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Everyone has experienced physical pain. For some, periods of pain are brief and rare, limited to a stubbed toe or occasional headache. Relief comes quickly with minimal medical care or sufficient time for healing. But for others, pain continues long after the usual period of recovery from illness or injury. It can be the result of progressive diseases, such as arthritis, or can exist in the absence of known disease or injury, as is the case in tension headache. In these cases, pain becomes a recurrent and sometimes constant problem that assumes a central role in people’s daily lives.
Although effective treatments for acute pain have long been available, it is only in recent years that the complex and perplexing problem of chronic pain has been understood and that treatments for reducing pain, if not completely eliminating it, have been developed.
Frequency and Costs
Historically, pain has been a major focus of the health care professions and continues, today, to be the most frequent complaint made to physicians. Chronic, disabling pain is estimated to affect over 50 million people in the U.S. alone. The costs, both monetary and personal, are substantial. Pain due to musculoskeletal disorders is the leading cause of disability in working-age people. Ranking second only to the common cold as the reason for absenteeism, pain causes the loss of 700 million workdays and the payment of 65 billion dollars in medical expenses annually. Individual suffering and disruption of family life and career are immeasurable.
History of Pain Treatment
Until the middle part of this century, pain was viewed as nothing more than a physiological alarm system in which stimulation of specialized nerves warned of damage to the body. The more extensive and serious the disease or injury, the greater the stimulation and, therefore, the more severe the pain. Getting rid of the pain was seen as a matter of curing the illness or injury. While generally accepted, problems arose with this traditional medical model of pain.
Clinicians found that complaints sometimes continued long after healing had occurred, and in some cases, pain was reported when no physical cause could be found. More confusing still, some patients with serious physical disorders reported minimal pain and disruption of daily activities.
Unfortunately, sometimes persons with unexplainable pain complaints were labeled as lazy, as fakers, or even as psychologically disturbed, whereas those with identified physical injuries who complained little were seen as possessing some form of inner strength.
As a result, sometimes the chronic pain sufferer was ignored. If treated he or she may have received painkilling medication, supportive counseling, physical medicine interventions (such as exercise), and psychotherapy. Often these measures resulted in little long-term reduction of pain.
Beginning in the 1960s, the health care community adopted a new view of chronic pain. Using behavioral and rehabilitation approaches, clinicians realized that chronic pain resulted from the interaction of many physical and psychological factors. These affected not only the experience of pain, but also the behaviors and disability that accompanied chronic pain. Acute and chronic pain were distinguished as separate entities.
Characteristics of Chronic Pain
There are seven primary characteristics of chronic pain.
First, chronic pain persists for long periods, typically for years. In contrast, acute pain is short-lived, lasting from a few seconds to a few weeks.
Second, the impact of chronic pain on the patient’s life-style may be dramatic and extreme. The pain often becomes the center of the patient’s life, and usual activities, such as work and recreation, are significantly disrupted.
Third, chronic pain persists despite standard medical treatments.
Fourth, reports of severity and level of disability are in excess of what would be expected from results of medical examinations and tests.
Fifth, the patient with chronic pain may suffer moderate to severe depression associated with life disruption.
Sixth, the chronic pain sufferer often uses the medical/pharmaceutical system ineffectively, becoming dependent on narcotics and consulting physician after physician in search of a “cure.”
Seventh, there are often significant motivational factors involved in the continuation of pain and illness behavior (actions such as complaining, limping, and moaning). These factors include the avoidance of unwanted responsibility as well as potential cash settlements from litigation.
Chronic pain results from the interaction of many factors. This interaction results in a self-perpetuating cycle of suffering, inactivity, and disability. To treat chronic pain effectively, each of the primary factors must be addressed. They are as follows:
Biological.Pain signals can be stimulated by a wide variety of factors outside the body (from a traumatic injury) or inside the body (from inflamation of the joints, etc.). Portions of the nervous system are exclusively responsible for carrying signals to pain centers in the brain.
Cognitive. The manner in which the patient evaluates information about himself and his environment has been found to play a central role in both the physical and behavioral aspects of pain. These cognitive factors include:
1) the manner in which the patient views the pain (e.g., as punishment, as a symptom of fatal illness, or as a sign of mental illness or weakness);
2) the manner in which the patient views his or her own ability to cope effectively with the pain and/or to learn ways to cope with it;
3) the patient’s acceptance of responsibility for changing behaviors and life styles that contribute to the pain; and
4) the patient’s frustration when expectations for care and assistance from family, employers, insurance companies, and attorneys are not met.
Behavioral. Whether they are reacting to a burnt finger or a compressed nerve, human beings respond to pain. The immediate reaction may be a reflex, such as the pulling back of a burnt hand from a hot kettle. This occurs in a nearly identical way for everyone. However, subsequent reactions, such as applying a heating pad to a sore back or seeking the help of a physician, vary between individuals.
These illness behaviors are learned, just as we learn social customs and accents in our speech. Furthermore, how often these behaviors occur depends on what happens when they occur, such as the reactions of family and friends.
Stressors. Some chronic pain sufferers have a history of social problems, dissatisfaction with work, or an inability to cope effectively with stressful situations. Chronic pain may add stress because of reduced income, family tensions, conflicts with employers, and the fear of permanent pain. The resulting increase in emotional distress and physical arousal stimulates further pain and pain behaviors. This cycle of stress-pain-stress perpetuates chronic pain and disability.
Emotional. In some extreme cases, as a result of persistent pain, life disruption, and the failure of efforts to help, persons suffering from chronic pain may experience a serious feeling of depression. Associated reductions in motivation may lead to inadequate efforts toward recovery. There is also accompanying anxiety due to fears of reinjury when pain sufferers attempt to increase activity. This emotional distress limits the patients’ abilities to learn and use effective coping strategies.
The first step in the treatment of chronic pain includes a description of the prior medical history; a description of the complaint, identifying situations and activities that increase and decrease pain; and an analysis of the client’s beliefs about pain, personal resources, coping skills, and recovery. Finally, interviews of family, significant others, and physicians are conducted.
A major decision in treatment planning is choosing an appropriate level of care. This can range from inpatient treatment within the context of a multidisciplinary pain center to weekly outpatient therapy sessions.
Treatment begins with a reorientation of the patient.
1) validation of the patient’s pain experience and dispelling ideas that the pain is imagined or in some way not real;
2) clarification of the interaction of physical and psychological factors in the development and maintenance of chronic pain;
3) recognition of the patient’s rights in the treatment process;
4) helping the patient assume personal responsibility for active participation in recovery; and
5) acceptance of an ongoing commitment to changing life-style and coping strategies.
An interdisciplinary team addresses medication use, psychological factors contributing to pain and disability, physical exercise and reconditioning, weight reduction, and vocational retraining.
The behavior therapist, one of the members of this team, focuses on five areas:
1) cognitive behavioral methods of identifying and challenging the patient’s unrealistic beliefs about pain, life circumstances, and personal resources, and methods for developing effective thinking, self talk, and problem-solving strategies;
2) behavioral or conditioning therapies that identify and reduce pain and illness behaviors, and that increase the positive outcome of healthy and productive behaviors;
3) psychophysiological techniques, such as biofeedback, that reduce unneeded physical arousal through the development of muscular release, imagery, and breathing techniques;
4) communication skills training to improve interactions among the patient, the family, and the health care system; and
5) bringing new pain-management skills into the patient’s daily life to avoid relapse.
Through such programs the chronic pain patient can receive help, regardless of medical diagnosis, in recovering from pain-related disability, in reducing the frequency and intensity of pain, and in returning to a productive life.