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Chronic Pain: A Disease in its Own Right

Melanie Thernstrom has written a superb book based on a historical, philosophical, and scientific review of pain: The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing, and the Science of Suffering. Herself a victim of chronic pain, she brings a personal perspective to the subject and also includes informative vignettes of doctors and patients she encountered at the many pain clinics she visited in her investigations. She shows that medical treatment of pain is suboptimal because most doctors have not yet incorporated recent scientific discoveries into their thinking, discoveries indicating that chronic pain is a disease in its own right, a state of pathological pain sensitivity.

Chronic pain often outlives its original causes, worsens over time, and takes on a puzzling life of its own… there is increasing evidence that over time, untreated pain eventually rewrites the central nervous system, causing pathological changes to the brain and spinal cord, and that these in turn cause greater pain. Even more disturbingly, recent evidence suggests that prolonged pain actually damages parts of the brain, including those involved in cognition.

Sometimes the original problem creates new ones as the patient distorts posture and avoids exercise in an attempt to reduce the pain.  In chronic pain, the protective mechanism of avoidance becomes maladaptive. Muscles atrophy from disuse and new sources of pain develop. Jerome Groopman, MD, in The Anatomy of Hope, told how he conquered years of chronic back pain by realizing that his pain was not a warning to avoid further damage but a false message that he could refuse to listen to; with exercise and physical therapy he rebuilt his muscles and became pain-free.

Dr. John Sarno believes that chronic musculoskeletal pain is a manifestation of “tension myositis syndrome” due to repressed negative emotions. He recommends renouncing all treatments, accepting that pain is only in the mind, and resuming normal activities. I don’t accept his psychosomatic premise, but there is a grain of truth in his method. If patients can re-frame their thinking and resume normal activities despite the pain, they are more likely to improve than if they maintain the self-image of a sick, disabled victim.

Distraction is effective in removing the awareness of pain. Thernstrom tells us that as she got better,

I wasn’t aware of being in pain all the time, but whenever I thought about whether I had pain, I always did. There were pain-free moments owing to my being preoccupied — happily or unhappily — with something else, but I was never able to “catch” a pain-free moment and enjoy it, which meant that, in some sense, I was always in pain.

Pain perception in the brain involves two different pain systems: one of pain perception and one of pain modulation. Acute injuries always hurt more later as the modulation effects diminish and the brain releases neurotransmitters into the spinal cord that amplify incoming signals and augment pain. This serves the adaptive purpose of enabling flight at first and then enforcing rest. It is possible to induce complete analgesia in humans and animals by electrically stimulating pain-modulating areas of the brain. Various cognitive and affective states activate the two systems, especially attention and expectation. Simply asking patients to think about their pain activates the pain-perception circuits. Anticipation of a placebo effect causes the pain-modulating release of endorphins in the brain.

One medication requires the placebo effect for all of its effectiveness. An intriguing 1995 clinical trial proved an analgesic called proglumide to be a more effective pain reliever than a placebo when both groups were told they were being given an exciting new painkiller. But then subjects were slipped proglumide without their knowledge, thus ensuring they had no placebo effect, they felt no relief at all. None.

It turns out proglumide enhances the endorphin response by blocking cholecystokinin receptors.  Thernstrom speculates that drugs could be designed to enhance or create a placebo effect. Hmm… what would medical ethicists have to say about that? For that matter, how can a treatment still be called a placebo if it is shown to have the effect of producing endorphins in the brain?

Opioids relieve pain, but they are both under-used and over-used. If acute pain were better controlled, fewer patients would develop chronic pain. On the other hand, many chronic pain patients develop opioid-induced hyperalgesia, where their body becomes more sensitive to pain stimuli or even ordinary stimuli; they develop pain in parts of their bodies remote from the original injury site.

Caution is required. Relieving pain sometimes causes harm. A phase 3 study of tanezumab was recently halted by the FDA. Although the drug relieved the pain of osteoarthritis, it also resulted in more joint failure, presumably because there was more wear and tear on the joints when pain was absent.

The Pain Chronicles is a fascinating glimpse into the world of pain sufferers as well as a good overview of our current scientific knowledge. It suggests avenues of investigation that may vastly improve our management of pain. I highly recommend it to anyone who wants to know more about any aspect of the pain experience and the science.

Posted in: Book & movie reviews, Neuroscience/Mental Health

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73 thoughts on “Chronic Pain: A Disease in its Own Right

  1. kirkmc says:

    It’s amazing that – from what I understand – actually treating pain as a problem, and not a side-effect of an illness, is something that is relatively recent. And even with that, pain treatment is far from being mainstream, and doctors don’t seem to know enough about treating different types of pain, or even identifying them.

  2. Dawn says:

    Sounds like a very interesting book. I’ll have to look for it.

  3. sowellfan says:

    Thanks for this post, Harriet – my ex-wife dealt with years of chronic pain that got progressively worse, though the original cause was fairly simple whiplash. My experience was anecdotal, but it follows the same course as this book apparently talks about – the more she concentrated on the pain, the worse it got – and it just added onto itself over time, centering more of her life around it. Fortunately, I think she’s much better now – she ended up living close to some young nieces and nephews that she really enjoys, and I think a lot of her attention got re-focused.

  4. dr.cosa says:

    Long time back pain sufferer, long time reader of Dr. John Sarno’s books (all 3 of them re-read over and over) and long time insurance adjudicator dealing principally with low back strain sufferers.

    Im saturated in low-back pain issues from all corners of my life and I have learned this much:

    approaches to back pain resolution are no better than nutritional advice: well meaning but lacking in evidence-based approaches that go beyond “lessening of pain” or “increasing mobility”.

    strengthening your back and or core muscles are the fashionable approaches employed by far too many educated professionals under the misguided notion that our backs suddenly become weak and feeble when we strain them one day and require development to get them back to where they were before. for many who feel the sudden tinge of their back “going out” either performing something strenuous or benign, can say that a sudden weakening of musculature fails to explain the cause or resolution of most back pain.

    a virtual army of chiropractors, physiotherapist, trainers and medical device peddlers have pet theories of back pain cures, few if any actually work and studies to date have shown a host of techniques that claim to work over conventional methods (or simple bed rest) but are far from concrete.

    compensation boards across the developed world face the challenge of chronic back pain becuase it is so prevalent and difficult to resolve. only recently has the psycho-social model been given some appreciation as a way to treat suffers as surgical interventions have been show for what they really are: an incomplete solution reserved for very specific cases that envoy’s limited long term success (beyond the standard Canadian metrics for lumbar spine surgical success of 6 months post-operative reduction in pain)

    Cognitive Behavioral Therapy has shown in clinical trials to be as effective and at times more effective than traditional approaches, and coupled together far more effective than either on its own. The role of the mind is well placed by Dr. Sarno’s work but he has only opened the door and a new generation schooled in the psycho-social model need to explore this medical frontier further and elaborate on the paradigm.

    How the brain could continue to generate pain signals long after they serve any physical necessity, is worth studying, as is its application to the panoply of soft-tissue injuries that have become conditions such as carpel tunnel syndrome, tennis elbow etc.

    Quackery occupies a significant place in this region precisely becuase the failure of mainstream medicine to devise a surefire cure for chronic lumbar pain. If the approach has been misguided, and if a mind-body theory takes hold, perhaps the first place family practitioners will refer low back pain patients to is a good cognitive behavioral therapist before considering surgical interventions as opposed to the current model which is reversed. how sad.

  5. Happy Camper says:

    Thank you Harriet for posting a subject close to my heart. A little over 15 years ago I was working in the backyard and hyper extended myself when I felt a sharp pain in my lower back above the right buttock like being stabbed with an icepick. In that moment my life changed and have been in pain ever since with what was diagnosed as sciatica. I was in great shape, 160lbs and a martial artist. To make a long story short at my worst I went to 210lbs and could barely make it to the mailbox let alone walk around the block.
    I am much better but still suffer from pain, (though not extreme) 180lbs, take nothing any stronger than OTC drugs and take daily walks and work out some but nowhere as much as I would like due to going lame and the onset of pain. Though I can block out most of the pain it is always there in the background and my range of motion is limited even though I do try to push through it but after any workout my right lower back hurts and right leg goes numb and standing is uncomfortable.
    From what I have read over 15 years is a little long for this to still be a problem.
    I am interested in receiving some additional insight as to what I can do and what to expect. Keep in mind I am skeptical that any intervention could be any better than what I am doing now.

  6. WilliamOBLivion says:

    “Dr. John Sarno believes that chronic musculoskeletal pain is a manifestation of “tension myositis syndrome” due to repressed negative emotions. He recommends renouncing all treatments, accepting that pain is only in the mind, and resuming normal activities. I don’t accept his psychosomatic premise, but there is a grain of truth in his method.”

    To be fair to Dr. Sarno he DOES say, or at least at one time said that one should be THOROUGHLY examined to eliminate physical causes before blaming it on TMS.

    @Happy Camper:

    If you have actual numbness in the whole leg that is what people call a “clue” that something is “Not Right”.

    Suggest you see a different doctor or set of doctors. Medicine has advanced a LOT in the last decade, and some doctors keep up better than others.

  7. Happy Camper says:

    @WilliamOBLivion

    No, just a hand sized area just above and outside the knee.

  8. Chris says:

    We are still going through the large amount of stuff that a relative left after her suicide. She was not just a hoarder, but a person who had suffered from a chronic migraine for thirty years.

    We found day planners going back over twenty years. She recorded appointments with regular doctors, naturapaths and a therapist for “rolfing.” Plus she also recorded the supplements, pills and nostrums she took (there were many, we actually found a box full of bottles).

    But what was even more interesting was she micro-recorded her levels of pain, her temperature and other various body measurements. All I could think of was making her always think about the pain could not have helped. Obviously, it didn’t.

  9. Robin says:

    Dr. John Sarno believes that chronic musculoskeletal pain is a manifestation of “tension myositis syndrome” due to repressed negative emotions

    Is this evidence based? Or a hypothesis?

  10. rmgw says:

    Anecdote alert – to underline the Sarno mentions: after three agonising episodes of sciatica, leaving permanent back pain, extreme caution in all the things recommended, Sarno’s convinced me to try again and so it proved: no extra caution, no reduced activities and very little pain.

  11. Harriet Hall says:

    Robin asked if Sarno’s advice is evidence based. I think the answer is yes and no. There is evidence that patients’ attitudes and behavior affect the course of chronic pain, but the idea that the pain is originally caused by negative emotions doesn’t make sense to me. That hasn’t been tested and I don’t know how you could reliably test it. Also, I don’t think his program has been tested against other regimens. I haven’t actually read his books and am just going by what I have seen on the Internet, so if I’m wrong, someone please correct me.

  12. pmoran says:

    For that matter, how can a treatment still be called a placebo if it is shown to have the effect of producing endorphins in the brain?

    A good summary of this area of research, with some reference to its tantalising ethical implications –.

    http://dcscience.net/placebo.pdf

  13. colli037 says:

    This is actually my area of clinical practice (chronic pain). Attitude influence pain perception (recall the difference between an injured soldier feeling minimal pain, and an injured civilian in pain from a leg fracture)

    Emotions influence pain as well, which is why depression+fibromyalgia are much more common than fibromyalgia alone, and probably explains why antidepressants can help fibromyalgia.

    Exercise (alone or with medications) is one of the proven treatments for several types of chronic pain where the brain is felt to have a lot to do with persistence of the pain (fibromyalgia, chronic regional pain syndrome or RSD), and may work as well or better than pain medications for back pain.

    Recently the focus of pain management (at least at the academic centers like where I practice) has been enabling a return to function rather than just pain relief. This requires changing the focus from just

    “is your pain better” to

    “are you able to do the activities that you want to do without making your pain significantly worse”.

    The second is a much more difficult discussion to have, as patients are reluctant to try to increase their activity, do to fears of increased pain or causing further injury.

    tim

  14. wertys says:

    Sarno’s approach is interesting as it recommends what is generally a helpful idea but for an entirely specious reason. It’s a bit like Semmelweiss, who was also right but understandably for the wrong reason (because he was pre-germ theory). “Tension Myositis Syndrome” is not a myositis (muscle inflammation) due to tension (whether mental or physical) and the term is entirely unsatisfactory. What his work does provide is a reasonable stab at trying to link the mental experience of consciousness with some more concrete physiological events that can result in widespread pain. It’s a good try but does fall well short of the current state of the art view of chronic pain and its mechanisms.

    For a nice discussion about why you could reasonably call chronic pain a disease of the central nervous system, see this very thoughtful article, well worth reading in full if you can get hold of it.

    http://www.ncbi.nlm.nih.gov/pubmed/19878862

  15. wertys says:

    @dr.cosa

    ‘perhaps the first place family practitioners will refer low back pain patients to is a good cognitive behavioral therapist before considering surgical interventions as opposed to the current model’

    There is evidence for doing exactly this in chronic discogenic back pain…

    http://www.ncbi.nlm.nih.gov/pubmed/15911537
    http://www.ncbi.nlm.nih.gov/pubmed/16545523
    http://www.ncbi.nlm.nih.gov/pubmed/19635718

    It is an interesting ethical challenge that when comparing 2 treatments for the same condition, which turn out to have equal efficacy, should you recommend the one which has a small but definite risk of paraplegia, but which patients request (surgery) over the one which has no such risk, but is often unacceptable to pts (CBT/Rehabilitation approaches)??

  16. cloudskimmer says:

    Chronic pain is a horrible situation, and one area where science-based medicine seems to be on a par with the quacks, because there are a lot of Doctors operating chronic pain clinics who seem to think they can address the problem. Taking pain medications over a long period of time produces unacceptable side effects, and they don’t work well anyhow. I’ve been trying for years to get help for my elderly mother; everything seems to work… for a couple of months, and then the pain worsens, and after flailing around for a bit, the Doctor gives up; so we go to another Doctor, or another pain clinic, and the whole process repeats itself with minor variation in the methods. Elderly people who don’t communicate well don’t get very good treatment in any case, and with an intractable problem it’s even worse. There doesn’t seem to be any clear association between medications and pain relief, but she takes them because she needs to do something. I hate the quacks because they market ineffective and fanciful ‘treatments,’ but it’s hard to see any difference between them and the medical profession when it comes to the treatment of chronic pain–which brings out the worst in everyone concerned.

    Another reason this problem is given short shrift could be due to more women than men being afflicted–or so I read in a recent newspaper article (probably NY or LA Times–I don’t remember.)

    It’ll be interesting to read the book, but I’m past thinking that anyone has any real answers to this problem, and it really hurts to watch someone I love suffer so much and get no relief.

  17. Chris says:

    cloudskimmer:

    it really hurts to watch someone I love suffer so much and get no relief.

    Tell me about it. It hurts, and it gets worse when your well intentioned suggestions like taking a walk and thinking about something else to distract from the pain are rebuffed. Even though it is a shirt-tail relative… the person is still someone in your life who you love and remember from happier times.

    She had a psychotic episode which may have been a combination of the meds and/or pain from lack of meds. She spent six weeks in the county psyche ward where they replaced the pain meds with meds for bipolar disorder, actually forced her to go for walks, and talk to a real psychiatrist. When she left she was the most pain free and healthy than she had been for years.

    But she went back to her online support groups, and decided to skip the outpatient clinic and went back to the naturapath. Oddly enough the pain returned.

    She seemed sympathetic when my back went out (something about getting kids in and out of car seats). But that waned when it turned out that my “evil” family doctor only prescribed specific exercises and it went away after six weeks. It was not a “minor” lower back ache. My muscles were sprained enough that I could not walk straight. My normal resting position was on my stomach with a heat pad on my lower back. But I did leg lifts daily, plus went swimming as much as possible (starting in the very very slow lane with a kick board and the lifeguard begging me to not drown). She actually resented that I recovered, and was cold to me at more recent family gatherings (okay, I did suggest she take walks — but that was also what her real docs told her to do!).

    I also hate quacks.

  18. Fifi says:

    dr.cosa – ‘perhaps the first place family practitioners will refer low back pain patients to is a good cognitive behavioral therapist before considering surgical interventions as opposed to the current model’

    A GP shouldn’t be referring someone with chronic pain for surgery in the first place, they should be referring their patient to a specialist (preferably a pain specialist and not a surgeon, since obvious surgeons tend to see surgery as the best solution). Not sure about in the US but it’s quite usual for pain clinics in Canada to be multidisciplinary – and to include psychologists as part of the team. The psychological components/aspects of pain aren’t a revelation to pain specialists – it’s actually the one area of medicine where the mind/body (or body/experience) relationship is considered in depth. (It’s also an area where the influence of culture and language are studied and considered.) So, just to say that the current model of treatment by pain specialists does often include CBT, as well as meditation or other techniques which can help one focus and think about pain differently.

  19. Fifi says:

    Chris – “The seemed sympathetic when my back went out (something about getting kids in and out of car seats). But that waned when it turned out that my “evil” family doctor only prescribed specific exercises and it went away after six weeks. It was not a “minor” lower back ache. My muscles were sprained enough that I could not walk straight. My normal resting position was on my stomach with a heat pad on my lower back. But I did leg lifts daily, plus went swimming as much as possible (starting in the very very slow lane with a kick board and the lifeguard begging me to not drown). She actually resented that I recovered, and was cold to me at more recent family gatherings (okay, I did suggest she take walks — but that was also what her real docs told her to do!).”

    Some chronic pain patients are very hard to treat because the pain (or the pain behavior more appropriately) serves an emotional/social purpose for them – meaning they have absolutely no desire to really get better. Being a victim/martyr/sick can be a very powerful position to manipulate others from – it can serve a narcissistic need. For some people, being sick is the only way they can ask for help or attention. For others it’s a way to manipulate the people around them. Sometimes the person is aware of what they’re doing, more often they’re not.

    While all these things may seem like radical insights into pain for people outside of the field – and many MDs who aren’t pain specialists seem unaware of the current state of research and thinking on pain (and their own cultural/personal biases regarding pain) – the ideas being presented here aren’t particularly novel. Good to see that the author also mentions the issues around prescribing effective pain killers in the US because of the hysteria about addiction and the “war on drugs”.

    Of course, the medical specialty of pain and research around pain have always been treated with suspicion by a lot of doctors and other medical specialists – and a great deal of that is because both the research and practice involve a psychological (and social/cultural) component as well. Some of this is because pain research does push the limits of what we considered plausible – just as neurobiology does, there’s a reason why the two specialties are often under the same roof or in the same department at a hospital – but it’s mainly because people don’t like the idea that pain is an experience that happens in the mind (even though the nerves play a role, when you hit your thumb with a hammer it’s your brain/mind that’s process the experience so, ultimately, pain really is all in our heads…or so the current research tends to indicate).

    Calling chronic pain a “disease” instead of a condition is a bit of interesting semantics – one that the most hypochondriac of patients, with the most psychosomatic/melodramatic manifestations, will welcome (which is not to their benefit or that of many patients in terms of their own ability to reconsider and recontextualize their experience of pain really). It may be somewhat beneficial for more stoic patients (but probably not for ones on disability who want to avoid the psychological component of their condition – which considering that their stoicism is likely to be a causative factor in their chronic pain isn’t really that helpful in the long run). While labeling chronic pain a disease rather than a condition may be expedient for researchers and pain specialists for personal reasons, and perhaps make some of the general public or a patient’s partner/family more sympathetic, the psychological effect of doing so may be less than optimal for the kinds of patients who end up in chronic pain clinics. (Keep in mind that chronic pain can have purely physical sources too that we can’t currently treat but even in these cases learning good pain management techniques can make a difference for the person suffering and those around them. It’s also worth noting that lots of people have chronic or recurring pain of various kinds but manage it fine on their own. Part of what goes on in pain clinics is often teaching people basic self awareness and self care – and cause and effect.)

  20. Fifi says:

    It would be great if the SBM blog is going to feature book reviews if they were done by the medical professionals who actually are specialists or in related fields – that way it would be being reviewed by someone who’s actually knowledgeable in the particular field. That’s not a slam of people who aren’t specialists (or Dr Hall in particular), generalists serve a very important function too and are no less or more important or necessary than specialists, they’re just obviously less knowledgeable than specialists are about a specialist subject. It’s more a recognition that medicine has specialties because there are areas of specialized knowledge and expertize so it makes sense to have the most qualified person in a particular field do book reviews about specific subjects if SBM is intended to be a source of validation or questioning of the science around a specific topic/field or proposed by a book dealing with a specific area of expertize. Particularly since one of the ongoing issues regarding GPs and pain treatment is that GPs often aren’t aware of their own enculturated beliefs about pain (which come from both our larger cultures and our family culture).

    1. Harriet Hall says:

      Fifi,
      You suggest that specialists review books in their field. I would argue that specialists often have their own biases (i.e. surgeons tend to look more favorably on surgery and might subtly downplay other treatments). An objective evaluation by an outsider may be preferable. Specialists can then contribute to the comments, as has happened here.

      A generalist doesn’t have the specialist’s depth of knowledge, but the specialist doesn’t have the generalist’s breadth of knowledge and may be less able to see things in perspective and to consider other aspects of the patient’s life. I hesitate to use the word, but I chose family medicine because I thought it was more “holistic.” I would argue that a generalist is actually the best qualified person to do book reviews about specialist subjects, particularly when the book is intended for the general public.

  21. Diane Jacobs says:

    Great review of Thernstrom’s book, Harriet – glad to see SBM take this topic on.

    I agree with the comments re: multi-disciplinary management of chronic pain.

    One wonders why some people are more susceptible to developing chronic pain than others. Something I’ve learned recently about infant nervous systems and their sensitization has given me great pause for thought, something as simple and ordinary and ubiquitous as premature babies getting heelstabs (among lots of other procedures) up to 15 times a day.
    Nurses are researching this issue (Celeste Johnston, her publications http://people.muhc.ca/celeste.johnston/ ). Also Liisa Holsti (an OT) is looking carefully into this, has published quite a few times. (link to her publications: http://www.ot.med.ubc.ca/ubc_cando_research_unit/cando_researchers/CanDo_Researcher_Liisa_Holsti.htm )

    Some of the background research on nervous systems around time of birth:
    * hyperinnervation of skin – large fiber receptors are all the way out in the epidermis (Jackman and Fitzgerald 2000)
    * hyperinnervation because of having more large fibers than necessary (pruning back in the DRGs to ordinary level happens by 20% but not until after week 1, of a full term neonate – think about what happens to a preemie) (Coggeshall et al 1994)
    * large-fiber sensory neurons enter the cord during the third week of gestation (Fitzgerald 1987) but C’s are not detected in spinal cord until day 5 post natal (Pignatelli et al 1989). C fibers are nociceptors proper – their small size helps slow noxious transmission down.
    * The A’s start working long before the C’s do (Fitzgerald 1988, Jennings and Fitzgerald 1998) and have way bigger receptive fields in skin over much tinier-sized anatomy.
    * The descending modulation pathways aren’t even hooked up yet. At all. The brain can “feel” sensory stimulation but can’t do anything about it yet. (Slater et al 2006; Bartocci et al 2006)

    This all makes sense when we consider that human pelvis size was an evolutionary constraint on brain size – humans have to be born in a less-matured state. There is still a sort of blanket belief operating in medicine that infants don’t feel pain because their systems aren’t fully myelinated. It turns out they can “feel” it, more, because the equipment for handling/dampening it isn’t fully grown in. Synaptic plasticity in the cord is “activity-associated”; this means descending modulation pathways still being laid down will be sculpted for better or worse by input those first few weeks of life.

    Diane

  22. Fifi says:

    Diane – “There is still a sort of blanket belief operating in medicine that infants don’t feel pain because their systems aren’t fully myelinated. It turns out they can “feel” it, more, because the equipment for handling/dampening it isn’t fully grown in. Synaptic plasticity in the cord is “activity-associated”; this means descending modulation pathways still being laid down will be sculpted for better or worse by input those first few weeks of life.”

    Thanks for that interesting insight into infants and pain.

    Medicine in North America in general is very influenced by various aspects of our culture and the dominant culture in medicine in North America is that of the establishment – meaning WASP (and Protestant/puritanical cultures are rather stoic when it comes to pain, as compared to Catholic or more emotionally expressive cultures…to give just one example that most people will be quite familiar with). While working in a pain clinic, it was fascinating to observe how cultural beliefs influence the perception of pain for both the observer (Dr/practioner or layperson) and experiencer (patient). And that does include taking a look at my own learned/enculturated beliefs and cultural biases – I don’t think I’m some special exception from the human condition just because I grew up around pain research and psychology, or because I’ve worked in a pain clinic.

    There’s a very worthwhile interview with the author over at Salon.

    http://www.salon.com/books/feature/2010/08/22/pain_chronicles_ext2010

    I found this particular quote to be particularly interesting – and even more interesting if we consider it in the context of an infant that has so few ways to express pain and how easily infant pain can be dismissed or minimized, and projected onto by medical professionals and parents so it serves their purposes and not the infants greater good.

    “A pain specialist once said to me, you have to value a person to value their pain. So it’s no surprise that poor people and minorities are the least likely to have their pain believed and treated. They also often have the fewest resources to pursue pain treatment. And it used to be in earlier eras — peaking in the 19th century — there were all these racist theories about how Africans couldn’t suffer from pain, that they were literally less pain sensitive than white people. The Victorians believed in a hierarchy of pain sensitivity with savages and slaves at the bottom just above animals and then rising up from there. Poor people were less sensitive than members of the upper class and most sensitive of all were white upper-class women.

    However, in contrast to these theories about Africans being less pain sensitive, there is very interesting contemporary research that shows that African-Americans are actually more pain sensitive on average and suffer from greater levels of chronic daily pain.”

    We’re still not really entirely free of Victorian values or the self-serving beliefs of colonialism (such as believing Africans or children feel less pain, or that babies don’t “remember” pain).

  23. Diane Jacobs says:

    @Fifi; “Calling chronic pain a “disease” instead of a condition is a bit of interesting semantics”

    I think this probably has something to do with being able to apply for/obtain research funding, is maybe one of those crucial words. Some “diseases” have much clearer biological boundaries around them than do others. Chronic pain has been classified so far as a bio-psycho-social ‘condition’. It’s the cumulative effect of whatever kind of genetics/nervous system someone was originally born with, coupled with whatever has been encoded into said NS over a lifetime to date (injuries, ‘slings & arrows’, stress, etc.), coupled with whatever meaning was gleaned by a NS and its own conscious awareness/prefrontals from the experiences as they accumulated (the psycho-social part). Pain is a tricky thing to classify, because it’s vital to survival, yet life-impacting (not in a good way) when it has become chronic and no longer serves any purpose, at which point it’s fairer to consider it as disease. It’s further complicated by being part and parcel of a nervous system which although comprising only 2% of a physical human body, soaks up 20% of available energy and glucose continuously through a lifespan, i.e., something more verb-like than noun, until recent years not well-studied, and still not comprehended.

    Diane

  24. Fifi says:

    It’s also worth noting that one big advantage of treating pain via a multidisciplinary approach is that there’s a team caring for the person and not just one person – this can go some way towards mitigating personal bias but, obviously, there can also be encultured biases that people from similar backgrounds may share. Unfortunately this approach takes time and requires a team, this tends to make both insurance companies and governments not want to support this approach to treating pain (or for only an inadequate time for the treatment to be effective). Pain patients often end up in a rather bad situation where they are already having difficulty coping with everyday demands and then they need to deal with hostile Workers Comp or insurance bureaucrats who are actively trying to prove – or demanding proof – that they are in pain.

    As an aside, the multidisciplinary approach was once known as a “holistic” approach in pain medicine, before that perfectly good and appropriate term got hijacked by pseudo-medicine.

  25. Fifi says:

    Diane – “Pain is a tricky thing to classify, because it’s vital to survival, yet life-impacting (not in a good way) when it has become chronic and no longer serves any purpose, at which point it’s fairer to consider it as disease. It’s further complicated by being part and parcel of a nervous system which although comprising only 2% of a physical human body, soaks up 20% of available energy and glucose continuously through a lifespan, i.e., something more verb-like than noun, until recent years not well-studied, and still not comprehended.”

    All very good points – and not only because I agree for the most part, except that I’m not convinced it is actually beneficial to patients in the long run. (Not that my being convinced makes something correct or incorrect :-) I can certainly see how classifying chronic pain as a disease serves the purposes of researchers and can also be helpful in changing the public perception of chronic pain but in many ways it seems to be more about semantics than really increasing understanding of the complexity of (and diversity of types) of chronic pain. Fibromyalgia isn’t the same as injuries from a car crash, etc. One of the things many doctors who aren’t pain specialists can be very uncomfortable with is the psycho-social aspects (not to mention their own potential inability to help someone who is suffering) – partly because they’d have to actually look at their own psycho-social beliefs about pain, partly because chronic pain treatment tends to go into body/mind territory and research things like meditation and things that “seem” to work (from medical procedures that are revealed to be placebos to acupuncture).

    As the book being reviewed points out, our cultural biases and beliefs have greatly effected our understanding of chronic pain and even ability to perceive when another is suffering. Doctors and researchers who like to believe that even scientific medicine isn’t influenced by culture, and cultural beliefs and values, will continue to want a purely biological explanation for chronic pain because it serves their purpose.

  26. weing says:

    Regarding the generalist vs specialist categories, I practice general internal medicine. As medical knowledge increases, the generalist knows less and less about more and more, while the specialist knows more and more about less and less. If things keep going this way, eventually I will know nothing about everything and the specialist will know everything about nothing.

  27. Somewhat related, somewhat tangential – A few years ago I heard an interview with an anesthesiologist at Walter Reed, Dr Chester Buckenmaier, who talked about using immediate pain relief on the battlefield in the hopes of preventing chronic pain from tramatic injuries. In that interview he talked about treating pain as a disease (that can be prevented) rather than a symptom.

    “The military is now training doctors in battle to deliver continuous peripheral nerve block as soon as possible after an injury. The sooner the pain signals are blocked, the better patients fare in dealing with injury. The patient reported only a brief and fleeting sensation of phantom limb pain, he said, adding that he believes that this aggressive response to acute pain may actually alter the story for these patients. I believe we are preventing chronic pain syndromes, he added. But that needs testing.”

    http://journals.lww.com/neurotodayonline/Fulltext/2007/11060/For_Amputations_and_Phantom_Limbs,_New.2.aspx

    My layman’s understanding of the idea is that the central nervous system habituates sending the pain signal and can continue to do so even after the injury has healed. Prevent the pain signal initially and one may prevent the chronic pain.

    Interesting stuff.

  28. Fifi says:

    michele – Yes, it is very interesting stuff – particularly in terms of treating acute pain in a way that potentially prevents at least some acute pain becoming chronic pain. However, we still need to better understand how to deal with chronic pain because it’s not just a consequence of acute pain or a one-time injury – civilian chronic pain patients run the gamut from people with work injuries that resulted in chronic pain to fibromyalgia and undiagnosed causes.

    weing – Yes, that’s one of the issues with specialization in our culture that’s not only seen in medicine. My main point was I would have loved to see an SBM review and evaluation done by one of the bloggers here who’s more knowledgeable in this area who could comment on the book from an SBM perspective (and hasn’t previously shown themselves to be biased on the subject of pain).

  29. weing says:

    “and hasn’t previously shown themselves to be biased on the subject of pain”

    Isn’t that sort of impossible? I mean, to be without bias. The not showing oneself to be biased sounds pretty simple to do.

  30. Fifi says:

    Yes it is impossible, particularly as an individual, to be without bias – - as explained in an earlier post (how very PoMo weing ;-). That said, people who are aware of their biases and willing to consider that they may be biased will bring less unconscious bias to any topic or at least be able to recognize their own bias. People who are convinced they have no bias and refuse to consider that they may, are obviously a poor second choice. It’s a bit like comparing science and woo really – science isn’t perfect but it’s the best we can do, woo is what happens when people refuse to acknowledge their personal beliefs/biases and then claim to being objective/doing science.

    That doesn’t mean someone who is a pain specialist or neurologist won’t bring their own confirmation biases or prejudices to a review – certainly neurologists and pain specialists aren’t always on the same page – but it does mean they’re more equipped to actually comment from an SBM perspective. And it’s just a bit weird to have someone who’s been very vocally dismissive regarding pain (and the role of cultural beliefs) – which is one of the topics that the book seems to touch on in depth – reviewing a book about pain.

    1. Harriet Hall says:

      ” it’s just a bit weird to have someone who’s been very vocally dismissive regarding pain (and the role of cultural beliefs) – which is one of the topics that the book seems to touch on in depth – reviewing a book about pain.”

      Fifi doesn’t like me. :-( She has misinterpreted things that I previously wrote. We have had this discussion before.
      I hope other readers will disregard her disparaging comments about me. I am certainly not dismissive of pain or the role of cultural beliefs; quite the contrary. Is there anything in my review of this book that suggests that I am dismissive of pain? I think not.

  31. Diane Jacobs says:

    Hi, back in here just to pop in another reference, by Celeste Johnston: http://www.ncbi.nlm.nih.gov/pubmed/20971562
    Johnston CC et al. Pain in neonates is different. PAIN (2010), doi:10.1016/j.pain.2010.10.008

    ABSTRACT: “Pain processing and management in neonates, especially preterm neonates, differs from older populations. In this review, a brief background on pain processing in neonatal life, pain exposure in Neonatal Intensive Care Units (NICU), the consequences of untreated pain, and the difficulties in treating procedural pain pharmacologically will be presented. A more detailed review of non-pharmacological interventions for procedural pain in neonates will include sensory stimulation approaches, oral sweet solutions, and maternal interventions. Some possible mechanisms for the effectiveness of non-pharmacological interventions are offered. Finally, avenues of research into similar interventions as adjuvant therapies or drug-sparing effects in older populations are suggested.”

    I listened carefully to Johnston’s very interesting plenary lecture at the recent IASP conference in Montreal. She has followed body/facial responses of infants who were heel-stuck while they were in full body skin contact (kangaroo-style) against torso of mother, compared to farther, compared to related female adult (e.g., aunt), compared to unrelated caregiver (as I recall). Full body contact with mother seemed by far to provide the most effective non-pharm analgesia.

    Diane

  32. A couple of folks have referred to fibromyalgia as being distinct from mechanical causes of pain.

    I thought the point was that it isn’t different. Whether there is an obvious mechanical/ chemical/ physical cause or not, pain still happens in the brain. Someone who has chronic pain from an obvious physical injury is at risk of their pain becoming ongoing, autonomous and chronic after the original injury has apparently healed.

  33. Diane Jacobs says:

    @Fifi – “..I agree for the most part, except that I’m not convinced it [pain] is actually beneficial to patients in the long run.”

    I think it is, because those who are born with no means by which to process ordinary nociceptive stimuli (“congenital insensitivity to pain”) often die of injury their brain does not instinctively learn to avoid, early in life, unless they have very diligent parents who make them wear helmets and goggles.

    “The girl who can’t feel pain”
    http://abcnews.go.com/GMA/OnCall/story?id=1386322

  34. Fifi says:

    Alison – Just to be clear, when I mentioned fibromyalgia patients being treated at pain clinics (as different than patients with chronic pain that’s a result of a one-time physical trauma) I didn’t mean that I view fibromyalgia as being psychosomatic and without mechanical causation. I was pointing out that the idea of preventing chronic pain via intensive pain reducing/eliminating asap after traumatic injury is only relevant to one portion of the people who end up suffering from chronic pain.

    All experience really happens in the brain, that’s the nature of cognition ;-) A multidisciplinary approach to pain reduction and management involves tailoring treatment to each individual and their context.

  35. Fifi says:

    Diane – I think you may have misunderstood (from the word you’ve inserted). I agree that pain has a purpose and is necessary for survival, what I think may not be useful for some patients is the idea that their pain is a disease. I’m talking about adults with chronic pain who end up in pain clinics, not infants :-)

  36. Diane Jacobs says:

    @Fifi, thanks for clarifying. I think I agree. Mostly, anyway.
    Would you mind sharing what you do/what profession you represent or emerge from at your pain clinic?

    @Harriet, I always have disregarded anything disparaging said about/toward you. I think you do the world a fabulous service here along with the other bloggers. Thank you.

  37. weing says:

    Harriet,

    The biases, about being dismissive, as perceived by others may or may not accurately reflect our real biases. They may be just like beauty. (In the eye of the beholder) I think it just boils down to the fact that we, generalists, get no respect.

  38. Fifi says:

    Dr Hall – “I hope other readers will disregard her disparaging comments about me. I am certainly not dismissive of pain or the role of cultural beliefs; quite the contrary. Is there anything in my review of this book that suggests that I am dismissive of pain? I think not.”

    The discussion around circumcision is what I am referring to – I wasn’t going to bring it up specifically but obviously it’s necessary since you want to pretend it’s about “liking” people and not your beliefs about pain (and inability to acknowledge that having done circumcisions yourself you may have a confirmation bias.)

    http://www.sciencebasedmedicine.org/?p=269

    I know you’d rather believe that when I object to something you’ve written that it’s just a personality conflict and because I “don’t like you”. Whatever, if that’s your narrative that allows you to ignore cognitive dissonance, go for it – just don’t expect everyone else to buy into it. For the record, I don’t know you so I don’t like or dislike you as a person. I am only dealing with what you write and present here – I don’t assume to know how you are in-person. Perhaps the issue is more that you don’t like me since you always come back to that and project that intent onto me? You’re the one trying to make it all about personality – my objection isn’t your personality, it’s the content of what you write and some of your rather obviously ideological assertions at times that you refuse to even consider looking at (let’s see…there was the propping up of industry funded global warming denier/minimizer, your oddly pro-pharmaceutical psychology/psychiatry post – the issue is when you try to pretend you’re an expert and scientific authority about things outside of your expertize). The “she doesn’t like me and is mean” victim gambit is just, well, a rather sad gambit from an adult woman.

  39. Fifi says:

    Diane – No, I don’t mind sharing. I used to work at a pain clinic as part of a team that included a pain specialist, psychologist and physio. My role was helping people understand the mind/body connection in basic, practical ways – this included teaching meditation and relaxation, helping people understand how everyday things like posture, breathing and proper nutrition influence our emotional/psychological state (you’d be surprised how many people drink 10 cups of coffee a day and then have “insomnia”) and quite practical lifestyle/self care related info. I don’t do it anymore but it was an interesting, if at times challenging, job. I did it in both French and English, and our patients came from a wide variety of ethnicities and classes, and it was very interesting to see how both family and ethnicity and religion all played into both how people experienced pain and how it influenced pain behavior.

    It was something I did to supplement my income to support my real career – that isn’t very lucrative but is my passion – that involved a few of my interests.

  40. daedalus2u says:

    The treating of battlefield pain to prevent PTSD worked best with morphine.

    http://www.nejm.org/doi/full/10.1056/NEJMoa0903326

    I suspect that is because opiates are highly involved in many aspects of the stress response and not just in pain.

    I have heard the suggestion that one of the reasons there was less PTSD from Vietnam compared with the two Iraq wars was the use of opiates by Vietnam vets in theater. It is my understanding that heroin was cheap and easy to get and many vets used it in theater, and then stopped when they went back to the states.

  41. Chris – “She spent six weeks in the county psyche ward where they replaced the pain meds with meds for bipolar disorder, actually forced her to go for walks, and talk to a real psychiatrist. When she left she was the most pain free and healthy than she had been for years.

    But she went back to her online support groups, and decided to skip the outpatient clinic and went back to the naturapath. Oddly enough the pain returned. ”

    Chris, I’m sorry for your loss. It sounds like your relative’s condition was pretty complex. I think it must be very sad and frustrating to see someone reject the therapies that have worked for them. Sadly, I think that can also be an integral part of dealing with mental health issues.

    It seems that even people with typical mood/emotional function have an average to poor success rate with lifestyle changes like adding exercise. Someone with the cognitive or mood issues that accompany hoarding and or bipolar who is also on two or three new medications (anti-depressant, mood stabilizer, maybe anti-seizure medication) may just not have had the skills to maintain the new, healthier lifestyle. I guess that why some of these chronic pain cases can be so very difficult to treat.

  42. Chris says:

    Thanks, Michele. The whole relationship between pain, mental health and trying to help is very complex. Because she was not a danger to anyone it was up to her to do the follow up. It was easy for her to avoid the outpatient clinic.

    You just cannot make a grown woman do things she does not want to do. She kept chasing the magic cure, looking for just the right supplement or pill. The real doctors would not make promises and required that she take control by actually leaving her house and exercising. Which is why the quacks are so attractive.

    (For a while I was on her email list of relatives to send the latest rumor… which I usually answered with a Snopes link. Then she actually sent me a whale.to link she got from her online support group about vaccines trying to “protect” my kids — I am afraid I told her exactly what I thought of John Scudamore. I was dropped from her list of relatives to who received her bits of Internet “wisdom.”)

  43. Fifi says:

    Happy Camper – Do you cross your legs a lot? You may be compressing a nerve when you do.

  44. “You just cannot make a grown woman do things she does not want to do. She kept chasing the magic cure, looking for just the right supplement or pill. The real doctors would not make promises and required that she take control by actually leaving her house and exercising. Which is why the quacks are so attractive.”

    No you can’t make people do what is best for them, that is the frustrating thing.

    On the other hand, just because a person’s physical health requires that they take control and get some exercise, does not mean that that person is mentally capable of doing so. When you talk about your relative, the hoarding and compulsive record keeping suggests a compulsive disorder. Sadly, compulsions can be somewhat counter-intuitive to deal with. Sometimes the focus on trying to control the compulsions can actually make them worse*. There are cognitive therapies directly targeted to gradually reduce compulsions and build skills to cope, but they do require a lot of commitment and energy from the patient and a practitioner knowledgeable in those disorders and therapies.

    A good website about OCD and compulsive hoarding is, http://www.ocfoundation.org/hoarding/

    *I had three relative (father, grandmother and aunt) who had varying levels of compulsive hoarding and a dear friend who appears to struggle with hoarding, so it’s an area of interest for me, but I am speaking purely as a layman who has done some reading.

  45. Fifi says:

    chris – “She kept chasing the magic cure, looking for just the right supplement or pill. The real doctors would not make promises and required that she take control by actually leaving her house and exercising. Which is why the quacks are so attractive.”

    Well, yes, being health is boring in comparison and it’s not necessarily the same as being happy. (And as Michele so rightly points out, lifestyle change isn’t easy if someone’s lifestyle is chaos.) Being healthy means being responsible to others, as well as to oneself – it also means giving up the manic highs and grandiose visions of oneself. And then you’re left with being just a person, and just a person who has a chemical imbalance, it’s not hard to see why some people prefer being bipolar when there’s a whole new age movement out there telling them their grandiose delusions – be they paranoid or self aggrandizing – are real.

  46. Chris says:

    Good points.

    She was okay in college, and then the head ache started. Then it became chronic… and the chase for the cure began.

    What came first: the chronic pain or the mental health issues?

    If there could be some way in a sense “conquer” chronic pain, would that improve mental health issues?

  47. I think it becomes a chicken and a egg situation. If one could find a cure for the pain, then the current mood/organizational skills may be sufficient to function in everyday life. If one had improved emotional organizational skills (mental health), then one may be better able to apply more difficult therapies, decrease the perception of pain by redirecting attention to more rewarding activities or cope with the pain in other more functional ways.

    It seems to me that a medical person’s role would be to look at what medicine (including drugs, cognitive therapy, diet) can offer on either the cause of the pain or the mental health side in the hopes of breaking the cycle. That is just IMO.

  48. Fifi says:

    Chris – That’s hard to know but if she suffers from obsessive compulsive and bipolar disorders, they’re not linked to chronic pain. (Though obviously the headache could be a symptom of the neurochemical imbalance.) One symptom of OCD is religiosity/being intensely superstitious (in an exaggerated way). The other possibility is that her physical pain is actually really quite minor but it serves some emotional/social/psychological purpose for her. One indicator that this may be the case is that she embraced your suffering and wanted to focus on it (to draw you into her world) but got angry and hostile when you got better. From what you recounted, it sounds as if she surrounds herself with people who affirm her delusions (or at least don’t confront her about them), she’s likely to be protecting her delusions more than anything else. There are people who use pain – real or psychosomatic – to manipulate people around them. Hell, there are people who pretend to have cancer to get people to pity them – people with NPDs have no issue using people’s empathy to selfish ends and, even people without NPDs can grow up learning that the only way to be cared for is to be sick. There’s no question that even people with psychosomatic pain are suffering and experience suffering – they also deserve compassion – it’s just much harder to get someone to let go of a behavior that serves a very deep, subconscious need, even if it’s in their ultimate best interests.

  49. weing
    “The biases, about being dismissive, as perceived by others may or may not accurately reflect our real biases. They may be just like beauty. (In the eye of the beholder) I think it just boils down to the fact that we, generalists, get no respect.”

    As far as book reviews, GP and specialists go, I would tend to say the more the merrier. When I used to work as a art director we would often ask for comps on the same project from a variety of graphic designers. It is always a delight to see how different people with very similar educations will have a very different perspective on the same project goals/requirements. I think a GP can bring a broad perspective to a book review that is interesting and informative, a specialist may focus on aspects of the book in more detail that can also be intriguing.

    There doesn’t always have to be one right answer. ;)

  50. Chris says:

    All good points, thanks. It is terribly complicated. Hmmm, let us take a pair of medicine’s most complicated and enigmatic problems, chronic pain and mental health, throw them in the blender and see what happens. It looks like it could fill several journals.

  51. “Hmmm, let us take a pair of medicine’s most complicated and enigmatic problems, chronic pain and mental health, throw them in the blender and see what happens.”

    Yeah, then we can add a dash (or two) of CAM just to make things more interesting. ;-)

  52. pmoran says:

    Happy Camper – Do you cross your legs a lot? You may be compressing a nerve when you do.

    The numbness described actually suggests lateral cutaneous nerve of the thigh compression, where it passes through the lateral extremity of the inguinal ligament.

  53. wertys says:

    Re prevention of chronic pain

    The neurobiological events which lead to chronic pain can begin within hours or days of the pain starting. Using peripheral field blocks to prevent the ‘barraging’ of the central nervous system that occurs and can increase the risks of making the leap to a chronic pain seems rational given our understanding of the science. The early studies in preventive analgesia in amputation patients do seem to offer qualified support for the hypothesis and with 2011 being designated the Global Year Against Acute Pain by the IASP here’s hoping that this knowledge translates into more attentive and professional acute pain care.

  54. Fifi says:

    wertys – Which is great for preventing potential future chronic pain and/or PTSD due to traumatic injury (though one suspects the political and social paranoia about opioid use will probably mean it will never get applied in a non-military context – as it is it already makes treating chronic pain difficult). And interesting as it is, it doesn’t apply to a very large portion of people who end up in chronic pain clinics since in the civilian population things like fibromyalgia, RSIs, arthritis and back pain unrelated to a traumatic event are often behind the pain. A lot of chronic pain isn’t due to acute injury related trauma, it seems to be more of slow build up. RSIs are quite preventable, of course, but we’d have to start treating (often) poorly paid workers better and creating healthy workplaces – you know, care about people’s well being and quality of life instead of exploiting them like objects. That, of course, would also help prevent at least a portion of work-related traumatic injuries as well.

    As the author of the book reviewed said in one interview (quoting a pain specialist) – you have to care about the person to treat (and/or prevent) chronic pain.

  55. FiFi – “(though one suspects the political and social paranoia about opioid use will probably mean it will never get applied in a non-military context – as it is it already makes treating chronic pain difficult).”

    If you get a chance to check out the article I linked, you’ll see that the military is using peripheral nerve block instead of standard morphine on the battlefield (when possible) in the hopes of preventing chronic pain, phantom limb. Part of the idea is that the use of alternatives to opioids, when possible, may prevent long-term dependency, which I understand is a real risk with these traumatic injuries with long recovery periods.

    “Dr. Buckenmaier is involved in a study to analyze the long-term consequences of peripheral nerve blocks versus the standard fare of morphine. Investigators will follow amputation patients to see which ones develop phantom limb pain and how quickly they return to routine activities.” http://journals.lww.com/neurotodayonline/Fulltext/2007/11060/For_Amputations_and_Phantom_Limbs,_New.2.aspx

    It does look like this would not be applicable to all chronic pain. But having known a few people who suffered traumatic injuries from car accidents and machinery accidents, I found it interesting for those sort of cases. Sometimes eliminating a problem is not so much finding one broad fix as it is knocking away at segments of the problem as we see applicable solutions.

  56. Diane Jacobs says:

    Peripheral blocks make a lot of sense.
    1. The heat of battle and shock can provide a lot of endogenous analgesia (through descending mechanisms to the dorsal horn, serotonin from RVM, norepinephrine from locus ceruleus, etc.) That’s good up until rescue..
    2. But then: something about rescue, about being attended, makes the brain think the threat has passed, it’s now safe, so it switches over to allow nociception to blast up the cord again.
    3. If the nociception or noxious input can be prevented by an immediate peripheral block from getting into the dorsal horn, the brain never has to “know” that the organism it looks after was ever “hurt” by having a limb blown off.
    4. After amputation there is still likely to be a phantom limb to learn to live with. But at least it’s less likely to be “in pain.”

  57. cloudskimmer says:

    One Doctor working under the auspices of Cedars Sinai in Los Angeles runs a pain clinic where his one-size-fits-all solution to back pain is targeted injections using x-rays, and when the offending nerve is identified to do nerve ablation to stop the pain. It sounds great, like the assertion that ‘the brain thinks the threat has passed.’ (Is there any evidence that this assertion has any basis in reality?) Unfortunately, as with many chronic pain treatments, it “works” for two or three months, and then the pain returns. The Doctor is discouraged, doesn’t know what to do, but urges additional appointments with no instruction as to how to cope with the returned pain. Eventually the patient realizes that the Doctor can’t help them and doesn’t return. I would suspect that a lot of them think that the patients who aren’t there have been cured by them, but lack of follow up to confirm this belief means they don’t know whether or not their treatment worked. There’s little difference between Doctors like this and quacks. Most pain clinics try various combinations and doses of medications, but with chronic pain, the symptoms seem to inevitably return.

    With chronic pain so prevalent, why aren’t there more studies to honestly try and find out what works and what doesn’t? I suspect that many elderly people are dying of chronic pain–from the results of the side effects of medications or debilitation caused by lack of strength from spending all day in bed because it’s too painful to be up and about.

    Books like this one and Dr. Groopman’s are uplifting because these are younger people who find a way to triumph over pain. No one wants to read about the real tragedies of people whose lives are consumed by their pain.

  58. # cloudskimmeron 12 Nov 2010 at 7:32 pm
    “One Doctor working under the auspices of Cedars Sinai in Los Angeles runs a pain clinic where his one-size-fits-all solution to back pain is targeted injections using x-rays, and when the offending nerve is identified to do nerve ablation to stop the pain.”

    cloudskimmer – the article that Diane Jacobs was responding to was one I posted upthread – http://journals.lww.com/neurotodayonline/Fulltext/2007/11060/For_Amputations_and_Phantom_Limbs,_New.2.aspx

    It is for traumatic injuries, it appears to be in research, so it is not proven, it is being investigated. As I understand it the idea is to basically prevent phantom pain that no longer has a source.

    Just from a layman’s perspective I would point out that if the source of the pain is not resolved, arthritis, nerve compression, etc, then it wouldn’t seem to me that such a method would work.

    For instance I have in the past had nagging hip, back, leg pain. This pain was recurring and at it’s worse lasted about 6 months or more. Luckily I was referred to a very detail orientated physical therapist who measure my legs, examined my hip angles looked at my feet, etc. She found (and this was confirmed by the orthopedic surgeon I saw) that because one of my legs is slightly longer than the other, my pelvic twists over time, distorting the SI joint and causing undue friction and pain. I was given a few exercise to do that push my pelvis back into shape and keep the muscles more limber, along with a recommendation for shoe inserts and as unlikely as it sounds, these solutions work quite well. I now experience the pain rarely and it doesn’t last for more than a day or two.

    Without those exercises, I pretty sure that any local block would offer only temporary relief.

  59. Fifi says:

    Diane – “It does look like this would not be applicable to all chronic pain. But having known a few people who suffered traumatic injuries from car accidents and machinery accidents, I found it interesting for those sort of cases. Sometimes eliminating a problem is not so much finding one broad fix as it is knocking away at segments of the problem as we see applicable solutions.”

    Oh, totally agreed that it’s interesting research and could be applied in a civilian context. (And thanks for the correction about the intervention in the particular study you were presenting – I didn’t go to the link because I’d read about this research quite a while ago – I obviously should have refreshed my memory :-) Whether it would be applied or not to the kinds of workers who end up in industrial accidents is another thing – a lot of work accidents (particularly RSIs) are a pretty direct result of the working conditions and lack of concern for worker health. I have no doubt it would be applied in affluent hospitals to people with gold-standard insurance who have car crashes though. Like was said, you have to care about the person first….

    While blocks may end up working well as a preventative measure, they’ve often more of a placebo in regards to chronic pain. It is very much a “the bigger the needle the bigger the placebo effect” situation. This effect is so profound that you can even inform some people it’s a placebo and it will still “work” – which is why harnessing one’s own mind to manage pain can be so effective.

    Phantom limb pain seems to be much better treated via tricking the mind into believing it has some control (and giving it some control). VS Ramachandran has done some incredibly interesting work in this area. That something as simple as a mirror box can work is pretty spectacular and speaks to how neurobiology can be manipulated via multiple routes – including many non-invasive and non-pharmaceutical ones. (Not that I am against pharmaceutical intervention – btw, there are a lot of myths about pain patients becoming addicted to opiates that are related to America’s ideological war on drugs and not even remotely science-based. Certainly some people become addicted but then addiction prone people are prone to becoming addicted. Sure people who use opiates need to up the dose over time but that’s the same for many, many drugs. Of course, there are also social issues regarding prescribing opiates instead of giving people a more comprehensive treatment – there’s a whole psycho-social side to multidisciplinary pain treatment that opens up questions that we as a society tend to try to avoid.)

    I highly doubt nerve blocks will prevent pain or annoying sensations associated with phantom limbs (and exactly what nerve would you be blocking). I can see opiates (and drugs like MDMA) being very effective in preventing PTSD (they usually make people feel safe/good and flood the brain with neurochemicals that give us safe/relaxed/loved experiences), and nerve blocks potentially working to prevent chronic pain associated with physical trauma as well. I can see it working in people who haven’t lost limbs but not so much with ones who have. The reason why I say this is because phantom limb pain seems to be more associated with the brain still believing the limb exists (the brain map is still there) – that’s why the mirror box works, it allows the brain to feel like it’s controlling the limb it still “senses” but that no longer exists outside the brain.

  60. Diane Jacobs says:

    @micheleinmichigan “As I understand it the idea is to basically prevent phantom pain that no longer has a source.”

    Even with physical limb gone, one must still contend with the origin of pain *experience*, which is in the brain. The brain’s representations of a limb (body schema) are still very much in place, however, even after a limb is gone. (How can one get at those, and ‘treat’ those?)

    (If one still does have a regular body with all its parts and can freely move them, despite having some pain, as you do, then for sure you can move not just the parts but also you can still shift/re-edge your own cortical brain maps as well.)

    On the side but somewhat related, there is a fascinating line of investigation going on re: the brain’s sense of self and ownership of its “body.” This works involves dislocating a subject’s sense of self to a mannequin or a rubber hand (“surprisingly easy to do”), threatening the objects to which sense of self has transferred, and measuring the autonomic responses in the subject. For this see Henrik Ehrsson: http://www.ehrssonlab.se/
    Also, for various pain and rubber hand studies, see Lorimer Moseley: http://theneuronetwork.com/profile/LorimerMoseley

  61. Diane Jacobs says:

    Oops, sorry about all the italics. Unintended. That will teach me to preview before posting.

  62. Fifi says:

    Diane – Yes, we also extend our sense of “body” into tools we use all the time – they become neurological extensions of our “selves” or our senses. A lot of research into cognition can challenge our “intuitive” beliefs about ourselves and who/what we “feel” (and think) we are. Chronic pain often changes/challenges people’s identity for a number of reasons – it can change people’s personalities but it also changes what people are capable of doing. It’s not always easy to shift one’s mental picture when one’s physical body changes (people who lose large amounts of weight usually have the same issue, it can take a long time for the brain to catch up with the body – for instance, you can often tell a formerly obese person by the way they walk because they still walk as if they’re physically bigger than they now are…anorexia is another obvious example of how brain maps/body image can be disconnected from the reality of the body).

  63. Diane Jacobs says:

    @Fifi – I think the quote you attributed to me Nov 13 11:11 am belongs to micheleinmichigan.

  64. Diane Jacobs says:

    Speaking of opioids, it’s common knowledge the brain makes these by itself (endogenously) and that there are receptors all over the place; an interesting paper about this is Petrovic, “A prefrontal non-opioid mechanism in placebo analgesia.” http://www.ncbi.nlm.nih.gov/pubmed/20399560

    If I read this right, it suggests that if opioids are administered, opioid receptors in the anterior cingulate will respond, but if relief is placeboically induced, receptors in orbitofrontal and ventrolateral cortex (more rostral to ACC) respond also.

    Nice that the brain can make its own painkillers, if provided a sufficiently inductive context. I consider this to be some science-based-support for non-pharmacologic human primate social grooming.

    (No preview function available. Hope I didn’t mess up the italics this time.)

  65. Fifi says:

    Diane – You’re quite right, my apologies about that and thanks for pointing out my error. Good explanation of how it’s the pain “experience” and how body schema plays into it. All very fascinating stuff since it’s ultimately about consciousness and neuroplasticity – and we’ve increased our understanding in leaps and bounds. I feel we should all humbly remember when discussing neuroscience that we’re still in exploratory territory. Not only because of some of the erroneous “scientific” beliefs that were rather strongly held previous to the ability to scan brains but also because mainstream medicine has, at times, been more accepting of pseudoscience – things such as medicalized procedures that are now shown to be placebos (blocks, certain knee surgery) when it comes to pain management because it looks “mediciney” and then hyper critical of explorations into things like mediation and yoga as “woo” when they’re actually starting to bear fruit. I’m looking forward to having some of my beliefs blown out of the water by science in the future (and maybe having some confirmed) – we do indeed live in interesting times!

  66. Diane Jacobs says:

    @Fifi
    Some of the cultural packaging around these intrinsic mechanisms is total woo-reinforcement and should be tossed with all possible haste. The mechanisms themselves must be examined and understood so that more science-based/ less unconscionable/woo-reinforcing delivery systems can be devised, distributed, adopted for/used in pain management.

  67. Fifi says:

    Diane – I’m not suggesting that woo should be supported – quite the opposite – I’m suggesting that it shouldn’t be supported when promoted by the medical profession or by the obvious woo-meisters. The cultural packaging that reinforces woo can come from both medicine (in the case of surgical placebos) and from pseudo-medicine and/or religion. Meditation doesn’t need to be taught in a religious context or have anything to do with woo – it’s just neuroplasticity and I always explained it that way to people who I was helping learn how to meditate. People may well have exceptional experiences while meditating but that too is part of neurobiology and what happens when we sit still and focus.

    So far the support for a cognitive-behavioral approach – and awareness meditation and practicing awareness are almost the same as CBT in practice – for both pain and depression is pretty good and getting better. I’m an atheist, born and bred, but I have to admit that the Buddhist theory of mind was much closer to the facts than the one considered scientific for quite a long time. We didn’t even believe neuroplasticity existed for most of the history of neuroscience. I grew up around neuroscience (starting as a kid in the 60s) so I’ve seen the radical shift over time and how much better science gets when societal prejudices are confronted and removed from science. Obviously scientists and doctors with integrity change their behavior and beliefs as new knowledge becomes available – while recognizing the error of what they believed and did previously. You can’t really be open to new knowledge unless you’re willing to allow yourself to be wrong – it’s why ideology and cultural biases are so dangerous in science, they can close our minds without us even realizing it. I, of course, have my own biases based upon my experiences and observations – and knowledge and lack of knowledge – too. However I’m more attached to my curiosity and finding neat stuff out than I am to being right so being wrong about something can actually be very exciting because it’s generally the beginning of a new understanding.

  68. Fifi says:

    It’s also rather dangerous to take on “science” as one’s personal identity or what one believes makes one superior to others or gives one personal authority. Science is a tool – it can be used to enlighten or endarken, it all depends on who’s using the tool and how. If we know enough contemporary neuroscience then we recognize that we are human and as much as we might have incorporated “I’m scientific” into our identity and have been trained to observe with as much objectivity as possible, we’re still doing so from a subjective human perspective. Cognition, it’s a bitch ;-) That’s my subjective take on it anyway, other’s perspectives may be, and are likely to be, different. Subjectivity, you can’t get away from it but we can design systems to try to minimize it so we can see more objectively. The objective world exists of course, but we can only see bits of it from our subjective perspective (even when our senses are greatly enhanced by the tools we’ve developed to extend them…starting with the microscope :-)

  69. weing says:

    Through extensive training I have become completely objective in my subjectivity.

  70. Diane Jacobs says:

    Back to the thread title, “Chronic pain, A disease in its own right”:
    I just sat through a very exacting pain-mechanism lecture by Clifford Woolf, aka the father of central sensitization, who nodded toward this idea to consider pain as a neurodegenerative disease in one of his last few slides, on structural synaptic plasticity, which contained references to:
    1. Loss of dorsal horn neurons/grey matter in an autopsy sample from a subject who had had post-herpetic neuralgia (Watson et al. 1988 Post-herpetic neuralgia: post-mortem analysis of a case.)
    http://www.ncbi.nlm.nih.gov/pubmed/3174152
    2. Same loss noted in an animal model with a sciatic nerve ligation, both ipsi- and contralateral to injury side (Scholz et al. 2005 Blocking caspase activity prevents transsynaptic neuronal apoptosis and the loss of inhibition in lamina II of the dorsal horn after peripheral nerve injury.) http://www.ncbi.nlm.nih.gov/pubmed/16093381
    3. Accelerated brain-grey matter loss in patients with FM (fMRI imaging) suggesting pain as a neurodegenerative disease. (Kuchinad et al. 2007 Accelerated Brain Gray Matter Loss in Fibromyalgia Patients: Premature Aging of the Brain?) http://www.jneurosci.org/cgi/content/full/27/15/4004

  71. Diane Jacobs – wow that some fascinating stuff. Thanks for taking the time to post it.

    I never realize the field of non-pharmacologic human/primate social grooming was so interesting. :)

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