Just Pain

I'm working up a couple of research proposals having to do with chronic pain. This subject is actually challenging clinically and philosophically, which means it also very challenging for physician-patient communication and relationships.

There used to be great controversy over the very existence of fibromyalgia, or the usefulness of the label. It just meant people with unexplained, widespread pain. People also would present with unexplained localized pain, such as low back pain or temporofacial pain. They'd get MRIs and what not and doctors could find no physiological explanation. Many people viewed these situations as having a psychodynamic origin, in other words the person was in fact obtaining some sort of reward from being sick or disabled, or acting out guilt or self-loathing, or just generally nuts.

Now we understand that people with otherwise unexplainable chronic pain are experiencing what's called Central Sensitization Syndrome (CSS). Pain signals (there's a fancy word for them, "nociceptive" which the blogger spell checker doesn't even recognize) do originate at the site where pain is perceived, but the sensation of pain is constructed in the brain, with maybe some intermediate processing in the spinal chord. The brain can also send signals back down to dampen nociception.

So what happens is that the systems in the brain that signal pain to your conscious awareness become hyperactive. If you close your eyes and just pay attention to your body right now, you will notice that you feel a bit of discomfort here and there. Maybe you have slightly achy joints, or your tuchy is a little uncomfortable on the chair, you have an itch, whatever. But it's minor and you weren't even paying attention to it. So, it shouldn't be hard to imagine that the circuits that process these sensations could get out of whack and continually scream "Pain!" at your frontal cortex.

Now that we have functional Magnetic Resonance Imaging, this has been confirmed. Researchers can see the circuits light up excessively in people with CSS. That doesn't help us know what to do about it, but at least we have an explanation. We also don't know why it happens. Often, people have a real injury that causes explainable acute pain, but after the injury heals, the pain persists. Somehow the circuit gets stuck in the open position, as it were. CSS also seems to be associated frequently with severe psychological trauma. But we don't have a good mechanistic explanation.

That said, if you tell people with CSS that there is in fact nothing wrong with the places where they feel pain, and the problem is in their brain, they generally don't like that answer. They hear you saying that the pain isn't real, that they are crazy, that they're faking it, that you aren't respecting their very real suffering which they perceive to be happening in their back and their joints or wherever.

Drugs don't usually help much. Long-term opioid therapy is generally a bad idea, I shouldn't have to tell you why. Anti-depressants and drugs that are used to treat seizures or neuropathy (pain caused by damage to peripheral nerves) are often prescribed, but only a small percentage of people really respond to them, and they have side effects. NSAIDs help only a little.

What people with CSS should do is basically not to let it get them down. Do what they call graded exercise -- a little bit more than is easy each day. Keep moving, keep up with your activities of daily living, have hope for the future, and really believe that there is nothing wrong with the parts of you that are hurting. It takes a long time, but often symptoms do ameliorate and even resolve. But if the pain beats you and you retreat from life and social contact, and stop moving, they won't.

So, how doctors and patients can communicate constructively in this situation, and form a therapeutic alliance that really works, is a big problem. Hopefully I'll be able to contribute.