HOW TO LIVE WITH PAIN AND THOSE WHO HAVE IT
HOW TO LIVE WITH PAIN
AND THOSE WHO HAVE IT
Robert Sprackland, Ph.D.
Dedicated to the biggest pains in my life, which reside in the greatest love of my life.
[Note: links to special sites with detailed follow-up information about specific subjects is provided in the text. -Ed.]
Chronic pain is everywhere, perhaps the most frequently discussed ailment of our time. The arthritis, rheumatism, gout, and sore backs that have long been familiar have been joined by tingling, "pins-and-needles," carpal tunnel syndrome, stressed joint pain, migraines and so many others that the whole field of pain research cannot keep up with demand for effective treatments. As of right now, six out of every ten Americans has, or has had, intense recurring or chronic pain.
To get a little perspective, let me give you some statistics. According to a 2005 survey by ABC News, USA Today and Stanford University Medical Center (http://abcnews.go.com/Health/PainManagement/story?id=732395), nearly forty percent of Americans suffer pain on a regular basis. That's roughly 80 million people! Sixty percent of the American population (120 million) says their pain is moderate or worse, and for twenty percent (40 million) the pain is severe. About twenty percent also claim their pain is chronic, lasting three or more months.
Not surprisingly, not all pain is the same. Thirty-four percent of Americans suffer from nerve pain, according to the American Chronic Pain Association (http://www.theacpa.org/). Nerve pain is distinct from aches and muscle soreness, which do not affect neurons directly. Carpal tunnel syndrome, and diabetic pain are typical example of nerve pain.
Here's an interesting point: there are no medical tests available to prove that a person is in pain. Doctors must therefore explore the patient's history and the specific features associated with the pain (http://www.merck.com/mmhe/sec06/ch078/ch078c.html).
This is why many pain sufferers find it unbelievable that their family and closest friends-and even their doctors-might not think that the pain is real, that the sufferer is a hypochondriac, and that the problem is "all in your head." Well, guess what? They are partially correct: depending on the type of pain you have, it is either largely or totally in your head. And it is also quite real!
In this series of reports, I shall explain precisely what causes pain, how pain affects your body, and the types of treatments that really work to reduce or eliminate pain. Too many people visit the medical folks and are told they have an ailment, but they fail to understand all the information that the doctor and nurses tell them. We have probably all met people who told us that, yes they have a pain and the doctor explained it, but they didn't understand any of it except the part about taking these pills. It is especially for those folks that I write these reports. The topics will be: What is Pain? - Types of Pain - What Makes Pain Chronic - Properly Diagnosing Your Pain -- Treating Pain Effectively - Living With People in Chronic Pain.
WHAT IS PAIN?
Your body contains the most intricate wiring system known, far more complex than the wires used to operate an airliner, your computer, or the entire Pentagon. There have been a lot of descriptions about how many brain cells we have, how much data the brain can store, and how quickly we can coordinate different messages to sign our name with a pen. Most of those accounts are guesswork. The nervous system is, so far, too complicated to be discussed in reductionist terms. But for all we do not yet know, we have learned a lot. In fact, between 1996 and 2006, scientific understanding of the brain increased by more than the entire history of brain research before 1996! Remember those TV shows and movies where some expert (or alien) claims that we use only ten percent of our brains? That was what we thought back during World War II days. Even by 1960 we knew that most of the brain did something, and we now have evidence that we do use 100 percent of the brain. That doesn't mean we know what all of it does, but we know all of it does something!
Extending out from the brain is an extraordinarily intricate series of thin living wires, which are our nerve cells. The majority of those nerve cells provide support and protection to other nerve cells, the ones that actually carry messages to and from the brain. Those active nerve cells are called neurons. Some neurons are involved with making a muscle contract, and others tell us when it is cold around us. Neurons are responsible for all of our sensory input, including seeing, smelling, tasting, hearing, maintaining balance, and touch. It is among that last group that we find the neurons that specifically tell us when something potentially serious is wrong. Those are our pain receptors.
Let us imagine that you are sewing and you accidentally prick your finger with the needle. You feel pain, right? What happens is this: the pain receptor neurons (called nociceptors) around the spot where the pin pierced your skin begin to fire off messages that travel up one particular wire of nerves that joins other wires at the spinal cord, and travel to the brain. The brain has a "receptionist" called the thalamus that routes incoming nerve messages to the appropriate part or parts of the rest of the brain. The pain signal is then sent primarily to the middle outer layer of the large cerebral cortex-the part most of us imagine when we think about the brain at all-and the right centers there tell us we have been stabbed by a small sharp object. That message usually gets translated as "Ouch!!" Only an astronomically tiny percent of humans are born and live without pain receptor nerves (http://www.nature.com/nature/journal/v444/n7121/full/444831a.html). In part, the intensity of pain is determined by where you are injured-there are up to 1,300 nociceptors per square inch of skin in sensitive areas-and how deeply the cause of injury penetrates your body. How you feel the pain depends on the type or types of pain receptors are activated. You have pain receptors for pressure, heat, cold, sound, and other senses.
So that, very briefly, is what pain is. It is the result of those special nerves in the skin that respond to stimuli that damage your body by sending a nerve message to the correct spot in the brain. The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage."
Now get this: ALL pain is felt in the brain, only in certain parts of the brain, and always in those parts of the brain. Your finger nerve can send a nerve signal, but only the brain "feels" that signal as pain. In this sense, then, all your pain IS literally in your head! (Unless you are one of those people who keeps their brain closer to the seat of one's chair...) That means if you do any one of three things, your finger will no longer feel pain:
- 1) Remove the nociceptor cells from your finger-this is not really possible unless, as a result of extensive injury or surgery, parts of the skin do dot regrow properly.
- 2) Remove the pain receptor sites in your brain-very "science fiction" and impractical. Besides, not feeling pain could be dangerous.
- 3) Stop the message sent by nociceptors from reaching the brain-Bingo! This is the only reasonable and, so far, possible way to handle pain, and those treatments come in several varieties.
Types of Pain
Pain may manifest itself in a great many ways, but it is always felt and processed by your nervous system in the one way, as described earlier. Where the types of pain can be confusing is when trying to understand the associated symptoms, such as dizziness, nausea, or tenseness. To understand the types of pain, you must understand the two main ways in which pain can be caused. Pain is classified in the medical profession as either acute or chronic.
If there is a reason why the body needs a pain signal to alert it to or help it stay aware of a problem, the pain is called acute. Acute pain disappears shortly after the cause of the pain has been treated, or the body has healed. Though acute pain may be related to other nervous conditions, such as anxiety, depression, and stress, its causes can usually be identified and, to some degree, treated.
Chronic pain is long-lasting pain, exceeding the time needed to recover after an injury or surgery, and where the cause may not be treatable. Doctors call pains that last for more than three months chronic, though this diagnosis is not always correct. For example, a woman who was involved in a minor car accident reported pain in the rotator cuff region of her right shoulder. Her doctor refused to take x-rays because there was no external or symptomatic sign of a break or dislocation, and because his medical system bosses would not approve the costly technique. It took three more doctors and two years before she strong-armed a pain specialist to x-ray her shoulder, whereupon it was discovered that she had no break, but had shattered part of her collar bone into tiny, sharp shards that were sawing her muscles and nerves!
With true chronic pain, however, the diagnosis includes pain to an area that shows no physical damage or disease, and in which the pain sensations are expected to persist. Chronic pain is reportedly the most common factor leading to suicide. Sadly, chronic pain can rarely be diminished with medical treatments.
What, then, causes the pain? If the pain affects a specific physical part of the body, it is the result of a physical injury. The injury may be a needle prick or knife wound; a sprained ankle or a Charlie-horse; a nauseated gut or your mouth after a tooth extraction. In each case of somatogenic pain (pain originating in body tissue), there is physical injury to the area sending pain signals to the brain. Ever stub your little toe? Feels like it's been sliced with a knife, doesn't it? You have lots of receptors in your toes, so even the little toe can send strong messages to the brain's pain recognition centers. Nausea is how the nociceptors in your gut are interpreted in the brain. Your brain is informed that something nasty is whittling away on your stomach or intestines, so your brain sends signals to other parts of the brain the cause gut muscles to spastically contract so you vomit and, hopefully, remove the pain-causing source.
A special type of somatogenic pain has been described as neuropathic pain, which specifically refers to pain caused by damage to nerves cells themselves. Nerve cells are damaged as a result of some diseases, including multiple sclerosis, diabetes, cancer, and Parkinson's disease.
If pain is not somatogenic, not caused by a wound or illness to specific body tissues, it is termed psychogenic pain. The older term was "psychosomatic," which indicated that the patient's pain was "all in their head" and they were making themselves sick. Today we recognize that the mind is still poorly understood, perhaps the area of our own biology we least know about. But if the mind can have an illness, the result could include pain. Thus, psychogenic pain is largely a product of psychological factors. The condition and pain are definitely real. The patient is genuinely experiencing pain, but the pain has either no organic explanation or else a weak one. Psychogenic pain often manifests itself as chronic headaches, lower back pain, or generic pains that the patient says are difficult to explain.
It is not unlikely that a patient will suffer more than one type of pain at the same time. Let me give an example of how several pain modes can come into play for a fictional patient named Gina:
Gina, aged 35, was brought to hospital because of acute abdominal (somatogenic) pain. By the time she was brought in, her digestive tract had begun to hurt and go into spasms of nausea (somatogenic). After each vomiting episode, she briefly felt better. After being tested, the attending physician informed Gina that she had contracted a severe case of food poisoning. Gina had seen in the news that a local food poisoning epidemic had killed four people, so she began to worry and developed a severe headache (psychogenic). She also realized that she would miss an important meeting at work the next day, which caused her added stomach pain (psychogenic). To treat her symptoms, Gina was given an IV tube, and she was aware of it being very painful (somatogenic). The next morning, she awoke feeling ill, but much better than the day before. Convinced now that she wasn't going to die, she had lost her headache and nausea. It was only after the nurse checked her on morning rounds did Gina remember that she'd only started her new job two weeks ago, and wouldn't be covered by medical insurance until she'd worked for sixty days. The thought of how much her medical expenses would be caused the headache and stomach cramps to return (psychogenic) and made her more sensitive to the presence of the IV tube.
To sum up: virtually all pain is real, and it is all in our heads. If the brain doesn't get a signal from a pain-receiving nerve wire, we cannot feel that pain. Acute pain is an alarm that tells us something is wrong in our body. Chronic pain is telling us that something may be wrong in our body, but more likely is the result of a psychological cause. Finally, pain caused by the mind-somatogenic or psychogenic-is real and should be treated as such by the patient, health-care givers, family, and friends.
Because chronic pain is the biggest mystery and cause of so much grief to so many people, the next section will specifically address the question of just what makes pain chronic.