Knowing pain

Understanding roots of chronic pain critical for its treatment

Pain is an emotional sensory experience and can be triggered or made worse by stress, anxiety, and/or depression — the experience of pain itself, especially chronic pain, can also cause more stress, anxiety and/or depression, which can lead to a vicious cycle of chronic pain. (Stock image)

MARQUETTE — It hurts terribly — it’s hard to stop thinking about it. Nothing helps reduce the pain. Fear grows — activities become limited, rest becomes frequent, a sense of helplessness develops. Anxiety and depression about the pain deepen as it continues. The pain lasts for days, weeks, months or even years — the pain, fear, anxiety, depression and sense of helplessness feels inescapable.

This an example of pain catastrophizing, which is “characterized by the tendency to magnify the threat value of pain stimulus and to feel helpless in the context of pain, and by a relative inability to inhibit pain-related thoughts in anticipation of, during or following a painful encounter,” and is often associated with a more intense experience of pain, as well as delayed recovery, according to a 2009 article published in Expert Review of Neurotherapeutics.

This is just one example of how our brains exert enormous control over our experience and perception of pain, especially in terms of chronic pain.

“All pain is real, but it is created by the brain as a result of perception of threat — this can be a physical threat or even an emotional threat, such as a very severe stress,” said Liz Peppin, physician assistant, emphasizing “pain is not a stimulus, it’s an emotional and sensory experience.”

Peppin and Kyle Aho, doctor of physical therapy at Active Physical Therapy in Marquette, shared their knowledge of cutting-edge neuroscience research on chronic pain during a presentation entitled “Your Brain on Pain” Thursday night as part of the Ore Dock Brewing Company’s Science on Tap series.

“Pain is a normal human experience but living in pain for a long time is not normal — an estimated one out of three people in the United States has some form of chronic pain,” Peppin said.

Peppin and Aho spoke about how the brain and body process chronic pain differently from acute pain — and why some of the current pain management practices may not be helpful for the treatment of chronic pain.

Chronic pain, which lasts from three to six months or more — sometimes years or even decades, is fundamentally different than acute pain, which is short-lived pain.

The biomedical model, developed by Descartes around 300 years ago posits symptoms and tissue pathology are positively correlated — meaning that if symptoms are severe, tissue pathology is likely to also be severe — while the biomedical model generally holds true for acute pain, the relationship between symptoms and tissue pathology breaks down in terms of chronic pain, Aho said.

In cases of chronic pain, pain and tissue pathology aren’t always connected — pain can be present without tissue pathology, he said.

This is because with chronic pain, the issue often goes far beyond the tissues — chronic pain can be influenced by fear, stress, beliefs and attitudes about pain itself.

“Pain is much more complex than we used to think — and beliefs, attitudes, immune system, genetics, stress, all these things can influence pain a lot more than we used to think,” Peppin said. “Certainly, the tissues are involved, but as pain continues for months or years, the tissues become less and less of a factor and pain moves to different areas in the brain.”

Because of this, different solutions are needed for chronic pain — while opioids can be effective for acute pain, this is often not the case for chronic pain.

“Opioids don’t work that well for chronic pain — they don’t really improve pain or function for most people with chronic pain,” Peppin said. “The brain adjusts to the drug over time, which leads to a decreasing efficacy from the same dose.”

Aho and Peppin explained how over-prescription of opioids, as well as the way the medical community talks about pain, can lead to harmful attitudes about pain and its management.

“Measuring pain as a vital sign does not improve the quality of pain management — yet we’re still doing it,” Peppin said. “Repeatedly asking patients to rate their pain makes them focus on it in a maladaptive way and it actually increases pain and fear.”

She says this practice “reinforces maladaptive pain processing pathways,” as well as the idea that pain necessitates a pill.

“If you’re in the hospitaal and somebody keeps asking you ‘what’s your pain level?’ and you say ‘well, it’s a seven out of 10,’ and they hand you a pill, the idea becomes ingrained that ‘if it’s a seven out of 10, I need a pill.'”

With many of the conventional treatments for acute pain being less effective for chronic pain, Aho and Peppin recommend several different approaches for treating chronic pain.

High-quality physical therapy, aerobic exercise, sleep, and psychological therapy can all be helpful for treating chronic pain, they said, adding that even education on chronic pain can be extremely helpful.

“Research shows that the more you know and the more understanding you have specially of how pain is created, the better off we’re going to be, the less sensitive we are to the painful stimuli,” Aho said.

He says building an understanding of painful situations is helpful to patients experiencing pain — while using language like “degenerative, herniated, crushed, ripped, torn, bone-on-bone” to describe a tissue condition can create more fear and stress in those experiencing pain.

“Instead of me teaching you and coaching you through what’s going on at the low back mechanics — which arguably a lot of people don’t want to hear much about — instead, I’ll teach you exactly what’s important about painful sensations,” Aho said.

He said the most important part about recovering from injury or chronic pain is to “make sure you get back to doing what you were doing beforehand. “

Aho and Peppin recommend those who suffer from chronic pain speak to a doctor about physical therapy — they also recommend education on pain management.

One program in the area is UPCAP’s Chronic Pain Self-Management program, which a six-week program that teaches practical skills for living with, or caring for someone with, chronic pain. According to UPCAP, the program “focuses on self-care, learning new coping strategies, and exercises to help manage pain.”

To register or find more information about the program, which is offered regularly, with the next beginning in Marquette on Aug. 8, call 211 or 906-786-4701, or visit http://upcap.org/event/path-for-pain-management-workshop-marquette/.

For more information on Active Physical Therapy, call 906-226-0574.