“Treat The Person, Not The Pain”

BUFFALO, N.Y. -- Dave was a healthy UPS driver until he stepped into a pothole and twisted his ankle while delivering a Christmas package. The nerve injury he sustained forced him to give up a satisfying, well-paying job, fishing trips with his son and nightly walks with his wife.

His personal physician, a neurologist and an orthopedic surgeon were unable to help, medications were prescribed without success and three months of physical therapy brought no relief. His pain affected every aspect of his life-finances, sleep, appetite, mood and his relationship with family and friends.

Dave suffers from a condition called reflex symptomatic dystrophy, one of a number of long-lasting pain syndromes that baffle physicians who are more comfortable and knowledgeable dealing with pain problems that are short-lived.

His plight is typical of the 250-plus people who come to the University at Buffalo's Center for Pain Management every month, hoping for relief from pain that seems to have no direct physical cause, but is as real as the air they breathe. The sad reality is, experts do not know what causes chronic pain and, for most sufferers, there's no cure.

Chronic pain is thought to affect one in four Americans and to account for 70 million doctors' visits annually. In addition to reflex symptomatic dystrophy, chronic-pain syndromes include such conditions as low-back pain, atypical chest pain, tension headaches, fibromyalgia (or muscle pain) and irritable bowel syndrome.

One national survey found that more than 550 million days are lost from work each year because of pain. The annual cost in disability compensation and lost productivity has been estimated to be as high as $100 billion.

Since there is no active physical injury to blame for such pain, Jeffrey Lackner, Psy.D., director of the Behavioral Medicine Clinic at the Pain Management Center, and other researchers have looked for other causes. Lackner helped establish the pain management center six years ago, and has seen the demand for its services grow.

Specialists in researching and treating chronic pain believe it involves the complex interplay of biology, psychology and learning.

"Most physicians and patients see pain as a symptom of an underlying disease," Lackner said. "With chronic pain, frequently there is no physical cause. For example, less than 25 percent of disability from low-back pain can be traced to a physical dysfunction.

"This doesn't mean these patients are weak, malingerers or that the pain is only in their heads. It means that, like all of us, their experience of pain is influenced by a distinctive mix of physical, psychological and environmental factors. Failing to address a patient's beliefs and attitudes toward pain, their coping skills or job satisfaction could result in ineffective treatment and continued pain and suffering."

In a study appearing in the journal Spine last November, Lackner described how a person's perceptions can influence the physical experience of pain.

"Patients who develop chronic problems appraise and process pain stimuli differently than do healthy controls. These patients attend selectively to pain cues, mislabel bodily sensations, inaccurately predict the probability of painful events, and have distorted memories for pain episodes."

At the center of this interplay, Lackner said, is the gate-control theory of pain. First proposed in 1965 by psychologist Ronald Melzack and anatomist Patrick Wall, the theory suggests that nerve impulses generated by a painful stimulus encounter a cellular "gate" on their way to the brain's pain center. When the gate is open, impulses reach the brain and cause the sensation of pain; when the gate is closed, those impulses are deflected.

Most researchers agree that psychological factors, such as attention to and fear of pain and how the pain is interpreted, can cause a gate to open or close. It is thought that when nerve signals reach the brain, they are processed in the context of a person's mood, emotions, beliefs and thought patterns.

"If you're playing baseball and skin your knee sliding into second base, your 'pain gates' are closed because your brain is focused on the game, not the pain," Lackner said. "On the other hand, if you are out of work with a back injury, if you worry that your pain means you have a broken back and you avoid activities you think may increase the pain, the 'gates' open and you experience terrible pain."

More recent research has found that the brain is so smart and powerful that it does not even need a "jump start" from the site of an injury to experience pain. Lackner said the brain appears to rewire itself to form a neural representation, or memory or pain, which can be activated by a simple touch, fear, memories, mood, expectations, attention, even visual images.

The key, then, to improving chronic pain is treating the person, Lackner said. "We teach people to use self-management skills to shut that pain gate."

Lackner and his colleague Susan Krasner, Ph.D., also a psychologist and a clinical assistant professor of anesthesiology at UB, prepare an individualized eight-to-15-week treatment plan based on an intensive interview. The interview is designed to assess the different aspects of the patient's pain, including its quality, location, triggers and factors that maintain it.

"We get far beyond 'Does it hurt?' and 'Where does it hurt?'" Lackner said. "For us the important question is, 'What personalized treatment plan, based on available scientific research, stands the best chance of improving this patient's functioning for his or her specific pain syndrome?' By integrating data from our medical pain specialists with that from behavioral evaluations, we identify the environmental, physical and personal factors that contribute to pain and then work to improve their functioning."

Armed with a clear picture of the type of pain and the type of person, Lackner and Krasner set out to teach their clients how to work around their pain and return to a better quality of life, drawing on a variety of clinically proven behavioral techniques. A plan may involve biofeedback and muscle-relaxation therapy to reduce physical tension; training to improve coping skills and cognitive-therapy techniques to challenge the thinking errors that influence pain and response to treatment.

"For example, pain patients learn to recognize the earliest thoughts and reactions that accompany a pain flare-up and modify their responses to them," Lackner said. "Patients are taught that 'automatic thoughts' such as 'the pain will never end,' 'I'm going to be crippled' and 'there is no hope' can be replaced with substitutes such as 'the pain has always lessened in the past,' 'I many not be able to do everything I used to do, but there are things I can do' and 'change is possible, there is always hope' to help to reduce pain and related distress."

"Cognitive-behavioral therapy can't promise patients total freedom from a medical problem as complex as chronic pain," Lackner said "but it can teach them to feel less hampered by it."

Patients who receive biobehavioral treatment at the UB Center for Pain Management reduce their pain 20-40 percent on average, reduce excessive medication use by 65 percent and significantly reduce their overall distress, the center's statistics show. Forty percent, including Dave, the UPS driver who came to the clinic with chronic back pain and has now returned to his job, are able to go back to work.

In addition, cost-effectiveness studies have shown a well-administered, biobehavioral medicine intervention reduces physicians' visits by 36 percent, Lackner noted.

"We think that's very impressive, but we don't help as much as we'd like," he said. "We need to improve on what we're doing. There is still a lot we don't know."