Issues Magazine

Understanding and Managing Pain

By Natalia Valentino

Very few people live life without pain at some stage. Our understanding of pain has improved but it is still not managed well.

Pain is a very common experience. At the same time it is a very personal experience that can affect your body and your mind.

Pain affects all people differently – even the same person can respond to pain differently depending on the situation. Just think about how sore a paper cut can be, yet rugby players have been known to continue playing the game with a broken bone.

Pain can affect anyone at any time. Acute pain is very common and responds to treatment. Chronic pain, where pain persists beyond the expected time of healing and does not respond to curative treatments, is more common in women and older people. Interestingly, although the incidence of pain increases with age, young adults are more likely to report that pain is interfering with their daily activities (www.www.iasp-pain.org/PainSummit/Australia_2010PainStrategy.pdf).

Pain is as old as humankind. And since the beginning of time people have tried to understand why we suffer pain. The 17th century French scientist René Descartes described acute pain very well: if you get too close to a stimulus for pain, it activates a thread that goes to the brain, and then you experience pain. He used the analogy of a bellringer. When the rope is pulled, the bell rings.

For Descartes this explained pain – something happens that leads to pain. This explanation works perfectly for a broken leg or paper cut but it doesn’t explain the ongoing chronic pain experienced by people living with arthritis.

Since Descartes’ time we have learnt that, instead of a thin thread, there are nerves going to the brain and centres of the brain that respond to pain sensation. The brain has been compared to a telephone: when signals go off the result is pain.

Even this model cannot explain chronic pain in many conditions. For example, in osteoarthritis (the most common type of arthritis) the level of pain and the severity of the condition are often not connected.

In the mid-1960s another theory appeared: the gate control theory. It was suggested that the system is not hardwired; the brain does not just sit back and receive pain signals as Descartes proposed. In fact, the brain is very active in monitoring and modifying pain on a moment-to-moment basis.

In 1999 Ron Melzack, a Canadian scientist who has been described as a “pain pioneer”, updated this theory. He suggested that, rather than a pain centre in the brain, there is a matrix of many parts that he called a neural signature of pain. When those areas are activated, we experience pain.

His model also says that our body might respond to pain differently under different conditions. For example, when we are stressed, pain is felt more acutely than if we are not stressed.

This led to some work that looks particularly at helping people manage pain using physical and psychological measures. This has been called the biopsychosocial model.

Unlike the earlier models, which separate the body and mind, the biopsychosocial model says that the mind and body are intertwined, and have to be considered together if you are to manage pain.

Pain is worse for people who are anxious, depressed or socially isolated. A number of studies have shown that pain is also worse for people who think it will be. This is called catastrophising (expecting the worst outcomes).

Catastrophising is now considered to be one of the most significant predictors of disability, pain and pain-related outcomes. Focusing on a person’s strengths and promoting their confidence that they can effectively problem-solve the challenges they face as a result of their pain has been shown to be very effective in helping people deal with pain.

Understanding pain is an important first step to dealing with pain. Chronic pain is a serious health issue. One in five Australians will suffer from chronic pain in their lifetime.

Musculoskeletal disorders such as arthritis and lower back pain are currently the leading cause of pain and disability in countries like Australia, according to the World Health Organisation’s Global Burden of Disease study published in 2012 (www.thelancet.com/themed/global-burden-of-disease).

Unfortunately, pain is not managed well. An Australian survey in 2012 showed that 80% of people with chronic pain are missing out on treatment that can improve their health and quality of life (www.painsummit.org.au/strategy/Strategy-NPS.pdf/view).

For someone like Carla, who was diagnosed with rheumatoid arthritis at the age of 14, pain became a constant companion. Pain in arthritis is frequently invisible. Sometimes Carla had a swollen ankle or wrist but to most of her friends she looked just the same as before – but she couldn’t do the things she used to.

At 14, all of Carla’s spare time was taken up with dancing and her dream was to become a professional dancer. The pain from her arthritis at times meant she couldn’t walk, let alone dance. Sometimes she became too scared to move when every movement caused pain.

By the time she was 17, Carla was having a hip replacement – and in the same ward as people her grandmother’s age. Carla says she did catastrophise – some days it seemed nothing would stop the pain and it kept getting worse.

Learning to manage her condition also meant learning to overcome her pain. Carla worked with a physiotherapist who helped her to exercise differently to reduce her pain. She no longer wears really high heels but has found flatter shoes that still look good and don’t hurt her feet.

After much trial and error, a medication that helps her rheumatoid arthritis has made a big difference. Carla worked with her doctors, the physiotherapist, the occupational therapist and the people from Arthritis New Zealand to work out what she could do.

There is evidence to show that managing pain involves a combination of medicines and other therapies. An integrated approach to pain management requires participation of a variety of health professionals who work as a team with the patient. Potential team members may include a doctor, specialist physiotherapist, psychologist, occupational therapist, nurse practitioner, podiatrist, arthritis educator, pharmacist, nutritionist/dietician and social worker. Carla didn’t see all of those people, but some people might.

Exercise, joint support, medications and relaxation are all important in dealing with pain. Research has shown that regular stretching and strengthening exercises can help reduce pain.

As well as all the treatments, Carla has a positive approach to life – she focuses her energy on the things she can do. Best of all, Carla can still teach dance. Even if she can’t be the dance professional on stage, her goal to live her life through dance has been achieved.

Along the way, Carla learned some lessons that are useful for others living with pain.

  • Pain doesn’t have to rule your life.
  • Exercise every day.
  • Take medications as prescribed.
  • Include relaxation and distraction in your daily routine.
  • Prevent pain from building by breaking up activities.
  • There are good days and bad days; have a plan for bad days.
  • There are no rights or wrongs – find what works for you.

For people living with arthritis, the first step towards effectively managing chronic pain is education. Access to up-to-date, trustworthy information can give an individual the confidence to start setting realistic goals, learning about causes and triggers, and developing vital management techniques.

No one person or single organisation can tackle the challenges of pain on their own. The whole community needs to recognise the scale and seriousness of the problem. Once acknowledged, together we can combat pain and lower the barriers that arise when we try to ignore it.

Some useful resources on pain management can be found at www.paintoolkit.org and www.healthnavigator.org.nz