Tuesday, May 31, 2016

Severe pain hurts a lot.

By: Matt Smith M.D. with Alabama Pain Physician's

Severe pain hurts a lot. This is a tautology, but sometimes it behooves us doctors to remind ourselves how unpleasant severe pain really is. When someone hurts, it becomes tremendously more difficult for her or him to do all of the things necessary to maintain a healthy, vibrant life. Recall the characteristics of someone who is depressed or who has generalized anxiety disorder. They are frequently the same behaviors we all take on when we hurt. We frequently want to be alone. We stay in bed. Highly palatable, highly processed, nutrient-poor food seems ever more attractive. It is nigh impossible to exercise. We stop seeing much sunlight. Our sleep is disrupted. Watching the Kardashians bicker and the 24 hour news cycle seem somewhat less onerous.

Not only do all these things frequently cause a downward spiral of eventually worse pain, but they also are a surefire recipe for getting the metabolic syndrome, or that cluster of diseases associated with insulin resistance, systemic inflammation, obesity, dyslipidemia, and oftentimes diabetes type two. Eat bad food. Don't move. Get poor sleep. Never get sunshine. That'll do it.

Thus it should be no surprise that chronic pain is tied to the metabolic syndrome, if only for common sense reasons.

And while everyone’s story is different, and every vicious cycle has its own character and history, there are often common denominators between chronic pain and such a host of other physiological and psychological pathologies.

Many of these vicious cycles are relatively simple and can be boiled down to simple maladaptive behavior. Acute pain becomes chronic. Chronic pain leads to bad habits like poor diet and no exercise. These maladaptive behaviors lead to more health problems and usually worse pain.

Yet, here’s where things get really interesting and here’s why the treatment of pain requires more than just advanced procedures and analgesics. There is now a tremendous amount of evidence that changes in behavior are only the tip of the iceberg relating severe pain to other pathologies. It is now incontrovertible that there is also a complicated web of physiology that causes various vicious cycles, making pain ever worse.

For example, consider the sympathetic nervous system, or that part of our bodies responsible for the “fight or flight” response. The sensation of pain, both conscious and unconscious, strongly stimulates the sympathetic response. When pain continues unchecked, the hypothalamic-pituitary-adrenal (HPA) axis becomes dysregulated. Cortisol soars and the so-called neurosteroids, or a class of hormones that attenuate the HPA axis, cannot compensate. Eventually, physiological exhaustion kicks in. While cortisol declines somewhat, many of these neurosteroids decline even more. As cortisol plummets, more generalized aches and pains start to ensue.

As HPA axis dysregulation and the metabolic syndrome kick in, the sex hormones also become affected. Chronic pain is strongly associated with sex hormone dysregulation and there are multiple reasons why this is. Visceral and subcutaneous adiposity tends to increase. Aromatase - an enzyme in the adrenal glands and adipose tissue that turns testosterone into estrogen - goes up. Systemic inflammation goes up. There is a greater preponderance now for increased damage to the initially injured area, as well as everywhere else in the body.

Perpetually elevated fight and flight. Lack of a compensatory response. Drops in the hormones that are associated with well-being. This picture of course looks very similar to the same pathophysiology behind depression and anxiety. And it is. Hence the extraordinarily high comorbidity of major depressive disorder and chronic pain. Fibromyalgia is a prototype of this interrelationship. Fibromyalgia is strongly associated with low cortisol, obesity, sleep disorders, and, of course, systemic inflammation. True to the nature of a vicious cycle, one causes the other, which causes the one.

But it gets worse. Not only is this self-reinforcing nature of chronic pain often inadequately understood, but oftentimes physicians and other clinicians misunderstand exactly what pain is. Pain is often like described as merely nociception, or the signals that peripheral nerves send to the spinal cord and brain that sometimes get translated to the conscious experience of pain. But pain is so much more. Pain also involves an immensely complicated cascade of processing at the dorsal root ganglia, spinal cord, brainstem, thalamus, cortex, and elsewhere. All of these other pathways and signaling mechanisms may act for good or ill in making pain better or worse, short lived or chronic.

To complicate matters even more, one must differentiate not just between nociception and pain, but between pain and suffering. While pain may be described as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”, suffering also involves the broad contexts in which pain occurs. Suffering is thus not just nociception and it is not just pain. Suffering is the experience of pain in the context of family, vocation, society, cultural norms, met and unmet personal goals and expectations, and a myriad other factors.

And this is the real challenge with pain medicine. Chronic, severe pain and suffering often a complicated web of vicious cycles of aberrant physiology, damaged anatomy, and maladapted psychology all couched in a myriad social contexts.

Fortunately, while this web of pathology is complex, realizing its complexity gives us a more nuanced ability to care for our patients more fully. It also explains why severe and chronic pain often does not respond adequately to just one intervention.

Realizing the complexity and nuances of pain and suffering also allows us to treat pain in a comprehensive manner. “Comprehensive care” is somewhat of a modern buzzword, oftentimes with little meaning besides a nod towards marketing. Yet when dealing with chronic pain, it is absolutely essential.

That is why with Alabama Pain Physicians, we have pioneered a model of comprehensive care that addresses all of the involved issues as described above, along with many more.

For instance, inherent to any adequate treatment of pain is an identification of any anatomical or physiological issue that may be addressed with an advanced procedure, whether that be neuroablation, injection of stem cells, or something equally sophisticated.

In the vast majority of cases of chronic pain, there is also muscle atrophy, loss of mobility, and changes in biomechanics that demand some type of physiotherapy and a lifelong regimen of appropriate exercises. That is why we work closely with numerous therapists and have our own specific training protocols.

Inherent in most patients with chronic pain, for hopefully now obvious reasons, are also depression, anxiety disorder, and many other psychological pathologies. That is why we incorporate mental healthcare extensively in our treatments.

And, of course, in almost all of our patients there are metabolic abnormalities that have resulted from some of the vicious cycles described. That is why we do advanced laboratory testing, advanced physical metrics, and tailored treatments to address these issues.

Because of this expanded view of the many overlapping and self-reinforcing cycles that cause chronic pain, adequate treatment requires looking at the whole person. This approach is something that must be done to adequately treat severe chronic pain. It is not optional.

When treating severe chronic pain, comprehensive care must be the standard of care. For more information on pain management and our Alabama Pain Physicians’ comprehensive treatments, visit Bamapain.com or call (205) 332-3160

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