Adapting to Chronic Pain Conditions

[gerry the neck]

So, what is ‘Pain’ , exactly ?

It’s really quite remarkable that we don’t as yet have a clearly organised definition of the pain event. There are many theories, from Cartesian to emergent, but, perhaps not too unstrangely, these theories seem to remain unchallenged within the small pockets of thinking fraternities which created them. There is an obvious lack of resonance between the theories and the subjective narrative of pain experience. Currently, the most aggressive theories suggest that pain is a psychological ‘emergent’ perception, which doesn’t require a direct link, nor correlation, to an actual threat of injury or disease. In other words, the ‘emergent’ perceptions can instigate themselves, and perpetuate themselves, with no known recognisable cause, and with no known predictive certainty about perpetuity. I am inclined to dispute such an overview because it would seem to relegate pain perceptions into relative insignificance when assessing any patient....’if the pain perceptions have no known origin, and if their fluctuations depend upon patient mindset variations, then there is obviously no pressing requirement for any interference other than attempting to alter a patient’s mindset ’ ! And so, I must ask again....’What is pain, exactly ?’, because I have an intuitive sense that conflicts with that theorised approach.

So, what is the most obvious attribute of a pain event/perception/sensation, besides the more obvious discomfort it causes ? For me, top of the list has to be the manner by which our normally clear and responsive thinking seems to lose its clarity. A confusion is imposed on conscious thought, which highlights the distress, but discourages reaction which might be inappropriate. This may well be the ‘purpose’ of the pain perception, especially if we consider that a hasty reaction might further threaten an already vulnerable situation. If we think of a ‘purposefully’ created pain perception, perhaps originating in the autonomic protective systems, and then manifested in the conscious mind, as a means of restraining conscious reactions, it would seem to tick a lot of boxes about pain perceptions which aren’t normally considered. Generally, we only tend to see pain perceptions as threat warnings, or as signals requiring reactions. So, if we tinker with our overview a little, it’s not too difficult to come up with an almost opposite explanation i.e. that pain is meant to restrain reactions. I don’t think there could be much of an argument against the possible beneficial effects of a restraining ‘purpose’ , thus feeding into the overview perception of pain being a ‘for the good’ essential tool of the autonomic protective systems. We already know that our autonomic systems, the nervous system and the immune system, operate for our benefit, almost perfectly, and without any conscious control or interference, so why not assume that pain perceptions are an integral feature of that same protectively organised structure.

My own understanding of pain perceptions, intuitively observed, incline me towards seeing pain perceptions as some ‘crossover’ event, where, because consciousness requires perceptions to function, and where we have no conscious perceptions of nervous system/immune system operations, there has somehow evolved a need for a restraining element to discourage any inappropriate reactions. Seeing pain perceptions in that light, I think it gives a ‘purpose’ to the pain event which can be rationalised, and would have a beneficial effect on the way patients currently understand and respond to their pain experiences. On the other hand, if we define pain as a variable event, lacking any particular purpose, are we not really just assuming that pain treatments might be irrelevant to the bigger picture of treating recognisable threats. For instance, with neurological painful conditions, where no obvious source has been detected, are we to assume that the patient’s pain narrative should be ignored as ‘possibly consciously invented’ ? The ethics involved in such assumptions flag themselves up automatically, and should be a pointer to re-thinking the entire ‘pain question’.

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[gerry the neck]

‘Chronic’ v ‘Persistent’

I’m just going to freewheel on this issue. I have to admit that I am totally baffled by the recent trend to replace the ‘chronic’ reference with the totally inappropriate ‘persistent’ reference. This trend has now seemingly penetrated into the inner circles of the Neuro specialists who are concerned with the pain theory and possible treatments of chronic pain conditions. It concerns me that incorrectly premised thinking will achieve nothing, and may even lead to inappropriate treatments evolving from basic misunderstandings. ‘Persistent’ means one thing....that an issue has continued after a known resolution point has been passed. To assume that meaning onto a ‘chronic’ issue, which means that an issue will continue over time with no known resolution point, is nothing less than an attempt to soften the ‘chronic’ undertones by supplanting them with a meaningless replacement description. So, I have to ask, what might have inspired this desire to impose an inappropriate descriptive reference (persistent) onto an already perfectly described condition (chronic).

Excuse my scepticism here, but perhaps it was a means for operators to not be too concerned with their failures in the treatment of chronic conditions. As such, it might have relevance as an operator’s placebo. Maybe it is considered that ‘persistent’ has less negative connotations in the chronic patient mindset, but that doesn’t excuse an unrequired complete change of meaning. Maybe there are those who don’t understand the continuance of chronic conditions, and they have to assume a resolution point somewhere in the process to validate their interactions. None of these possible reasons for an insistence on ‘persistence’ to replace ‘chronic’ has any relevance whatsoever on the subjective ‘chronic’ experience....which remains ‘chronic’ regardless. So what’s the problem here ? Patients do not have a problem with their condition being referred to as ‘chronic’.....so why the need for changing that to something which simply doesn’t make any sense to the patient. Chronic conditions are called ‘chronic’ because there is no known possible resolution over time. Is there really a need to confuse that issue ? A chronic patient is entitled to receive treatment for their presented condition, rather than treatment for some imaginary condition which has seemingly passed its expected resolution point.

Let’s be clear about this. Any operators assuming that a chronic condition is really a persistent condition, may well be operating off a false premise. That has ethical implications which might mean inappropriate treatments for chronic patients. That is what’s at stake when the reality and meaning of a medical condition have an unsuitable meaning imposed on them for the convenience of operators. And it must be challenged vigorously, before it insidiously becomes the norm and affects future advances in treatments. As a chronic patient myself (cervical spondylosis) I find it meaningless to have my condition referred to as ‘persistent’. I know my condition is chronic, it’s degenerative, and I have no problem perceiving it as such. It would further bother me if I had to perceive it as something which should have resolved, but has somehow ‘persisted’ without explanation.

So, let’s stick with the definitions which make sense, no matter how difficult it is to accept a ‘chronic’ overview. At least patients will understand that their condition is understood when presenting for treatments.