Mind Over Matter

The way chronic pain is defined and treated has changed, with growing recognition of how attitudes, beliefs, personality and social factors influence outcomes.

“THE KEY IS NOT TO THINK OF PAIN AS A THING.”

The role of the mind in the pain we feel is now at the forefront of painmanagement approaches. Research shows pain is both an unpleasant sensory and an emotional experience and a person’s perceived pain is highly subjective.

Participants given the placebo in pain medication studies have reported their symptoms easing, highlighting how psychology can provide symptomatic relief.

A gradual shift in the understanding of pain and its management over the past few decades has resulted in The International Association for the Study of Pain introducing a revised definition earlier this year.

This update replaces a definition that was published more than 40 years ago. The revision aims to better convey the complex nature of pain, with a view to improving its assessment and management through an understanding of pain being an emotional and personal experience and not in direct correlation with physical injury.

Acute pain is usually of short duration, for example, from something like a fall, cut or burn. Chronic pain is pain that persists for more than three months. It may have started from an injury that had physically healed, but the pain persists. There are also more than 300 conditions that may lead to chronic pain.

One in five people live with chronic pain. The total associated cost of lost workdays and healthcare was approximately $73.2 billion in Australia in 2019 – making it one of the country’s most costly healthcare problems. Jeremy Yung, a senior physiotherapist at Pain Management and Rehabilitation Services, works with patients who have suffered with chronic pain for varying durations. He uses both physiological and psychological approaches.

“I recently had someone who is still, 25 years after a car accident, in massive amounts of pain,” he says. “The body has had time to physically repair, but the pain is still high. They are convinced they are still injured; they have been for multiple tests and X-rays and the doctor will tell them that they’ve healed.

“But essentially what has happened is there’s been a shift. In the old pain model, if you have a high amount of pain, you have a high amount of tissue damage or harm. A small amount of pain, a small amount of damage. Now we know that is not true.”

The key is not to think of pain as a thing, but as an experience, says Professor Michael Nicholas, director of pain education and pain management programs at The University of Sydney’s Pain Management Research Institute. “It’s not something you can see on an X-ray or a CT scan,” says Nicholas. “The amount of pain a person feels from a given injury or disease will vary within and between people with essentially similar causes and that is because the experience of pain is modulated by a number of contributors and the emotional state of the person is a key contributor.”

When we feel pain, this is picked up by sensory receptors of the nervous system and sent via nerve

Chronic pain is pain that persists for more than three months. fibres to the spinal cord and brainstem and then on to the brain. The part of the brain that perceives the pain is called the limbic system. It deals with emotions, behaviour and memory.

“You could say, for example, when you have an acute tissue injury, that 90 per cent of the pain could be due to the physical tissue damage, and 10 per cent is from factors such as emotion and mood,” says Yung.

“Five or six months later, the pain is at the same level but the proportions have changed. Now the pain coming from the physical damage is down to 10 per cent and 90 per cent is from peripheral sensitisation or central sensitisation.”

The Institute for Chronic Pain describes central sensitisation as a condition of the nervous system that is associated with the development and maintenance of chronic pain. When central sensitisation occurs, the nervous system goes through a process called wind-up and gets regulated in a persistent state of high reactivity, maintaining pain even after the initial injury may have healed.

PACING & ACCEPTANCE

Akii Ngo is executive director of Chronic Pain Australia and also a chronic pain and chronic illness sufferer. Over the years, they have managed their condition through a multi-disciplinary approach of medication, surgery and mental health support and associated psychological techniques: “It’s relentless, day in day out, just trying to get through the day. It’s mentally exhausting. I’m just really tired, physically and mentally.”

A multidisciplinary approach includes a combination of medical, physical and psychological therapies and has proven to be an effective way to treat pain. It also aims to address all the factors that influence the pain experience using a range of treatments and strategies.

According to statistics published by Pain Australia and the electronic Persistent Pain Outcomes Collaboration (ePPOC), almost half of all patients were able to reduce their opioid medication by 50 per cent or more after multidisciplinary pain treatment, but patients experience long waiting times to access these services in public hospitals – frequently more than a year and

sometimes up to two years – resulting in deterioration in quality of life and reduction in ability to return to work.

Ngo considers an important step is to stop pushing yourself and set your own goals in line with your abilities: “Pacing and acceptance are big things that have been spoken about to me. If you are a healthy person, you might have 10, 12, 13 usable hours in the day. People with chronic pain, or who are chronically ill or have disabilities, their usable hours may only be five, or even less.

“Pacing is a psychological technique to break things down, to ensure you have a baseline where you can manage the things you need to manage in the usable hours you have. Spacing your activities throughout the day allows you to stay within the limits of what your body can handle.”

Nicholas says the Pain Management Research Institute teaches chronic pain sufferers to gradually build up to things and to not be working around pain all the time. “There are some things that may still be limited by pain, then you have got to have a plan to deal with them and occasionally your pain will flare up – so you need a strategy for dealing with that.

“Getting people to set their own goals is very important, whether it’s working back towards work, leisure, hobbies, family or social events.”

Psychological techniques and therapies including adaptive coping strategies are used to help people control their pain – rather than it controlling them – by changing the way it’s perceived. “You are learning to adapt to your pain, trying to train your brain not to see these signals – this experience of pain as a threat, which it is wired to do,” says Nicholas, “People will say, ‘I still have my pain but it doesn’t bother me as much.’”

Yung treats patients with chronic pain utilising approaches such as visualisation, hypnosis, regulated breathing and technologies such as biofeedback and neurofeedback. “Pain is such an abstract concept. You can manipulate their pain by manipulating the image of their pain in their mind,” says Yung, while explaining the approach of visualisation: “If it’s hot and red, perhaps we change it to a cool blue. If it’s sharp and spiky, can you think of it as round and smooth?”

Emotions that have proven to worsen pain include distress, anxiety or worry. Those that lessen the experience are feeling calm and relaxed. “We look into education about pain, help people identify mood – depression, anxiety, fear, worry – and we address it,” says Nicholas.

As well as emotions, behaviour can also affect how much pain is felt. “Sometimes behaviour has become part of the problem. They have developed habits such as lying down and resting a lot, avoiding things that stir up the pain,” says Nicholas. This risks causing further issues associated with not keeping mobile and active and limiting your daily life.

Understanding can also influence pain. If you are fearful, and it’s not understood, it will worsen. If you have a good understanding, it will lessen the fear and stress. Our learned experiences with pain in the past may build up fear, anticipation and anxiety, causing us to view similar events or tasks as a threat. Fearing that a bad experience may be repeated can affect how much pain you will feel.

“Some things can provoke people’s pain. This makes no sense with the old model of pain. If you see pain as a smoke alarm – a warning device that’s telling you of the harm that might happen, not the harm that has happened – then it makes a lot of sense,” says Yung.

THE PLACEBO EFFECT

Placebos won’t heal a broken bone or cure an illness, yet placebos have been proven to work on symptoms modulated by the brain, such as the perception of pain.

In a study trialling the efficacy of a glucosamine and chondroitin medicine versus a placebo for knee osteoarthritis pain, the placebo worked better. People who took the medicine had a 19 per cent reduction in pain scores after six months and those who took the placebo had a 33 per cent reduction.

Speculation about the results included that the brain associated taking pills with pain relief, and so it triggered that reaction.

Also within the context of a medical environment, doctors in white coats giving examinations can result in the patient believing that the pill will work, triggering a reduction in pain. Chronic Pain Australia’s National Pain Survey 2020 surveyed Australians living with chronic pain. When asked: how would you rate your feelings of stigma or negative attitudes because of your chronic pain? The average response was seven out of 10 (one being not at all, and 10 being constant). “A lot of our community highlights that sometimes the stigma can be worse than the pain. Persuading people to believe you is exhausting,” says Ngo.

The invisibility of some people’s pain carries with it a level of misunderstanding, with those living with chronic pain being disbelieved and subjected to stigma and even abuse. As part of Chronic Pain Australia’s Pain Week, ‘Faces of Pain’ stories are collated from those living with chronic pain, and various conditions, illnesses and disabilities, to raise awareness that pain can be suffered by anyone, no matter what they look like.

“I have a disability parking permit, and I’ve been abused for it,” says Ngo. “I’ve had people put notes on my car saying, ‘You should be ashamed of yourself.’ I’ve had people shout at me and follow me. Sometimes I use a mobility aid and sometimes I don’t. Just because they can or can’t see it doesn’t mean the disability is not there. Chronic pain is buried. With me, there is clear pathology, but with some people there is no clear pathology. There is a lot of stigma, as you can’t see pain.”

With 20 per cent of the population living with chronic pain, making it a pressing medical issue, it’s shocking that the general population, medical professionals, workplaces and even sufferers themselves lack understanding of how to treat their pain and the complexities of its causes and management.

“Complex problems usually require complex solutions,” says Nicholas. “But people don’t want to hear that, they want the quick fix.

“It’s much harder selling a psychological treatment than a pill, because there is a bit of work. It’s rewarding because you have got to do it yourself and the more you do it, the better at it you get.”