Pain: Acute, Cancer, Non-Malignant - Chronic

Pain is a complex, subjective, perceptual phenomenon with a number of contributing factors that are uniquely experienced by each individual. One of the things that influence our pain is the injury itself, which is often long healed, and the severity of the original injury is not at all correlated with how much pain we feel. Another influence includes the context or situation in which the pain occurs. Other factors include our attention to the pain (are we focused on it or distracted by something else), our expectations about the impact the pain will have on our lives, and our memories of previous, similar pain.

There are three types of pain:

1) acute

2) cancer related

3) chronic nonmalignant

Acute pain is what happens to you when you first hurt yourself. It is a message to you to stop whatever you were doing and check out the extent of the injury. This message is an important one and not to be ignored.

How do we feel acute pain?
Several areas of the body act together to allow us to feel the pain. We use peripheral areas like our skin and muscles, in addition to our spinal cord and brain. The message from the area where we hurt ourselves is carried to the brain via nerves. The perception of pain is also controlled by descending nerve pathways that complete a feedback loop from the periphery to the brain and back again. "No Brain, No Pain." Although the pain we feel is not "in our head" it cannot be perceived without the brain.

In the brain, some parts help us to perceive the pain (is it hot, sharp, or aching). Another part helps to determine how severe it is (mild, miserable, agonizing, unbearable, excruciating). Still another part influences our emotions about it (are we scared, sad or angry). Studies have shown that we can learn to shut off the emotional part of our brain, and when we do so, we can tolerate more pain for a longer period of time. Fear, worry and anxiety or being nervous makes the pain worse; we actually hurt more. If we are prepared and not scared we can tolerate more pain. (This is why "Natural childbirth" works for so many women.) The context in which we experience pain has a lot to do with how well we can tolerate it.

Cancer pain is usually caused by the tumor taking up space and crowding other organs or by destroying the bone. We will not discuss this much here except to say that today we have ways of controlling cancer pain that do not interfere with the patient's ability to be alert, have good sleep and maintain good relationships with their friend and families. There is less concern today about addiction to pain medication in those who do not have a prior history of addiction. Addiction is not defined in terms of withdrawal from medication or tolerance but rather by continued use despite adverse consequences, cravings and loss of control.

Chronic nonmalignant pain persists beyond the point of tissue damage: the original injury has healed but we still hurt. For instance, if you slam your finger in a car door, what you first feel is acute pain, but if in the years that follow you can tell when it is going to rain by the pain in your finger, this is chronic benign pain. It isn't in your head; you aren't imagining it; you aren't crazy; your finger really does hurt, but you need not stop what you are doing and attend to the pain. That is a rather insignificant example, but how many of you have back pain? 50% of adults will tell you that their back hurts right now. In fact 85% of all adults will have an episode of back pain at some time in their life. Most will get better within a month, but 2% will go on to develop chronic pain syndrome.

When we start to limit our behavior based on chronic pain we can get into trouble. When you are not active, you become de-conditioned. Then, any time you try to do activities you experience more pain. This causes you to do even less, becoming more and more de-conditioned. This sounds like a vicious circle but what really happens is a downward spiral because each time you try to do something and then rest, you actually get worse. Remember how we said that emotions effect pain? Well when you end up spending your life on the couch or in bed watching re-runs on TV, sooner or later you become depressed. Maybe you get anxious, irritable and frustrated. Well, what we know about pain is that these emotions will make you hurt more; left untreated people with chronic pain syndrome can become very disabled.

Relaxation training, either with or without the assistance of biofeedback, can help reduce pain and help reduce suffering. Biofeedback is a technique where you are hooked up to equipment that will measure muscle tension, temperature and galvanic skin response (sweating). This allows you to monitor how tense your muscles are and whether the pain is also causing other types of autonomic arousal that can make pain worse. With the use of this feedback you can learn to relax tense muscles, improve your posture by changing how you stand and sit and teach yourself to control your arousal. When we have pain, we often become more tense, guarded, and generally more physiologically aroused. This not only gives us more pain but after a while, it is exhausting. When we learn to relax we also release endorphins which are the bodies natural painkillers.

Biofeedback and relaxation training have been shown to reduce the frequency and severity of headaches, low back pain and other painful conditions. Combined with Cognitive Behavioral Therapy, this is an effective way of learning to "get your life back" and "manage the pain rather than the pain managing you." What we tell ourselves when we feel pain (e.g. "It is going to kill me") as well as how we behave when we have pain (e.g. resting) can effect both our physical and psychological well being. If we rest excessively, we become deconditioned. If we constantly perceive threat to our well being, we become depressed and anxious. Effective therapy for chronic pain needs to take into account how we are doing physically and emotionally, as both strongly have an impact on our perception of pain.