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Pain - It's Complicated!


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 experiencing 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 surgeons, 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

Aggressive: Surgery

Interventional: Acupuncture, Decompression

Behavioral: Cognitive Behavioral Therapy (CBT), Biofeedback

Pharmacologic: Medication

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.