hydrangea

Divergent pathways in pain management


I’ve been watching and listening to discussions about what is important in pain management over many years – the debate between reducing pain or improving function as the priority continues.  Often it’s a divergence of opinion between the ‘interventionist’ medical team and the ‘self management’ therapy team – and it can lead to some mighty divisions that don’t seem to resolve.  Of course, it’s not a simple one or the other… but over time the focus can and should change – when the emphasis should shift away from pain reduction is the multi-million-dollar question!

In this particular debate, the waters are very murky indeed because, as most of us know, given the possibility of removing or eliminating pain, patients (and yes, I include myself here!) would just love to at least try something that might ‘work’ – and in acute pain, usually it does.

Our problem is that as humans we all seem to have a tendency to maintain this focus on pain=bad-let’s-get-rid-of-it even when the pain is ongoing, the investigations time-consuming and tedious, and the interventions have minimal effect and it all gets in the way of living life.  As humans we’re pretty good at overlooking the negative on the off-chance of a positive (think of our hardy gamblers!).

In the literature on chronic pain management, studies can focus on either pain reduction as the primary outcome (but fail to consider reduced distress, increased function, or any of the other psychosocial factors that might influence pain intensity), or on disability reduction.  The problem is that even when a study looks at disability reduction, if it’s reported in the media – and pain reduction is included as one of the outcome measures – pain is the part that catches the attention! And it’s not only media, it can grab the attention of naive readers – and those with a purist set of assumptions about pain and disability such as the purely biomedical model.   One medical practitioner told me that if the pain is abolished the person ‘reverts to normal’ and any psychosocial factors no longer count.

This view fails to recognise that people are not just their bodies.  They’re not passive recipients of information.  They live in a continuum of experience – past experiences, memories, expectations, attitudes – and future predictions, interpretations and beliefs based both on what they’ve personally experienced and what they’ve seen and heard from others (or the media).  If they’ve had a successful procedure to rid them of their pain – they still process the meaning of their pain (and the procedure) and its not always ‘life as normal’.

The argument for focusing on pain reduction is often based on the ethical drive to ‘reduce suffering’. I have no problem with this at all – reducing suffering is surely one of the reasons many of us chose to work in health.  The problem I have is with the idea that if someone is experiencing pain, he or she is also inevitably experiencing suffering.  The concept of suffering involves the person making a judgement about his or her experience – is it ‘good’ or is it ‘bad’?

I’m sure we can all think of situations in which we as clinicians are comfortable not only with personally undergoing a painful procedure, but also inflict pain on another person.  Just ask the mother cleaning a child’s graze! Or the nurse giving an injection.  Or the physiotherapist carrying out a stretch on a person’s limb.  There are also plenty of activities that we do as humans that involve pain – ever watched a marathon runner at the end of a race? A rugby player in a tackle?

Humans can experience pain and not suffer.  And people with ongoing pain can, and do, live really good lives despite having their pain, and in many cases, decide not to look for treatment because pain is seen a simply part of life and of little consequence.

Disability in chronic pain is about the effect of pain on function. The ability to do things that are important in life.  Disability is influenced by so many more things than just tissue status.  It’s about the physical environment – if a checkout operator with back pain can vary her standing and sitting positions throughout the day, she can maintain her work status.  It’s about the social environment – if that checkout operator’s supervisor allows her to take short breaks or stretch or wear flat shoes, she can stay working.  It’s about beliefs and attitudes – if that checkout operator believes that her back pain is ‘just a sensitive nervous system’ and that it’s OK to change the way she does things, she’ll probably stay working.  It’s about healthcare provider’s attitudes and beliefs – if the checkout operator’s GP thinks it’s healthy to stay at work, and supports her with a health certificate that says she is OK to work, she’ll probably do so.  And so many more factors that I haven’t listed.

To return to my original observation – the divergent pathways in pain management.

There are several reasons for focusing on pain reduction especially in the early stages of an injury.  Yes  it’s about relieving suffering, but it’s more about facilitating return to normal movement and activity. This helps people remain in their job, their family roles, keep exercising, and probably normalises the input from the body to the neuromatrix, reducing potential neuromatrix disruption.

Usually this emphasis is only needed in the short term because acute pain does fade away over time, and most people start doing normal activity despite having a bit of an increase in pain – it’s seen as ‘normal’.

It’s when the pain doesn’t reduce over time that the debate heats up.

Because pain relief is effective (at least a bit) for most problems, it seems pretty sensible to carry on finding ways to just do this for longer. But if it’s not effective, or only partially effective, or effective only for short periods of time, or fails to change function, or becomes the focus rather than being seen as a means to an end – then it gets in the way of the real reason for living, and that is to live!  To do things, to be the person we’re meant to be, to occupy that role or purpose that only you or I can do.

And so, I think part of the problem with pain management is that people forget why pain becomes a problem – it becomes a problem because it interferes with living life.

As a result of this gap in our collective memory, the pursuit of pain reduction can become all-important.  Even when there are ways to reduce suffering and disability that don’t change pain but do enhance living well!

Do I think we should eliminate the search for pain reduction? Well, don’t be fooled – that’s not what I intend at all!  I just think that the emphasis on reducing pain as a priority shouldn’t divert our focus from why we want to do this in the first place.  I also think the emphasis shifts as pain persists.

Because of our human drive to fix on simple solutions, quick fixes, and because of our cognitive biases toward doing what has worked once (even if it doesn’t work again), following what other (influential) people suggest, confirming what we already suspect rather than looking at alternatives and so on, that’s not an easy shift to make – either for some health providers, or some people with pain.

If our focus moved from considering the problem of ‘chronic pain’ but instead redefined the problem as ‘chronic disability attributed to pain’ maybe our focus could become clearer.  We could start to look at the multiple factors that influence disability rather than the simple but oh-so-poorly-correlated pain and disability equation.  Maybe we would measure disability rather more than pain intensity. Measure attitudes towards activity and movement rather quality of pain.  Things like sleep, mood, interference, role fulfilment would become the target of intervention rather than just pain intensity.

Would this mean pain intensity wouldn’t be addressed? Not at all – but the emphasis over time would, and the total burden of seeking and receiving treatment would be included in the equation.  How many hours do people with disability attributed to pain spend sitting in waiting rooms, waiting for investigations, waiting for reports, waiting for someone and something else to happen while life passes by?

If there’s a pathway that I think has got hidden by the undergrowth of biomedical power, prestige and popularity, it’s the one leading to living well as a person.  And I think the signpost to it says ‘Pain management is about living well’.

7 comments

  1. I agree.
    Sometimes when pain is reduced a person does not learn how to cope better. If there’s pain once, there’s likely to be pain again in some way later. We’re all growing older after all if nothing else. So we have a societal addiction to “looking young, acting young, etc.” Doesn’t this make it harder for us all – also?
    Anyway, as one with fibromyalgia and arthritis, my pain level becomes more or less manageable day to day. I think it’s important to have the motivation to learn to cope better and that sometimes doesn’t come with too much pain reduction too quickly.
    I’m probably in the minority.

    1. Nope, I don’t think you’re in the minority – but because people like you don’t go off looking for treatment all the time, you’re not as easily studied. People who are more distressed, feel more disabled by their pain look for treatment, get treatment – and maybe some of the mechanisms that lead to them looking for treatment also maintain them in that mode (by this I mean social/psychological mechanisms). I think we’re all prone to loving the quick fix (liposuction instead of a diet?!!) but in pain it’s so much easier to be encouraged and supported down this track even when it doesn’t really help reduce disability because of the myths around pain=reason for disability. If only it were so simple!

  2. Once again I love your posts – thanks.

    To further your ‘arguments’…

    It seems many people view decreasing suffering for those with complex pain problems with the same model they would use for those with severe pain in a palliative care situation. In this latter situation, function is not typically a high priority for the person in pain. So the focus of intervention is on decreasing pain and suffering.
    The situtation of a person experiencing intense pain while dying, and also wishing to not receive medication so they can maintain their cognitive abilities certainly supports your discussion as well.

    In these same medical professions AND in the self-management arena is the view that we treat chronic pain as a problem that is identical to other chronic illness such as diabetes. There are similarities in the problems and in the self-management techniques that help. However, science and clinical practice tell us that it is possible to change pain through self-management – thanks to neuroplasticity.
    The point we get to is that it is possible, and preferable in the long term, to have the following goal: any intervention for the person with pain should decrease pain, improve function, and/or improve quality of life. A focus on only pain, suffering or only function is guided by out-dated scientific paradigms. I believe this is your point as well.

    It seems that any intervention that decreases pain but does not alter function and/or quality of life is likely not going to be benficial in the long-run. As you say, our focus seems to be on the quick fix. This extends itself even into self-management where distraction is often recommended as one of the ‘best’ techniques for pain control. A considerable amount of research supports opposing views to the usefulness of distraction for chronic pain management, and in clinical practice it seems rare to find that a person can use distraction as a technique that leads to recovery. As in the case of dissociation, masterful distraction has a place in immediate pain control, but less so in long-term control.
    My guess is that distraction and other powerful immediate ‘fixes’ for the pain don’t lead to adaptive neuroplastic changes.

    Much of the research is now looking at the changes in the brain, spinal cord and peripheral nervous sytems that are associated with chronic pain. Some researchers are moving forward with studies showing that these dramatic shifts in the chemistry, function and structure of the nervous system can be changed back towards ‘normal’ with specific interventions. Incredibly, when these neuroplastic changes shift back towards normal, there is an associated decrease in pain, along with the improvement in function. That’s promising! And much more likely to be effective that asking people in mod-severe pain to do their best to ignore and push through their pain so they can improve their function despite the pain.
    You point out that chronic pain is multifactorial, and as such, when one of the problems caused by the pain is ‘fixed’ it is not necessarily so that all the others return to normal as well. That’s not so promising. However as a clinicians this means that usually the person in pain will need to work on many aspects of problem concurrently in order to attain the best recovery. Science supports that too! There’s usually no magic fix, and interdisciplinary treatment is typically most beneficial.
    For the person in pain, it’s all easier said than done, and rarely is it simple.

    Neil

    1. Thank you for the compliment! I’m trying to ‘think out loud’ I think, so the questions I ask everyone are the ones I’m asking myself both as a person with pain and a clinician/researcher/teacher. I think it’s great to know that neuroplasticity offers an opportunity for the breain to get its act together again, and to know that pain reduction is a possibility – the risk is for that to be the target and focus, and I think this leads some people to ‘hold out’ for pain reduction when (a) it may not happen for a long time and (b) it may not happen at all because the pain is not simply about cortical processes but also about other neurobiological processes below the cortex (and including inflammatory/hormonal/biomechanical etc influences). It’s something I have seen with people doing mirrorbox and motor imagery for CRPS – when the pain doesn’t reduce, they can become incredibly despondent and lack the drive to look into the other parts of their life that ARE working well – and subsequently lose those good things as well.
      So it is most definitely a multifactorial problem, and requires us as both clinicians and people with pain to look beyond linear processes and into networked serial processes. Sometimes this is incredibly difficult because people with pain are also trying to be good partners, parents, workers, and maybe even have fun, relax, go on holiday, do the gardening and even grow and become more than who they were before their pain – and there’s no doubt that treatment takes up time.
      It’s partly the complexity that makes this field so exciting to work in – and also so demanding and difficult. I hope I have a long life to keep learning about it!
      cheers
      Bronnie

      1. I’m with you Bronnie. We’ve got to work on all aspects of the person, and expect that changes will not happen quickly. (sometimes 40-60 hours of practice to create a new neurotag)
        One of the limitations to recovery, I think, is our theoretical construct of pain. For most, we view pain as linear, rather than circular, fluid and dynamic. Even when we clinicians discuss the biopsychosocial model and the pain neuromatrix model, there is a striking tendency to treat them as linear – which of course pain is not, as you have pointed out.
        If you have time to say more about “pain not being simply about cortical processes’, I would love to know.
        I guessed that the ‘neuroplasticity techniques’ were about changing processes in the ACC, insula, thalamus, hypothalamus, amygdala and hippocampus,…, and also the prefrontal cortex.

        neil

      2. The experience of pain is cortical, certainly – we have to be conscious to feel pain – but the contributing factors are both peripheral and central, such as inflammatory responses – probably drawing on Clifford Woolf’s work I think…Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management, Clifford J. Woolf, MD Ann Intern Med. 2004;140:441-451. So I suppose I’m getting at the thought that the pain experience is cortical while the contribution from the periphery can have ongoing influence over the experience (along with those other psychological and social aspects). Not sure I’m making sense to myself at this point, but I agree with you that the pain experience isn’t linear – from periphery to central mechanisms, it’s just as equally from the central to peripheral – and central processes being influenced by psychological and social means. I am a bit of a reductionist in some ways, in that I do think over time we wil be able to understand the mechanisms that produce ‘psychological’ aspects of people such as attention, attitude, belief etc – at the moment we’re limited by our technology and the models we have. At the same time, there are both micro and macro ways of looking at the world – and something comes from the interaction of individuals within a system, and this can also influence what is and isn’t construed as ‘pain’ – probably goes back to the old disability vs impairment distinction too.
        Thanks for the challenge!

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