SDPAN0050 • Rev. 01/04

Understanding Chronic Pain ManagementPain Management Center

Pain is a purely subjective, personal experience. Despite all of our technical advancements, there is still no way to directly measure how much pain someone is experiencing. Nor can medical science simply go by how much tissue damage is found. The fact is the same amount of tissue damage from an injury or disease can cause different lev-els of pain in different people and even in the same person at different times. In addition, there are some people who experience severe pain where no physical problem can be identified, and others, with clear physical damage, who report “no” pain.

Why is there so much variability in the experience of pain? What can be done to manage a chronic pain problem? These are the questions we will address in this pamphlet.

The Traditional View of Pain

As you well know, when you stub your toe, it hurts almost immediately. You also probably know that your stubbed toe caused messages to be sent to your brain at great speed which resulted in your experiencing pain in your toe. You are also no doubt aware that when you stub your toe lightly, it hurts less than when you stub your toe very hard. Stated

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as a pain transmission model, one might say that pain is the result of the quantity and quality of pain signals travel-ing from the point of injury to the brain. These signals vary in accordance with the degree of actual tissue damage. This common sense view of pain transmission fits our usual experience of pain, and has dominated our understand-ing of pain for many years. However, it doesn’t hold up well under close examination.

People have long observed that someone can have a seri-ous injury without noticing any pain if their attention is focused elsewhere. This can happen during a life-threaten-ing event, or even while playing an intense football game. Scientists and clinicians have also noted there is very little relationship between the amount of tissue damage found, and the degree of pain complaint or disability observed in chronic pain. Additionally, even when nerves transmitting pain signals to the brain are blocked or severed, pain is not always relieved. Clearly, there have to be other important factors involved in pain, and most importantly in chronic pain, beyond our traditional and common sense view of pain transmission.

Factors Affecting Pain Experience

In 1965 Drs. Melzack and Wall described the Gate Control Theory of pain transmission. This theory maintained that pain signals do not just go from the point of injury or pain site to the brain. Rather, the brain itself was able to trans-mit information to block or diminish incoming pain signals. Although there are many other important factors involved in pain modulation, this theory opened the door for our current understanding of how mental, emotional and behavioral fac-tors can influence pain experience by allowing us to block some or all of incoming pain signals. You may be interested to know that it was Dr. Howard Fields, one of the found-

Each of these strategies is provided through the Pain Management Center. See our pamphlet “Stress and Chronic Pain for more information on this topic.

Summing It Up

Good medical treatment is always the first step in deal-ing with a pain problem. Evaluation at the UCSF Pain Management Center always includes medical evaluation by pain specialists to determine a diagnosis of your physical problem, and any medical interventions that may be of help. This medical evaluation reviews the appropriateness of your medication regimen, and which interventional treatments, if any, may be of help.

Optimal pain management is the synthesis of medical, phar-macological and self-management therapies. It is for this reason that the UCSF Pain Management Center offers mul-tidisciplinary treatment of your pain problem. By doing this, we greatly minimize the chance that an important aspect of your pain problem will be missed. However, this broad approach also demands that you actively participate in your own treatment and rehabilitation. We hope this pamphlet on “Understanding Chronic Pain Management” will help you to do that.

© Copyright 1990 - The Regents of the University of California updated, January, 2004

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Luckily, depression can be successfully treated even when the pain problem cannot be physically corrected. Additionally, as depression is relieved, people not only feel better in terms of mood, but actually feel better able to toler-ate pain. Indeed, they typically express having less pain. See our handout entitled “Depression and Chronic Pain” for more information on this topic.

Stress

Ask most chronic pain patients what their most signifi-cant source of stress is, and they will usually tell you that it is pain. Pain however, is not only something that causes stress, it also is aggravated by stress. When someone is under stress, muscles tighten putting added tension on joints and connective tissues. Our nervous system becomes more active under stress which can increase pain signals and pain sensitivity. These factors can greatly increase pain, causing more stress and concern. Stress also adds to depression.

Managing stress and managing chronic pain go hand in hand. Strategies for decreasing both pain and stress include:

• regular exercise

• adequate sleep

• maintaining meaningful activities and relationships

• using direct communication

• correcting negative thinking styles

• biofeedback

• relaxation and self-hypnosis exercises

• individual and group counseling

• antidepressant medication

ers of the UCSF Pain Management Center, working with Dr. Allan Basbaum, who were first to map out the brain path-ways for pain modulation.

Since this groundbreaking work, it has become widely accepted by pain experts everywhere that chronic pain cannot be adequately understood or treated without looking at mental, emotional, social and behavioral factors in addi-tion to the pure physical, or sensory, aspects of pain. This is true even though a physical cause for a pain is clearly pres-ent, or when other factors involved in a person’s pain expe-rience only developed as a consequence of the physical pain. For example, even though increased stress or depres-sion may be a direct result of a chronic pain problem, this increase in stress or depression will nevertheless further increase pain and suffering.

Although all pain experiences include physical, emotional, mental and behavioral dimensions, it is in chronic pain that these dimensions become particularly important.

Acute Versus Chronic Illnesses

“Acute” is used to refer to a pain or illness of recent onset and short duration, though short duration can be consid-ered anything up to six months. Using pain as an example, we can see that people differ greatly in terms of how they react to acute pain from a broken bone, heart attack, kid-ney stones, medical procedure, or any number of other pain causing problems. Some people worry more than others, some ask more questions, and some try to get back to full activities too soon, while others restrict activities too much. These variable reactions to acute pain however, are general-ly not very complicating to the course of the problem (prog-nosis) as is the case with a chronic pain, or other chronic ill-ness. This is because the medical care of an acute disease or injury plays such a large role in how well the body heals.

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Medicine is well prepared to deal with acute problems, and the model employed is often referred to as the medi-cal model. The way the medical model works is like this: Symptoms of some underlying problem motivate a person to enter into the medical system. The symptoms can be pain, a fever, unexplained weight loss, or anything that cre-ates concern. The doctor then attempts to diagnose the underlying problem causing the symptoms, rather than simply treating the symptoms as the primary or only prob-lem. If the diagnosis is correct, and the appropriate treat-ment available, the underlying problem is corrected which resolves the symptoms. The patient plays a relatively small role in determining the outcome of their problem, and is mainly expected to be passive and compliant.

“Chronic” refers to any ongoing medical condition of long duration. Almost by definition, a chronic pain is one which has not responded to traditional medical interventions, or where a medical “cure” is not available. There either is no clear diagnosis to explain the pain and disability experi-enced, or the cause is known, but there is no appropriate or effective way to correct the underlying problem. With a chronic pain, the emphasis changes from finding a diagno-sis and cure to rehabilitation and minimization of the nega-tive effects of chronic pain. This is a tremendously important distinction since it switches primary responsibility for man-agement of the physical problem from the doctors to the patient. It also changes the focus of treatment away from the “underlying cause” to the pain itself and the lifestyle dis-ruption it creates. Pain is no longer just a symptom, chronic pain is the actual problem. This type of pain is not provid-ing a useful signal to tell us an injury is occurring, or that we need to rest a particular area of our body, and because of that, it becomes a primary problem in it’s own right. This type of pain is technically referred to as chronic “benign” pain to distinguish it from acute pain and from chronic pain stemming from a malignancy such as cancer pain.

cise program. Any concerns or questions about the exercises should be discussed with your physical therapist or doctor.

When people have some physical problem such as pain or stiffness that varies day to day, it’s common to try to do too much on good days and too little on other days. You need to pace activity and exercise so that you gradually build up strength and mobility. This will allow you to avoid aggravating a condition. You will also want to use proper body mechan-ics when bending, lifting or reaching so not to worsen the condition. Physical therapy includes instruction on these points.

Depression

Persons with a chronic pain problem often show decreases in meaningful and enjoyable activities. Relationships and finances are often strained. Social contacts are reduced, and coping resources depleted. Not surprisingly, many chronic pain patients become depressed. And even though this depression is usually brought on directly by the pain, it nev-ertheless is a legitimate depression and a legitimate problem. Depression greatly adds to the suffering or perceived pain intensity experienced by someone with pain. It also interferes with an individual’s motivation and ability to keep their life full and moving ahead, despite pain.

Depression and chronic illness are often confused by patients and doctors alike. This is because the consequenc-es of chronic pain and the symptoms of depression look very similar. In fact, groups of chronic pain patients who are asked to generate a list of pain consequences and a list of symptoms of depression are usually surprised to find that the lists are virtually identical. It becomes impossible for patients to disentangle what part of their suffering, pessi-mism, and lack of energy are due to pain, and what part is due to depression.

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Physical Reconditioning

Regular exercise is important when we are well, and it is critical when we have a chronic illness. Chronic pain and other illnesses place limitations on our physical function-ing. When we were healthy, not being at the top of our per-sonal potential for physical conditioning did not significantly restrict us. We could be out of shape and still function in normal activities. This often is not the case, though, when we have a chronic illness. Here we need to pay extra atten-tion to exercise needs so as to retain a normal range of functioning and/or to avoid further physical decline. When you have a chronic illness, you want to be in the best physi-cal condition that you can. It is for this reason that our physical therapy program provides training in home recon-ditioning exercises.

Rehabilitative Exercises

Stretching and strengthening exercises directed at restor-ing or maintaining physical functioning following an injury, hospitalization or to counter disease, fall under this category. Following periods of disuse, muscle mass and tone are decreased, tendons can constrict decreasing mobility, and problematic joints can become more stiff and painful. To counteract this, physical therapists prescribe particular reha-bilitative exercises to stretch, strengthen and ensure mobility of specific and general problem areas.

When rehabilitative exercises are followed regularly, they can often do wonders to counteract what many people have feared was the beginning of a steady, downhill course. When you start these exercises, there will probably be some dis-comfort as areas not used to exercising are stretched and strengthened. Communication between you and the physical therapist is very important to ensure the best possible exer-

Consequences of Chronic Pain

When a pain first begins, it is appropriately handled as an acute pain problem. Medical attention is sought and the doctor is relied upon to diagnose the problem and recom-mend or provide a way to resolve it. Restriction of move-ment for the afflicted area may be recommended. However, even when this is not specifically recommended, people naturally tend to limit movements that create pain. The patient’s role is to be compliant and trust in the medical system for the ultimate answer. After all, “if they can trans-plant hearts, they certainly can stop a pain.”

Unfortunately, some pain problems cannot be “fixed” and the pain becomes chronic. The appropriate medical cure that was originally sought can turn into endless doc-tor shopping, getting ever more tests, increasingly risky procedures, and ever more medications. In addition, the natural restriction of movement which can be very impor-tant in allowing an acute injury to heal, later only serves to decrease strength and range of motion. Reliance on doc-tors for “the answer,” which has not been forthcoming, cre-ates frustration, often anger and increasing despair. The relationship with doctors can also become more difficult as the doctors themselves become frustrated with a pain problem that doesn’t get better, and a patient who has often become reliant on ever-increasing drugs for pain control. Failure to respond to treatment can also lead to occasional suggestions that the pain has a “psychological basis.” Such labeling tends to further damage the doctor/patient relationship.

As if this weren’t enough, there are often many other nega-tive changes occurring because of the chronic pain. Pain frequently disturbs sleep and this loss of sleep can by itself decrease a person’s ability to handle pain, or any day

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to day demands for that matter. Decreasing activities not only bring increasing disability through loss of strength and mobility, but will add to boredom, isolation, and despair. Not surprisingly, a very high percentage of persons with chronic pain become clinically depressed. Family relationships and finances often become strained. Stress levels increase at a time when coping resources are already low. Medications can become a way of life, and often produce unwanted side effects such as drowsiness, confusion, and dependence.

As terrible as this sounds, it is not an uncommon chain of events. Fortunately, it’s a sequence that can be reversed.

Managing Chronic Pain

A person’s overall quality of life is made up of many fac-tors. Among them are friends, family, work, recreational pastimes, and health status. People with chronic pain often spend less and less time with friends, family, work and rec-reation, which means that their quality of life becomes more and more dominated by pain. This is illustrated in the fol-lowing chart:

Meaningful and Enjoyable Activities

Many chronic pain problems are aggravated by strenuous activity and lead people into a pattern of ever-decreasing activity. Negative moods can also add to decreased inter-est and motivation to keep up “unnecessary” activities. What this often leads to is people continuing to do chores, but giving up the activities which give their life meaning and satisfaction. This pattern has to be changed if depres-sion, stress and chronic pain itself is to be conquered. By increasing meaningful and enjoyable activities, a person appropriately makes pain just one (small) part of their over-all quality of life. The pie chart shows graphically a quality of life made up primarily of pain.

Maintaining Relationships

As with meaningful arid enjoyable activities, maintaining social contacts and open communication is a fundamental way to combat both stress and depression. Chronic pain places stress on relationships. Friends and family may feel frustrated at not being able to understand someone’s pain problem or how to help them. They may also try to help too much, thus adding to a person’s dependency and passive patient role. Conversely, the person with chronic pain may increasingly avoid interactions with others to avoid relation-ship strain. Unfortunately, this only adds to their sense of isolation and despair.

As long as a person’s life revolves around pain or other chronic illness, life will be relatively miserable. Taking con-trol means putting back into your life all the things that make it worthwhile, despite the pain. This includes main-taining relationships and keeping up meaningful and enjoy-able activities.