The down side is that it’s possible to get obsessed with your scores. If you start feeling overly distressed by your ratings or read too much into them, these negatives will have to be weighed against the benefits of keeping a log. Please remember that your ratings are simply an attempt to capture an experience (that of pain) at the precise time you write down your score for the day. Virtually all the scientific methods of measuring pain are attempting the same thing and limited by the difficulty of translating a personal experience into a set of numbers.

One of the simplest tools for measuring pain is the visual analogue scale. A recent study showed it is more reliable than measuring your pain on a scale of 1-10.  Simply measure a 10 cm. line on a piece of paper. On the right end of the line mark ‘no pain’ and on the left ‘worst pain’.

To measure your pain simply put a mark on the line somewhere between ‘no pain’ and ‘worst pain’. Try not to think in numbers but simply on the severity of what you are feeling when you decide on your rating. The distance in centimeters between ‘no pain’ and your mark is your pain score. Round off your measurements to the nearest 0.5 cm.

If you do this daily and at the same time every day, you will have a fairly reliable record of your pain. Research indicates that changes of less than 2.0 cm. probably mean very little in terms of real changes in your pain. This should remind you to keep any changes in your scores in perspective.

The visual analog scale is one of many tools used to measure pain. Some are more reliable and/or valid than others. Some are simple and some complex. But they all run into the same barrier: how can we objectively measure what is a subjective phenomenon, the lived experience of chronic pain?

How do you know when you are trying too hard? It is when you start tensing muscles that aren’t necessary for doing the exercise or tensing the necessary muscles too much. Muscle tension can aggravate your pain and if an exercise always aggravates your pain then why on Earth would you keep doing it?

We know that exercise is good for people and that includes those with pain. But too often we assume the harder we exercise the greater the benefit. This may have a little truth in it up to a point, but for people with pain, the harder they do some exercises (if not most exercise), the more it hurts. The more it hurts the less likely they are to keep doing that exercise no matter how beneficial it is supposed to be.

Therefore we show participants how it is possible to maintain a posture using only those muscles needed to stay upright while relaxing everything else. We teach movement based on the same idea of relaxing all unneeded muscles. Going slowly helps one relax more deeply and signals when a movement becomes painful in enough time to stop. Our training methods are rooted in the same principles found in such Chinese internal arts as Taijiquan and Baguazhang. The masters of these arts were reputed to be great fighters and we feel some of their methods can be enlisted in the far more difficult fight against pain.

We believe it is better to do a little bit of exercise with as little pain as possible instead of doing a lot while struggling with pain. We want people to come away from our sessions feeling more relaxed and in less pain. After all isn’t that the point of pain therapy?

Here is a quotation that was posted on the Nine Dragon Baguazhang Facebook page. It offers a way of looking at meditation in a non-denominational but nevertheless spiritual way.

“The word meditation comes from the Latin ‘meditare’, which is the passive form of the verb, meaning ‘being moved to the center.’ It is not the active form, which is ‘moving to the center’. We are being moved to the center. This center is our own essence. Sitting after sitting, letting everything go, we become more aware of our own personal center. We become more rooted in it. This simple act of sitting absolutely still, letting everything drop off, has far-reaching effects.

“Sitting still is not what some of us may have imagined spiritual practice to be. We may think that it involves something more impressive. But those of us who do it, those of us who are present at this moment, know that this is it. Sitting absolutely still, body and mind are not separate. Our state of mind at any given moment becomes clearer in this condition of being present, completely present. And there is great healing power in this.”

 - Maurine Stuart Roshi

Most of us find meditation a difficult practice but over time it becomes easier to sit still, relax the muscles and calm down if we stick to it. It’s fair to say then, that meditation is a skill that improves with practice. But can we ever say that we’re good at meditation?

Well, one problem with this question is: how could you tell? I suppose you could you use an EMG to measure muscle relaxation, an EEG machine to measure alpha waves and a functional MRI scanner to look at brain activity in general but what would all this really mean? Such measurements say very little about the actual individual experience of meditation.

Our practice is to sit quietly, relax, pay attention to the breath and simply notice whatever else is going on, inside of us and out.  In this we do not differ from Mindfulness meditation or the Vipassana tradition of practice in Buddhism.  Even long time meditators experience churning thoughts, emotions and sensations while sitting. Does this mean they aren’t very good?

In our practice there is no effort to calm the mind. Instead we practice noticing or being mindful of what is going on in the mind and body while staying as relaxed as possible. We do our best to notice but not judge or react to the thoughts and feelings that happen in us all when we meditate.

If you have a troublesome thought or sensation while meditating, you do your best stay relaxed and calm, returning your attention to your breath. If you think you aren’t relaxed enough, still enough or calm enough, those are simply other troublesome thoughts and you just do the same thing with them: go back to your breath and stay as relaxed as you can.

The paradox of all this is that the easier it gets, the less sense it makes to talk about being good at meditation. That would involve making exactly the kind of judgment about our meditation experience that we practice avoiding when we sit. Nevertheless, you could still argue that we get better at being non-judgmental and that is a good thing. This is true but the fact remains that during practice all of us will feel good or bad, tense or relaxed to varying degrees no matter how long we practice or how good we think we are.

If you are meditating because you have chronic pain it is important to understand that research has shown that meditation practice is good for you but it has not been able to characterize what you experience during practice as good or bad. It is the practice that is important, not whether you think you are having a good or bad session.

We can all get better at meditation but to get better we have to forget about getting good at it.  We just practice.

Our pain group sessions are fairly simple. We talk a bit about pain, practice meditation, use guided imagery, train posture and do various other physical/mental exercises, most involving relaxation. When most people begin to attend, they find it difficult to relax their muscles and correct their posture. Perhaps the most common early experience occurs during meditation practice when people realize how busy their minds seem, filled with thoughts, memories, emotions and the sensation of pain.

Over the years, we’ve seen that most of the participants who practice and attend regularly improve their ability to relax, stand upright and sit more comfortably for longer. Some say that during meditation their thoughts are less troublesome and they can concentrate a bit better. They generally move and do the exercises more easily. Many say that all these things have helped them in some way with their pain.

Current research in pain management is increasingly supportive of self-management techniques such as those we teach. Focused attention, relaxation and meditative exercises are key ingredients shared by what we do in our sessions and such things as yoga, taijiquan (tai chi) and qigong.

Like those taijiquan or yoga students who become more skilled with practice, so do our participants. Focused attention, relaxation and use of the body can obviously be trained. They are skills that can be improved through repetitive use like most human endeavors whether in sports, arts, science or business.

There is one important thing to remember in all this. It takes years to develop skills in some things. Taijiquan, golf or playing the piano can’t be mastered in a few months and neither, unfortunately can pain self-management methods. Nevertheless, practice itself can be immediately rewarding: just playing is fun if you enjoy what you are doing. Furthermore, every time you practice you get a little better.

Pain management isn’t an all or nothing thing. It is not about getting rid of all one’s pain or else one has failed. It is about learning different things that can help one have a better life. These things may or may not directly reduce pain but they still make a difference. The more one learns the better one’s life.

So, when we say pain management is a skill, one thing we really mean is that one simply practices to get better.

]]> http://mindbodypainclinics.com/is-pain-management-a-skill/feed/ 2 http://mindbodypainclinics.com/good-times-bad-times-pain-times/ http://mindbodypainclinics.com/good-times-bad-times-pain-times/#comments Wed, 23 Jan 2013 13:00:54 +0000 Jan Carstoniu http://mindbodypainclinics.com/?p=2565 A while ago, in one of our sessions, I pointed out that no matter what, we all have good days and bad.  Some days the pain is so bad that getting out of bed is the biggest challenge you may want to face. No matter what you do, take extra medications or meditate, nothing seems to help.

Does this mean that everything you’ve learned to help you with your pain and your medications are useless?  If they’ve helped you in the past then the answer is of course not.

It might help to think of it this way: no matter how skilled one becomes at something, be it boxing or solving an equation, there is always an opponent you can’t beat or a problem that you can’t solve, especially if you are having a bad day. It doesn’t mean your skill is all for nothing. It means that today’s opponent is too strong or problem too hard for your present level of skill.

Remember that pain is very, very tough to deal with and that any success you’ve had is an accomplishment you wouldn’t have achieved without your practice or other treatments you use. Just because you are having a bad day is no reason to give up your practice or your treatment. A good boxer keeps training to get better and a good mathematician keeps on solving problems even after a defeat.

If you understand that you and your pain are subject to change by things that are beyond your control, you will weather the bad times and not get smug about the good times. You will learn to hunker down when the pain is bad and make the most of the times when it is good.

Terms like biopsychosocial or psychophysiology speak to our inability to conceptualize the workings of human beings without referring to mind and body as somehow separate. But where does “psych” end and “physio” begin anyway?

What if we stopped using the terms body and mind, and assumed that cognition and awareness are simply functions of another biological system among the many systems that make up a human being. The “cognitive system”, like the endocrine, cardiovascular, and musculoskeletal systems, receives input from the environment and other systems, and creates output to them. In doing so the system can regulate and be regulated to maintain optimal function.

In this view, the mind is simply another part of the whole, another system that is inseparable from other biological systems. No need to argue about whether pain is “in” the mind or body. Trauma, stress and perceived threats to survival may precipitate reactions that lead to the activation of these systems to differing degrees with varying consequences depending on the magnitude of the noxious stimulation, the severity of the trauma, previous exposure and other factors.

If what I’m saying has any validity, then it follows (to me at least) that in treating pain, the use of psychotherapy, drugs, surgery and physical therapy might all be valuable to varying degrees by having effects on the different systems involved in the experience of pain.  Speculating even further, it may be that no one modality of treatment can treat all pain if it fails to address all the systems involved in maintaining chronic pain in an individual patient. The successes that occur may represent the ability of the systems treated to influence the others, but do not prove that those systems were solely responsible for pain in the first place.

Of course the above is quite simplistic, but I think this kind of view might do away with conceptual constructs such as id, ego and the unconscious that are functionally autonomous, things somehow apart from biological processes. It might offer relief from such flowery Freudian notions of repression and suppression in which the pressure of past trauma breaks through defenses to manifest as pain or other somatoform disorders.

Our current way(s) of conceptualizing pain has yielded lots of knowledge but not enough wisdom. Pain care remains in a dismal state. As others have said before me, it’s time for a new paradigm to help us make better sense of what we see.

Although personal experience that a treatment works (or seems to work) is compelling evidence to all of us, logic dictates that the strongest evidence for a treatment comes from controlling non-treatment factors that could affect pain.

This is often a tough job and designing a good study requires training in logic, statistics and probability, not to mention knowledge of the condition under study and its other treatments. Honesty, an open mind and objectivity are equally important when it comes to good research. This is a tall order and we humans often fail to live up to the high standards required for good study design. As with all human endeavors some research is good and some not so much.

An important benefit of good research is to allow us to determine the degree of confidence we can place in claims made about any kind of treatment, medical, surgical or otherwise. Well-controlled studies provide evidence that is objectively verifiable so paying customers can make rational decisions instead of being swayed by emotion. Good research is a bulwark against superstition, quacks and clever marketing. Sadly, good research is hard to find when it comes to pain in particular.

Understanding how research works and what makes a study strong or weak also requires knowledge and some brain sweat.  Research is published with the idea that everyone who reads the study can see the flaws in design and use that understanding to design better research. Work and study are involved and it is easier for most of us to accept the evidence of personal experience as the highest form of evidence (saves a lot of reading boring scientific literature) instead of examining our experience critically.

If you believe you have discovered something that would benefit pain patients and want to have the best possible evidence that it really does work then I would suggest seeking the advice of a statistician and research scientist to help you design an appropriate study. This takes time and money but sometimes the old saying about getting what you pay for is true.

The problem is that there are still no theories good enough to explain conflicting research results or settle arguments about causes of chronic pain. A good theory has to be able to explain everything we do know about pain and push us toward new avenues of research.

For example, once Einstein published his theory of relativity, the door opened to new kinds of research and amazing discoveries. The discovery of how DNA works caused a revolution in biological science. Pain medicine could stand a little revolution if that would lead us to better treatment.

Many of us who work in this field feel this way and some are working hard toward a revolution in pain medicine. In my reading about pain I came across a scientific article that impressed me as a big step toward rethinking pain. It’s long, complicated and demands a lot of the reader – it is not light reading.

Nevertheless it is a great example of scientific reasoning and creativity. I think it is a very important paper because it suggests chronic pain may be related to specific biological systems that can be activated by stress and trauma. It pulls together a lot of different knowledge to arrive at its conclusions and suggests lots of new research.

Here is a link:

http://www.painaustralia.org.au/healthcare-professionals/research.html

Look for the following title and click on it.

An Evolutionary Stress-Response Hypothesis for Chronic Widespread Pain (Fibromyalgia Syndrome)

Give it a try and let us know what you think. It is a fresh look at chronic pain but only time and more research will tell us how useful it is.

Nevertheless we often talk about pain as a cause even though it is really an effect. We say that pain disrupts sleep, changes mood and disturbs memory. This seems an obvious thing to say and I have often said this myself. It follows from this kind of thinking that if we treat the pain everything else should get better.

The big problem is that modern medicine and alternative medicine aren’t very good at treating chronic pain. Although there are all kinds of studies showing some benefits of all kinds of treatments, overall, chronic pain continues to be a huge and costly problem. It seems that thinking about pain as a cause of a whole rafter of other problems hasn’t been that fruitful.

One could argue that doctors just haven’t found the exact source of pain in someone and that is why it is so difficult to treat that person’s pain. The reality is that science has spent years looking for sources and has wound up with many competing theories that try to localize a cause of chronic pain to one area of the body/mind or another. None are close to being proven.

Maybe we need to think differently, focusing on the fact that pain is an effect of processes set in motion by trauma and disease.  Perhaps problems with sleep, mood, concentration, memory, fatigue, digestion, elimination and other things that often occur with chronic pain are the result of the same or similar processes that lead to the feeling of pain.

This means that chronic pain and its associated symptoms may be part of a generalized response to trauma and disease. If this is true then we need to study that response very closely. A new way of thinking about chronic pain might lead us to better treatment. The old way seems to have led to a dead end.