An Introduction to Pain and its relation to Nervous System Disorders
Maeve had an unpleasant forceps delivery when her third child was born; the interventionwas traumatic and painful at the time and after delivery the pain did not go away – it radiated into her thigh, across her perineum, it raged away and affected her recovery, her self‐esteem, her care of her child. And no one believed her, it was inexplicable, there were no physical signs of damage, no major nerve had been severed, it did not fit any diagnostic category, therefore it was not real. Bitterness, loss of self‐confidence, loss of hope, litigation ensued, but still the pain persisted. Is this scenario explained by new research into the neurobiology of pain? Is brain imaging making it easier for us to understand it? Every small step forward adds a small piece to the jigsaw; but there is a long way to go. She could not wait, her life lay in tatters with smouldering anger and resentment.
Hilary Mantel writes eloquently about her own chronic pain from endometriosis. She rebukes doctors for not listening and finds that the best therapy is an empathic and supportive relationship with a caring doctor who may not have any answers but who listens, cajoles, explains as much as he or she understands and tries to wear the shoes of the pain sufferer. Maeve found a similar pathway four years after her pain started and now, 14 years later, she leads a normal life – still with a small amount of medication that she dare not stop, and with an annual review. It was not injections or sophisticated gadgetry that helped her, but a listening ear and guidance from an educated pain professional.
Loraine suffered a whiplash injury 20 years ago; she had persistent tingling and pain in her arm and hand but no demonstrable nerve injury. In the course of her rehabilitation she was lucky enough to be referred to a pain management programme. She continues to see her physiotherapist. As a result, she returned to full‐time work and manages her children without assistance. It could have been very different.
Wilbur is 32 years old and moves slowly; he has a constant back pain. He has been successfully treated for aplastic anaemia with chemotherapy and no longer needs any blood transfusions. Despite his miraculous ‘cure’, he appears angry, as the back pain is ‘ruling my life’. He has served several spells in prison and has been deserted by family and friends because of outbursts of uncontrolled anger. His gold front teeth flash as he relaxes into an engaging smile and talks about his fears. A scan of his back shows stable marrow changes but no pathology to account for his pain. His back movements are reduced and painful in all directions, pain being exacerbated by anxiety and anxiety causing more pain. He is very willing to engage with a psychologist, to learn how to control his anger and to go to the gym. He seems to need permission to do so. Resolve to change the course of your life needs support and nurture.
There are many patients with chronic pain who have not managed to lead a fulfilling life and who continue to look for a cure. Injections, surgical operations and more operations often make the situation worse. There is always the hope that this time it will be different; if there is no hope there is despair, and this features highly in chronic pain sufferers. It is hard for attending health professionals to manage such a complex condition as chronic pain. We may not be able to alter the level of pain, but we can alter life around the pain, provide hope where there is despair, laughter instead of tears, relaxation instead of anxiety, and we can encourage physical activity that may have seemed an impossible task. We can alleviate only some of the suffering that chronic pain causes in one’s life.
This book looks at some very needy populations in intractable pain. Pain within a serious neurological disorder such as Parkinson’s disease or multiple sclerosis leads to a double dose of suffering; pain in dementia can be very hard to treat, as the normal distraction of performing simple tasks is often absent; pain in the neonate and in the autistic adult needs a whole new level of understanding. Pain, depression anxiety are recurring themes in patients with chronic pain. We cannot remove the pain, so we must address the things we can help; depression and anxiety can very definitely be helped by counselling, mindfulness and other psychological techniques, and through the judicious use of drugs. There is increasing awareness that opioids do not work well in the management of chronic non‐cancerous pain and may cause more harm than good. Injection therapies and neuromodulation, in highly selected cases, have a small but important part to play in pain management.
The science of pain has moved way ahead of the techniques available for managing pain, which get fewer and fewer as research shows that any one technique or drug works well in only 15–30 per cent of people. New pain pathways and receptors are being discovered in the nervous system, neuroimmune mechanisms are shown to have an important role, genetics plays its part, plasticity is all important; but there is no single answer for any individual, and there is more complexity for the doctor to deal with. We must not lose sight of the person who suffers. Science cannot explain suffering but it can add insights into the causes of suffering.
Despite these scientific advances, pain medicine remains an art; but the insights from scientific discovery serve to further our understanding of the origin and perpetuation of chronic pain. Helping to alter thinking and behavioural patterns in an individual requires devoted input from doctors, nurses, psychologists, physiotherapists, the pain sufferer and his or her family and friends. When pain management is well done, it is remarkably effective.
27 February 2015
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