Living with it
Despite advances in technology and drug therapy, 'persisting' or 'chronic' pain affects up to 20 per cent of Australians at any one time. And, as Dr Paul Goyen reports for Living Well, there is no 'quick fix'. Rather, a combination of therapies - including keeping a healthy state of mind - is likely to offer the greatest relief.
- Types of persisting pain
- Other factors that affect pain perception
- Tackling pain: teamwork required
- The pain management toolkit: what's inside?
- Where to find help and support
- Cognitive behavioural therapy (CBT) for persisting pain
Happily, we can expect most acute episodes of pain to resolve completely. Some illnesses, however, are associated with persisting pain: that is, pain that lasts longer than three months, which is the time it takes for most body injuries to heal.
Persisting pain generally occurs for two reasons: because the initial cause of the painful stimulus - such as cancer or worsening arthritis - is still present, or when there is a change in the way our body perceives pain.
The changes involved in the second case are not well understood but are thought to be related to the brain, spinal cord and nerves. It may be that, in some cases, the nervous system is 'wound up' or 'hyper-excited', causing an exaggerated response to painful stimuli, like a poorly adjusted house alarm being set off by a mouse. This may also mean that usually benign stimuli such as touch, pressure or stroking are felt as pain.
As a consequence in these cases, the 'cause' of the persisting pain often appears to be insignificant compared to the pain being experienced.
Cancer is another common cause of persisting pain. It is a complex subject in itself, with different treatment requirements. It is, therefore, not covered in this article.
As well as causing physical distress and an increased likelihood of depression and anxiety, persisting pain can adversely affect every aspect of your life and that of your family, friends and workmates.
Adding to strained relationships, social activities, finances and self-esteem, persisting pain can also lead to unhealthy levels of medication usage and a destructive cycle of reduced activity due to fear of further injury, leading to muscle weakness that actually worsens matters.
To help halt and reverse the development of this scenario, it is important to get help early, especially if initial attempts to address the problem have been unsuccessful.
Types of persisting pain
Persisting pain can be divided into two groups:
Nociceptive pain results from tissue injury that does not involve damage to the nervous system. It is characterised by a gradual improvement once the initial injury resolves, if resolution does occur. Examples are pain due to severe joint injury or arthritis.
Neuropathic pain results from damage to part of the nervous system and is due mostly to a change in pain perception as outlined above. It is often:
- shooting or burning in nature;
- brought on by minimal stimulus (touching);
- severe and likely to persist;
- made worse by stress;
- responsive to some extent to antidepressants and other drugs acting on the nervous system (eg anti-epileptic drugs); and
- poorly responsive to many pain killing medications.
Some causes of neuropathic pain include nerve damage due to surgery, trauma, compression from a cancer, back or spinal injury, diabetes and other disease.
In some circumstances, such as following traumatic injury or surgery, both types of persisting pain can occur.
Other factors that affect pain perception
As well as the physical mechanisms concerned, many other factors influence the way you perceive pain. These include:
- the degree to which it has changed your life, both physically and mentally;
- cultural conditioning - different cultures vary in their acceptance of disability associated with persisting pain;
- home and/or work circumstances such as how much family support you receive or your type of job;
- secondary gains such as attention from relatives or financial benefit from compensation;
- the coping strategies you have learned during life;
- the reaction of (or reinforcement given by) others, including health workers.
Changing pain perception can be a long and challenging task and all the above factors need to be addressed openly for the best chance of success.
Tackling pain: teamwork required
As with many chronic conditions, there are numerous treatments offered for persisting pain - some despite little evidence of benefit. The trick is to find which ones work for you. With this in mind and accepting that individual treatments for specific conditions may work well, you should always:
- ask for (or seek out yourself) good evidence that the treatment being offered works; and
- acknowledge that some diseases have no cure and accept this.
This can save you wasting time (and often money) chasing non-existent cures or, even more importantly, stop you from delaying focusing on the benefits of adapting your life in ways that are proven to help manage the problem.
What has been shown to work well is a team approach. This includes input from doctors, psychologists, physiotherapists and occupational therapists. These teams are often based in specialist pain clinics in hospitals. They aim to improve pain management and restore as much of your physical and social activity as possible.
An integral part of achieving these goals is psychological assessment and treatment which targets altering your pain perception and response.
Cognitive Behavioural Therapy (CBT), which helps people modify the way they think about and react to a problem, has been shown to be very helpful in managing persisting pain (see box overleaf).
A psychologist or psychiatrist can also help with anxiety, depression and many other common but debilitating problems that you may be experiencing.
The pain management toolkit: what's inside?
Addressing pain successfully is likely to involve a variety of techniques and interventions, including regular visits to your GP or specialist for review. These include:
- medication - a wide range of analgesics (painkillers) is available, from simple paracetamol and aspirin-like medicines to potent opioids such as morphine. Use depends on the individual situation. However, opioid use is increasing despite little good evidence of benefit in relieving persisting pain, especially neuropathic pain. Thorough assessment is needed before opioids are used. Other medication may also be offered, mostly for the relief of neuropathic pain.
- neuromodulation involves nerve stimulation via the skin using transcutaneous electrical nerve stimulation (TENS) or implanted devices and can help reduce pain perception.
- relaxation and meditation can help by reducing muscle tension and improving mental well-being.
- massage assists by giving a feeling of deep relaxation and calm through reduced muscle tension and increased joint mobility.
- maintaining a healthy diet and normal weight will improve your general health. There is little evidence that unusual dietary modifications or the use of dietary supplements help.
- acupuncture is widely used, although the evidence base for its benefit is at present not substantial.
- physical activity can aid your return to active life as soon as possible, including work, social and community activities. This may mean learning new skills with help from an occupational therapist and physiotherapist. It is important to establish realistic activity goals, usually achieved via a series of planned 'small steps'.
About the author: Dr Paul Goyen is a Sydney GP and author of 'Live Well, Live Long', published by Allen & Unwin. The book contains accessible information and advice about staying in good health and enjoying life.
Where to find help and support
Your local GP or physiotherapist.
- Your nearest major public hospital - ask about specialist pain clinics.
- 'Manage your pain - practical and positive ways of adapting to chronic pain' by Michael Nicholas, ABC Books, Sydney 2000, RRP $27.95.
- 'Change your thinking' by Sarah Edelman, ABC Books, Sydney 2002, RRP $29.95, is a good book on Cognitive Behavioural Therapy.
- Helpful websites include the Australasian Cochrane Centre at www.cochrane.org.au/index.html Select Cochrane Library, then log on and search for evidence about specific treatments.
Cognitive behavioural therapy (CBT) for persisting pain
CBT aims to improve the way people think about and react to their pain (ie develop better coping skills). Initially, the therapist identifies the unhelpful thoughts or beliefs that the patient has about their pain and the unhelpful behaviours the patient has adopted because of their pain. (It may be necessary to ask family about these behaviours.)
Once established, the validity of these thoughts and actions is challenged with the facts and helpful alternatives are then proposed. This process focuses on establishing realistic, achievable goals such as increased activity.
CBT is also very helpful in the treatment of the anxiety and depression that often accompany persisting pain.
Some common examples of 'unhelpful thinking' associated with persisting pain include:
I can't do anything to change the situation
Such thoughts can encourage you to take an unhelpful passive role in your therapy (ie the doctor will fix it). Most people can and do improve pain themselves through physical and psychological therapies.
Something has been missed - there will be a cure if I look hard enough
This belief can cause a focus on a non-existent cure rather than on improved coping strategies. Reassurance that major treatable illnesses have been excluded and that the chance of further injury is low is helpful.
Continuing pain means the injury is getting worse
Such thoughts cause anxiety and activity avoidance which, in turn, leads to muscle weakening. Increasing activity often leads to an overall improvement in pain, although pain may increase temporarily in the process.
I can't do things when I am in pain
Doing things in the presence of pain can actually reduce pain perception and helps increase general activity levels.