Pain Editorial: I'm gonna change my way of thinking

[Guest guest]

Biomechanics Magazine http://biomech.com July 2006

I'm gonna change my way of thinking

By: R.

http://biomech.com/showArticle.jhtml?articleID=191601699

Bob Dylan might have had something else in mind when he wrote that

song, but in the biomechanics mainstream, an area in which we might

need to change our way of thinking is how patients with chronic pain

are treated.

There is so much we don't understand about pain, its origin, and its

treatment. We understand that some pains are easily treatable by

stretching, ice, time, and over-the-counter or homeopathic

treatments. But we also understand that there is much pain that will

not fade so quickly.

I am certain you've had any number of patients whose pain has become

chronic and debilitating. Maybe it's from an injury or damaged

nerves; maybe it's a lack of some key chemical in their body. It

could be arthritis, or something that was misdiagnosed. Maybe it's

complex regional pain syndrome. Who knows?

This is often exactly the problem. There are literally thousands of

pain syndromes (OK, there are 12,598 entries on PubMed for " pain

syndrome " ) and isolating the exact one can be a long, difficult, and

costly process in all definitions of the term.

In fact, in an article in The New York Times on May 30 ( " Doctors

struggle to treat mysterious and unbearable pain, " page D5),

K. Portenoy, MD, chair of the pain medicine and palliative care

department at Beth Israel Medical Center in New York said

pharmaceutical treatment is a " trial and error " process.

" In many cases, doctors need to perform sequential trials to find out

which drug or combination of drugs helps the most, " he said.

It should be noted that he was specifically talking about complex

regional pain syndrome. I have no reason to question Dr. Portenoy's

hard-earned clinical experience. But, if you were a patient with

chronic pain, would you be pleased to essentially be an ongoing

trial? Of course not. And yet really, what else can be offered?

Ketamine treatments, which may potentially put patients into a coma

(see the same NYT article)?

And sometimes the best treatment isn't a pharmaceutical. It may be

acupuncture, a change in diet, a new rehabilitation regiment,

electrical stimulation, Chinese herbs, massage, regular treatments of

something the body is missing, or a new device. The list could go on

and on.

And a further issue is that we can't yet define what role the mind

plays in dealing with pain. This complicates an already difficult

situation, as living with chronic pain must be incredibly

debilitating.

Yet, without doing a double-blind study, I would guess that at some

point, most patients get the message that " it's all in their head. "

Maybe those aren't the exact terms, but the implication is that

they " need to get on with their lives. " And when a patient's pain

doesn't respond to initial-or even to longer term-treatments,

everyone gets frustrated. You wouldn't be a practitioner if you

didn't want to help people get better. Becoming frustrated when your

patients don't is understandable.

I want to genuinely ask, has telling a patient that it's in his or

her head ever helped anyone? Maybe it has, I don't know. I'm asking

in hopes of sparking a conversation. Maybe there are patients who

respond to this, but if so, it seems like those case reports don't

make it to the peer-reviewed journals I read.

I'm not holding BioMechanics above reproach. We give each article

a " running head, " essentially listing the general category it fits

into (sports medicine, wound care, and so on). And we label articles

about treating pain " pain management, " instead of " pain

treatment, " " pain solutions, " or something more optimistic. Well, no

more.

What I am hoping for is a revised approach to treating pain; i.e., no

longer limiting our goals to " managing " pain, but instead, treating

it with the goal of eliminating it, or as much of it as possible. It

might well be that in many cases, the pain needs to be " managed, " but

let's start with language that isn't limiting; language and treatment

that aim to restore and heal, rather than manage.