A Pain Physician on Why Chronic Pain is So Confusing and Agonizing
Reading Time: 5 minutesHave you consulted doctor the pain that affects your ability to enjoy life? Participating in activities you used to enjoy? Even just being with your family and friends? Have you gotten every lab and imaging test but are still left with more questions than answers? Have your complaints of persistent pain been dismissed as psychological or “all in your head”? If any that resonates, you aren’t alone. As a pain physician, patients come to me with these frustrations every day. Chronic pain is a common experience of the over 50 million Americans, according to the CDC. What really is chronic pain? When many people think of pain, they think of acute pain, such as a broken bone or sprain. This type of pain comes from tissue damage. We can see a broken bone on an X-Ray or deduce a sprain from an MRI but we can’t “see” the pain. We can also view lab results that suggest inflammation, but we again can’t “see” the pain. We can’t know how another individual experiences it. Pain is more complicated than the simple equation of: broken bone equals pain. Soldiers with limbs blown off in combat have dragged other fellow combatants from the battlefield with their remaining limbs. If pain was tied only to tissue damage, these soldiers would be writhing in pain, unable to do anything except lay there and scream in agony. The International Association for the Study of Pain defines pain as an unpleasant sensory AND emotional experience associated with actual OR potential tissue damage. Put another way, tissue damage does not have to be present to have pain; pain involves the body and the mind. To treat pain, we have to address the body and mind. Acute pain – pain caused by tissue damage – is easier to understand and is something we are all familiar with. You might think chronic pain is just a temporal continuation of acute pain – pain that lasts longer than 3 months. There would be good reason to think this; after all Webster’s Dictionary defines acute and chronic as differences in duration and “chronic pain” in its simplest definition is pain that lasts over three months. But chronic pain is actually an altogether different beast than acute pain. If acute pain is a small wave; chronic pain is a tsunami. Acute pain tends to only affect one part of the body such as a broken or burned leg or arm. The treatment for this type of pain is staying still to allow the body to heal itself. Because the source of pain is usually obvious for acute pain, family and friends step up to help with tasks that the injured person can’t do and provide comfort and company during the healing process. Medications such as anti-inflammatories and opioids can help support the injured person as the body heals. Once the tissue heals, medications are no longer required and pain recedes. Life returns to its pre-injury state! In acute pain, the body is supported with rest and mind is supported by social supports. Pain eventually recedes like water from the shoreline. Chronic pain, on the other hand, can be in one part of the body but often affects many body parts or even the whole body. Chronic pain begets more chronic pain; it’s its own disease state. To understand this, we have to understand that the nervous system transmits all types of sensations from the external environment that is interpreted by your brain in different ways. What if this nervous system started to hotwire on its own? What if it generated sensations interpreted to your brain as painful without any physical trigger? This is chronic pain. Many people go to a physician when they have pain, but because our diagnostic tests identified structural issues and not signaling problems, one test after another is obtained with no answers. Patients with chronic pain become frustrated because each normal test invalidates their experience. No way can this amount of pain be normal! Patients are often sent away from doctors’ offices without any better understanding of their symptoms or how they will achieve relief. But you know what? Many medical professionals do not have an adequate understanding of chronic pain either! Please forgive the doctor that accused the pain of being all in your head. He or she did not know better. American medical schools teach medical students on average 11 hours of pain instruction. Override is working to make chronic pain knowledge more accessible to both providers and patients alike. Chronic pain is truly complex and can affect the whole person. Because chronic pain is a signaling issue, no one can see the problem. As a result, people with chronic pain can feel very isolated. Those around the affected person cannot understand why she isn’t working a normal job, exercising, or socializing like she used to. Without relief in sight and appropriate empathy and validation from close ones, anxiety and depression or frequent results of sustained periods of chronic pain. Just as a tsunami tends to engulf entire cities, chronic pain can engulf entire lives. Effective chronic pain treatment is also far less straightforward. The suggested course of action for acute pain – stay still and rest until the pain goes away – doesn’t work for chronic pain. It can actually be counterproductive. That’s because the nervous system is designed to adapt to the current environment. If a person avoids moving parts of your body, the nerves don’t receive normal interactions and they adjust to the new normal. They even start causing continued pain sensations to maintain that new normal of not moving the parts of the body they perceived to be injured and damaged. The “hot wiring” of the nerves in that part of the body become even more revved up, which increases the sensitization of the nervous system and leads to continued and amplified pain. The treatment for chronic pain at its core is a carefully formulated combination of physical activity, pain education, and cognitive behavioral therapy to reset the nervous system. Medications alone
Sympathy vs. Empathy and Why It Matters
Reading Time: 3 minutesWhen I was in rehab for a spinal chord injury, I had a friend who would come into my room, stand at the foot of my bed, and sob. She would stay until she couldn’t take it anymore. I remember feeling so helpless. I wanted to be the friend she wanted—that healthy woman that could do anything. But there was nothing I could do about this. I was lying in a bed unable to care for myself. Her sympathy and pity fed my own victimhood, which wasn’t helpful to my recovery. Sympathy paralyzes, while empathy energizes, empowers, and restores. True empathy is enabling. When someone deeply understands and listens, it empowers others. Someone once told me that I’m an advocate for those with chronic pain. I didn’t want to be an advocate. Because the only advocates I could think of were those who were sympathizing instead of empathizing. Advocacy can be paralyzing. It can encourage a victim mentality and trap those with chronic pain. It keeps them dependent on drugs, procedures, pills, and searching for cures. It makes them dependent on others. Empathy is jumping in the hole with them. It’s saying, “Let’s figure out a way out of here. What can we do?” It is recognizing the reality of another’s situation to the extent that you are willing to put yourself in their reality. It empowers others to crawl out of the hole they have been in, and helps them to be able to thrive. When I was in my deepest pit, my doctor sat on a chair across from me and grabbed a yellow pad of paper and a pen. He asked, “Tell me about your pain. What has worked? What’s not working? What do you value? How can I help?” When I told him there was a medication that worked well for me, he lit up, “Really? Which one?” I replied, “Valium. It really takes the edge off this central nerve pain.” But because Dr. Gorsuch had been truly listening to me, and he understood that I valued a clear mind, my family, and a life of meaning and purpose, he didn’t take the easy way out. He didn’t just prescribe the more Valium and send me on my way. Instead, he said. “You don’t want that life. I promise you. Let’s look for other solutions. OK?” I’m so grateful for his empathy rather than sympathy. And that he helped me find another way. Research studies have shown that empathy in medical care enhances clinical results. In one study with over 20,000 diabetic patients, patients treated by physicians with high empathy scores had a significantly lower rate of acute medical complications from their condition. The same is extendable to nonphysician care for chronic conditions. We see this with the power of coaching: When we use a coachlike approach that prioritizes empathy, it empowers others. That is the compassionate restorative healing approach we utilize here at Override.
I Wanted So Badly to Make It to the Top
Reading Time: 4 minutesFrom the moment I heard about my law school best friend’s bachelorette party in Asheville, North Carolina, I worried about the activities she was planning and whether I would be able to participate. The scariest: she planned a couple hikes. Don’t get me wrong, I’m perfectly in shape. I eat well and exercise multiple times a week. Sometimes people look at me and say that they can tell I was a tennis player. My complex chronic pain syndrome, however, can make it difficult for me at times to walk limitlessly or participate in physical activities. Unfortunately, I sprained my ankle a few months before the trip when I tripped down a flight of steps. A few months is plenty of time for an ankle sprain to heal, but my injuries often don’t heal the way they do for other (“normal”) people. See, when I get hurt, my body (or more accurately, my brain and central nervous system) doesn’t necessarily let go of the pain when the injury heals. So three months after my sprain, my ankle was still in severe pain. I understood that the sprain was realistically healed at the time of the hike – that even though the pain lingered, it was no longer acute pain and had crossed the line into chronic pain that was perpetuated more by my brain and central nervous system than by any lingering tissue damage. At this point when the pain enters into the chronic pain phase, I know from years of experience and learning about pain that it’s time to go back to normal use and build back the affected area’s strength. Sending messages of safety to the body through normal movement and use is one of the best ways to convince the brain that the body is no longer hurt and eventually calm the pain down. It’s a tricky balance, though, because the brain’s first instinct to resumed activity will be to increase the pain. It does this as a misguided form of protecting the body. Too much pain will only make pain levels worse by increasing the fear and messages of danger sent to the brain. Pounding the affected area relentlessly, just like continuing to rest and not use it, are both counterproductive. It’s a fine line that isn’t easy to locate. Several weeks before the bachelorette weekend, I started taking small walks – 10-15 minutes at a time – by myself. I hadn’t broke through the pain yet, but I set the goal of going on one hike during bachelorette weekend. I discussed it at length with the bride and her sister so that I would know in advance the total distance of the hike (2 miles). I decided together with my pain coach that I was ready for it. I wanted to do it. I envisioned the satisfaction I would feel after completing it. About 15 minutes into the hike, though, I asked the other women how far they thought we had gone. One of them looked at her Apple watch and said we had only gone.35 miles, which meant we had another .65 miles to the top and then another full mile to the bottom. My ankle was already flaring and I didn’t think I could push it another 1.65 miles. I told the group that I was going to stop there and see them at the bottom. Making that decision and saying it aloud to the others was really hard for me. For better or worse, nobody tried to stop me. Nobody encouraged me to keep going. Nobody asked if they should walk me back down. Nobody asked if I was going to be okay. They kept climbing, while I stopped. So there I was in the middle of the mountain. Alone. Disappointed. Defeated. Defeat is something I don’t take lightly. I was a nationally ranked tennis and squash player and I took great pride in my scrappiness and fighting spirit. I still do. Knowing I had time to kill before the rest of the group would finish the hike, I took a seat on a nearby rock. I tried to appreciate the view. (“Tried” is the keyword.) I tried not to cry. (I succeeded.) I took a picture of myself smiling. (That didn’t feel right.) I took another photo – this time without smiling so much. And then I did what I always do when I am upset: I called my mom. She was upset for me. She told me she wished I hadn’t gone on the hike and tried at all. She wasn’t sure why I did. But I disagree. Even though I didn’t like the outcome and was sad I didn’t make it to the top of the mountain, I was glad I tried. I still got to participate for some of the hike instead of waiting in the cramped van. I still got to see the view from the hiking trail. I still got fresh air. I still got a picture. And while I was embarrassed and concerned about the group judging me for not completing the hike, I reminded myself that nobody else was really focused on it except me. I’ll make it to the top another time.
A Metaphor: Pain as a Friend
Reading Time: 3 minutesViewing pain as a friend may seem counterintuitive at first, as pain is typically associated with discomfort and distress, and friends are not. However, my perspective is rooted in the idea that pain can serve as a valuable and informative companion on our life journey. The role of pain Pain is most often thought of as an enemy, but are there situations where pain is our friend? Yes! Leprosy (Hansen’s disease) patients can lose the sensation of pain due to damaged peripheral nerves. As a result, people with leprosy suffer medical complications and death due to the absence of pain signals. For them, the sensation of pain is a friend that lets them know when they are in danger. Pain is the body’s way of signaling that something is wrong. It acts as an internal alarm system, drawing attention to areas that need care and attention. Just as a caring friend tries to warn you before things go wrong, pain alerts you to potential harm or damage – prompting you to take necessary actions to address the underlying issues. This is how we survive. Chronic pain as an error signal But sometimes that friend ends up hurting you more than helping you. We all have had friends like that. Chronic pain is a dysfunctional type of pain, hurting you for no good reason. So what do you do when a human friend hurts you? You might recognize the friendship is dysfunctional, confront your friend, set boundaries, attempt reconciliation – any number of things. When it seems that your friend’s intentions are simply malicious, you might decide to turn your back on that friend and not be friends anymore. We have a similarly complicated dynamic with chronic pain, and eventually we want to find a way to and the friendship with chronic pain (not acute pain). While acute pain (that pain you feel when you touch a hot stove or slam a hammer on your thumb) helps keep us safe, chronic pain is just an error message that causes unnecessary suffering. Yet it’s usually not easy or quick to say goodbye to chronic pain, and it requires a great amount of courage and growth to do so. In the meantime, we can still treat pain – even chronic pain – like a friend. Pain has a role in personal growth Embracing pain as a friend means recognizing that challenges and difficulties often lead to personal growth. Difficult experiences can teach us important lessons about ourselves, our resilience, and our capacity to overcome obstacles. In this sense, pain becomes a wise teacher guiding us through the lessons of life. Facing and enduring pain can build resilience and inner strength. Like a friend who encourages you to face challenges head-on, pain can push you to discover untapped reserves of strength and courage within yourself. Overcoming pain fosters a sense of empowerment and confidence. Chronic pain also demands our attention and presence in the current moment. Instead of trying to avoid or numb the pain, acknowledging it allows for a deeper understanding of its source. This mindfulness can lead to a more profound connection with oneself and the ability to navigate difficult emotions with greater awareness. Chronic pain often serves as a powerful motivator for change. Just as a concerned friend might encourage you to make positive shifts in your life, the discomfort of pain can inspire a reevaluation of habits, lifestyle, and priorities, leading to positive transformations. Experiencing pain can enhance our appreciation for pleasure and joy. Like a friend who helps you appreciate the good times by contrasting them with the difficult ones, pain can amplify the beauty of life’s positive experiences. Sharing pain can also deepen connections with others. When we open up about our struggles in group coaching, for example, we often find empathy and support from those who have faced similar challenges. Pain, in this sense, becomes a common ground that fosters understanding and compassion in relationships. Shifting perspectives on pain While embracing pain as a friend doesn’t mean seeking out unnecessary suffering, it does encourage a shift in perspective. By acknowledging the role of pain in our lives and approaching it with curiosity and resilience, we can extract valuable lessons and foster personal growth. This mindset reframes pain from being solely an adversary to becoming a companion in the complex journey of life. Through intentional treatment and a supportive care team, our hope for you is that you will learn to navigate your relationship with chronic pain, such that you can reap the benefits from what living with pain has taught you but also put chronic pain in its place so it is no longer wreaking havoc on your life.
Does Living with Chronic Pain Make Us Brave?
Reading Time: 2 minutesI was getting an annual checkup the other day. While we were talking about my chronic pain, the doctor looked me in the eye and said, “you guys are the bravest of the bunch.” She said in a way that made it clear she really meant it, like she wouldn’t wish chronic pain on her worst enemy. I kept repeating the phrase over and over in my head for the next few days. What really is bravery? I’ve always thought it was funny that people refer to other people on their deathbed, suffering with cancer, or experiencing the debilitating chronic illness as “brave.” Why? What’s brave about it? It wasn’t a choice to be dealing with these things. To me, bravery always seemed like an innate characteristic that made you choose certain things – certain things that fear would’ve prevented you from doing. After all, I think that the opposite of bravery is fear. For instance, being brave to me is enlisting in the military, running into a burning building, having a difficult conversation with someone, embarking on an adventure, taking a big risk. But getting sick or experiencing pain don’t fit in that category. They aren’t something that any of us chose. Being brave and chronic pain Here’s what I decided about bravery and living with chronic pain: the way that some people with chronic pain live their lives is brave. I don’t think it can be applied to everyone with chronic pain. I don’t think that the very nature of having chronic pain makes someone brave. But I do think bravery applies to people who look their pain boldly in the face, spit at it, and tell it that it’s not going to stop them from living their best life. Better than that, they can tell the pain that they are not scared of it. (That part is easier said than done.) The reality is that it’s usually not this binary. Most people with chronic pain aren’t “brave” all the time. And that’s okay. Most of us with chronic pain go through darker periods where we are totally defeated by it, where we feel sorry for ourselves, where we hide in our beds or in front of the TV for days, and where we wish everything would stop. Bravery comes into play when we decide to pick ourselves back up. It’s when we decide to go to that in dinner or party we really don’t feel up to going to, force our bodies to move even when there’s a lot of protest from within, laughter tears, love with her whole heart, do something for other people, or enroll in a new pain program even when the last 15 haven’t worked. It’s when we dare to have hope that one day things will be better. To me, that’s bravery.
Types of Chronic Pain and Why it Matters
Reading Time: 2 minutesLiving with chronic pain can be a daily battle, affecting not only your physical well-being but also your emotional and mental health. Chronic pain is a complex condition that can manifest in various ways, and understanding the different types of pain is crucial for receiving appropriate treatment. In this blog post, we will explore the various types of pain and explain why identifying your specific type of pain is essential for effective management and relief. Nociceptive Pain Nociceptive pain is perhaps the most common type of pain. It results from the activation of nociceptors, which are specialized nerve endings that detect harmful stimuli such as tissue damage or inflammation. Nociceptive pain can be further categorized into two subtypes: Somatic Pain: This type of pain originates from the skin, muscles, bones, and joints. Conditions like arthritis, fractures, and muscle strains often lead to somatic pain. If you have this type of pain, you can usually point to where it hurts with 1 finger. Visceral Pain: Visceral pain arises from the internal organs and can be caused by conditions like irritable bowel syndrome, endometriosis, or gallbladder disease. This pain feels duller and vaguer. It’s hard to pinpoint the location of pain with 1 finger. Neuropathic Pain Neuropathic pain is the result of damage or malfunction in the nervous system itself. Unlike nociceptive pain, neuropathic pain does not serve as a warning sign of injury, but rather persists long after the initial cause is gone. Conditions such as diabetic neuropathy, post-herpetic neuralgia, and sciatica fall under Mixed Pain Mixed pain is a combination of nociceptive and neuropathic pain. It often occurs when a chronic condition causes damage to both the tissues and nerves. For example, in conditions like complex regional pain syndrome (CRPS), patients experience both burning and throbbing pain (nociceptive) as well as numbness and tingling (neuropathic). Central Sensitization Central sensitization occurs when the central nervous system becomes hypersensitive to pain signals, amplifying pain perception. This type of chronic pain is common in fibromyalgia, where the brain’s processing of pain signals is altered, causing widespread pain, fatigue, and sleep disturbances. Why Identifying the Type of Pain Matters Understanding the specific type of pain you have is essential for several reasons: Tailored Treatment Plans: Different types of chronic pain respond differently to treatments. Knowing the underlying cause and pain type allows healthcare providers to develop personalized treatment plans that target the root issue. Medication Selection: Certain medications, such as anti-inflammatories would be better for nociceptive pain whereas nerve pain medications are more effective for neuropathic pain. Accurate diagnosis helps in selecting the most appropriate medication. Lifestyle Modifications: Lifestyle changes, physical therapy, and coping strategies can vary based on the type of pain. For instance, therapeutic modalities that improve pain in central sensitization would not help a person who only has nociceptive pain. Understanding your pain type empowers you to communicate effectively with healthcare providers, leading to more successful pain management strategies. Conclusion Pain is a complex and personal experience, with various types that require tailored approaches to treatment. By working closely with healthcare professionals like Override’s multispecialty chronic pain specialists to identify the type of pain you have, you can pave the way for more effective pain management and ultimately improve your quality of life. You don’t have to face chronic pain alone – seek the support and guidance from specialists to better work towards relief and recovery.
