PAIN

Pain is perhaps the most common health complaint.

It is involved in the vast majority of health problems and is one of the primary motivating factors in seeking medical care. Pain is a warning signal that lets us know something is wrong but, sometimes it can become so severe or chronic that is becomes the focus of treatment. Although it still is not clearly understood, there are numerous pain organizations to assist in finding relief from pain (see links).

Pain is defined as both a physical and psychological experience. Much like when a telephone rings, the nerve pathways (phone line) transmits pain signals to the brain which converts the signals to a conscious alert (phone ringer). Like a telephone, it takes both the pain signal and interpretation in order to create a pain experience. If there is any disruption in nerves, signal, or brain and mind, there will be a change in the pain experience.  Pain can be short lived (acute) or become chronic, lasting over six months. It can be constant or intermittent. There are literally dozens of ways a person can describe their pain. And like descriptions, there are many different causes of pain. 

Pain can be classified as malignant (cancerous) or benign (non-cancerous). Pain can be caused by diseases or injury. Examples of pain due to disease include cancer, sickle cell, and arthritis. Herniated discs are perhaps the most common cause of pain due to injury. Some pain may be psychogenic which means that there is no known physical cause of pain experienced by the person. Some of these pains are psychosomatic which means that once the underlying psychological cause is treated, the physical pain will usually go away. Since both psychological factors and physical factors are involved in all pain, sometimes it is often difficult to properly diagnose and treat. Headaches are an example of pain that typically involves several factors and can be difficult to treat. 

One of the best ways to help someone understand the pain process is to use the example of a stubbed toe. Certainly everyone has stubbed their toe and can easily remember the experience. From out of nowhere, an intense pain signal races through the sleep center of the brain making us wide awake and then on to the midbrain where we experience fear. The pain signal continues to the executive center of the brain which tells you to find out what happened. You look down at your toe and determine that no serious injury has occurred to the toe and that it happened as a result of hitting your toe on the table leg. Once you determine that there is no damage to the toe and what happened, your fear turns to anger. You then call the table a few names and determine what, if anything needs to be done to take care of the toe and reduce the pain. After this you return to the  activities you were engaged in prior to the pain. All of this occurred within a split second. You stubbed your toe, pain signals were sent all the way to the brain, the pain signals passed through the brain stem affecting your heart rate, breathing, and arousal level, then through the midbrain triggering fear (flight stress response) since you don't yet know what is going on, and then to the higher brain centers making you consciously aware of the pain signal so that you can assess the situation and take the appropriate plan of action. Your midbrain then becomes angry (fight stress response) as a result of your assessment and your executive center sends you to rub your toe or put ice on it to reduce pain and swelling. After 15 minutes, you have pretty much returned to your previous activities with only a little caution around tables that will also fade as the day progresses. Now imagine a much more serious injury where the pain and injury itself will not go away in a few minutes but may require weeks or months to heal. The emotions that are involved in these type of pain experiences are much more intense and prolonged that that from the stubbed toe example. 

Some injuries that produce pain may require surgery either immediately or after other attempts to treatment have not succeeded. Often a person is given pain pills and told to rest for a couple weeks and return in a month for a follow up. This is often the first step in developing a chronic pain syndrome. It also starts the process of being a victim or being helpless oneself against pain. The anxiety intensifies as the patient sits or lays around unable to do anything other than take a pain pill to fight the pain. The anxiety and tension "feeds" the pain and the only weapon available is to take pain pills. If and when a person finally gets physical therapy, the patient is generally afraid of hurting themselves and complains that any form of exercise hurts them or aggravates their pain so they are relegated to passive therapies consisting of heat/cold, some massage, electrical stimulation, and/or other feel good treatment. The patient then begins to become frustrated that nothing is getting rid of the pain (notice here that the person is relying on someone or something else to fix the problem and not to themselves here?). The only thing that seems to help them function is the pain pill. This frustration continues to grow into agitation by weeks or months now of poor sleep that is getting worse, lost time at work and income, inability to perform normal daily activities, and a deterioration of family relations as well as everything in their life. Fear of pain begins to incapacitate the patient more and more, agitation increases, and sleep continues to deteriorate until depression begins to set in. Two major factors lead to the depression. First, the pain signals and resultant effects of these signals on the brain as described above will eventually lead to a depletion of important neurotransmitters in the brain such as serotonin, epinephrine, norepinephrine, and GABA. Secondly, the fixation on all the negative aspects of pain and its effects on your life begin the negative, problem-oriented way of thinking. Imbalances of these neurotransmitters and negative thinking are the major components of depression. The situational problems associated with chronic pain are also characteristic of depression. By this time, a referral to a psychologist or psychiatrist is often made. Patients are often upset by this and feel that everyone is suggesting that their pain is "all in my head". Of course it is but not in the way they are thinking. By now, there may be numerous doctors involved in the patient's treatment but much of the treatment is now geared at treating certain aspects or effects of the pain rather than the pain itself. 

The best way to treat pain is from a multi-disciplinary approach to begin usually within the first two weeks after an injury. While many cases will heal with bedrest, if it has not after two weeks, a more aggressive approach is vital to recovery. The patient should seek help from a doctor who is well versed in pain rehabilitation and will approach treatment from many different aspects at once. The biggest reason for failure in the treatment of pain is that patients are only treated by one modality at a time. It takes a concerted effort with medical, psychological, physical therapies, and other treatments. Medications, injections, nerve blocks, massage, and passive physical therapies may help pain but are not cures themselves in most cases. They should be used to help facilitate more active treatments such as rehab exercises and behavioral treatments. Psychological treatment should address the emotional components of pain such as fear, anger, and depression. Fear of pain is the most significant component of pain! Developing a positive attitude towards pain and changing from a problem-oriented to a solution-focused thinker is critical to pain management. Biofeedback can be extremely effective especially when used in conjunction with other approaches. Sleep hygiene and other ways to restore sleep will significantly improve pain and mood as well as healing. 

The best way to approach the diagnosis of a pain disorder is to evaluate the seven areas involved in disease with that patient as explained in Principles of Wellness. Once the factors are identified from these seven areas, an appropriate treatment program can be established. Since, most health care providers are only trained in one area of expertise, they may make incomplete diagnoses and treatment may be only partially or temporarily effective. For this reason, true pain centers are multi-disciplinary and generally consist of a core team (e.g., neurologist/anesthesiologist and psychologist/psychiatrist and physical therapist/chiropractic physician and nurse/physician assistant). Numerous other specialists may be involved on a consulting basis. If a pain center is not readily available, the patient should look for a certified pain specialist. Beware of pain treatment that only relies on shots or pills. Rarely does such a quick fix work. This is often the preferred route of care by insurance companies that are interested in cutting their costs. Likewise, beware of surgery as the only option. When you are only given surgery as an option, it is wise to seek a second opinion from someone who is not a surgeon to gain a better understanding of your treatment options. Proper pain rehabilitation involves a multi-faceted approach that follows the Principles of Wellness. When the factors involved from the seven areas of health are addressed, the patient has the greatest chance of regaining a normal, productive life with the least possible pain. The Pain Program at Hopper Institute offers a highly effective and comprehensive pain treatment program.