Conquering Pain: How to Prevent It, Treat It and Lead a Better Life

SECTION I

Understanding Pain

1

Introduction to Pain

DR MARY ABRAHAM

Case Study: Mr A.M.

‘Ah! This pain will only go once I’m dead!’, exclaimed the middle-aged man (whom I shall call Mr A.M.) while waiting for his turn to consult me. ‘Old age is really bad. It brings in too many problems. I have consulted so many doctors but no one has been able to help me.’ He appeared visibly distressed and teary-eyed. His discomfort was so severe that I brought him up the queue. Since this was his first visit, I took down a detailed history of his problems.

About five years ago, Mr A.M. had fallen off a horse while on a pilgrimage to a hill temple and had experienced acute backache. He had consulted a physician who ordered an X-ray and MRI of the spine, but neither revealed any abnormality. He was advised conservative treatment with anti-inflammatory analgesics along with physiotherapy, but that did not give him any relief. His pain continued, unrelenting.

On further questioning, he revealed that the pain occurred mainly while sitting. In fact, it was so uncomfortable that he had to sit at the edge of a chair or with his body tilted slightly sideways. This was quite embarrassing for him, especially at work. On examination, his back muscles were stiff and in spasm. There was acute tenderness in the coccyx (tailbone) and it was so tender that he winced in pain when I palpated it with my fingers to examine it. An X-ray of the lower end of the spine was ordered and it revealed a fracture in one of the little bones comprising the tailbone.

Based on the clinical and X-ray findings, a diagnosis of coccycodynia was made, which is a condition where the tail bone hurts severely, especially while sitting. In Mr A.M.’s case, the fracture had probably occurred when he fell off the horse, with his buttocks taking the full impact of the body weight as he hit the ground. Unfortunately, it had remained undiagnosed since these many years.

On further inquiry, it appeared that he had never really complied with any treatment programme prescribed, and he had a ready answer for this. He said that anti-inflammatory medicines damaged the kidneys and all the exercises and ‘electrical’ pain-relieving techniques used by physiotherapists only weakened muscles. He further said that his barber was a masseuse and periodically, when the pain worsened, he would go for a massage. He had done so this time as well. However, the pain had persisted and his wife had forced him to seek medical help.

In fact, during the interview, it seemed that the relationship between him and his wife was strained. He appeared sad and resigned, exceedingly anxious about any kind of medical intervention, almost behaving as if he was trapped by the doctors, with no escape this time.

With this history of non-compliance to any treatment prescribed, being so emotionally charged and anxious and lacking motivation for treatment, he was referred for psychological evaluation. As soon as he was informed about the referral, he flared up and shouted, ‘I’m not mad. You people take advantage of patients who are suffering. I will NOT see a psychologist.’

Due to his hostility, the nurse had to intervene to calm him down. I explained to him that pain could lead to other problems like anxiety, emotional distress and depression, which in turn would increase the pain. All aspects—physical, psychological and social—needed to be addressed simultaneously for holistic treatment. After much persuasion, he agreed to meet the psychologist, Dr Vandana V. Prakash.

DR VANDANA V. PRAKASH

Case Study: Mr A.M.

When Mr A.M. came to my chambers, he was still angry, aggressive and hostile. I adopted a relaxed and friendly interviewing manner to mitigate his anger and gain his confidence. Some important facts emerged from the interview. He had married his wife against his family’s wishes, hoping the family would relent and accept her once he was married. Instead, his parents disowned him.

He soon became clinically depressed and his fairly successful business began to fail. His father-in-law, who was against this marriage from the very beginning, then employed him—but treated him more as an employee than a son-in-law. Whenever Mr A.M. wanted to quit and seek employment elsewhere, his wife threatened to commit suicide. The pain itself became a bone of contention between him and his father-in-law, who viewed it solely as an excuse to shirk work. The father-in-law also took very unkindly to his absenteeism from work on the days when the pain was severe. Mr A.M. said he did not remember the last time that he had laughed.

His anxiety towards medical treatment stemmed from a childhood belief instilled by his family that doctors took advantage of their patients. Ever since his fall from the horse, his colleagues and family made fun of his sitting posture. He was embarrassed and refused to speak even to doctors about the part of his body that was painful.

Another sentiment was his unspoken defiance of the dictates of his wife and father-in-law, who he felt were pushing him to seek medical advice against his wishes and beliefs. On his wife’s insistence, he would consult doctors but would secretly refuse treatment by being non-compliant. In addition to pain, he was diagnosed as suffering from dysthymia (low-grade depression for more than two years) and also experiencing anxiety, repressed anger and chronic stress.

In our journey through life, pain is present in some form or the other, from birth till death. Though pain does have a significant role to play in our very survival, being in pain is an undesirable experience. Pain is sometimes endured under duress and can become an unwelcome intrusion into our lives. Most people will go to great lengths to avoid or reduce pain. Pain that is experienced for short durations, in discrete and isolated instances, may have a lesser impact on us, but chronic pain leaves a distinct impact on our body and mind.

Pain encompasses in its ambit not only the unpleasant feelings stemming from a physical injury but mental suffering as well. In fact, in 1979, the International Association for the Study of Pain (IASP) defined pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.’¹

This emphasizes the fact that pain is not just one-dimensional, with merely a physical aspect, but also has an affective (emotional) and a cognitive (thought) aspect as well. Over a decade earlier, in 1968, Margo McCaffery had given a realistic and simpler definition of pain: ‘Pain is whatever the experiencing patient says is existing, whenever he/she says it does.’² In simple terms, ‘pain is what the patient says hurts’.

When a patient describes pain, we have to believe them, as pain is a subjective experience with no objective criteria.

DEVELOPMENT OF PAIN THEORIES: A BRIEF HISTORY

Pain as a recorded sensation is as old as mankind. In ancient times, the sensation of pain was regarded as a form of punishment and even an evil influence. The word ‘pain’ was derived from ‘Poena’, the Goddess of Punishment in Latin mythology. Plato and Aristotle did not view pain as a sensation but more as an emotion, describing it as ‘passions of the soul’.³

Later, Hippocrates believed that pain resulted from an imbalance of the ‘humours’ or vital fluids coursing through the human body. The actual journey of discovery of pain started in the seventeenth century, when René Descartes in his 1664 work, L’Homme (Treatise of Man, translated and with commentary by T.S. Hall, 1972), mentioned pain as a disturbance along the nerve fibres that reaches the brain.⁴ This dramatic revelation changed the concept of pain altogether, from spiritual punishment to physical genesis of pain, from appeasement of God for pain reduction to physical treatment; shifting the centre of pain from the heart to the brain. In 1794, Erasmus Darwin re-linked pain with emotions in his comprehensive work Zoonomia.⁵

In 1811, Scottish anatomist Charles Bell was the first to propose that different sensory receptors existed for different types of stimuli, and the receptors responded to only one stimulus at a time.⁶ To this, Johannes Muller further added, in 1839, that a physical injury could produce different sensations depending upon which types of nerves were being stimulated.⁷ Wilhelm Erb (1874) felt that pain could be produced by any stimulus that had sufficient intensity, and so, his theory was termed the Intensity Theory.⁸

In 1895, Max von Frey proposed his Specificity Theory, which is one of the first modern theories for pain. This theory proposes that pain is an independent sensation and there are specific pain receptors (a receptor is a group of cells that receives stimuli) that transmit the signal of pain to a ‘pain centre’ in the brain that leads to the perception of pain.⁹

The next major shift came in 1953, when Willem Noordenbos described two systems that transmit pain: the fast and the slow systems.¹⁰ The speed was governed by the diameter of the fibres carrying messages to the brain. He observed that broad fibres carrying touch, temperature and sense of vibration tended to inhibit the activity of the thin fibres which carry pain. Therefore, the intensity of the pain depended upon the ratio between the thick and thin fibres.

The Biopsychosocial Model of Pain

‘... if someone has a pain in his hand, then the hand does not say so... and one does not comfort the hand, but the sufferer: one looks into his face.’¹¹

—Ludwig Wittgenstein

In the 1960s, G.L. Engel firmly believed that pain was governed by not just physical sensations but by psychological as well as social factors.¹², ¹³ He floated the concept of a ‘biopsychosocial model’. This model, though not specific to pain, attempts to explain the cause of various disorders and how different factors—physical, psychological, social and cultural—affect the development and sustenance of a particular disorder. Pain too has been understood in a similar way.

The pain phenomenon is at present understood as interplay between physiological, psychological and social processes. Whereas the biological or physiological component is examined to understand the cause of pain from the functioning of the human body, certain characteristics—such as age, gender, genetic inheritance, race, ethnicity and type of personality—play an important role in the perception, reaction and continuation of pain. Pain is also affected by the ability of individuals to cope with stress, as well as by their cognition (thoughts) and mood.

Let us discuss the case of Mr A.M. from a ‘biopsychosocial’ point of view so that his management can be tailored in a holistic manner.

Since pain is an unpleasant sensation produced by processes that either damage the tissues or are capable of doing so, it is considered ‘noxious’ and the specific sensors or sensory receptors that detect it are called ‘nociceptors’. Nociceptor originates from the Latin word ‘nocere’ or ‘to do harm’ and ‘receptor’, as mentioned above, is a group of cells that receives stimuli. In a nutshell, a nociceptor is a sensor that responds to pain. The neural pathways are a series of connected nerves along which electrical impulses travel. The neural pathways for pain carry information from the site of disturbance or tissue damage to multiple areas in the brain where pain is perceived or sensed. Physical pain, especially localization of pain, is identified by an area of the brain called the somatosensory area.

In Mr A.M.’s case, he felt pain while sitting and to minimize the pain, had started sitting on the edge of the chair or tilting sideways. He had to sit this way so as to take the pressure off the tail bone as it was very tender. This was the physical aspect of his pain. The most probable cause of his physical pain was due to trauma to his tail bone after the fall.

The psychological aspect of pain takes the three components of pain behaviour into consideration—cognition (thought), affect (emotion) and conation (behaviour). Since pain, apart from physical discomfort, causes emotional distress, negative and catastrophic thinking and sometimes a feeling of loss of control as well, it undoubtedly has a significant effect on the psyche and functionality of the person.

Pain can also be psychogenic (related to mental, emotional or psychological factors) in origin. There are several conditions where physical pain is the main complaint, but the actual reason for the pain is psychological. Disorders such as somatoform disorders, atypical depression and somatic delusions (a fixed false belief that the functionality of body is abnormal in some way) in schizophrenia have pain as the chief complaint—though the origin is psychological.

The pain experienced in these conditions is real, but the underlying reason for pain is strong emotional distress. The distress may be caused by feelings of guilt, repressed or unexpressed anger, hostility and hatred. Mr A.M., whose case is cited above, had many psychological issues.

Mr A.M. had the feeling of being abandoned by his family of origin, lack of understanding between him and his spouse leading to marital discord, not being able to take his own decisions, lack of cordiality between him and his in-laws, work-related humiliation that he suffered almost on a daily basis, a strong feeling of embarrassment regarding the site of injury, and a mistrust of allopathic medicines and procedures. These emotional issues as well as the hostility he felt towards his wife and father-in-law actually became instrumental in his not seeking medical treatment.

When physical and emotional distress is present, it has an effect on social relationships too. Most people with pain report having disturbed relations or unsettling functionality with their family and society at large. Chronic pain has a debilitating effect on the familial relationship. Relationships may become affected if the person experiencing pain is either given too much attention or too little attention.

A demanding victim is capable of creating all kinds of claims on time, money and effort, which the family can often ill afford. Such a person’s professional work, and even the work of the caregiver, might be adversely impacted, leading to further distress. When a number of patients in society do not take treatment, either due to helplessness or deliberately, as in the case of Mr A.M., there is a heavy loss to overall work production, called ‘pain drain’.

Mr A.M.’s untreated pain not only caused physical and emotional suffering but also social and familial issues. His absenteeism was considered work evasion and instigated quarrels between him and his wife. A vicious cycle had formed. Pain led to absenteeism from work, he was pushed to visit doctors, their advice would be disregarded, leading to either increase or continuation of the pain, which again would precipitate further absenteeism from work and again enhance antagonism between him, his wife and father-in-law.

The biopsychosocial model has been further expanded to encompass religious, cultural and spiritual components too. Religious beliefs determine how one regards pain and exhibits pain behaviour. In certain religious groups, pain is accepted stoically. Religious beliefs may also determine motivation and willingness to adhere to a prescribed treatment programme.

Persons with strong religious beliefs and those who are spiritually inclined sometimes benefit positively from treatment, especially in cancer pain. Cultural beliefs and attitudes too can affect how the person responds to their own pain and that of others. Pain expression, pain language and social roles differ in each cultural milieu. These are important factors that can sensitize pain therapists on how to understand pain behaviour and use culturally relevant beliefs to motivate a patient and provide treatment.

The basic idea behind the biopsychosocial model is that the mind and body are not discrete entities and they tend to affect each other. When there is physical injury, it will affect the person emotionally and socially. Conversely, a person affected socially and emotionally by a psychological illness may also find it affecting physical well-being by manifesting as pain. To summarize, let us once again revisit the case cited above—that of Mr A.M.

What began as a simple physical injury due to a fall became a complicated mire of emotional and social upheaval for the gentleman, affecting his thoughts, decisions and non-compliance regarding treatment itself. It also affected his relationship with his spouse and resulted in unsatisfactory job performance.

The Gate Control Theory of Pain

A major change took place in the understanding of the mechanism of pain in 1965, when Ronald Melzack and Patrick Wall suggested a specific neural model for the perception of pain in their theory on Gate Control.¹⁴ Melzack and Wall proposed that not all pain impulses generated in the periphery (site of tissue damage) are allowed to be relayed to the brain, as there is a gating mechanism en route in the spinal cord. Various sensations like touch, pressure, pain, etc., have to pass through this so-called, ‘neural gate’ before they reach the brain and are perceived there. Depending on various circumstances, which are discussed in Chapter 3 ‘Pain Pathways’, the neural gate can either open or close to the passage of pain impulses.

In other words, the pain experience is not simply the result of linear processes that begin with the stimulation of pain pathways and terminate with the perception of pain in the brain, as was the understanding till that point of time. Rather, the pain impulse from the periphery is subject to modulation at the level of the spinal cord by a ‘gate-like’ mechanism before it is transmitted to the brain.

Current View: The Neuromatrix Theory of Pain

A further shift in the understanding of pain took place with the advent of modern neuroimaging methods by which researchers in the field of pain medicine could look into the structure and function of the nervous system with respect to pain. It was found that the pain experience is perceived by multiple areas in the brain, and this is responsible for the physical, emotional, cognitive and motor aspects of pain.

This theory of pain, the body-self Neuromatrix Theory, was postulated by Ronald Melzack in 1999, who had earlier proposed the Gate Control Theory of pain with Patrick Wall.¹⁵ Complex networks in the brain, or the neuromatrix as it is called, integrate multiple inputs (physical, emotional and evaluative) to generate the output, which is the total pain experience.

Thus, there has been a paradigm shift in the current understanding of the concept of pain. Pain is now viewed as a complex, multidimensional and multilayered phenomena. Sometimes, the multifaceted nature of pain itself (physical, psychological, social and cultural) makes it difficult for the pain physician to assess, investigate and treat pain. The complexity is visible as each dimension itself has innumerable factors associated with it.

Physical pain indicates the actual damage that has taken place due to an insult to the physical body. This could be due to tissue injury, inflammation or nerve injury/malfunction. Psychological pain deals with emotions like anger, hurt and fears; mood disturbances like depression and anxiety; and cognitive aspects like catastrophic thinking, attitudes, motivation and self-esteem. Social pain deals with role of the family, social roles, role reversal and loss of prestige, loss of job, financial difficulties and conflicts in the family. Spiritual pain deals with anger with fate, anger with God, loss of faith, inability to find meaning in life, pain and fears related to the unknown and, in cancer patients, fear of death.

Development of the Concept of Total Pain

The concept of ‘total pain’ was introduced by Dame Cicely Saunders when she started the hospice movement for cancer patients in the United Kingdom in the 1960s.¹⁶ She alluded to ‘total pain’, in which she describes the inseparability of physical pain from mental processes. She concurred that ‘much of our total pain experience is composed of our mental reactions’. Subsequently, in a paper published in Nursing Mirror in 1964, she narrates verbatim the experiences of a lady admitted in a hospice in Hackney:¹⁷

‘Well doctor, the pain began in my back, but now it seems that all of me is wrong.’ She gave a description of various symptoms and ills and then went on to say, ‘My husband and son were marvellous but they were at work and they would have had to stay off and lose their money. I could have cried for the pills and injections although I knew I shouldn’t. Everything seemed to be against me and nobody seemed to understand.’ And then she paused before she said, ‘But it’s so wonderful to begin to feel safe again.’ Without any further questioning, she had talked of her mental as well as physical distress, of her social problems and of her spiritual need for security.

Saunders picked up and emphasized the importance of the phrase, ‘all of me is wrong’, thereby underlining the importance of the multidimensional aspect of pain that included physical suffering, mental distress, social predicaments and emotional difficulties that the patient had been experiencing.

The concept of ‘Total Pain’ can be graphically represented, as seen in the diagram.

Thus, as Arthur W. Frank (2001) sums up:

Fear and depression are a part of life. In illness there are no ‘negative emotions’, only experiences that have to be lived through. What is needed in these moments is not denial but recognition. The ill person’s suffering should be affirmed, whether or not it can be treated. What I wanted when I was most ill was the response, ‘Yes, we see your pain; we accept your fear.’¹⁸

Yes, as clinicians, we have seen pain and accepted the fears of those who suffer and have tried our best to help them. But that is only one side of the coin. Our experience with the confusion that patients have about where to go, how to go about it and what to do when in pain, prompted us to look at the issue in depth. Unless patients are aware of where to seek help, it cannot be extended or judiciously reached. Thus, we endeavour in this book to present the intricacies and interplay of the various components that singularly and collectively affect the individual in pain, citing examples from our clinical practice, along with a holistic treatment programme for pain.

As Sulmasy aptly says:¹⁹

A human is a being in relationship—biologically, psychologically, socially and transcendentally. Illness disrupts all the dimensions of a relationship that constitute the patient as a human person and, therefore, only a ‘holistic’ or biopsychosocial-spiritual model can provide a foundation for treating a patient holistically.

2

Types of Pain

Most patients who suffer pain describe pain in various parts of the body with varying symptoms and varying degrees of discomfort. However, medically speaking, all varieties of pain can be clubbed into six types, classified under three broad headings: (i) length of time that pain has existed, classified as acute or chronic; (ii) cause of pain, categorized as nociceptive or neuropathic; and finally, (iii) whether pain is due to cancer or has non-cancer genesis.

These three broad areas cover, in entirety, all the types of pain that we human beings can potentially go through in one lifetime. On that cheerful note, let’s examine these classifications further.

THE NERVOUS SYSTEM: BASIC FACTS

To understand this better, it is important to know some facts about our nervous system. The human nervous system is a marvel both in structure and function and is composed of myriads of nerve endings and cells called neurons. These neurons are organized structurally into a core part, the central nervous system, and a peripheral part, called the peripheral nervous system. The central nervous system includes the brain housed in the skull and the spinal cord housed in the spine. The peripheral nervous system comprises a vast network of nerves that branch out from the brain and spinal cord all across the body including the skin, muscles and internal organs.

The peripheral nervous system sends and receives messages to and from the brain and enables us to respond to our environment, circumstances and even life events in the way that we do and is our link to the outside world. It is further divided into the somatic and autonomic nervous system. The somatic (‘soma’ means ‘body’) nervous system is not only responsible for transmitting sensations to the nervous system (sensory function) but also responsible for voluntary movement (motor function). Pain is one of the many senses in our body that is sensed and perceived by our nervous system.

The autonomic nervous system is responsible for body functions that happen involuntarily, i.e., without our voluntary control or knowledge. This includes the blood flow in our body, digestion, heartbeat, breathing, etc. The sympathetic nervous system is a part of the autonomic nervous system that regulates the ‘fight or flight’ responses of our body that enables our body to react to potential threats in our environment.

Pain is one such potential threat. It can either have a protective function or it could be a disease in itself. Let us see how.

PAIN: ACUTE OR CHRONIC?

A very common misconception is that pain is ‘acute’, if it is ‘severe’ or ‘intense’. Actually, pain is termed ‘acute’ depending solely on whether or not it disappears as soon as its cause is healed—and this healing usually occurs in three months or less. For instance, the pain of a fracture or a sprain is acute and will totally disappear as soon as the fracture or the sprain is healed, i.e., within three months or less. In some cases, healing may take longer and the doctor will expect the pain to disappear between three and six months. However, if the pain carries on beyond that, then it moves into the category of ‘chronic’ pain, and the causes for it must be further investigated.

Thus, chronic pain is defined as: (i) pain that lasts longer than three to six months; and (ii) where the previously identified cause is no longer sufficient to explain the presence and intensity of pain. Chronic pain also disrupts sleep, activities of daily living and the functionality of the person. In other words, chronic pain affects quality of life and has the potential to cause disability.

Having understood the medical differentiation between these two types of pain, let us look at acute and chronic pain in detail. You will find references to nociceptive and neuropathic pain, with chronic cancer pain and non-cancer pain woven into these discussions as well. That is because—whether nociceptive or neuropathic, chronic cancer pain or non-cancer pain—all types of pain manifest as either acute or chronic and, in rare cases, as a mix of the two.

Acute Pain

Acute pain is usually nociceptive in nature, i.e., the natural consequence of tissue damage, injury or any kind of inflammation. When such damage/injury/inflammation occurs, pain impulses are transmitted from the injured site to the brain by healthy nerves that are functioning normally. On the other hand, in the case of neuropathic pain, the nerves themselves are damaged and the transmission of pain impulses thus goes awry—but more of that later. Coming back to acute pain, it can be either ‘somatic’ or ‘visceral’.

Somatic pain—(‘soma’ or ‘body’)—is usually sharp, pricking, throbbing and well localized. It originates from skin, joints or soft tissues like muscles, tendons or ligaments. Common examples include pain due to sprains, cuts, inflammation or muscle injury.

Visceral pain—(originating from structures deep within the body, such as the internal organs or viscera)—is usually dull, deep and sometimes colicky, and frequently cannot be well localized. Visceral pain can originate from various organs such as the liver, kidney, stomach, uterus, etc., and may be caused by the distension, stretching, contraction or inflammation of the organ. Common examples of visceral pain include appendicitis, abdominal colic, renal colic, gastritis and inflammation of the gall bladder (cholecystitis).

Acute pain is the normal response of the body to injury. Its main purpose is to activate the body’s arousal system to form a protective response. The ‘message’ of tissue damage or injury is transmitted along well-functioning healthy nerves to the brain for interpretation, resulting in an outpouring of adrenaline that elicits the fight or flight response. This is manifested as a fast pulse rate, rise in blood pressure, raised blood sugars, dilated pupils, cold and clammy skin, perspiration and goose bumps depending on the severity of pain.

Patients describe the pain as sharp, aching, throbbing or colicky, if it originates in the internal organs. It usually has a finite period and it will then ‘go away’. The trend is that it gets better with time, usually within a period of three months.