Understanding chronic pain (Part 1)
As a movement professional, I meet a lot of people in pain. Likely the #1 thing that brings someone to take a Pilates class or to see me for a private lesson is that they have physical pain that is not enough to justify physiotherapy, but nagging, distracting, and uncomfortable regardless.
What is chronic pain? Pain that has lasted more than 3 months and does not have a clear cause. Often, someone with this type of pain has already seen all the doctors, specialists, and physios before they wind up accepting their misfortune. When they join my movement classes they explain to me about their “bad knees” that won’t let them kneel anymore. I take these stories very seriously. Having gone through the healthcare system, and trying all the advice and treatments without significant change, people arrive to class disgruntled and believing that there is no potential left to change. They are ready to work around their “defects.” Beliefs reinforced by experience are their greatest limiting factor.
I wanted to understand chronic pain because it would make me better at my job. So, when I had to write a paper for a university course I have recently taken, I chose to research chronic pain and learn the current science on non-drug treatments. I wrote a beautifully academic paper and got an A for it. I cited eleven relevant studies and read even more.
I’m not going to make anyone, other than my professor, read that paper. This is my attempt to tell you what I’ve learned. So this is a LONG post because it was a well-researched paper. I’ll include the original references at the end. This post exists for when I get asked about pain and want to explain by pointing someone here. This is not medical advice.
The important thing to understand about pain is that it is not only a physical sensation. It is an experience. Any single pain, like a papercut, has the physical sensation (sensory: ouch!), emotional response (affective: @#$%!!!!), and thoughts or beliefs about what happened (cognitive: it's a papercut). It has to be interpreted through our past experiences and contextualized to be understood as either an imminent threat needing immediate attention or an unpleasant experience we might attempt to ignore that still brings up emotional reactions like frustration. In this way, we can consider pain as a multidimensional experience that involves all 3 factors; sensory, affective, and cognitive. Any of these factors might be manipulated to vary the experience of pain to different degrees of success. This is where the research comes in.
In focusing on the sensory (read: physical) factors of pain like the strength and how long it lasts, healthcare systems worldwide turned to drugs that dulled or completely stopped the sensations. However, drugs are not treatments for recovery and have led to an epidemic of opioid abuse. In other words, no, you don’t feel pain, but that is not the same as treating the injury. You not only won't get better faster, but you also risk other health problems. The body is a self-healing system with the right environment and time. We know the length of time needed to heal just about anything physical.
This is why there are currently so many studies on psychological treatments. The idea is that if we can adjust the cognitive factors (thoughts and beliefs) around the experience of pain we will recover better in the long term. There are some promising results to this. In a clinician’s guide of evidence-based approaches to chronic pain, cognitive-behavioral therapy (CBT) was identified as the most likely to help, and that the best programs for chronic pain were based on CBT principles. CBT programs typically include a combination of psycho-education, relaxation, attentional strategies, cognitive restructuring, problem-solving, assertiveness, and communication. When compared to people who received a non-psychological treatment for their pain, such as an exercise program or education about managing pain, people treated with CBT probably experience very slightly less pain, disability, and distress by treatment end (Eccleston, Morley, & Williams, 2020).
So, the research says that addressing the thoughts and beliefs about pain hasn’t proven to offer more than a slight benefit. This brings us to the last pain factor and one of the most interesting studies I found on pain which was done for nurses on the treatment for physical pain in the Intensive Care Unit (ICU) of hospitals. In intensive care, pain is often divided into intensity and distress - a description of the physical and emotional components of pain. When considering the acute injuries to be expected in an ICU the presence of physical pain symptoms is a given, and yet it was the emotional memory of pain that had the most lasting effect on the patients.
INTENSITY = PHYSICAL & DISTRESS = EMOTIONAL
In the study of managing pain in the ICU, it was concluded that the overall experiences of pain among patients are dependent on control: either the lack of control or the struggle for control. They noted that pain generated feelings of chaos and incapacitation and the emotional experience of pain was more important than the physical intensity concerns. In previous studies, it had been shown that patients' scores for remembered pain in the ICU were significantly higher than what was actually reported during their stay. Many memories had faded except the emotional memory of pain, which had increased over time.
This tells us that the lasting quality of emotional responses to pain might be why pain can last longer than the physical injury. Pain intensity, the physical aspect, is not reproduced by memory. Thus, the emotional experience surrounding it and social interactions that resulted are the lasting impressions that must be addressed in future discussions. Pain management strategies suggested by this study for the acute treatment of pain are to individualize the response, facilitate good communication, and bolster the patients' feelings of being in control through a person-centered care (PCC) approach.
Based on the idea that the important thing for an ICU nurse in managing a patient’s pain is to help that patient feel in control of their own care, what are the important considerations for the millions of chronic pain sufferers seeking drug-free, self-facilitated pain therapy?
Next month, in Part 2, I'll cover the body's stress-system; what it is, what it does, and why it
matters to this discussion.