TO YOUR HEALTH
Understanding Persistent Pain
BY PHILIP R. APPEL, PHD According to the International Association for the Study of Pain (IASP), the definition of pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or de- scribed in terms of such damage” (derived from a 1964 definition by Harold Merskey; first published in 1979 by IASP in the journal PAIN , number 6, page 250). The key words here for your understanding are emotional experience and potential . When one has persistent pain, it is not uncommon to become overly focused on trying to avoid the pain. Many times, an individual is reacting to how intense the pain has been and is thinking how intense the pain might become, even though in a particular moment it may not be at that level of intensity. Years before 1964, much was learned about pain during World War II. Dr. Henry Beecher, an Army physician, noticed that soldiers who were able to be treated at the front because of the nature of their wounds seemed to be in more pain and suffering than the soldiers who were so severely wounded they needed to be evacuated. He realized those evacuees with severe wounds had tickets out of hell, and were happy to be leaving; whereas the soldiers treated at the front had to face going back into battle, and perhaps being wounded more severely the next time. The meaning of the wounds influenced the experience and intensity of suffering, because pain is also an emotional experi - ence. Your health care providers frequently ask you to rate your pain on a scale of 0 to 10, where 0 is the absence of pain and 10 is the worst pain you ever experienced. It is important to understand this question is one related to your personal experience of pain over the course of your life. There is no such thing as a rating of 10 for everyone, because everyone tolerates pain differently. Levels of pain intensity from 1 to 3 are considered mild, 4-6 mod - erate and 7-10 severe. My own experience of pain changed when I had contracted a rare form of Lyme disease that left me with a lesion in my spine. Before that, I had pain from a broken leg, soft tissue injuries from motorcycle accidents, and a herniated disk; what I thought was rated an 8 or 9 then became a 2 or 3 in light of the spinal pain from the lesion. Your health care professional is trying to understand the inten - sity of your pain using this scale. Sometimes, rather than numbers, a visual face scaling question is used where you would be asked to point to the face that represents the intensity of your pain.
times of intense storms, and we should recognize them when they are happening and not be fearful. For most of us pain has been temporary; it has been a sensory ex- perience that alerted us to injury or illness. With treatment and res- toration of homeostasis (i.e., balance) of the body, the pain usually subsides and fades away. But when pain is unremitting and unrelent - ing, it challenges a person’s notion of the way the body is supposed to work; for the first time, you may begin to perceive how vulnerable and fragile we mortal humans are. And you may begin to feel out of control should the body not respond to treatment or heal on its own as it once did. Being in constant pain becomes an existential situation, wherein you, the individual, must journey alone, as the experience cannot be shared or even described in a way another can experience. A person with persistent pain will have emotional reactions to the uncomfort- able sensations in the body. We call the emotional reaction to the sen- sory qualities of the pain the “affective component” of the pain; and it is the pain’s affective component that determines the extent of a person’s suffering. When the pain is imagined or thought to represent a threat to self or body, there will be an anxious or perhaps a depressed response. Clinical experience has demonstrated to me that patients’ emotional experiences are driven by their unconscious as well as conscious judg- ments and beliefs about the pain. With frequent, repeated, or contin- ued experience of pain, that particular pain becomes associated with illness, injury and self. Many individuals think of themselves as sick or ill because of the pain rather than being injured or even having a damaged body part. Levels of Pain and Pain Behavior My goal is to teach about Response-Ability, i.e., the ability to re - spond to your pain in a confident manner as you care for yourself. You will need to gain the ability to self-soothe, to self-motivate and self- coach, and to rebuild self through gaining more stamina, endurance, and flexibility, both physically and mentally. It’s important to under - stand from the outset that getting better correlates with what you do for yourself, rather than with what the health care team does. Consider the diagram from the surgeon Dr. John Loeser, which characterizes how pain ripples through our mind and body changing our behavior. The diagram comes from Loeser’s discussion of pain and suffering, where he states how the larger the circle, the bigger the problem is for the physician. So, what is “Pain Behavior”? And why would it be the largest problem?
Pain behavior refers to all the brac- ing, guarding, and alteration of natu- ral movements an individual engages in because of the presence of pain. These behaviors frequently affect the natural biomechanics of the body, and paradoxically, increase pain and delay recovery. For example, I once worked with a woman who had fractured sev- eral toes on the job when she acciden- tally kicked an electrical box that pro- truded from the warehouse floor. In order to avoid the pain in her toes, she
Image source: www.researchgate.net/figure/11914002_fig1_Fig-1-Top-Faces-Pain-Scale-Bieri-et-al-1990-scored-0-to-6-Bottom-Faces-Pain]
If you say your pain is at a level of 10, but you are able to maintain your voice tone, pay good attention and have a reasonable conversa- tion, all you will be conveying is that you want to be believed that you are in pain and need relief. This is not to say that there aren’t times when you are having pain at an intensity of 10, finding it hard to con - centrate on anything, to maintain your mood, to talk in a normal voice and to feel desperate to escape! However, it is important to have your health care providers not think you are just responding in a way to get them to take you seriously. Instead, tell them the range of your in- tensity — say what it is now, and include what the worst and the least levels of intensity are, too. Pain is often like the weather — there are
limited weight bearing on that leg and foot by raising her hip. Over time, she developed back trouble with chronic muscle tension in the
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PATHWAYS—Fall 24—17
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