The ultimate sacrifice

His book caught my attention in the first chapter when he related the story of his missionary family moving to a remote area of India where no one had ventured because of a deadly type of malaria. Sure enough, his father died relatively soon from it, but his mother spent the rest of her life there serving the medical needs of these people living in incredibly remote area. He went on to become an orthopedic hand surgeon and spent the first years of his practice in India dealing with patients with leprosy. You may know that they routinely develop severe grotesque deformities of their arms and legs. He would perform corrective surgery and kept meticulous records of his approaches both for learning and teaching.

Leprosy

Since the beginning of time, lepers have been treated as outcasts with their limb and facial deformities being nothing short of hideous. After it was figured out that that the leprosy bacteria was the reason for these problems, they still were not treated that well, but at least it wasn’t some type of evil humor or demon possession. Doctors felt that the bacterium directly attacked the tissues and caused the disfigurement.

Dr. Brand figured out that the deformities were not directly caused from the leprosy bacteria, but because the bacteria destroyed sensory nerves and they had lost protective sensation. Your pain system sends signals to the brain, which interprets them to indicate danger any time the limits of a structure or tissue are being challenged that could result in damage. For example, a morsel of food would fall into the cooking fire and the person would reach right into the coals to lift it out. If there was an injury to an ankle, normally you would rest in order to allow it to heal. These people would just keep walking and eventually the joint would disintegrate. A common descriptive term is, “a bag of bones.”

Diabetes

When he returned to the United States from India in the 60’s, he began to notice similarities between his patients with diabetic foot and leg breakdown and his observations of leprosy. There were poorly healing skin ulcerations, infections that would not heal easily, and joints were severely breaking down. Doctors felt that the elevated blood sugars were the cause of the problem. He quickly noted that it was the same problem that existed in lepers; the sensory nerves were being damaged and that they losing protective sensation. It was his pioneering work that led to more aggressive control of blood sugars, protective footwear, healing casts, and patient education to learn ways to protect themselves. He made a huge difference in many people’s lives.

 Congenital indifference to pain

He also described the problems that are created when people are born without a functioning pain system. It is a rare condition called, “congenital indifference to pain.” They have no way of programming their brain as to what might be dangerous or safe. They routinely exceed the limits of their tissues. They don’t even know how to avoid a hot stove. Their lifespan is only about 10-15 years and they die from repeated infections.

Dr. Brand, as a part of his work and research, was given a large government grant to develop a device that would warn people without protective sensation of danger. He devised a tight fitting body sensor suit that would send unpleasant warning signals to the brain when there was potential tissue damage. For example, if a person was using a wrench to tighten a bolt and was pulling too hard, they would receive an unpleasant electrical jolt. The problem was that the person didn’t want to be bothered and would just remove the glove and proceed to damage his or her joints.

The state of your central nervous system

After multiple attempts, everyone gave up. There has never been a solution for someone not having a protective pain system. The problem is that it is incredibly complex system that exists in a delicate balance. Additionally, the final perception of pain is determined by the state of your central nervous system as well as your prior experiences. For example, one night of poor sleep will significantly increase your pain the next day. (2) Consistent lack of sleep actually causes chronic low back pain. (3) Arguing with your spouse instantly increases pain. (4) Running into the bully at school may cause your stomach to churn. This list is infinite. Why would this be the case? Because pain is only pain because your brain says it is so. Your brain is analyzing about 20 million bits of information per second and is programmed to keep you safe and alive. The species of creatures who did not pay attention to environment cues did not survive. Pain is a major part of all of this and is a gift that allows you to safely navigate this planet.

The curse of chronic pain

Chronic pain is not a gift. For many reasons this intricate and balanced pain system is broken. It continues to fire away even when there is no danger. So, now you have a scenario where you are experiencing a sensation that is intended to be so unpleasant that it compels you to take protective action, but you cannot turn it off. It is like a car alarm that won’t turn off except it is incredibly more disruptive. It may be one of the worst experiences of the human existence.  Research has shown that living in chronic pain has a similar impact on a person’s life as experiencing terminal cancer. (5) The problem is that while suffering from chronic pain, you are not being told the nature of the problem, and where is the endpoint? You could argue that it is worse than having terminal cancer.

Fortunately, chronic pain is solvable by first understanding the nature of the problem and then learning approaches to bring the system back into balance. The DOC Journey represents the sequence of many patients who have broken out of the grip of pain. You first have to understand the nature of a problem before you can solve it.

The Journey also begins by embracing your disbelief. You have already tried everything that has been suggested, why would you try this process? Although a positive vision is necessary to move forward, this Journey is not about positive thinking. It is about becoming connected and engaged to what is right in front of you regardless of how pleasant or unpleasant it may be. Then you can move on.

Don’t let the gift of pain that has spun out of control take way from your gift of life. Treat yourself this Holiday by taking  your life back.

1. Yancey, P and Paul Brand. Pain: The Gift Nobody Wants. DIANE Publishing Company (1999).
2. Kahol K, et al. “Effect of fatigue on psychomotor and cognitive skills.” Am Jrn Surg (2008); 195: 195-204.
3. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.
4. Burns, JW, et al. Temporal associations between spouse criticism/ hostility and pain among patients with chronic pain: A within-couple daily diary study. Pain (2103); 154: 2715-2721.

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Conceptualizing pain

What is pain? We toss the word around a lot without really understanding what it actually means. A loud noise is uncomfortable. Bitter tastes are unpleasant. Ringing in your ears is more than annoying. What about when someone, “hurts your feelings?”

The way every living species of creatures evolved and survives is by processing multiple types of sensory input and interpreting the sum total of it as safe or dangerous. Then its behavior is directed towards safety and rewards while also avoiding threat. These automatic actions in response to this input keeps us in a neutral zone most of the time so we remain functional and comfortable.

Nociceptive pain

The name for this function of the nervous system is called, “the nociceptive system.” When the limits of safety are exceeded for a given part of the body, your receptors will signal danger and cause you to engage in corrective action. The intensity of the signal will depend on the input from a specific part of the body. For example, a bright spotlight shined in your eye would not be tolerated for very long. Your brain knows your eyes would be damaged quickly and the danger signal is sent out for you to close your eyes or move away from the light. But what if the same light was focused on the bottom of your foot? No problem because there is no threat from light alone to that part of your body. Pain is simply a warning signal that there is potential damage to a specific body part.

So, acute pain is necessary and protective. It is a gift and people who are born without a pain system don’t survive more than 10-15 years. They can’t sense danger. Tissues are destroyed and they die of infection. (1)

A nightmare

But there is nothing useful about chronic pain. A delicately balanced signaling system is out of kilter and it can no longer accurately interpret the environment. You are trapped by incredibly unpleasant sensations without any hope of escape. It may be one of the worst experiences of the human condition.

Based on the last 10 years of neuroscience research, new definitions of chronic pain are being created. Here is one proposed by the IASP.

IASP definitions of chronic pain

For the first time since 1979, the International Association for the Study of Pain (IASP) revised its definition of pain. This was made necessary by the research showing clearly that pain could arise from sources other than physical tissue damage. Although the revision is a relatively small one, it has big implications for appreciating the complexity of pain and expanding our ability to assess and manage pain with multi-disciplinary approaches.

Old 1979 definition of chronic pain

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

Revised 2020 Definition

“An unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage.”

This definition is expanded by 6 key points

1. Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors
2. Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
3. Through their life experiences, individuals learn the concept of pain.
4. A person’s report of an experience as pain should be respected.
5. Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
6. Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

By adding the words resembling that associated with allows for an expanded understanding and appreciation of pain beyond that which was previously limited to actual tissue damage.

Dropping the phrase “describe” the pain, allows for acceptance of pain from those who may not have the ability to describe their pain whether infants, cognitively impaired individuals, those with communicative disorders, or any other reason that a description of pain may not be possible including nonhuman animals.

Commentary on the six key points

1. It logically has to be personal since each person is genetically different and we are programmed with regards to safety vs threat by our past. If you come from a less than nurturing background, more things in the present will seem dangerous because when you were younger they were dangerous. You will spend a higher percent of your time in a “high alert” and the sustained exposure to stress hormones and inflammation will create physical symptoms and serious diseases.
2. Acute pain is the danger signal that indicates that you have exceeded the safety limit of a given structure of your body. The nociceptive system keeps your behaviors in a range to protect you. Chronic pain happens when the signals have become disconnected from the environment and keep firing even in the presence of safety.
3. Pain being a learned experience is well established in the medical literature. One classic study involved looking at childhood trauma. A scoring system was developed called the ACE score (adverse childhood experiences) looking at 10 factors such as various kinds of abuse, parent(s) in prison, addicted to drugs, or having a mental health diagnosis. There is a marked increase in chronic diseases including chronic pain. (2)
4. Patients in chronic pain are often labeled. They include, “drug addict”, low pain threshold”, “faker”, “drug seeker”, “unmotivated”, and the list is endless. Often the labels are even more disparaging. No one likes being labeled. Once a person has been labeled, you can no longer “see them”. Since physical symptoms are created by the patient’s interaction with his or her environment, it is critical to know them and also their life circumstances. How can you solve any problem without deeply understanding it?
5. There is no usefulness in chronic pain. It is a disaster and it always interferes with function, social interactions, and psychological well-being – ALWAYS.
6. Chronic pain is so disruptive to every aspect of your life that words do not come close to describing the depth of suffering. It has been shown that the impact of chronic pain is greater than that of having terminal cancer. (3) The term that best reflects this condition is, “The Abyss.” It is a really dark place without a way out.

Unfortunately, mainstream medicine has not incorporated the last 20 years of neuroscience research into their treatment approach. It continues to recommend random simplistic treatments for a complex problem. It can’t and doesn’t work.

The new IASP definition is a start and opens the door for a better treatment paradigm. Chronic pain is solvable with an understanding of it and the principles behind the solutions. The starting point is for YOU to better understand it and then solve it with using the medical system as a resource. Once you take charge, it is game on.

1. Yancey, P and Paul Brand. Pain: The Gift Nobody Wants. DIANE Publishing Company (1999).
2. Anda RF, et al. “The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology.” European Archives of Psychiatry and Clinical Neuroscience (2006); 256: 174–186.
3. Fredheim OM, Kaasa S, Fayers P, Saltnes T, Jordhøy M, Bortchgrevink PC. Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients. Acta Anaesthesiol Scand. 2008;52(1):143-148. 

The post Clarifying the New IASP Definition of Chronic Pain first appeared on Back in Control.

The post Clarifying the New IASP Definition of Chronic Pain appeared first on Back in Control.