Chronic Pain: The stigmatized invisible condition and how to manage
A lot of my work includes working with chronic pain patients. It’s more common than realized, such an invisible condition that is too often stigmatized and overlooked not only within society but within certain parts of our medical field. I thought it would helpful to provide a piece on understanding the chronic pain condition as well as ways to help treat it.
How I become interested in chronic pain issues
This was completely by accident. While in undergrad at San Francisco State University, I was accepted into a research lab who’s focus was examining chronic pain within an underserved population residing within the San Francisco Bay Area. Among many things, we commonly saw a lot of co-occuring factors such as depression, anxiety, and trauma. It was at this point that chronic pain continued to show itself across all the areas and populations I began studying and treating throughout my educational career. Patients with depression, PTSD, insomnia and anxiety in particular. So I became really interested in learning more about that relationship and decided to pursue the area of chronic pain and how to treat it.
Let’s get down to it - What is chronic pain?
Chronic pain frequently originates with some initial trauma or injury. However, it is possible that there could be an ongoing cause of chronic pain. It is important to note though that there are those individuals who suffer from chronic pain without the presence of a past injury or trauma. It is important to understand that the pain these individuals feel is no less real than that pain caused by an ongoing disease or injury.
Examples of chronic pain: arthritis, headaches, back pain, neuropathy, fibromyalgia (widespread musculoskeletal pain, often with fatigue and tenderness in various areas of the body), just to name a few.
According to the International Association for the Study of Pain (IASP), chronic pain involves suffering from pain in a particular area of the body for at least three to six months. Chronic pain may be as severe as, if not more severe than, acute pain but the individual's experience is ''modulated and compounded by the prolonged or recurrent nature of the chronic state, and further complicated by a multitude of economic and psychosocial factors”.
Chronic pain prevalence
Chronic Pain is unfortunately too common - one in three Americans (more than twelve million people) suffers from some kind of recurring pain in their lifetime. In fact, for Americans, pain is the most common ailment over hypertension, diabetes and cancer combined. Some studies [1, 3] have indicated that chronic pain ranges from 10.1% to 55.2% of the population.
What can result from chronic pain
Chronic pain conditions can last for years. The biggest effect chronic pain has on individuals is an alteration of lifestyle; many individuals who experience chronic pain are unable to complete daily tasks in the same way they had previously been able to complete them. Chronic pain can also lead to a syndrome known as disuse, which means that people in chronic pain sometimes limit their activities in an effort to avoid pain. This in turn leads to weakness, which prompts the patient to limit activity even further, creating a vicious cycle. We’ll address that later in more detail. Additionally, there may be psychological complications that arise as a result of chronic pain - such as depression, insomnia, fatigue, stress, irritability, depression, lowered immune system, becoming sick, drug abuse, addiction and suicidal ideation. However, the individual’s psychological state at the time they experience the pain plays a huge role as well. All of these things can lead to further problems in the individual’s daily life.
Factors that can increase chronic pain
Based on the biopsychosocial model, I categorize these factors into 4 domains: Physical: degenerative changes, muscle tension, drug abuse, too little or too much physical movement, and poor diet
Cognitive: paying too much attention to your pain, believing that your pain is uncontrollable, fear of pain are some common cognitive distortions that actually increase pain severity.
Emotional: depression, fear, anxiety, anger. Negative emotions actually increase pain severity.
Social: imbalance between work social and recreational activity, poor support from family/friends, others focusing on your pain or protecting you from your pain too much
The Biopsychosocial framework in understanding and treating chronic pain
Just as chronic pain itself is very complex and multidimensional, so needs to be the treatment of it. The best treatment model comes from whats called a Biopsychosocial approach in understanding and treating pain. Essentially what this says, is that there are biological, psychological, and social underpinnings of what is causing and maintaining the pain, as well as how to go about treating it in these different domains. For example, the biological approach for understanding pain is the physiology going on within the parts of the brain, nerves, and fibers that are all playing a roll in the sensation of feeling pain. The biological approach in treating it then would of course be medication. Pain medication may be administered in a number of ways, including orally, through swallowing of a liquid or pill, intravenously, by way of a needle inserted into a vein, or via a skin patch or cream. The discussion about using medications such as opioids could be lengthy enough for another blog (or tow) in and of itself, so to keep this brief - while medication can be substantial in providing relief and helping with withdrawal, with it comes a plethora of negatives including addiction, tolerance, hyperalgeezia (when a person using longer opioids actually develop an extra sensitivity to pain), and a variety of additional medical and physical ailments, and of course, overdose and fatality.
The other domains of the biopsychosocial model
These would be the non pharmacological management approaches. The non-pharmacological management of pain refers to pain management without medication. Generally, non-pharmacological pain management uses ways to alter thoughts or socially and behaviorally focus to help decrease pain.
Pain is so complex. There are so many treatment options. Some of these options within the psychological and social domains of treatment include:
- surgery - restructuring inaccurate thought processes
- meditation - relaxation - hypnosis
- CBT - Creams/gels - massage
- biofeedback - chiropractor - stress management
- exercise - physical therapy
- stretching - acupuncture - nerve stimulation
- pacing - support groups
Some options work, some don’t. Some work all the time, some work some of the time. To effectively manage chronic pain, you must be open to trying different treatments, sometimes in combination with each other. If one strategy isn’t working right away, keep trying as it may take a while for it to be effective.
Stress and the negative impact on the chronic pain patient
Stress about the pain, needing to accept and adjust one’s lifestyle, being limited in what they were able to do prior to this is extremely stressful, yet can actually perpetuate pain flair ups and a whole of host of other things such as: depressed mood, digestive disorders, can raise cholesterol levels, create hypertension, damage/block arteries which causes heart disease, can lower the immune system, and slow the body’s recovery time from injuries.
An interesting fact for example, 35% of people with Chronic Pain also have PTSD. Prolonged stress creates pain. Here’s why: Fight or flight occurs when one is stressed out (threatened, etc). Our Fight/Flight response is there as protection to us when encountering danger. Of the many things this physiological system does, is releases chemicals into our blood stream (cortisol, epinephrine) in order to essentially either flee or fight. It’s very job is to physically prepare our bodies to fight or run away from danger. The problem is that when that protective system occurs for too long (which occurs in PTSD and general anxiety for example), the body begins to take a toll (like driving your car in high RPM for a long period of time). Not only do these stress chemicals cause damage to the body, if we are in overdrive constantly, so is your physical tension and muscles.
Where to start
There is so much that can be impacted just by stress alone. So what’s the best approach to address this? RELAXATION is the key to counteract this negative reaction on our bodies. The “relaxation response” is a physical state of deep rest that changes the physical and emotional responses to stress… which is the opposite of the flight or flight response. You can manage stress through relaxation by way of: breathing exercises, yoga, progressive muscle relaxation, meditation, mantra, guided imagery.
Your breath
Breathing in particular is perhaps one of the best strategies for coping with stress (and pain). One of the first ways that stress causes a physiological dysfunction is our breathing becoming sped up and shallower, lowering our supply of O2 oxygen to the brain, muscles, and nervous system. This creates a feeling of panic as the brain is always gasping for air, creating an alarm response. When we begin to experience stress, we start to breath incorrectly (shallow, rapid breathing). This incorrect breathing causes are body to receive too much CO2 (Carbon dioxide) and too little O2 (Oxygen), which then directly tells our brain to start panicking (i.e. turn on Fight/Flight response).
Therefore, in order to stop this circuit, all we have to do is breath slowly to turn down our system. When you slow down the breathing, so will your heart rate, and so will your entire nervous system.
My rule of thumb is do what feels most comfortable to you, but with the intention of breathing slowly and especially prolonging the exhale out. THere’s one technique called “Calm breathing” - Hold your breath for 5 seconds. Exhale slowly through your nose with your mouth closed, letting all the air out of your lungs. Pause for a count of 4 and then take the next breath in. Then repeat this process. It may be difficult to remember this breathing technique when you need it during actual stressful times! That’s why practicing routinely during the day will help make this technique become second nature to you for the times when you really do need it.
Progressive Muscle Relaxation
Practicing muscle relaxation is useful in the same ways as “calm breathing”. The important part of muscle relaxation is becoming aware when your muscles are tense, then use relaxation techniques to loosen and lessen that tension. To use this technique, you practice tensing and then releasing, or relaxing, all of your muscle groups, one by one.
Guided Imagery and what this entails
It’s pretty simple. The point is to really just put yourself mentally and visually in a place that works best for you in terms of relaxing you. Envisioning being on a beach, next to a river, your backyard, really just making your’s in order to put yourself there, even using your senses in a way to deepen the relaxation experience. It’s great because you put yourself in a very tranquil place for as little as just 5 minutes. This can really decrease your tension.
Relationship between food and pain
Nutrition is important for everyone because food gives us the nutrients our body needs to remain healthy, heal, and work properly. Food also has a major role in how we feel physical pain. Here’s why: depending on what you eat, certain foods can cause an inflammatory response in your body. Inflammation is what your immune system creates when there is some kind of insult or damage to your tissue. Inflammation is not the only cause of pain, but it can make your pain feel more intense and last longer. Fat cells are particularly a source of inflammatory chemistry. For those who are overweight, the chronic low back, hip, knee and foot pain you feel may actually be caused by where and how the bones and joints are supporting that weight.
For migraine sufferers
If you suffer from migraines, further inflammation can be caused by:
caffeine (coffee, tea, soda, chocolate) – caffeine seems to set off chemical reactions in the brain that can result in migraines for some people born with a predisposition for headaches. However, small amounts of chocolate can actually help relieve the pain of headaches (which, unfortunately, means your body has become dependent on caffeine). In addition to caffeine, other foods you may try to limit or avoid are:
- cheese (tyramine)
- Red wine (Tyramine)
- junk food
If you suffer from arthritis, further inflammation can be caused by food with nitrates in them: which include high fatty foods, bacon, deep fried foods, eggs, cheese, soda, processed meats (like hot dogs and sausage)
junk food
Well this is disappointing. So, no fun?!
I always say, keep things in moderation. Just know, that if you make the choice to indulge in something you know may cause a flair up or discomfort, be mindful of how you will cope, and give yourself permission to fully enjoy in that moment. But again, keep it minimal.
On the flip side, there are foods that actually help with inflammation:
So like fruits, vegetables, nuts, seeds, vitamin C supports our immune system and fights inflammation. In particular fish and other foods rich in Omega 3 oils also fight inflammation. And of course, drink lots of water, stay hydrated – our body is 70% water, so if we don’t drink enough water, this can affect your skin, muscles, nerves, and digestion.
Try this strategy
A colleague of mine Chandler Walker, a specialist in chronic pain and gut health, suggests creating a chart of betterment, which involves a 1-10 scale on how you felt that day and average it out over the week. Then look at your success over time. Throughout the weeks, remove certain foods like Nightshade foods, peppers, eggs, dairy, gluten. You're basically using an elimination process to pinpoint what’s causing the response and promoting the pain cascade.bThen after 45 days reintroduce one food at a time, wait 7 days and see what causes an issue to come back. Especially joint pain. But also pain from autoimmune disease which is usually related in some way. Fibro and MS.
Chronic pain and romantic relationships?
Chronic pain has often times been referred to in the literature as the silent illness. You can’t see it and so often the person living with it can struggle with not being understood, believed, can be given a stigma, and can even become isolated. It’s an incredibly defeating and frustrating thing to live with. Life altering. It impacts not only the patient but also their loved ones around them, most notably a significant other. Depending on the type of chronic pain you’re living with, your life as an individual and also as couple can turn very limiting and change a lot of things within the relationship. With these changes can bring about frustration, decrease in outings and activities, physical intimacy, emotional intimacy, resentment, fatigue, and stress.
This shift in the couple dynamic puts a lot of extra stress onto the couple and I imagine could become quite problematic for the fate of this relationship if not properly handled. First and foremost - education. Not only educating the patient about chronic pain, but just as important educate the patient’s loved ones. Like I said, it’s just an invisible condition, unless you are explicitly told what this all entails, you're not going to know. There has been an abundance of studies showing that the intensity of pain level is actually decreased when that person feels a sense of love and connection with somebody else. So, in this way, having a partner that is on the same page and is supportive and knowledgable about what the patient is going through can actually serve as an intervention in and of itself. Communication is key. Patience is key. Knowing, grieving, and accepting the reality of what is changing within the relationship is key. Teaching the couple assertiveness, active listening, and emphasizing that every long standing couple evolves together, and living with chronic pain is a way of evolving that can be met either with resistance or learning to manage it together.
Finding the balance
A lot of what I’m referring to regarding a change in relationships is that the chronic pain patient is unable to be as active as they once were, which in turn affects the relationship. The key is finding balance of still trying to remain active and understanding/preventing the costs of too much inactivity
There is the huge reality of needing to make life adjustments, however, some folks will go a bit overboard in decreasing their activity too much. People living with chronic pain will try to prevent further injury or to try to decrease the pain by doing too little and gaining short-term relief from their pain. By being too inactive, this actually causes more problems. Here’s why:
This approach actually aggravates pain by decreasing your body’s flexibility and stamina. What can happen when you move and are stiff is you are more susceptible to pulling a muscle, or your body just hurts from this new movement. Additionally what can happen is what’s called muscle atrophy – which occurs when you stop using your muscles (disuse atrophy). This can cause further damage and weakness. The other downfall of not being active enough has to do with whats called Synovial fluid - (it’s the fluid that keeps joints lubricated for movement). This fluid can decrease as a result of LACK of exercise. When joints have decreased fluid to keep them lubricated, joint pain increases. Lastly, underactivity can worsen depression, worthlessness, and isolation
So how does one find that balance then?
The concept of pacing is very common in the field of chronic pain treatment. So literally, pace yourself in your physical activities! This can be an extremely frustrating process at first because you’re essentially learning your new limits. For many, pain on some days is better than other days. On those good days, its not uncommon to want to catch up on your To Do list. Depending on your personality, you may find it difficult to stop doing a project until it’s finished. Many will work on the project non-stop despite the onset of pain. What happens? You overdo it.
People with chronic pain will sometimes want to “work through the pain” in order to complete their task. The problem with pushing through the pain too much is that more pain and fatigue will result, which in turn will set you back even more days.
Steps for pacing
First, identify a task that you typically do every day that tends to cause you pain (or more pain). This could be doing the laundry, gardening, running errands, walking, using the stationary bike. Identify how long it will take you to do that task safely without causing a pain flare-up – this number will be your “active” time. This amount of time should be a few minutes before the point where you actually start to feel pain.
Identify how long your break will be before you can become active again – this number will be your “rest” time. To help keep yourself accountable and master your pacing, I suggest creating whats called an Activity Monitoring Worksheet, where you write down your activity, along with your “active” time and “rest” time for that activity. Take some notes on how it went each day.
Mindfulness
Take breaks before the pain begins. This ends up causing more productivity in the end. Don’t use PAIN as an indicator to stop or take a break, use TIME. Mindfulness is huge in managing pain. Meaning, be present, be aware of how your body is moving, how you're feeling, what you're thinking. Be mindful of the activities you are doing and how your body is responding. Avoid rushing. Try to spread your activities evenly throughout the week to avoid overdoing it one day. Be flexible with schedule, if you need to switch some things around, its ok. Be reasonable. Use relaxation and other pain coping strategies during these activities.
Exercise and chronic pain
As an athlete myself, a particular passion of mine is fitness. Especially with the importance of maintaining an active lifestyle with exercise for a chronic pain patient.This goes with the proper pacing and activity level, and actually more specifically to exercise in and of itself, exercise helps with pain threshold. With chronic pain, your threshold drops. But, with cardiovascular, strength training, and flexibility exercises, you actually improve your pain threshold. ln addition, exercise releases a chemical called endorphins, which, impact the pain receptors in your brain that will then reduce your perception of pain. These endorphins also act as natural analgesics and sedatives, again, diminishing the perception of pain. Having said this though, consult with you doctor or pain specialist before engaging in any exercise on your own. Again, pacing is key.
Pain and sleep
Sleep plays a huge role in helping managing your pain. Yet, painful and sleepless nights are unfortunately common for those living with chronic pain. While it varies, many studies show that 7 hours of sleep is the ideal amount, especially for those living with pain. Specifically, sleep helps with: healing the body – this is called restorative sleep. Not enough of this restorative sleep can actually increase chronic pain flair ups, which then in turn make it even more difficult to sleep and thus perpetuates the viscous cycle. You may notice that after a bad night’s sleep you may feel your aches and pains a bit more than usual.
Lack of sleep compromises our immune system and healing process (in particular parts of the body due to illness or injury that need healing), can cause low mood or depression, decrease our energy for the day, effect work/school/getting tasks done, has been linked to weight gain, hypertension, diabetes, concentration, memory, and decision making. In order to improve sleep which then can help to alleviate chronic pain, it is important to engage in proper “sleep hygiene”. For more information on specific techniques for better sleep, check out my blog section on sleep and insomnia.
The Biopsychosocial model of pain and how one’s thoughts play a roll
The relationship between our thoughts, emotions, and behaviors play a very dynamic roll in the experience of chronic pain. This specifically refers to the Cognitive Behavioral theory. Essentially, when an upsetting situation occurs, we automatically try to make sense of it (this is an automatic thought). This automatic thought then determines how we will emotionally feel about it, which in turn determines how we will then behave.
For example - I’ll ask, what happens to your body when a situation occurs that makes you angry, frustrated, or stressed out? You become tense, you tense your muscles, heart rate goes up, pacing, etc). These behavioral reactions worsen chronic pain.
Another example is learning that you have been invited to a gathering. Your immediate thought is you will be in too much to enjoy yourself. You now feel defeated and maybe frustrated, and thus behave by not going to the party, staying in bed and isolating. This exacerbates the vicious cycle of pain and mood.
In addition, negative thoughts specifically about pain can have a direct impact on your experience of pain. If you’re constantly thinking about your pain, you will be attending to how much pain your are feeling. Pain-specific thoughts like the following can affect your expectations of your ability to cope with pain:
I can’t cope with this
My pain is going to kill me
This pain is too much for me
I can’t do a thing because of my pain
My pain is getting the better of me
Im a burden to my family
These thoughts can lead to negative feelings which then increase your pain. The key then is to identify these cognitive distortions in your automatic thoughts and change them into more realistic, positive thoughts.
Gender differences and pain
Researchers believe that women tend to recover more quickly than do men from pain, partly because estrogen helps women recognize pain more easily. Women also seek help more readily and quickly for pain. Studies of adult volunteers indicate that women tend to recover from pain more quickly than men, cope more effectively with it, and are less likely to allow pain to control their lives. Research has shown that sex hormones in mammals affect the level of tolerance for pain. The male sex hormone, testosterone, appears to raise the pain threshold in experimental animals. In addition, women appear to be less sensitive to pain when their estrogen and progesterone levels are high, as happens during pregnancy and certain phases of the menstrual cycle.
In closing
If reading this as a chronic pain patient - you are seen. You are heard. You are believed. Keep going.
~ You’ve got this!
References
1. Harstall C. How prevalent is chronic pain? IASP Pain Clinical Updates XI. 2003: 1-4.
2. Hernandez-Reif M. Migraine headaches are reduced by massage therapy. Intern J Neuroscience 1998;96:1-11.
3. McCleane GJ, Suzuki R, Dickenson AH. Does a single intravenous injection of the
5HT3 receptor antagonist ondansetron have an analgesic effect in neuropathic pain? A double-blinded, placebo-controlled cross-over study. Anesth Analg 2003;97:1474-8.