HOW TO LIVE WITH PAIN AND THOSE WHO HAVE IT Part II
HOW TO LIVE WITH PAIN
AND THOSE WHO HAVE IT
Robert Sprackland, Ph.D.
[Note: links to special sites with detailed follow-up information about specific subjects is provided in the text. -Ed.]
What Makes Pain Chronic?
The word "chronic" comes to us from the Greek word "chronos," which means "time." That root is also contained in the English words chronology, chronometer, and chronicle, all of which refer to time. For pain to qualify as chronic it must (a) last for a long period of time and (b) persist even after the likely cause has healed. I have already described one way in which chronic pain may have an acute cause-when doctors fail to properly diagnose small bone shards near the rotator cuff following a whiplash-like accident. Such false chronic pain may also be the result of a surgical accident; we've probably all heard of surgery patients who later discover that someone left a scissor, scalpel, or other instrument in their body that later had to be extracted, or a war veteran who retained some shrapnel in a region that surgeons thought was to sensitive to remove by surgery. The comfort such sufferers may have comes from knowing that the medical establishment acknowledges they have "real" pain, a reason for the pain. That is because the cause of the pain has not been treated and therefore has not healed. The acute pain caused by "something" becomes a chronic pain that may or may not be treatable.
The more insidious chronic pains are the ones for which no good medical reason can be provided, and where it may be that the patient is perceived as suffering from imaginary causes, perhaps mental stability or deeply-rooted psychological causes. While these explanations are certainly possible, they should not be considered the only explanations, nor should they be used as excuses to claim that the patient is not actually in pain. Fortunately, the past decade has brought a renaissance of medical outlook on the subject of chronic pain, and while many physicians are slow to accept the new research data-yes, Virginia, there are some medical luddites out there-the great majority have embraced those data.
The concept of the causes of chronic pain are difficult to understand unless you know a bit about how your nerves and brain interact, so I shall provide a classic example of a chronic pain and how it works. Perhaps the best-known example involves an amputee who later reports feeling itching or tingling sensations in the missing limb. Certainly, many would say, the poor person is deluded, suffering from a psychological condition brought on by great stress and the memories of having the limb. Perhaps, sometimes. But there is another simple explanation.
In Part I of this series I described how nerves send messages to the brain. At the receiving end is a nociceptor, or pain-sensing, neuron in the skin or gut. That nerve cell sends a chemical message to a cell just slightly closer to the brain, and that cell passes the message on to the next neuron, and so on, until the message has been relayed to the brain's pain recognition centers. Without getting too technical, you can get the brain to receive a pain message even if the nociceptors are not stimulated if you can cause a nerve further along the chain to become active and start an impulse. To visualize this, imagine a row of standing dominoes ready to be made to fall by knocking over just one domino. Normally there is a "start" domino, the first in the series that we are expected to push over to begin the chain reaction of getting all the other dominoes to topple. But suppose we bypass the first 50 dominoes in the sequence and carefully push over domino number 51; all the subsequent dominoes will fall as expected while the first fifty remain upright. In precisely the same way, if we can stimulate a nerve closer to the brain to fire, it will send a message to the brain and the first set of neurons-from the skin's nociceptors to the nerve just before the one stimulated-will remain at rest.
Now remember, all pain is in your head. That means that when a message comes into the brain from the line of nerves coming from the nociceptors, that message will be received and interpreted as pain coming from the location of the nociceptor. If I could push a very thin needle into the right place in your shoulder, for example, so I could gently poke (not stab) just one neuron in the series coming from your pinky, your brain would suddenly get a pain message and tell your consciousness that something nasty has just happened to your pinky. In fact, nothing has happened to your pinky; poking that one neuron does not even send a duplicate message down the arm to your little finger. And further, you do not even have to have that little finger or hand or arm in order for your brain to say that the finger has been injured. Medically this is referred to as phantom pain, but in reality it is caused because the brain is still receiving occasional messages from the part of the nerve "wire" that remains in the body. Here's the important part:
As long as the brain gets a neuron message, the person will feel real pain because all pain is in the brain!
Furthermore, that pain must be treated. It is as real as pain caused by sticking a pin into the pinky. In the physiology of pain there will always be pain if the brain gets a message from a pain nerve sequence. You can see from this example how blind people may occasionally see light (stimulate any neuron along the optic nerve tract and a visual signal is sent to the brain) and deaf people may hear ringing sounds. The problem in treating chronic pain is that the typical source of the pain is absent; you can't make that pinky feel better by removing a needle or thorn if there is no pinky! What remains, then, is to treat the pain centers in the brain.
Properly Diagnosing Your Pain
Perhaps the biggest and most frustrating problem for sufferers of chronic pain is getting the right people to believe that your pain is real. We expect our physicians to take our complaints seriously and to do whatever it takes to properly diagnose the cause of our pain, but we also know that this is not always done. Why not? Isn't the role of a healer to heal? Doesn't the United States have the best medical care in the world, as our leaders loudly proclaim each election cycle? To take that last question first, the answer is "No." According to the February 2007 report on the ranking of the world's health care systems by the World Health Organization, the United States came in #37 out of 190 (http://www.photius.com/rankings/healthranks.html). The first 21 places go mostly to European countries and Singapore, and Colombia (yes, where the drug cartels make it a very dangerous nation) ranks 22nd. "We're number 37!" is probably not a rallying chant you'll hear coming from a political candidate's supporters, but that doesn't change the reality.
Problems associated with getting a reliable diagnosis for chronic pain come from different areas. There are those medical luddites who simply aren't up to speed-or believe in-the latest neurological research and treatments. To them, the pain is a figment of your imagination, perhaps a way of getting attention or ducking a task or job you dislike. More likely the physician works in a system that puts a quota on the number of patients seen per day. Modern doctors rarely know their patients, the family histories, or details of your life that are important in diagnosing chronic pain. Their employers want them to see and release patients in ten or fifteen-minute blocks of time and the insurance companies want them to keep costs associated with costly testing to a minimum. Patients are more and more being seen as assembly-line products, pretty much alike and needing minor adjustments to keep happy. Chronic pain, however, is rarely properly diagnosed in a 10-minute examination and without some sort of additional testing. (For one very interesting take on the way insurance companies influence health care, visit http://theiciexperience.blogspot.com/2007/09/new-youtube-video-go-ahead-and-die.html and play the video--with sound on!)
There are also some old (mis)perceptions by some doctors. I know an example of a patient who had complained of severe acute shoulder pain following a minor whiplash accident. She was told that exams were taken of her back and neck, but not her shoulder, because "women tend to feel back pain differently"! This is the same patient who was eventually diagnosed with having tiny glass-like shards of broken bones-in her shoulder!
So how do you get a proper diagnosis for chronic pain? Assuming you cannot get to France, Italy, or San Marino (the top three healthcare systems on the planet), you must be a strong advocate for yourself. If you have pain in the shoulder, do not be satisfied with the doctor taking an x-ray of your spine. If you art being told the problem is minor or will go away, you might want to go away to see another doctor. Don't be afraid to get a second or third opinion, but also don't be afraid to do some homework on a potential physician first. Whenever I chose a physician I go through a short checklist of questions I want answered. That person will be treating MY body, and I certainly have a right to know something about his qualifications and experience. Here is a suggested list of questions to ask a potential physician being interviewed for the job of treating your pain:
- What is the doctor's specialty? (Family practice is good to start; after that you want neurologists who work with chronic pain.)
- In what areas is the doctor board certified? (Tells you a bit about just how specialized she is.)
- What experience does she have in treating chronic pain patients?
- What medical school did she attend?
- How long is scheduled for a comprehensive exam for chronic pain? (Hint: It better be more than 15 minutes.)
- With which hospitals does the doctor have privileges? (If the answer is only pediatric hospitals, pass on this doctor.)
- What types of testing are usually/initially used to assess and diagnose chronic pain?
And yes, that doctor is interviewing for a job. He or she gets your money (even if you have insurance, who do you think pays the premiums?), and so works for you. If you have a doctor who doesn't get that or likes to be mistaken for God, you might seriously consider that it is time to get a new doctor.
The next part is really important: once a diagnosis has been determined, be sure to have the doctor explain the condition to you so that you understand the problem. If it still doesn't make sense after the third attempt, ask again, or ask for a referral to a counselor or specialty nurse who may be able to do a better job at explanation. For too many patients the result of a post-consultation visit leads to patients saying "I don't know what it all means, but it sounded okay." That is not okay. If you do not get your doctor to help you understand, go get another interpreter. Frankly, most medically trained people-doctors and nurses working a given specialty-should be able to convert medical jargon into colloquial English. That means you should not settle for this:
"You have an impinged nerve between the third and fourth sacral vertebrae resulting from a herniated disc..."
if you need this:
"One of the discs in your lower back burst, losing its fluid and allowing two of your backbones to pinch the nerve between them."
These suggestions are fine if your chronic pain is actually a form of undiagnosed acute pain, but what if you suffer from phantom pain, or psychologically-induced pain? How do you get these diagnosed?
Phantom pain is certainly easier to discover; if something that you no longer have hurts, it is phantom pain. Much of the time it is caused by impulses started along the remains of the nociceptor nerve wire that remains, and some part will always remain. If the pain occurs rarely, it may be brought on by an unusual movement, or lying in an odd position, which in turn puts pressure on the old nerve wire that is not normally present. Such pain may return from time to time, but often goes away soon after starting. If the pain is truly chronic-persistent, frequent, and distracting-other treatment is necessary. This is a case where you want to see a specialist who deals not only in chronic pain, but successful treatment of chronic phantom pain.
Finally, there is the possibility that the cause of the pain is truly all in your head, the result of your brain sending pain signals to your consciousness by itself. The causes may be purely psychological, the result of the neuron equivalent of faulty wiring or overloaded circuits, or they may be the result of a stroke, tumor, or other physical damage to the brain. Diagnosis may require x-rays and MRI examinations-one does not want a purely psychological course of treatment if the problem is induced by a brain tumor-as well as a psychological evaluation. The more you can tell the examining physician about the pain, the better the accuracy of the diagnosis. For example, your brain does not respond to all pain in just one format. You can certainly tell the difference between burning your finger with a match and banging it with a hammer! Though the parts of the brain that analyze pain are near each other, the regions that respond to specific kinds of pain tend to cluster together in small groups of their own kind. Thus, a burning pain suggests a problem in one part of the brain, a stabbing pain is associated with another, and a dull, throbbing ache yet another.
It is essential to have a correct diagnosis if your pain is going to get properly treated. Take the steps needed to find a cause and understand what is happening. Only then can you be sure to see the right type of physician to get appropriate treatment that may reduce or eliminate your pain. And yes, even the 37th-ranked county for medical care has plenty of qualified practitioners to diagnose and effectively treat your pain. Treating chronic pain is the subject of Part III of this series.
Hey, at least we're not in Myanmar; they ranked 190th out of 190!
[Robert Sprackland, Ph.D., has taught human anatomy and physiology for nearly twenty years. Part I of this series is also available on Hub Pages.]