blossom of snow

Deciding when to say when: pain cure? or pain managed?


I think the subject of this post is the singularly most important yet neglected topic in chronic pain research today. When is it time to say “All this looking at pain cure, or reducing your pain isn’t working, it’s time to accept that pain is going to part of your life.” It’s difficult for so many reasons whether you’re the person experiencing the pain, or the clinician trying to help. It’s also incredibly important for everyone including our community.

Cures for pain that persists are not easily found. One possibility is that the underlying disease or dysfunction has not yet been treated – pain in this case is the experience we have when there’s an unresolved threat to body tissues. Find the source of the problem, treat it, and voila! No pain.

Another possibility is that a new or groovy treatment has been developed – something extraordinary, or something that’s being applied to a different problem or something that’s emerging from the experimental phase to clinical practice.  This means clinicians need to have heard about it, maybe will have had to think hard about their clinical reasoning, have developed skills to apply it, and be ready to talk about it with the person they’re treating.

In the case of much chronic pain, pharmacological approaches simply do not work. Machado and colleagues (2009), in a large meta-analysis of placebo-controlled randomised trials, found 76 eligible trials reporting on 34 treatments. Fifty percent of the treatments had statistically significant effects, but for most the effects were small or moderate … the analgesic effects of many treatments for non-specific low back pain are small”, while Machado, Maher and colleagues found that paracetamol was “ineffective” for reducing pain intensity or improving quality of life for people with low back pain, and although there was a statistically significant result for paracetamol on osteoarthritis pain (hip or knee), this was not clinically important (Machado, Maher, Ferreira, Pinheiro, Lin, et al_2015).  Clifford Woolf said “most existing analgesics for persistent pain are relatively ineffective… the number of patients who are needed to be treated to achieve 50% reduction in neuropathic pain in one patient is more than four – a high cost for the three unsuccessfully treated patients and their physicians” (Woolf, 2010).

Woolf’s sentence ends with an important statement: A high cost for the three unsuccessfully treated patients and their physicians. I have emphasised the final three words, because this might be the most difficult to process. It’s hard for clinicians to say “I can’t reduce your pain”, and “there isn’t a cure”. It’s incredibly hard. And it’s perhaps because it’s so hard that I’ve found very little published research looking at the way clinicians go about telling people their pain is likely to be ongoing. It’s like a taboo – let’s not talk about it, let’s pretend it doesn’t happen, after all it doesn’t happen often.  Really?

Amongst allied health (I can’t bear to use the word “non-medical”), and in particular, physiotherapists, there continues to be a push to address pain intensity and (ultimately) to cure pain.  Innovative treatments such as mirror therapy, graded motor imagery, therapeutic pain neuroscience (we used to call it psycho-education in the 1980’s when I first started working in this area), reducing the threat value of the experience have all come into their own over the past 15 years or so. Even long-standing pain problems apparently respond to these approaches – people cured! Who wouldn’t be keen to try them?

Most of these latter treatments are based on the idea that our neurology is plastic; that is, it can change as we change input and thoughts/beliefs about what’s going on.  Unfortunately, the systematic reviews of trials, and at least one “real world” trial of graded motor imagery haven’t shown effects as great as promised from the early research (eg Johnson, Hall, Barnett, Draper, Derbyshire et al, 2012). There are sure to be people who can point to amazing outcomes in the people they treat. I’m certain that it’s not just the “treatment” but an awful lot to do with the person delivering the treatment – and the treatment context – that might make a difference to outcomes.

But where this all leads me to is who makes the decision to stop chasing pain reduction and pain cure? When does it happen? What’s the process? And what if we treatment providers are actually prolonging disability out of the goodness of our hearts to find a cure?

Let me unpack this a little.

In my research, several important factors led to people deciding to begin flexibly persisting (and getting on with life as it is, not as it was, or might be).

  • The first was knowing the diagnosis and that it would not be completely cured but could be managed.
  • The second, that hurting didn’t mean harm (pain is just pain, not a sign of ongoing damage).
  • The third, that there was something important the person wanted or needed to do to be themselves.

There were other things as well, like having a clinician who would stand by the person even if the person didn’t “do as the Doctor ordered”, and developing their own personalised model or explanation for their pain as it fluctuated from day-to-day. BUT the single most important factor was knowing that the problem needed to be managed because there was no cure. Knowing this meant that energy used chasing a cure was redirected towards learning to live well and be the person they were, rather than a patient or being dominated by pain.

Unfortunately, I think that many clinicians confuse the idea of managing pain with that of resignation to a lesser life. Even the wonderful Lorimer Moseley and crew wrote recently that “CBT literature seemed to focus on this idea of ‘pain is now unavoidable so it is now time to learn how to cope with it.’ He goes on to argue that because a CBT approach focuses on thoughts and beliefs (much like Explain Pain does), it’s not incompatible with the idea that the plastic brain can learn to reduce the threat value even further to ultimately “helping them live well with less pain, or perhaps without any pain at all.”

Here’s my concern: Right now there are many people living with chronic pain who have lost their sense of hope. They’ve pursued pain cure after pain cure, and in doing so, they’ve lost normal routines and habits, lost their usual occupations (activities), stopped being around people, stopped working, and have suffered in the true sense of the word – they’ve lost their sense of self. While I applaud the efforts of researchers like Moseley and colleagues, and I think we must continue to seek treatments to reverse the neurobiological underpinnings of pain, at the same time I think we need to look at the psychological and social aspects of our attitudes and expectations towards experiencing pain. And we must think of the negative effects of our emotional response to seeing another person who is experiencing pain.

Is it so terrible to experience pain every day? Speaking as one who does – despite my knowledge of neuroplasticity – my pain doesn’t represent a threat. It’s just an experience. It’s there. I notice it, I can feel it. And the participants in my research similarly acknowledged pain as present – but it didn’t have the emotional primacy that pain can represent before it is explained. In fact, some of the participants said they’d learned important things because they’d had pain. A lot like having a mood disorder (that must be managed), or diabetes (that must be managed), or heart disease (that must be managed), or respiratory disease (that must be managed), perhaps it’s OK to have pain – that must be managed. Because until our research has advanced a LOT further than it has, there are an awful lot of people living with chronic pain, and who will continue to live with chronic pain. And even more sadly, there are an awful lot of people who don’t even get the opportunity to know that it’s possible to live well despite experiencing chronic pain because we (as part of society) still don’t accept that pain can be present without it being a threat.

Sometimes I wonder at our (clinicians and researchers) blind spot. We just don’t seem to be ready to accept persisting pain as something that can be lived with. Is it time to look at our own discomfort with allowing pain to be part of life?

 

Bowering, K. J., O’Connell, N. E., Tabor, A., Catley, M. J., Leake, H. B., Moseley, G. L., & Stanton, T. R. (2013). The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis. Journal of Pain, 14(1), 3-13.

Cossins, L., Okell, R. W., Cameron, H., Simpson, B., Poole, H. M., & Goebel, A. (2013). Treatment of complex regional pain syndrome in adults: a systematic review of randomized controlled trials published from June 2000 to February 2012. European Journal of Pain, 17(2), 158-173.

Johnson, S., Hall, J., Barnett, S., Draper, M., Derbyshire, G., Haynes, L., . . . Goebel, A. (2012). Using graded motor imagery for complex regional pain syndrome in clinical practice: failure to improve pain. European Journal of Pain, 16(4), 550-561.

Machado, LAC, Kamper, SJ, Herbert, RD, Maher, CG, & McAuley, JH. (2009). Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology, 48(5), 520-527.

Machado, Gustavo C, Maher, Chris G, Ferreira, Paulo H, Pinheiro, Marina B, Lin, Chung-Wei Christine, Day, Richard O, . . . Ferreira, Manuela L. (2015). Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials (Vol. 350).

Woolf, Clifford J. (2010). Overcoming obstacles to developing new analgesics. Nature Medical, 16(11), 1241-1247. doi: doi:10.1038/nm.2230

22 comments

  1. Thanks Bronnie! Your posts never disappoint….beautifully put. I agree that so many people are held back by our fear (as professionals) of looking beyond the biological and actually paying attention to the reality that comes with patients.

    1. Thanks so much Ethel. I wrote this with a little trepidation because I know it’s a touchy subject, but at the same time I can’t ignore the qualitative research from people living with pain. This research indicates that people really need to know that it’s not going to go away – but we need to learn how to convey this in an appropriate way.

  2. Bronnie, as always you are speaking directly to me with this post! Yes, yes, yes! This is me, a person who has pain and successfully and meaningfully lives with it without it overly concerning me anymore, without it consuming my thoughts and causing anxiety and worry and a sense of always having to work toward getting rid of it or making it better. When that is our constant focus we set ourselves up for failure when the pain sticks around, which it’s going to for a whole lot of folks.

    But having pain that is not eradicated or ‘cured’ is not a failure in my view, instead I see failing to live a valued and meaningful life waiting for the pain to go away is a much bigger travesty. It wasn’t until I stopped battling the pain, stopped waiting for the pain to go away, and finally accepted pain as a part of my life that I was able to get on with living. And accepting the pain didn’t mean I gave up or conceded to it, it wasn’t a battle to be won (that mindset hurt me for too long), I just made space for it so I could make room for all the other things in my life that mattered to me – my husband, my dog, my family and friends, my writing, getting out into nature, getting back to trail running, photography, sharing my story and trying to help others change their pain experience – so I could get on with living, not waiting, not fighting, not failing: living.

    Once I made this switch in how I viewed my pain experience, once I removed the negative valence from the words ‘chronic’ and ‘pain’ and just accepted them as a part of the human experience and not one that need be overcome to live meaningfully and successfully, the meaning of my pain changed – that’s the greatest success! The pain no longer meant that I was less than I was before or that I was less than others who have overcome their pain. The pain no longer meant that I needed to suffer or fight or concede – those were no longer my only options. Once I understood the nature of pain a bit better, once I knew that I wasn’t under threat even though the pain was still there, the pain stopped being a limiting factor, I felt comfortable and confident in pursuing my life, living my life, enjoying my life. Changing my understanding of pain meant that I could do all that matters to me, even when it was still present.

    But I had to stop defining success as the pain being gone, because what if it’s never gone, despite all my knowledge and all my best efforts? So that no longer became my measure of success, how I was living my life became my measure of success. It took pain’s power away when I no longer felt like I had to get rid of it. It no longer defined me or limited me. I was no longer a person with chronic pain; I am just a person who experiences pain, just as I experience joy and happiness and sadness and frustration and calm and anger and curiosity and stress and exultation and anxiety and hope and excitement and disappointment and laughter and love. I am just a human with human experiences, of which one is pain. By no means does that one experience define me, just as no one of the others does, I am a combination of all of my experiences.

    And I like being human! And so I want to have as many human experiences as possible, which wasn’t possible when I was in my little world of pain. It wasn’t until I understood pain, though, that I could expand my world and get back out into it. It wasn’t until pain became non-threatening, even if it was still there, that I felt I could get back to living and loving and life.

    That’s success. At least to me.

    1. Oh thank you so much Jo! Again, such profound words from you, such amazing insights. I found this ” I see failing to live a valued and meaningful life waiting for the pain to go away is a much bigger travesty” and “Once I understood the nature of pain a bit better, once I knew that I wasn’t under threat even though the pain was still there, the pain stopped being a limiting factor, I felt comfortable and confident in pursuing my life, living my life, enjoying my life. Changing my understanding of pain meant that I could do all that matters to me, even when it was still present.” SO incredibly important!

      Experiencing happiness, sadness, disappointment, joy, pleasure, disgruntlement (is that even a word?!), and pain ARE human experiences. And while I think it’s trite to say that you need the negative to fully appreciate the positive, it’s true to say that these opposites give us insight into other dimensions of being that we would be the less for, if we didn’t have them.
      I so appreciate you taking the time to comment, having your voice in this necessary but neglected conversation is critical.

      1. I am so thankful you are such an advocate not just for pain science and pain education and pain treatment but for chronic pain patient’s voices, too. You have no idea how much that means to me and how much I value and treasure your support and your ongoing contributions to my own ability to change my pain and live my life.

  3. Hi Bronnie. I liked your blog but it also raises more questions than it answers, but that’s life. I’ll play devils advocate here a bit, and I hope I don’t over simplify the thread of your blog. As a practitioner people come to me for hopefully an answer,help, and God forbid, maybe even a cure, mostly for pain , or 95% of them do anyway. I think pain has been poorly managed by health professionals for a long time.I also applaud Moseley and Butler’s work to try a bring some positive influence into this area. But…is the general public ready or willing to accept the new paradigm? It’s a very delicate area to start to suggest to patients that experiencing pain is ok, if not delivered correctly, you better be able to duck quickly if you know what I mean! That’s at worst, and at best, the patient leaves crestfallen with their impression of the consult being “they said there is nothing they can do for me”. I am constantly trying to reconceptualise patients perception of pain, but at the end of the day it’s generally an unpleasant experience that’s hard to talk up. Imagine someone who hates chocolate cake with a passion, but constantly telling them, “it’s nice, just try it” , I’m not trying to be flippant, just using a metaphor. I could ramble on for hours here and probably not say much. So maybe I’ll just say pain is complex and humans are even more complex, and I like your blog!

    1. Thanks so much for your kind words. I agree, this is complicated and pain is weird. I think proposing that pain is something to accept needs to be taken in context and as part of an interaction between a person experiencing pain and a person hoping to help. I think people living with pain need to, as I said in my blog, have been able to “make sense” of their pain, knowing their diagnosis and what it means, understanding their range of symptoms and how these are affected by various factors, and being able to just “exist” for a while without taking on new challenges. I think the experience of deciding occurs naturally in the presence of a trustworthy clinician, one who says he or she will partner the person as they find their own way through learning to live with pain. I think it depends SO much on occupational drive – the drive to engage in the occupations that make up a sense of self. Without these things, I think we would naturally expect the person to be distressed. BUT I also think that being realistic about the dismal outcomes, particularly on pain intensity, from most treatments is just as important. Expressing these outcomes in terms of numbers needed to treat and “real world” results is equally important. And identifying the opportunity cost of engaging in a treatment must also be considered. Then in the end, it’s not MY choice, it’s the person living with pain who makes the decision. The problem is I don’t believe many people living with pain EVER get to hear that it’s possible to live well WITH pain. Where are our pain heroes? We have depression heroes, asthma heroes, cancer heroes – but no-one is put forward in public health announcements showing that despite living with pain it’s OK to go and be who you really are. Given this, and the existing media messages around pain (the “war” against pain, the constant description of pain “sufferers”, the emphasis everywhere that to have pain is bad, not normal and must be removed, and it’s no wonder people living with pain continue seeking help – and we as health professionals also think that having pain is bad.
      The point is, people living with pain are living with it anyway. I’m suggesting that health professionals might consider open discussions about the cost of seeking treatment at the expense of opening up to do things that are meaningful. Opportunity costs of treatment include all that time sitting in a waiting room, or waiting for results, or putting life on hold while a new treatment is tried, not including the time spent doing all the things health professionals think should be done to reduce pain. Isn’t Moseley’s GMI meant to be done five – ten minutes every hour every day? And what does that do to the ability to return to work, play with the kids, have a beer with the lads, or simply laze about NOT thinking about pain? The opportunity cost is also the cost of NOT looking at what CAN be done.
      The general public isn’t ready to think about chronic pain in general, I’d say. But I’m not talking about the general public, I’m talking about people who are living with this experience and want to have lives full of meaning and joy and rather less grind and “exercises”.
      Thanks so much for commenting – despite my fiery rebuttal, I completely understand where you’re coming from! I don’t have “the” answer, but I hope to start the conversations – like this – and it helps me, and people living with pain, begin to ponder what the alternatives might be,

    2. As a patient I’d like to add my perspective on interactions with healthcare providers. First, I don’t think it gives enough credit to patient’s to think that they can’t understand the difference between ‘there’s nothing they can do for me’ and “the doctor actually listened to me and took the time to explain to me what pain is and what contributes to it and he gave me all these resources for me to be able to manage my pain and get on with life. My pain condition is something that may be around for a while but it no longer has to limit my life, I now understand that pain isn’t something I have to fear or worry so much about and I he gave me permission to get on with life while still holding out hope for one day overcoming pain’.

      When patients go to a doctor for a cure, they expect a cure. If the cure doesn’t work, they have failed yet again, they have more reason to lose hope, they feel defeated and depressed and go to some deep and dark places, at least I did when I kept seeking the solution in a person or a method and those person’s and methods didn’t work for me. I felt I failed as a patient and that I was doing this whole pain thing wrong because the pain was still there.

      Is this a better scenario than explaining to a patient that chronic pain is complex and that there are many factors that contribute to it and that while sometimes not all of the pain will go away, that doesn’t mean that we’re damaged or broken and in need of fixing. Because so many things contribute to pain, we have lots of entry points into changing it and being able to live with it and that when we do this, the pain becomes less, not always in intensity (though often it is), but it becomes less prominent in our lives and allows us to pursue the things that matter to us.

      To me, being given realistic expectations is much more important than being given false hope, which in my view is much more harmful to the patient, though it may make the healthcare provider feel better (not a dig, just my perception). For patient’s whose pain persists, those given realistic expectations have been given the education, tools, and ‘permission’ to deal with it and get on with life while those given false hope just keep seeking that next doctor, that next method, that next fix that will ‘cure’ there pain and in the mean time put life on hold.

      Being truthful and realistic is not painting a dismal picture – it can actually give patients hope and reassurance. They are not failures. They are not to blame, just as their healthcare providers are not to blame. Once I accepted that the pain might not go away, I was able to start living again. It doesn’t mean I’ve given up hope of a cure, I’m just not waiting for it any more.

      It’s not an easy conversation to have but it’s a necessary one if the patient has any chance of living their life. We need to stop pussy-footing around difficult conversations around personal responsibility and being active participants in our health, the more we continue to foster the notion that we have to go to the doctor to fix what ails us, the sicker we’ll all remain. Patients need to be empowered to manage their own health, all patients, not just pain patients. We’re the only ones living in our bodies/minds 24 hours a day 365 days a year.

      Do people want to hear it? No. Does that matter? I don’t think so. I’m not saying to be crass or harsh, but we need to be honest and face these truths together so we can start coming up with some better solutions, our current models aren’t working.

      I apologize for getting all amped up! I’m just frustrated in general on the passive medicalization of pain patients when I think that is the worst thing for them. And they’ll never get out of that passive, someone needs to fix me mode if we don’t start having different conversations.

      I appreciate you being the devil’s advocate and bringing this perspective to bear because we need to have these discussions so we can figure out the best way forward.

      1. applause
        Thank you Jo, that’s put in words exactly what I’ve seen in people I’ve worked with – the anguish of hope then despair seems so much more difficult to deal with than learning that yes, pain is complex, and for this reason it’s possible we don’t have all the answers, but we have many ways “in” to change the experience and live well. You have my utmost respect.

      2. Thank you, Bronnie! And I you. You mentioned how we need pain heroes in your initial reply and you are definitely one of my pain heroes! I am grateful to you.

        I think so much of this comes down to how we define success when it comes to managing/treating pain – for both the patient’s and the practitioners. If it continues to be ‘curing’ pain, too many patients will fail treatment and too many practitioners will feel like they’re failing their patients. But that doesn’t have to be the case! Both patients and practitioners can be successful if we change our understanding of pain and our definitions of what a successful ‘pain patient’ looks like. I think we can make huge progress in pain treatment if we do so, on both sides of the equation.

  4. Thanks for this post Bronnie, and for the great comments already posted above. As an OT I do struggle with the right way to say that it’s time to start living your life in spite of this pain that isn’t going to go away. I think it’s important to first listen and discuss how pain works before rushing to the next steps. Now, I’m experiencing pain myself. I grieved a bit, but then chose to be as active as possible since that wouldn’t make it worse. We met in Edmonton when I was about 6 weeks post-ankle surgery. Now, it’s been about 3.5 months and I’m walking without a cane. I have found that when I can exercise enough, it really helps! It is still possible that my pain will go away in time when the nerve injury heals, but this pain experience has been meaningful. I hope it will give me the credibility to have these conversations with clients.

    1. Well done you! That’s awesome Bonnie, to know that you’re beginning to walk without a cane! So, if I understand you right, it seems that you “made a decision” to be as active as possible because it wouldn’t make it worse – but I’m curious, did you have positive reasons to “make that decision”? ie did you have something important (or more than one thing!) that propelled you forward to keep doing things?

      1. I did have something. When I chose to have surgery, I had clear functional goals, not pain relief as my important outcome. The surgeon seemed to appreciate that. I’m well on my way to achieving my goal of hiking with a stable ankle. I’ve already done some easy hikes. I still have in mind the hike I will do in Lake Louise to the tea house that will be the real endpoint of this journey. It’s also good to be back to work. I’m feeling very appreciated lately.

  5. Hey Bronnie – great post!
    I want you to know that there are some who are using the new information from pain science, as well as pain neurophysiology education to teach people options and alternatives for moving with more ease. Many clinicians might be thinking that explain pain is about teaching people to cure pain – I don’t know. However, there are a bunch, at least, who are using this same education and information to help people find more ease of movement, and improved quality of life. Sometimes finding ways to move consistently with more ease, and to have more peace in life will lead to less pain – sort of ‘whittle it down’ a bit, as we are told by some with pain.
    I find it of huge interest that for some people, understanding pain physiology provides the information needed to consistently perform techniques, that in the end allow for less pain and greater ease of movement. As if the knowledge is the proof required to continue when things don’t change right away. For others it is the proof that there are ways to move that aren’t so bad, that allows us to stick with being active as we are able.

    It is also of huge interest that for many people in pain, the manner in which professionals educate them to move is not consistent with the information they teach in pain neuroscience education. That is a huge problem too.
    Many don’t have the skill or understanding to provide this education without turning it into something that sounds to people in pain as if we think that pain is a cognitive emotional problem, unrelated to the state of the tissues.

    Anyway – don’t loose all hope that some good will come from the pain care education we provide. Chances are there will be some new charismatic teachers coming along who will better integrate the lived experience of pain into these new ideas of pain education.

  6. Thanks so much Neil. I was responding a little to Lorimer Moseley’s comments in Body in Mind where he says that “It seems to me that scientific evidence compels us to extend the idea of helping people live well with pain, to the possibility of helping them live well with less pain, or perhaps without any pain at all.” While I’m comfortable with this idea for the future, I don’t see this as realistic right now.

  7. This is all so brilliant and I hope that you can continue to find ways to reach a wide audience. It’s taken me years to get to the level of acceptance I now have about my condition, and it’s that acceptance that has helped me to live better, and be healthier. The energy and disappointment in searching for the perfect solution where it does not (yet) exist was exhausting. Acceptance of a life with pain doesn’t mean I’ve given up hope; just the opposite: I’m learning to live well with pain.

    I am a pain hero!

    A little anecdote:
    I recently had an experience where after seeing multiple gastro docs who were unable to help my symptoms (but who did not put this reality into words as seems to be the norm) I saw a new gastro doc who told me this:
    “You’re doing everything you can and taking great care of yourself. As this is an ongoing issue with no magic cure that is not causing damage, it’s okay if you want to stop seeing us and manage this with all your other supports.”

    At first I was disappointed that this new doc didn’t have medical answers, but ultimately, the relief I felt after seeing her was incredible. To hear that I am living the best I can with the pain was validating, and to hear that I didn’t have to keep returning to their clinic month after month for more useless tests and the same advice over and over means I can conserve my energy, and probably have less pain as a result.

    Sure, patients don’t likely want to hear off the bat that they need to work on acceptance; there’s a natural and necessary fight that most of us engage in first, and that makes sense! Of course we want to look for all the possible answers to wellness. But there comes a time when acceptance is also helpful and necessary, even if at first it’s hard to hear.

    I’m lucky to have friends with chronic pain who shared this wisdom with me early on. It made the road to acceptance just a bit smoother.

    Bronnie, I have such deep respect for your work. It reflects the reality of my lived experience so accurately. I hope that you are able to continue this work for a long time. If I can help in away from afar, please let me know.

    1. Anna I have tears in my eyes at your wonderful words. Thank you SO much. It’s not always very easy to bring a controversial point of view to this kind of healthcare, but I think (and completely confirmed by your comments, and those of others who have been so generous with their words and time) that it’s a critical part of being there for people who have this chronic health problem. Likewise I think your work is SO important. It’s not very often that the very people health professionals want to help actually get their voices heard, and it strikes me as very odd. You are totally the Pain Hero!!!
      And please, let me know if there’s anything I can do to help you with your work. This is a lifelong thing for me (so completely nuts!) but also I hope will become a movement that gathers momentum and brings a revolution to the way we as health care professionals and we as people living with pain can come together to make our lives more enriched and fulfilling.

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