Pain is a protective experience: It’s our brain’s siren call to get us to pay attention to what it perceives as a dangerous situation for the body. If you accidentally sprain your ankle while running, the brain tells you that it hurts so that you tend to your ankle immediately. If you didn’t feel the pain after spraining your ankle, you’d keep running and seriously damage your ankle. “Pain is one of life’s most sophisticated mechanisms, assisting us to successfully navigate our physical environments,” says Lorimer Moseley, professor of clinical neurosciences and chair in physiotherapy, School of Health Sciences, University of South Australia, in an email interview.
Sometimes, though, pain can become the illness itself. In 1931, French medical missionary Albert Schweitzer wrote that “pain is a more terrible lord of mankind than even death itself”. Chronic pain, or pain that extends for three months or more, is a disease of relentless anguish. According to a report published in May by Global Industry Analysts, Inc., a US-based market research firm, more than 1.5 billion people worldwide suffer from chronic pain, and though exact figures are hard to come by, doctors assume that a few million of those sufferers live in India.
The how and why
Chronic pain can begin with a legitimate cause like an ear infection or even cancer, but people can suffer from chronic pain even when there is no evidence of infection or body damage.Common chronic pain diseases in adults include lower back pain, arthritis pain and fibromyalgia (widespread musculoskeletal pain).
Chronic pain is a strange beast—the mechanisms of all types of chronic pain have not been clearly understood. Fibromyalgia, for example, is a tricky disease where there is no infection or body damage but there is a distinct pain syndrome. There is little consensus about what causes it, but it has been linked to fatigue, sleep problems, headaches, depression and anxiety. There are no known prevention methods either.
In other cases, where the pain is localized, like lower back pain or neck pain, the causes are usually structural, caused by weak muscles and poor posture.
Karthic Babu Natarajan, consultant pain physician at the back and pain centre, Apollo Hospitals, Chennai, says the most common chronic pain that he sees is lower back pain—nearly 70% of his patients suffer from it.
“Four in five people will have lower back pain at some point of time in their lives,” Dr Natarajan says, “though most of them will suffer from it acutely for a short period of time. Our spine is strong enough to carry our weight and flexible enough for most tasks but unless we exercise and keep good posture it gets affected.”
But once the pain manifests and lingers, he finds that Indian patients often suffer in silence, either because they are willing to tolerate it, or because they are unaware that the pain can be treated effectively. By the time most patients come to him, they have been suffering for at least three months, if not more.
Dr Natarajan says if you have back pain that is associated with a fall or results in an inability to move a limb or is accompanied with urinary incontinence or a fever, you should see a doctor as soon as possible. For any other kind of back pain you can wait for six weeks before you see a pain specialist. For all other kinds of chronic pain, like joint pain or neck pain, wait for a week or two but no more before going to see a pain specialist.
Taking over-the-counter pain medicine like Crocin or Brufen is fine in the short term, but all that does is treat symptoms, and not the actual cause, and the long-term use of pain killers can cause gastritis and kidney damage.
Dr Moseley concurs, saying it is important to seek help immediately, especially if the pain is intense, since acute pain intensity is a good indicator that it might turn chronic. “How we learn to manage the pain and to cope with it plays a role in determining its course,” he says.
Lakshmi Vas, director of the Ashirvad Institute of Pain Management and Research, Mumbai, says women suffer more from chronic pain than men. She attributes this difference to the hormonal shifts that women undergo and the many physical, emotional and social pressures they face. Research on pain has also shown that women are more sensitive to pain.
Women suffer from anxiety more often than men and a research article published in the Pain journal in September found that this increased susceptibility to anxiety could be the reason for the increased pain sensitivity seen in women. The article, “Sex Differences in Perceived Pain Are Affected by An Anxious Brain”, was based on the study results of Serge Marchand and his colleagues from the department of neurosurgery, University of Sherbrooke, Canada. The results indicated that the mind plays a role not only in the creation of pain but also shapes its qualitative experience, and severity.
The treatment of chronic pain requires a three-pronged approach and is a combination of pharmacotherapy, physiotherapy and psychotherapy, says Dr Vas. The successful treatment of chronic pain requires that all treatment modalities be expertly employed, and Dr Moseley endorses this multidisciplinary method. “Our approach is to find everything that is contributing to the brain’s conviction of tissue danger, remove all the contributors we can and then train the brain, over time, to stop trying to protect the body,” he says.
“For example,” says Dr Moseley, “we have experts in pain biology that teach patients about how pain really works. We nearly always have to introduce people to a new way of thinking and we have learnt that the best way to do this is via stories and metaphors. We often need a good psychologist who can help the patient to think differently, to learn skills that make the pain more manageable, to develop other skills that make the long journey to recovery more likely. Then we need a very astute and informed musculoskeletal physician who can diagnose and modify a structure or a nerve with an injection or other procedure.” Once this is done, a physiotherapist steps in for rehabilitation to help the patient return to an active life safely and manageably.
A recent research report published in the journal Complementary Therapies in Medicine in June shows that a seven-day residential yoga programme can help reduce pain and improve spinal mobility more effectively than physiotherapy in chronic lower back pain sufferers. This study was carried out by H.R. Nagendra and his colleagues from the Swami Vivekananda Yoga Anusandhana Samsthana (Svyasa) in Bangalore. Dr Vas agrees that yoga can be beneficial, but cautions that “yoga is as good as its teacher”. Given that many yoga teachers aren’t sufficiently trained to address the needs of a patient suffering from chronic pain, she says it is best to think of yoga as a preventive form of exercise, to keep pain at bay, rather than a prescriptive form.
In terms of prevention, the right attitude is key, says Dr Moseley. Be respectful of pain but not afraid of it. If you have lower back pain,don’t avoid movement and activity altogether. And if you are chronic-pain free and would like to remain that way, then healthy eating, regular exercise, good friends, laughter and regular sleep are all very important, says Dr Moseley.
Sujata Kelkar Shetty, PhD, writes on public health issues and is a research scientist trained at the National Institutes of Health in Bethesda, US.
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