By Mark Johnson
The prevalence of chronic pain in the general adult population worldwide may be as high as 30%. Yet pain is not seen as a major health care problem by politicians, probably because people do not die of pain, although many people die in pain. Chronic pain challenges our traditional beliefs about the process of diagnosis, treatment, and cure, with over 40% of individuals reporting inadequate management of chronic pain. Chronic pain is an enigma.
We have all experienced pain and we know with certainty when we have it. Yet, we may doubt others who tell us that they are in pain especially if their pain has a vague or uncertain diagnosis and is not responding to conventional treatment. The medical management of pain evolved from the view that pain is a symptom of pathology and diagnosis, and treatment of pathology will relieve pain. This approach usually works well for pains associated with recent tissue damage (acute pain) but starts to fall apart when pain becomes chronic. This is because the link between pain and tissue damage (pathology) is not quite as strong as we are led to believe. For example, soldiers seriously injured in battle often report no pain for some time after the injury occurred. The link between pathology and chronic pain is particularly variable. In fact chronic pain may uncouple from the pathology that caused the pain in the first place. In essence, pain can become a disease entity in its own right.
Life experiences teach us that pain warns of tissue damage and we adapt our behaviours to avoid pain accordingly. Body parts often become “sensitive” in the presence of tissue damage so that non-painful activities become painful. Pain makes us avoid things that may hinder tissue healing so we learn to “fear” walking on a twisted ankle for example, because it provokes pain. Sensitivity associated with pathology results from the nervous system amplifying input from the site of tissue damage increasing the input to the pain producing brain — no brain, no pain. Pain resulting from sensitivity within the nervous system fades over time as tissue heals, although occasionally the nervous system remains in a persistent sensitive state despite tissue having healed. The consequence is chronic pain that has uncoupled from the original tissue damage. Pain of this nature has limited usefulness and is detrimental to well-being and reflects a dysfunctional pain system.
In such circumstances medical tests may fail to detect appreciable pathology, diagnosis may become vague, and treatment uncertain and unsuccessful. Practitioners may start to doubt the legitimacy of the person’s pain and believe that the pain is “psychogenic” (fake). This is entirely irrational because it is impossible to prove or disprove that a person is in pain, because pain is a subjective phenomenon with no objective way of measuring. The only way to gain insight into a person’s personal pain experience is through their self-report — pain is whatever the patients says it is. If a person reports that they are experiencing pain, they should be believed.
Knowledge that pain may persist without appreciable tissue damage has shifted the focus of management strategies for chronic pain that advocate progressive return to and continuation of normal activities despite the presence of pain. The challenge for the practitioner is balancing advice about under-activity, leading to disability, with over-activity leading to further pain and harm. The challenge for the patient is being able to accept and commit to a pain management plan that encourages undertaking activities in the presence of pain, because this is counterintuitive to life experiences that have taught us to avoid pain because it warns of harm. Accepting that total resolution of pain may be unlikely and committing to integrating a painful body into normal life has been shown to have a positive impact on suffering and long-term disability. In fact inactivity is a risk factor for the development of long-term pain, suffering and disability. Easy explanations of the factors contributing to chronic pain to promote a benign view of chronic pain can help individuals to change the way they think and behave about their pain. Pain management plans offering advice about the risk of harm of daily activities and self-management techniques to find solutions for pain flare ups, medication use, sleep disturbances, depression, anger, and relationship problems are becoming available.
Exercise regimes aim to get individuals to return to normal activities through stretching, strengthening, and cardiovascular fitness with the focus on progressive return to activities. Manual therapies such as massage of soft tissue and mobilization and manipulation of joints, and electrophysical agents such as transcutaneous electrical nerve stimulation (TENS), acupuncture, low level laser therapy, and ultrasound, are all part of the multidisciplinary pain management team’s toolkit. Clinical experience suggests that these non-pharmacological interventions are beneficial and popular with patients, although the findings of clinical research have been inconsistent. This is due to the complex nature of administering some of the interventions where optimal technique (dose) is not known.
So the puzzle of chronic pain is being unravelled with the realization that a reliance on diagnosis and treatment of pathology causing pain may not be the most effective way to help patients. We need a multidisciplinary model of care that is flexible enough to shift in emphasis from a biopsychosocial model in the acute phase to a “sociopsychobio” model in the chronic phase.
Mark Johnson is Professor of Pain and Analgesia at Leeds Metropolitan University in the UK. He is author of Transcutaneous Electrical Nerve Stimulation (TENS): Research to support clinical practice.
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Image: Doctor talking with a patient by National Cancer Institute. Public domain via Wikimedia Commons.
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Lauren, Publicity Assistant
If you haven’t already heard, unfriend is the New Oxford American Dictionary Word of the Year. In honor of this announcement, I surveyed Facebook users across the country about why they would choose to unfriend someone.
1. They’ve turned into a robot.
“People send me Green Patches all the time,” said Jane Kim, a television research assistant in NYC. “It’s annoying. And that’s all I ever get from them. Clearly, they’re not interested in actually being friends.”
That’s because your friends are robots, Jane. Marketing robots. These are the friends you never hear from except when they want you to join a cause, sign a petition, donate money, become a fan of a product, or otherwise promote something. Farmville robots are increasingly becoming problems as well, but are not yet grounds for unfriending.
2. You don’t know who they are.
“A few days ago, Facebook suggested I reconnect with a friend whose name I didn’t recognize,” said Jessica Kay, a lawyer in Kansas City. “She’d recently gotten married, but I hadn’t even known she was engaged. I’ll probably unfriend her later. Along with some random people I met at parties in college.”
“You’re tired of seeing [that mystery name] your newsfeed,” said Jonathan Evans, a contract specialist in Seattle. “You haven’t talked to that person since the random class you took together, and you’ll probably never talk to them again.”
3. They broke your heart.
Jonathan Lethem, author of Chronic City, shared that his number one reason to unfriend someone is “because they just broke up with you on Facebook.”
So, maybe they didn’t break your heart. But if the only reason you were friends on Facebook is because you two were somehow involved, it might be time to play some Beyoncé, crack open the Haagen-Dazs and click “Remove from Friends”.
4. You don’t like them anymore.
In the early years of Facebook, users would friend everyone their dorm, everyone from high school, and every person they had ever shared a sandbox with. But now, many people are finding they no longer like a number of their friends, and spend time creating limited profiles, customizing the newsfeed, and avoiding Facebook chat.
Teresa Hynes, a student at St. John’s University, pointed out that it’s silly to be concerned one of these people might find out you’ve unfriended them and get angry. “You are never going to see them again,” she said. “You don’t want to see them ever again. You hated them in high school. Your mass communications group project is over.”
5. Annoying status updates.
“I don’t want to see ‘So-and-so wishes it was over,’” said Andrew Varhol, a marketing manager in NYC. “Or the cheers of bandwagon sports fans—when suddenly someone’s, ‘Go Yankees! Go Jeter!’ Where were you before October?”
Excessive status updates are one example of Facebook abuse. Amy Labagh of powerHouse Books admits she is irritated by frequent updates. “It’s like they want you to think they’re cool,” she said, “but they’re not.”
A professor at NYU, agreed, and said he finds a number of these frequent updates to be “too bourgie.” “It’ll say something like, ‘So-and-so is drinking whatever in the beautiful scenery of some field.’ I mean, really?!”
The style and type of each update is also important. A number of users agree that song lyrics, poetry, and literary quotations can be extremely annoying. Updates with misspellings or lacking punctuation were also noted. “I once unfriended someone because they updated their statuses in all caps,” said Erin Meehan, a marketing associate in NYC.
6. Obnoxious photo uploads.
Everyone has a different idea about what photos are appropriate to post , but a popular complaint from Facebook users in their 20s concerned wedding and baby photos. “It’s just weird,” said a bartender in Manhattan. “I know that older people are joining now, but if you’re at the stage in your life when most the photos are of your kids, I mean, what are you doing on Facebook?”
“I think makeout photos are worse,” said his coworker. “My sister always posts photos of her and her boyfriend kissing. Sometimes I want to unfriend and unfamily her.”
Across the board, a number of users found partially nude photos, or images of someone flexing their muscles as grounds for unfriending. Another reason, as cited specifically by Margitte Kristjansson, graduate student at UC San Diego, could be if “they upload inappropriate pictures of their stab wounds.”
7. Clashing religious or political views.
“I can’t handle it when someone’s updates are always about Jesus,” said Robert Wilder, a writer in New York.
In the same vein, Phil Lee, lead singer of The Muskies, said he’s extremely irritated by “religious proselytizing and over-enthusiastic praise and Bible quoting. Often in all caps.”
An anonymous Brooklynite shared that he purged his Facebook account after the last Presidential election. “It was a big deal to me,” he said. “I found it hard to be friends with people who didn’t vote for Obama.” After which his friend added, “I voted for McKinney.”
8. “I wanted a free Whopper.”
In January, Burger King launched the Whopper Sacrifice application, which promised each Facebook user a free Whopper if they unfriended 10 people. It sounded simple enough, but if you chose to unfriend someone via the application, it sent a notification to that person, announcing they had been sacrificed for the burger. Burger King disabled the application within the month when the Whopper “proved to be stronger than 233,906 friendships.”
Since Facebook has made the home page much more customizable than it used to be, you might wonder, “Why unfriend when I can hide?” More and more, Facebook users are choosing to use limited profiles and editing their newsfeed so undesirable friends disappear from view. “I find lately I’m friending more people, then blocking them,” said Gary Ferrar, a magician in New York. “That way no one gets mad, no one’s feelings get hurt.”
Do you have another reason? Tell us about it!
Dr. John D. Otis is the Director of Medical Psychology at Boston University School of Medicine and the director of the Pain Management Psychology Services at the VA Boston Healthcare System. He is also Associate Professor of Psychology and Psychiatry at Boston University. In his newest book, Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach, Workbook, which is part of our Treatments That Work Series, Otis provides a guide to increasing productivity in the face of chronic pain. Below are some tips, excerpted from the book, which will help you decrease the stress in your life, which in turn decreases your pain.
Stress and pain reinforce each other. You may have noticed that when you are stressed out, your pain gets worse. On the other hand, chronic pain is often a source of stress. This can result in a cycle of pain and stress…
Ways to Decrease Stress:
Given the relationship between stress and pain, it is important to learn how to manage stress. The good news is that there are things you can do to decrease your stress….
Change Lifestyle Habits:
-Decrease caffeine intake (coffee, tea, colas, chocolate)
-Maintain a balanced diet and decrease consumption of junk food
-Eat Slowly and at regular intervals
-Exercise regularly (at least 30 minutes three times per week)
-Get adequate sleep (figure out how much you need)
-Take time-outs and leisure time (do something for yourself every day)
-Do relaxation exercises (e.g., breathing, imagery, PMR)
Change How you Approach Situations:
-Time and money management
-Assertiveness
-Problem-solving coping skills
Change your Thinking:
-Have realistic expectations (when expectations are more realistic, life seems more manageable)
-Keep a sense of humor (being able to see the humor in the things helps o lighten the situation)
-Have a support system (speak with someone or write down your thoughts)
-Focus on the positive (think half-full versus half-empty)
-Challenge negative thinking using cognitive restructuring skills
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The Oxford American Pain Library provides practical guides that cover current approaches and new developments in the assessment and management of pain. The Diagnosis and Treatment of Breakthrough Pain is meant for doctors and nurses but can also provide some insight into treatment options for patients suffering from uncontrolled pain flares. In the excerpt below we learn what breakthrough pain really is.
The term “breakthrough pain” began appearing in the medical literature in the 1980s on the heels of the 
increased attention, brought about by the World Health Organization, to the global problem of undertreated cancer pain. During that time, it became apparent that cancer patients commonly experience intermittent exacerbations of severe pain against a background of continuous, or baseline, pain. Episodic pains that would “break through” during the treatment of background pain that was otherwise well controlled through the use of around-the-clock opioid therapy were catergorized by Portenoy and Hagen (1990) in a seminal work titled “Breakthrough pain: Definition, prevalence and characteristics.” The definition of breakthrough pain proffered in that article took root and has been used in pain management parlance ever since.
As opioid therapy has become more commonly used in the treatment of chronic noncancer pain over the last decade, it have become equally apparent that similar patern of supervening severe pain episodes can confound otherwise well-managed chronic pain (Seppetella et al., 2001). Recognizing the similarities of sympotms, independent of underlying pathophysiology, a group of pain managment experts came together in 2006 to create a unifying definition, based on a review of all the literature on the subject in all populations studied to date. The more generalized definition incorporates the additional observation that breathrough pain seriously disrupts the quality of patients lives. Therefore, the term breakthrough pain is now categorically determined to define the particular clinical circumstance wherein patients who have controlled baseline pain experience severe episodes of pain that breaks through the medical therapy (usually opioids) that has relieved the baseline pain.
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