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What is chronic pain about…really?

Suffering from chronic pain is a debilitating, frustrating and depressing experience. Often, a sufferer does not exhibit many, if any, externally visible symptoms of their pain, and so it is easy for carers, family and friends to fail to understand the extent and variability of the pain experience. But what is chronic pain anyway?

A medical definition of chronic pain goes something like this:

Chronic pain is pain that lasts beyond normal healing time after injury or illness—generally three to six months. It is a common and complex condition, and the pain experienced can be anything from mild to severe. The defining characteristic of chronic pain is that it is ongoing and experienced on most days of the week. Chronic pain can result from injury, surgery, musculoskeletal conditions such as arthritis, or other medical conditions such as cancer, endometriosis or migraines. In some cases, there may be no apparent physical cause.

Source: Australian Institute of Health & Welfare

Let’s try and pick this apart a little to see how we can better understand the experience of chronic pain, whether we’re a sufferer ourselves, or a carer, friend or family member for someone who is suffering.

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Normal Healing Time

First, we have the concept of ‘normal healing time’. We understand that an injury or illness typically takes some time to resolve, even with effective treatment. The body and mind do not recover immediately, and tissues and psychological impacts can take some time to improve and to reach whatever was considered typical for that person before the beginnings of chronic pain. It’s clear that normal healing time is going to be different for different people with different illnesses or injuries, different support systems and treatments, different immune systems and responses, different mental resilience, experience and flexibility among other likely differences.

A three to six month time period is a somewhat arbitrary timeframe, probably chosen to reflect a reasonable amount of time for the body to adjust following the completion of medical or psychological treatment. It’s important that allowance needs to be made for those individuals who are following a significantly faster or slower timeframe than this guideline.

Mild and Severe Chronic Pain

Chronic pain can range from mild to severe – often a surprise for those who are not regularly involved with chronic pain. Surely mild chronic pain isn’t much of an issue? This can be a very incorrect conclusion.

For example, tinnitus is a well recognized medical condition, often with complex causes and difficult treatment regimens. While the physical ‘pain’ associated with tinnitus may be relatively mild, it can definitely be a debilitating, frustrating and depressing experience, and there are unfortunately cases of people who have attempted suicide due to the impact of tinnitus on their lives. Even relatively mild pain, when extended over long periods, often with little or no practical relief, can quickly become a life-threatening problem and it needs to be addressed.

Continuity of Chronic Pain

Chronic pain is described as ‘ongoing and experienced most days of the week’. Again, this can be somewhat surprising to some – surely chronic pain is ever-present? This is not always the case, and periods of reprieve from pain can also come with their own accompanying concerns – how long will this relief last, and how bad will the pain be when it returns? Can I dare to hope that my pain is fading away, or will that hope be dashed by the return of my pain, sometimes with a renewed strength or impact? All of these aspects come with their own physical and psychological costs…

Cause of Chronic Pain

It’s probably easy to understand when chronic pain results from an injury or illness, including the terrible illnesses of cancer, arthritis, inflammatory disease and so on. However, how is it possible that chronic pain can arise without any apparent cause? This can be extremely challenging for both the sufferer and for their support network – for many people, it just doesn’t make any sense, and it can offend your sense of a fair and just world. 

“Why is this happening to me?”, you may ask. “Why is this happening to them?”, your family or friends may well ask. Worse however, is when the question “Is this really happening to them?” comes to mind. For frustrated carers, family and friends, it’s very tempting to actively or passively wonder if the sufferer is really suffering to the extent that they appear to be, or that they report to be. From the sufferer’s perspective, describing their experience of pain is tiring, repetitive and can indeed increase focus on the pain experience, so it’s very common for sufferers to actually under-report their pain experience to those who are closest to them. Often this is with the intent of shielding or protecting them from the worst, in the hope that the sufferer can manage by themselves, and not constantly have to rely on medications, therapies, attention and support.

By understanding a little more about the experience of chronic pain, we can have a better chance of determining the most appropriate course of action to help improve and indeed, sometimes even resolve, the experience of chronic pain, both for the immediate sufferer and for their support network of family, friends and colleagues.

A Better Understanding of the Mechanisms of Pain

Of course, it’s important to separate chronic pain from acute pain, where acute pain is generally defined as pain that comes on suddenly, and lasts for a limited time. Acute pain is generally easier to diagnose and treat, often associated with a relatively well-defined and understood injury or illness. It doesn’t mean that acute pain is better or worse than chronic pain, but it is clear that the mental toll of a pain experience that extends over a lengthy period causes additional factors, challenges and concerns.

Any experience of pain that we can have is really only experienced in the brain. This may not seem accurate at first glance, after all, my chronic back pain is surely located in my back, isn’t it? The reality, however, is that injured systems in the body send messages via the nervous system to the brain, and it is only within the brain that the perception of pain takes place within our consciousness. This is a highly relevant distinction to make, and fortunately, it opens the door to many effective and helpful therapies that focus on the perception of pain, rather than just trying to deal with the injury, the illness and/or the nervous system signals that carry information about the impacted body systems to the brain.

Pain as a Learned Response

We are all learning organisms, endlessly converting our day to day experiences into our personal patterns, habits and building beliefs and responses that seem to best serve our needs and desires. Learning again seems to take place within the brain, where patterns of thinking, acting and responding create and reinforce neural pathways within the brain. As we learn a musical instrument, for example, we lay down patterns of movements that make playing the instrument progress from initially hard, conscious effort through to more and more automatic movements, where we eventually reach such a stage of automatic behaviour that we can move our attention to the nuance of the music, rather than the core of the performance. All of this takes time, and practice, and more time, and more practice. What we don’t always realise though, is that we are carrying out this type of learning process across all aspects of our lives. 

With pain, we can quickly learn patterns and habits that can unfortunately hamper our experience, rather than help. Pain creates a protection response, very useful to protect an injured limb, but when this protection response becomes overly-learned, we can tend to protect ourselves when protection is no longer really needed, and the perception of pain becomes a habitual response to maintain that protection. The effect has become the cause, and the feedback loop is then out of sync with the original cause or trigger of the pain.  Breaking this feedback loop can be a real challenge once it is firmly established.

Benefiting from a Better Understanding of Chronic Pain

Hopefully, by getting a deeper understanding of the nature of chronic pain, you can begin to sympathise and even empathise with the sufferers and support network of those dealing with chronic pain. However, beyond the better understanding, we can begin to see how we can find cracks in the mechanisms that create and maintain chronic pain. We can find and use techniques to interrupt the progress of the pain learning mechanism, and replace it with healthy habits and patterns that can really improve the daily experience of pain, even rendering it much less of an impact on our freedom of choice, movement, thinking and feeling.

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