When the pain doesn't go
Dave was a healthy UPS driver until he stepped into a pothole and twisted his ankle while delivering a Christmas package. The nerve injury he sustained forced him to give up a satisfying, well-paying job, fishing trips with his son and nightly walks with his wife. His personal physician, a neurologist and an orthopaedic surgeon were unable to help; medications were prescribed without success; and three months of physical therapy brought no relief. His pain affected every aspect of his life—finances, sleep, appetite, mood and his relationships with family and friends.
“We get far beyond ‘Does it hurt?’ and ‘Where does it hurt?’ By integrating
data from our medical pain specialists with that from behavioral evaluations,
we identify the environmental, physical and personal factors that
contribute to pain and then work to improve their functioning.”
His plight is typical of the approximately 250 people who come every month to UB’s Center for Pain Management at the Erie County Medical Center, hoping for relief from pain that seems to have no direct physical cause but is as real as the air they breathe.
The center offers the only fully multidisciplinary approach to pain management in the Buffalo-Niagara region. Its core of pain specialists includes rehabilitation-medicine physicians, a pain-trained anesthesiologist, physical therapists and pain psychologists. When necessary, they may call upon the expertise of occupational therapists, ergonomists, vocational counselors, clinical nurse specialists and exercise physiologists.
Many clients end up in the office of Jeffrey Lackner, director of the center’s Behavioral Medicine Clinic. A pain psychologist and clinical assistant professor of anesthesiology, Lackner’s job is to help identify the biobehavioral factors that worsen pain and limit function, and to help these people resume productive lives.
Lackner helped establish the pain management center six years ago, and has seen the demand for its services grow. The sad reality is, experts do not know what causes chronic pain and, for most sufferers, there’s no cure.
“Most physicians and patients see pain as a symptom of an underlying disease,” Lackner says. “With chronic pain, frequently there is no physical cause. For example, less than 25 percent of disability from low-back pain can be traced to a physical dysfunction.
“This doesn’t mean these patients are weak, malingerers or that the pain is only in their heads. It means that, like all of us, their experience of pain is influenced by a distinctive mix of physical, psychological and environmental factors. Failing to address a patient’s beliefs and attitudes toward pain, their coping skills or their job satisfaction could result in ineffective treatment and continued pain.”
Chronic pain is thought to affect one in four Americans and to account for 70 million doctors’ visits annually. In addition to low-back pain, chronic-pain syndromes include such conditions as atypical chest pain, tension headaches, fibromyalgia (muscle pain) and irritable bowel syndrome. One national survey found that more than 550 million days are lost from work each year because of pain. The annual cost in disability compensation and lost productivity has been estimated to be as high as $100 billion.
Since there is no active physical injury to blame for such pain, researchers have looked for other causes. Lackner, along with other pain researchers, believes the problem involves the complex interplay of biology, psychology and learning.
At the center of this interplay, they think, is the “gate-control” theory of pain. First proposed in 1965 by psychologist Ronald Melzack and anatomist Patrick Wall, the theory suggests that nerve impulses generated by a painful stimulus encounter a cellular “gate” on their way to the brain’s pain center. When the gate is open, impulses reach the brain and cause the sensation of pain; when the gate is closed, those impulses are deflected and there is no pain.
Most researchers agree that psychological factors, such as attention to and fear of pain and how the pain is interpreted, can cause a gate to open or close. It is thought that when nerve signals reach the brain, they are processed in the context of a person’s mood, emotions, beliefs and thought patterns.
“If you’re playing baseball and skin your knee sliding into second base, your ‘pain gates’ are closed because your brain is focused on the game, not the pain,” Lackner says. “On the other hand, if you are out of work with a back injury, if you worry that your pain means you have a broken back and you avoid activities you think may increase the pain, the ‘gates’ open and you experience terrible pain.”
More recent research has found that the brain appears to rewire itself to form a neural representation, or memory of pain, which can be activated by a touch, fear, memories, mood, even visual images. The key, then, to improving chronic pain is treating the person, Lackner says.
He and colleague Susan Krasner, also a psychologist and clinical assistant professor of anesthesiology, prepare an individualized 8-to-15-week treatment plan based on an intensive interview. The interview is designed to assess the different aspects of the patient’s pain, including its quality, location, triggers and factors that maintain it.
“We get far beyond ‘Does it hurt?’ and ‘Where does it hurt?’” Lackner says. “By integrating data from our medical pain specialists with that from behavioral evaluations, we identify the environmental, physical and personal factors that contribute to pain and then work to improve their functioning.”
Armed with a picture of the type of pain and the type of person, Lackner and Krasner set out to teach clients how to work around pain and return to a better quality of life. To accomplish this goal, they draw on a variety of clinically proven behavioral techniques. A plan may involve biofeedback and muscle-relaxation therapy to reduce physical tension; training to improve coping skills; and cognitive-therapy techniques to challenge the thinking errors that influence pain and response to treatment.
“For example, pain patients learn to recognize the earliest thoughts and reactions that accompany a pain flare-up and modify their responses to them,” Lackner says. “Patients are taught that ‘automatic thoughts’ such as ‘the pain will never end,’ ‘I’m going to be crippled’ and ‘there is no hope’ can be replaced with substitutes such as ‘the pain has always lessened in the past,’ ‘I may not be able to do everything I used to do, but there are things I can do’ and ‘change is possible, there is always hope’ to help reduce pain and related distress.”
Center statistics show that patients who receive biobehavioral treatment at the center reduce their pain 20 to 40 percent on average, reduce excessive medication use by 65 percent and significantly reduce their overall distress. Forty percent are able to return to work.
To contact the Behavioral Medicine Clinic, call (716) 898-5671.
Lois Baker is senior health sciences editor with University News Services.