful disease. The joint pain caused by rheumatoid arthritis may be considered an example of this type of somatic nociceptive pain.

“Visceral” pain refers to pain that originates from ongoing injury to the internal organs or the tissues that support them. When the injured tissue is a hollow structure, like the intestine or the gall bladder, the pain often is poorly localized and cramping. When the injured structure is not a hollow organ, the pain may be pressure-like, deep, and stabbing.

Neuropathic Pain:

Neuropathic pain is believed to be caused by changes in the nervous system that sustain pain even after an injury heals. In most cases, the injury that starts the pain involves the peripheral nerves or the central nervous system itself. It can be associated with trauma or with many different types of diseases, such as diabetes. There are many neuropathic pain syndromes, such as diabetic neuropathy, trigeminal neuralgia, postherpetic neuralgia (“shingles”), post-stroke pain, and complex regional pain syndromes (also called reflex sympathetic dystrophy or “RSD” and causalgia). Some patients who get neuropathic pain describe it as bizarre, unfamiliar pain, which may be burning or like electricity. The pain may be associated with sensitivity of the skin.

An interesting account of the mystery of chronic neuropathic pain

click on link below:-

Mystery of chronic pain

Psychogenic Pain:
Most patients with chronic pain have some degree of psychological disturbance. Patients may be anxious or depressed, or have trouble coping. Psychological distress may not only be a consequence of the pain, but may also contribute to the pain itself. “Psychogenic” pain is a simple label for all kinds of pain that can be best explained by psychological problems.

This close relationship between pain and psychological distress means that all patients with chronic pain should have an assessment of these psychological factors, and psychological treatments should be considered an important aspect of pain therapy. In some cases, psychological problems appear to be a main cause of the pain. This does not mean that the person is not actually experiencing the pain. Rather, the patient is truly suffering but the main cause somehow relates to the emotions, or to learning, or to some other psychological process. Although doctors sometimes encounter patients who pretend to be in pain (some can be called malingerers), this appears to be a rare occurrence. Most patients with pain that appears to be determined primarily by psychological processes are hurting just like those who have pain associated with a clear injury to the body.

Sometimes, psychogenic pain occurs in the absence of any identifiable disease in the body. More often, there is a physical problem but the psychological cause for the pain is believed to be the major cause for the pain.

Another website which gives interesting insights into pain is:-
http://painconcern.org.uk
It also has a series of podcasts which talk about various aspects of pain the edition talks about exploring the possibility of controlling pain through techniques that focus on the brain and the mind using mindfulness a topic I wrote about in a previous blog.

Pain

Pain

http://audioboo.fm/boos/1709910-airing-pain-programme-47-the-power-of-the-mind-05-11-13

Because chronic pain is so complex, there are often multiple treatment goals. These goals may include more comfort (being “pain-free” is often not possible when pain has become chronic), better physical functioning, improved coping and less distress, getting back to work, helping the family cope, and other positive outcomes. To accomplish these goals, chronic pain often is best managed using what is called a “multimodality” approach.

The patient’s response to therapies may be influenced by age, gender, race or ethnicity, cultural beliefs, or any of a variety of physical, emotional, social, family, occupational, and spiritual circumstances. Treatments for pain must be tailored to the individual, based on each person’s unique condition.

A multimodality approach to chronic pain includes a combination of therapies selected from eight broad categories:

  • drug therapies
  • psychological therapies
  • rehabilitative therapies
  • anesthesiological therapies
  • neurostimulatory therapies
  • surgical therapies
  • lifestyle changes
  • complementary and alternative medicine therapies

In many cases, a multimodality strategy requires the involvement of several types of health care professionals -the interdisciplinary team.

Effective pain management is therefore collaborative in nature, involving good communication among the patient, family, and the practitioners involved in the care. A sense of partnership in trying to find the best therapeutic approach promotes the most creative, and ultimately the most effective, approaches. Patient-practitioner partnership can maximize the patient’s involvement and sense of control in the healing process. Patients must feel empowered to seek the best care and to act in a way that uses their own resources in the service of health. If an interdisciplinary team of practitioners is involved in developing a multimodality approach, the members must communicate freely to ensure the appropriate targeting of therapy. Family communication helps promote positive patterns within the family and may reduce the stress caused by prolonged pain and impaired function.

Integrative pain managementFrom this perspective, Integrative Pain Therapy is a natural extension of state-of-the-art conventional pain management.

Integrative Pain Therapy

The term, “integrative pain therapy,” can be used to describe a broad therapeutic approach to the management of chronic pain, which attempts to combine the best of traditional treatments for pain and disability with the best of the therapies widely considered complementary or alternative. It is part of a larger effort to develop an “integrative medicine approach” to many clinical problems.

This integrative medicine approach links traditional, so-called allopathic, medical treatments with varied complementary and alternative treatments. It is a comprehensive system of medicine, which emphasizes wellness and the healing of the whole person (physical, psychological, social, and spiritual), above and beyond the treatment of any specific symptom or disease (Bell, 2002). It involves the use of all safe and effective therapeutic approaches that can potentially facilitate healing, while empowering the patient to participate in the process of healing. Integrative medicine acknowledges the complexity of health and illness by identifying multiple causes of disease and multiple interventions based on the physical, biochemical, psychological, social and spiritual aspects of health and disease. It recognizes that multiple outcomes may be positive for the individual, and that these outcomes may vary from one person to the next (Rosomoff, 1999).

The goals of an integrative pain therapy approach may include:

  • reducing or eliminating pain
  • using medicines that are appropriate, provide sustained benefits, have tolerable side effects, and support the functional goals of the patient
  • reducing distress and enhancing comfort, peace of mind and quality of life
  • improving the understanding of the role of emotions, behavior and attitudes in pain
  • improving the ability to function physically and perform activities of daily living
  • improving the ability to function in social and family roles
  • supporting the patient’s ability to return to work and function on the job
  • educating patients in ways to maintain rehabilitation gains and avoid re-injury
  • empowering patients to actively participate in pain control strategies
  • promoting awareness and understanding of the factors that contribute to physical and emotional distress related to pain
  • developing the skills and knowledge needed to increase the patient’s sense of control over pain

Integrative pain therapy draws from a broad spectrum of therapeutic approaches. It recognizes the value of multiple approaches to pain management (a multimodality approach) and acknowledges the individualized nature of good medical care. The goal is to employ the safest and most effective therapies to provide maximum benefit.

Foundations of Health

In developing an integrative approach to pain therapy, the starting point is a broad view of health and well being. The foundations of health include at least four elements:

    • stress management
    • proper diet and nutrition</li
    • regular exercise
    • psychosocial support

There are literally thousands of studies confirming the importance of each of these foundations. Careful attention to each can have profound effects on health and illness. The work of Dean Ornish (Ornish, 1999), for example, demonstrated that interventions targeted to these areas can not only halt, but actually reverse, coronary artery disease.
Stress Management.
All people experience stress and some degree of stress may be needed to generate excitement, engage fully in tasks, and perform well. However, too much stress, or poor coping with stress, can undermine health and well being.There are many tools available to help reduce the debilitating effects of acute and chronic stress. The most important approach is to recognize triggers and behavior patterns, and to utilize emotional and spiritual approaches to reverse stress’s negative effects. These approaches can be learned in a variety of ways, such as psychotherapy, education, and training in mind-body techniques. Sometimes, herbal, nutritional or pharmacologic therapies are needed to assist in coping with persistent stress.

Proper Diet and Nutrition

Although science has a great deal more to learn about the role of nutrition in health and disease, it is certain that poor nutrition can contribute to a range of problems. Poor nutrition is common in many developing countries, and there is clear evidence that people living in developed countries, such as the United States, may not obtain enough of the essential nutrients needed for maintaining health (Fairfield & Fletcher, 2002). Because the diet may not be a complete source of all the nutrients needed for optimum health, the use of supplements may be necessary, either to help prevent disease or to aid in treatment.

Exercise

Proper exercise maintains fitness and is very helpful in reducing stress. Intense aerobic exercise is not necessary to achieve these benefits. Brisk walking may be sufficient for many people. Modest, regular exercise, particularly when combined with stretching and relaxation, or approaches such as yoga and tai chi, provides another essential element for optimum health.

Psychosocial Support

There is a huge body of research that demonstrates the importance of psychological and social factors in health and disease. Emotions, thoughts, connections to others, the response of others to our behaviors-all these factors contribute. Dealing with these types of issues and problems is an essential part of pain management.
Although integrative pain therapy as an approach to the management of chronic pain is in its infancy, several recommendations are possible.

Based on current research the integration of psychological approaches (such as behavioral and relaxation therapies) with conventional medical treatment is strongly recommended for the successful treatment of chronic pain conditions. Some mind/body strategies, like biofeedback, hypnosis, and imagery, are already considered to be mainstream treatments by pain specialists. Others, such as meditation, Qigong, and yoga have extensive historical use and need more study to determine their exact role in an integrative program. The potential benefit of all these approaches is the ability to learn to regulate anxiety, improve coping, and possibly reduce pain.

Research also supports physical activity and exercise as a part of most treatment programs for chronic pain. For example, active back exercises can be effective in reducing pain intensity, pain frequency and disability, as well as in helping to prevent recurrences of back pain. Activity can be supported by conventional physical therapy and exercise approaches, or by a wide range of movement therapies.

There is strong support for a treatment strategy that combines therapies that address the physical, psychological and social aspects of chronic pain. Based on a slowly growing experience, the integration of complementary/alternative approaches with standard treatments may offer the best chance of addressing these broad concerns. All patients should be educated about the range of options and the goals of treatment.

The interdisciplinary approach to chronic pain may involve not only traditional health care providers, including physicians, nurses, psychologists, and physical therapists, but integrative providers comfortable with the widest array of healing modalities, whether conventional or complementary, as well as specialists in specific complementary approaches.

In Ealing we are fortunate that we have an excellent Community Musculoskeletal service which offers standard treatments alongside Complementary therapy.
Shortly,The Ealing improving access to psychological therapies (IAPT) service offers support for common mental health problems such as depression, anxiety and panic for people living in Ealing.
It can provide self-help treatments, cognitive behaviour therapy (CBT), counselling and sign-posting to other servces. For more information view http://www.mhws.org.uk.
It will be offering Mindfulness therapy with a special reference to Chronic Pain in the New Year.
Referral information
Ask your GP for more information, or call 020 3313 5660 or email wellbeing.selfreferral@nhs.net.

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Posted by on December 20, 2013 in Training and Advice

 

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