‘Chronic pain is a very isolating condition,” says Leigh*. “You can’t easily talk about it to family, friends or colleagues, because they often see it as whining and you fear being seen as a hypochondriac. You end up feeling pretty lonely.”
But Leigh is far from alone. A large South African cross-sectional study, published in 2008, found a prevalence of chronic pain of 48,1% — just less than half the population, or about 24-million people. If just 10% of these people have a level of chronic pain similar to Leigh’s — pain that seriously eats into your enjoyment of life and limits your ability to function normally — then a few million South Africans share her experience.
Patients like Leigh have long been a puzzle — and frustration — to medical science. Her pain began with an injury many years ago, but it has persisted way past the point where healing was anticipated. Although she has some minor lasting damage from the injury, it is not enough — according to the traditional model of pain — to trigger the kind of constant pain she experiences.
“I’ve been told it’s ‘all in my head’. In fact, one doctor told me the pain was caused by depression and prescribed antidepressants. I felt that constant debilitating pain was the cause of my low mood, not the other way around!”
Is it in her head? Leigh’s brain may well play an important role in her pain, but her pain is not “psychosomatic”. It is not the result of psychological problems. It may well be because her central nervous system is too clever for its own good.
Traditional model fails patients
Here’s the traditional “Western” model of pain: pain is an unpleasant sensory and emotional experience that may result from damage to the body’s tissues or even the thought of pain in those damaged tissues.
Leigh did all the right things, according to the traditional model. When the injury occurred, she went to casualty for X-rays and treatment and was sent home with a bag of pills. When the pain persisted, she consulted her GP. When it continued, even worsened — in spite of his best efforts — she started a long journey from one health practitioner to the other.
“In the past 15-odd years I’ve consulted chiropractors, physiotherapists, sports massage therapists, osteopaths, orthopaedic surgeons, podiatrists and body stress release therapists,” she says. “I’ve taken anti-inflammatories, homeopathic remedies, painkillers, muscle relaxants, sleeping pills and even, briefly, antidepressants.”
The brain remembers past pain
At a recent presentation by the Gauteng branch of the Pain Management Physiotherapy Special Interest Group (PMPG), there was a recognition that the traditional model of pain is failing far too many patients and there is an enormous need to broaden the understanding and treatment of pain.
“We now recognise that the mind and the body are integrated and that they operate within an emotional, cultural and social environment, all of which has an impact on how pain happens and how it is experienced,” says physiotherapist Phyllis Berger, an internationally recognised expert on pain and its management.
Treatment of chronic pain needs to draw on a wide range of health disciplines, including psychology, which is why psychologist Lynn Pamensky’s insights about treating pain with psychological tools such as narrative hypnosis is key.
Berger offers an important clue on how the brain can be involved in the chronic pain picture. In chronic pain, she says, the neurons retain memories of previous pain and amp up current pain. “Chronic pain results in changes in the conduction of nerve fibres, causing these fibres to become hyperexcitable.”
So the pain is not a result of your thoughts (“all in your head”); it is about activity taking place at a much simpler level, the level of the neurons, those electrically excitable little nerve cells that transmit information electrically and then produce changes in the chemical milieu of the cells and ultimately the tissues.
Neurons are the core of the nervous system and they network readily with one another (“Neurons that fire together wire together,” as Donald Hebbs recognised back in 1949). Networking between neurons will therefore amplify pain. And thoughts about the pain (such as fear, distress and overanxiousness) will increase activity in neurons, creating an increase in pain substances in the body, which obviously also pumps up the pain.
The brain ‘learns’ pain
So instead of the simple mechanical concept proposed by René Descartes, that nerves are like little tubes along which messages run. We have a “learning” central nervous system in which each experience amplifies sensitivity. For example, pain causes an emotion; the “emotion” neurons fire (and network) with the “pain” neurons, so from now on the sensation of pain can also be triggered by that emotion.
These changes can be seen in scans of the brain in action: a chronic pain patient has much larger and diffuse activity in the brain than someone who experiences acute pain of limited duration.
The nervous system is a learning organ in more than one way. It can unlearn those patterns and networks too. Which is why Berger and Pamensky are partners in therapy. Berger uses a vast range of tools, from physio-therapy (one method she uses is electrical modalities, some with developed currents, the specific frequencies of which have an impact on particular pain symptoms) to acupuncture and even hydrotherapy, but she very often refers chronic pain patients to Pamensky, who can talk directly to the brain.
Talking the patient out of pain
With the patient in a state of hypnosis, Pamensky tells the central nervous system a different “story”. She uses vocal tools that plug into different parts of the brain (chanting in a sing-song voice, for example, using different frequencies to excite different levels of the brain). With narrative hypnosis, she has even been able to get patients whose limbs were immobilised by pain to move. “Psychotherapy is an absolute trump card,” says Berger. “There have been a number of studies that show how effective the modalities Lynn uses are, from breathing exercises to hypnosis. In conjunction with what we as physiotherapists can do, it gets amazing results.”
This is good news for medical schemes because they could reduce expenditure on chronic pain patients significantly. It’s good news for employers who want fully present and productive employees. Good news too for families and spouses who are placed under enormous strain by this condition. And good news for the vast numbers of frustrated, exhausted and miserable chronic pain patients.
*Name changed to protect privacy
Michael Sullivan is an international expert in the broad-spectrum treatment of chronic pain. He will be in South Africa in May 2011. Contact PMPG chair Bev Bolton via email for more on how to register for his lectures.