E.O. Wilson, a Pulitzer Prize-winning biologist known for developing the
field of sociobiology, said – “We are drowning in information
while starving for wisdom.” The “answer” to many of
life’s questions can now be “found” with a few keystrokes
on a computer keyboard or swipes on a smartphone. Especially for patients
chronic pain, they can access more information about what they’re going through
than ever before. Of course, not all of it is good or accurate information.
The unfortunate reality is a lot of it is precisely the opposite and much
of it lacks the wisdom necessary to apply it appropriately to ease their pain.
As I have written extensively,
pain is complex, challenging to treat, and often poorly managed for the patients experiencing
it. The keys to success for pain patients, and the physicians caring for
them, include a comprehensive understanding of pain, vigilance in figuring
out an accurate identification of the pain or a specific pain “generator,”
respect for and willingness to try alternative pain paradigms and
treatment options, and an empathetic and multi-disciplinary approach. Moreover, it is critical
to understand that pain is produced in the brain. It is an “output”
that the brain produces in response to what it perceives as actual injury
or damage that represents a threat to health, wellbeing, and survival.
What exactly is pain? Depending on the dictionary source you access, most
definitions consider pain: An unpleasant sensory and emotional experience
associated with actual or potential tissue damage. This definition seems
simple, but it is anything but for sufferers. First, the definition acknowledges
that pain is both a sensory (physical, physiological) experience AND an
emotional (mental, psychological) experience. Indeed, the “domains”
involved in the background of pain aren’t only physical –
they are also mental, emotional, and even cultural. Further, this definition
also recognizes that pain may or may not result from actual tissue damage.
Frustratingly for patients and their health providers, sometimes the source
of the pain isn’t easily identified, or even present at all.
Pain has multiple classifications:
Acute Pain – Usually occurs suddenly and is caused by something identifiable and specific
(broken bones, labor, childbirth, burns, or cuts). This type of pain does
not usually last longer than six months.
Chronic Pain – This is ongoing and usually lasts longer than 3 months – even after
the initial “cause” has healed or subsided or in cases where
there is no identifiable cause.
Nociceptive Pain – Pain usually caused by tissue damage or injury – like a
severe cut or broken bone, for example. This kind of pain is usually inflammatory
in nature and the intensity of the pain correlates with the degree of
injury or stimulation.
Neuropathic Pain – Pain that can have various causes but develops as a result of
problems with nerve signals, usually resulting from damage to or diseases
affecting the nerves or some abnormality in how the nervous system is
processing pain signals. This kind of pain may be disassociated from the
degree of injury or stimulation. In other words, with Neuropathic pain
even mild stimulation can result in severe pain.
The consequences of pain are also multifactorial. Unmanaged pain can give
rise to a variety of effects:
Behavioral – Psychologic issues, sleep concerns, problems with daily productivity.
Physiologic – Initiates stress response and increases immunoglobin production.
Musculoskeletal – Features joint and muscle stiffness and myofascial pain and dysfunction.
Neurologic – Central and peripheral sensitization and wind-up.
Because pain is such a complex phenomenon and often unique to the person
experiencing it, numerous medical specialists treat pain, including orthopedic
neurologists, neurosurgeons, anesthesiologists, physiatrists, physical therapists,
athletic trainers, and chiropractors, as well as a multitude of options
to address it:
Conservative: physical therapy, massage, bracing, rest
Interventional: Acupuncture, Decompression
Behavioral: Cognitive Behavioral Therapy (CBT), Biofeedback
The historical approach to diagnosing pain is based on identifying pain
as a generator or “lesion” that must be eliminated, fixed,
or cured. But what do you and your doctor do if there are multiple “lesions”
to treat, or there is no identifiable lesion or “cause at all?”
In other words, sometimes, those in
pain management need to think about things differently. Thankfully, newer thinking, research,
and studies have given way to advanced approaches to treating pain, which
recognize that traditional paradigms can be improved with alternative methods.
Because pain medicine is complicated, even for the experts who have made
it their life’s work, we must ensure that our patients are as informed
as possible about their conditions. That’s on us as the experts. In
my practice, I have found that detailed descriptions of a patient’s pain experience,
from a clinical perspective, can enhance their understanding, improve
their compliance with suggested treatments, and can also positively impact
the descending pathways of pain. Pain is complicated, to be sure. But
with wisdom and discernment, we can get to the bottom of it – together.