Features January 2005 Issue

Battling Chronic Pain

You can play a major role in combating your own debilitating discomfort.

The art of life, Thomas Jefferson once observed, “is the art of avoiding pain.” For countless Americans, the pursuit of this “art” is a full-time, frustrating, and all-too-often fruitless endeavor. Among its practitioners are the estimated 20 million men and women afflicted by osteoarthritis, the two million-plus with rheumatoid arthritis, and the additional millions of people experiencing chronic pain brought on by one of more than 100 other forms of debilitating rheumatic disease.

As opposed to acute pain—the type of intense and usually brief discomfort you suffer when you stub your toe or bump your head—chronic pain is long-lasting. It can persist constantly or intermittently for years, perhaps a lifetime. “Some people have defined chronic pain as pain that lasts longer than three months,” says Edward Covington, M.D., a pain-management specialist and psychiatrist in The Cleveland Clinic’s Department of Psychiatry and Psychology, and head of the Clinic’s Chronic Pain Rehabilitation Program. “I prefer to define it as pain that has persisted beyond the expected time of healing.”

The function of pain
Unpleasant as it is, pain itself tends to play a critically important role in the maintenance of your health and well-being, sending out messages that something, somewhere in your body, has gone awry and needs attention.  It sends these messages thanks to receptors located throughout the body that transmit electrical impulses along nerves to the spinal cord and then to the brain. And that’s when the hurting begins.

In arthritis, the sources of chronic pain vary. The signals to the brain may originate in strained or inflamed muscles, tendons, ligaments, or joint tissues, or from all of them at once. Over time, the pathways that carry the signals can become progressively well-worn and easier to travel.

Likewise, the intensity, frequency, and duration of the discomfort vary widely from patient to patient. According to Dr. Covington,  “Most people will say that their pain is pretty much constant, but it’s usually intermittent—periods of pain and periods of no pain—and this intermittent pattern can go on for decades.”

Emotional influences
While the frequency and intensity of chronic pain is largely determined by such factors as the amount of swelling or the extent of damage within a joint or tissue, emotional disposition can also be influential. “There are very few pains that you can attribute entirely to the psyche,” says Dr. Covington, “but there is probably no pain that isn’t affected to some extent by the psyche.”

Are some personality types, therefore, at greater risk than others for being assailed by chronic pain? “No,” he says, “but there are personality types that are at greater risk for not being able to cope with chronic pain.”

In general, patients who are most adept at dealing with chronic pain are those with what Dr. Covington calls an “internal locus of control.”  They have a strong sense of competence; they are confident in their own abilities; they realize that they are in charge of their own lives.

Personality factors associated with poor coping ability are the opposite.  “People who suffer most from chronic pain,” says Dr. Covington, “often have a strong need to regress. The sick role is very similar to the child role, in that you are taken care of and powerful people tell you what to do. Such people tend to cope more poorly with chronic pain.”

At the same time, he notes, there are people who will cope more poorly with chronic pain due to external factors. “It’s well established,” he points out, “that with many chronic pain problems—spinal arthritis, for example—the likelihood of people being disabled has much less to do with the amount of spine disease they have than it does with how they’re treated at work, or how they think they’re treated at work. Are they at the bottom of the pile, or are they in a position where they feel important and respected? Corporate CEOs aren’t likely to become disabled with rheumatoid arthritis, whereas people who are in situations they hate are much more likely to.”

Pain management today
Owing to a heightened awareness of the mind-body relationship, today’s multidisciplinary approach to pain management increasingly relies on a team approach that utilizes the services of psychiatrists, psychologists, and group-therapy experts to complement the efforts of such specialists as radiologists, neurologists, osteopathic physicians, and physical therapists.

Medication, however, remains at the core of treatment in cases of chronic pain. The medications most commonly prescribed in the treatment of chronic arthritic pain include analgesics, such as acetaminophen; non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen; biological response modifiers, which reduce joint inflammation; disease-modifying antirheumatic drugs (DMARDs), which influence immune-system response; and muscle relaxants.

In some cases, chronic-pain management relies on the use of such invasive techniques as the direct delivery of steroids or anesthetics to nerves or joints, injections to stimulate blood circulation and ligament repair, and the implantation of either devices that electrically stimulate nerves or drugs that mute their response.

Comprehensive pain-management treatment is also likely to include routine exercise programs—under the guidance, at least initially, of a physical therapist trained in the special needs of people suffering from chronic pain. Routines, calibrated according to the needs and physical capabilities of individual patients, may include aquatic exercise, aerobic workouts, weight lifting, massage, and other activities aimed at improving muscle strength, joint mobility, endurance, and comfort in the activities of daily living.

As part of a broad-based pain-management plan, private psychiatric evaluation, psychological counseling, and group-therapy sessions are also recommended in some cases as a means of assisting chronic pain patients in finding a path toward coping with their discomfort.

The Chronic Pain Rehabilitation Program that Dr. Covington oversees at The Cleveland Clinic involves, in his words, “a lot of therapy that is directed toward helping patients to achieve some sort of acceptance that their pain is not likely to go away completely, and to helping them learn strategies for having the maximum degree of function and quality of life that is possible for them, whatever their conditions may be.”

Patients, who typically participate in the program for three to four weeks, also take part in what Dr. Covington terms self-regulation training. “Some people practice  biofeedback,” he says, “and others take up yoga, or progressive muscle relaxation, or self-hypnosis. All of these measures will enable the patient to have voluntary control over some bodily processes that they have previously considered involuntary.

“The most important psychological defense for people with chronic pain is education. Learning about their pain helps them get over the feeling that it is mysterious. And this, in turn, helps them get over their fear of it.

“You can have a good quality of life even without a 100 percent cure if you become educated about your pain, take your meds, do your exercises, pace yourself, and adopt the attitude that you have the pain, the pain doesn’t have you.”