Living a Healthy Life with Chronic Pain (3 page)

A truly satisfactory definition of chronic pain simply does not exist. One common misconception is that chronic pain is just like acute pain, except that chronic pain persists. But acute pain and chronic pain are different in some very important ways. Understanding these differences, which are listed in
Table 1.2
on
page 9
, is essential for you to better cope with and manage your chronic pain condition. It is also important for your family to understand these differences, because an informed support system is an important part of successful self-management of pain.

Table 1.2
Differences Between Acute and Chronic Pain

All of us have experienced acute pain. Whether it is the stubbed toe we talked about on
page 6
, a sore throat, a toothache, or the aftereffects of surgery, these are pains that have an identifiable cause and usually go away once healing has taken place. Pain in these situations is a very important part of the body’s defense mechanism because it warns us of danger and harm. It has survival value. We pay attention to the pain. We take action and do what we can to alleviate it.

The biological mechanisms of acute pain have been studied extensively and are well understood. An injury or illness opens the gate in the spinal cord (see
page 6
) to allow nerve signals to go to the brain. At the same time, the brain and spinal cord release substances that start the healing process and help us cope with the pain (See
Figure 1.1
and
page 7
).

It is important to understand that, because acute pain has a survival function, our approach to its management is very different from our approach to chronic pain. In the early stages, acute pain can be linked to anxiety and fear. We wonder:
What is the cause of the pain? How bad will the pain get? Will it go away?
But once we understand the cause and seek treatment, and we start to feel better, our emotional response usually subsides.

The brain also instructs the body to protect the injured area. Muscles can go into spasm. We can unconsciously hold our muscles in tension. If it hurts enough, we stop, rest, and conserve our energy so healing can take place. If, for example, we have had surgery or are feeling the aches and pains of influenza, being too active can slow healing. Rest is best. As the pain subsides and the healing improves, the protective mechanisms diminish. We gradually increase our activity and get back to normal.

When dealing with acute pain, our role and the role of our health care providers are clear: we go to the doctor for a diagnosis and to get advice on how to treat our condition. For the most part, we follow that advice. We don’t usually argue about whether we need surgery for a burst appendix or whether we should take antibiotics for a severe chest infection. As a result, healing occurs and the pain usually goes away.

But what if the pain does not go away? What if the brain network continues to interpret nerve impulses as “dangerous,” even when they are not?

There are many ways to classify chronic pain. In this book, we talk about two main kinds of chronic pain. One is pain associated with a chronic disease. Examples include pain from arthritis or angina. In these cases, pain is a symptom of a generally well-understood disease process, and medical pain management is often specific to the disease that’s causing the pain.

The other kind of chronic pain is idiopathic pain. Idiopathic means that there is no known cause for the pain. Examples of idiopathic chronic pain include musculoskeletal pain (such as chronic neck, shoulder, and lower back pain), whiplash injuries, fibromyalgia, chronic regional pain syndromes, repetitive strain injuries, postsurgical pain, phantom limb pain, chronic pelvic pain, neuropathic or neuralgia pain, and central pain that persists after a stroke. Persistent headache and pain from poorly understood chronic conditions such as irritable bowel syndrome, Crohn’s disease, and interstitial cystitis are other examples. Initially, these pains may have been triggered by an event like a workplace injury, a minor fall, a surgical procedure, or a virus. Sometimes the pain may stem from nothing in particular. In either case, these conditions started as acute pain and should have gone away but did not. As such, chronic pain is defined as pain lasting longer than three to six months, which is beyond the normal time for healing and recovery.

Unlike acute pain, chronic pain can vary considerably in intensity, and it is often unpredictable. Some days the pain is mild and other days it is very intense. It can affect just one area of the body or be felt in multiple areas. Once pain has persisted beyond the normal time for healing, it no longer warns us of danger or harm. But the brain network misinterprets the pattern of nerve impulses and keeps signaling that the body is in danger. However, injured tissues have already healed entirely or as much as they are going to. In these circumstances, the pain has no survival value any more. But it still must be managed.

The mechanisms that result in acute pain (see
pages 6
–
7
and
Figure 1.1
) become amplified and exaggerated in chronic pain. Healing should calm down the nervous system. Instead, nerve cells continue to fire even though there is no new tissue damage. And our brain continues to interpret these signals as ‘danger’. Pain, action responses, and stress responses just get stronger. Imagine that you set the thermostat to 68 degrees but your furnace keeps turning on so that the house is 85 degrees and rising. Something is wrong. It could be the thermostat, the wiring, or the furnace that’s broken … or maybe it’s a combination of all three. Chronic pain is like that—it’s a disturbance of a complex interactive system that includes billions of nerve cells, the spinal cord, and the brain, as well as the immune system, our stress response system, and our individual genetic makeups.

When the body is bombarded with persistent intense nerve signals that are interpreted
as pain, our nervous system eventually loses its ability to respond effectively. As a result, areas of the spinal cord and brain fundamentally change over time. These changes cause some people to become more sensitive to weaker body signals. They develop a hypersensitivity to even mild stimuli that would normally not cause pain. For others, pain that was once located in only one body part seems to spread to other areas, causing widespread pain. That’s why people don’t get “used to” having chronic pain, because it changes.

Another finding is that people with chronic pain may have an increase in some neurochemicals and a decrease in others. For example, some people have excess release of cortisol that can itself produce destruction of tissues and more chronic pain. Others have reduced amounts of endorphins, serotonin (important for sleep and mood regulation), and others that help regulate stress and immune responses. It’s as though the body can’t keep up with the demand for neurochemicals. The good news is that there are things you can do to increase the levels of these helpful neurochemicals, including exercise, relaxation and meditation, positive thinking, and even just laughing. Exercise can play an important role in chronic pain management. Note that unlike acute pain that initially requires rest, you need to be active when you have chronic pain. Exercise can help your brain reinterpret body movements as safe and not dangerous.

Understandably, the emotional response to chronic pain is different from the response to acute pain. In a very real sense, chronic pain is a form of chronic stress and can be associated with ongoing tension, anxiety, fatigue, and a host of difficult emotions such as frustration and anger. This can lead to feelings of helplessness, hopelessness, and depression. Nagging questions inevitably arise:
Why me? Why is the pain persisting? What do I really have? How can I explain this to other people when I can’t understand it myself? What does the future hold?
All these questions and concerns are very real. But the way forward is to look for solutions about how to manage your pain, not what caused it, because you may never know what caused it. Learn as much as you can about your condition and how to manage it. Instead of obsessing about your pain, be kind to yourself, and make a decision to enjoy your life even with chronic pain.

This brings us to the appropriate relationship between you, as the person with pain, and your health care providers. Collaboration and partnership are the cornerstones of effective care. Health care professionals may well be experts in disease, but you are the expert in your own life, and you are the expert in your daily experience with chronic pain. Because you are responsible for managing your condition day-to-day, the advice and lifestyle changes proposed by health professionals must be based on your needs.

If you are interested in exploring concepts about pain beyond this brief introduction, review the multiple resources provided for you at the end of this chapter and other chapters in this book. The sources listed in the Suggested Further Reading section of the chapter are great places to go to find out more about this important topic. You will also find more information on strategies to “close the gate” and retrain the brain in
Chapters 4
and
5
.

Figure 1.2
The Vicious Cycle: Chronic Pain and Symptoms

Unlike acute pain, where full recovery is expected, chronic pain usually leads to additional symptoms and sometimes loss of functioning. With chronic pain, many people assume that the symptoms they are experiencing are due to the pain itself. While chronic pain can certainly cause fatigue, restricted movement, depression, and the like, it is not the sole cause. What’s more, each of these symptoms can feed off each other. For example, depression causes fatigue and tight, tense muscles cause physical limitations, both of which can lead back to poor sleep and more fatigue. The interactions of these symptoms make the pain condition worse. It becomes a vicious cycle, illustrated in
Figure 1.2
, that doesn’t stop unless we find a way to break the cycle.