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August, 2016

Blog on Pain ??? A disease in its own right | Multispeciality Hospital in Bangalore - Sakra

Pain A disease in its own right!! -Dr. Hirachand Mutagi

The world is waking up to an epidemic of persistent pain. We grow up being told and understand that pain is a symptom of disease. To start with, it is absolutely the right thing to do. Pain serves as a warning signal, that we investigate and find underlying causes to treat them. Nobody can argue against this ideology.

But, what about the tests and scans not finding anything of significant, a very common scenario. Great! I don’t have cancer, TB, Infection, etc. But, I still have the pain! A google scholarly article search on “medically unexplained symptoms” confirms a rapidly expanding literature on this aspect. A survey of symptoms that went on to have an identifiable cause in western world general practice unearths sobering patterns.

 

Let’s look at the “glass half full scenario” – Only a small proportion of patients with symptoms have an identifiable cause and the others have normal investigations (blood tests and scans). That sounds good.

Now the “Glass Half empty scenario” - A large proportion of people don’t have an identifiable / and hence curable cause for their symptoms. Here begins a journey of seeing multiple specialists spread across a wide geographical area, each providing nuggets on information to create a concoction of confused understanding about causation, treatment options and prognosis. Each of these nuggets of information / treatment are absolutely right in a specific context, but considering the overall individual it adds to the confusion. Into this scenario, add the contribution of quacks and divine healers and you have a path to disaster for that confused individual (don’t forget the plight of near and dear ones). A multitude of health care providers (doctors and non-doctors) with specialization focus on symptoms specific to their specialization and provide a diagnosis / treatment. Varied explanations from each is counterproductive in the long run, As is rightly said “ Too many cooks spoil the both”.

Factors in development of medically unexplained symptoms

  • Expectation of instant curet
  • Appearance of uncertainty and inability to provide an explanation
  • Expressed concern about disease explanations
  • Failure to convince patient that the complaint is accepted as genuine
  • Reassurance without a positive explanation being given
  • Ambiguous and contradictory advice
  • Excessive investigation and treatment

 

Patients' understandable attempts to alleviate their symptoms may paradoxically exacerbate them. For example, excessive rest to reduce pain or fatigue may contribute to disability in the longer term. Doctors may also contribute to this by failing to address patients' concern or unwittingly increasing fear of disease (such as by excessive investigation). Patients views about treatment being focused on medicines, immediate cure, curative surgery, reluctance to engage in physiotherapy and aversion to address frustration / low mood all contribute to a treatment failure. Here we go , ready for the next specialist consultation.....

The World is Waking Up

The medical fraternity is slowly waking up to the fact that “Persistent pain is a medical condition by itself.” So much so that conferences are organized to raise awareness of the issue, as in - “Chronic Pain – A disease in its own right” Second Lilly Pain Masterclass Meeting held at the Royal College of Physicians in London 2012.

The EFIC (European Federation of IASP Chapters) current declaration on pain is that “Pain is as a major health problem, a disease in its own right”.

An organization called the International Association for the Study of Pain has defined pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described of in terms of such damage”. Even then there are 500 types of chronic pain and no two patients suffer in a similar fashion. The words emotional experience have great significant in defining pain. The fact that we can’t explain it does not mean it does not exist for that patient.

Current Thinking and Lines of Research

Chronic pain often outlives its original causes, worsens over time, and takes on a puzzling life of its own. There is emerging evidence that over time, untreated pain eventually rewrites the central nervous system, causing pathological changes to the brain and spinal cord, and that these in turn cause greater pain. Sometimes the original problem creates new ones as the patient distorts posture and avoids exercise in an attempt to reduce the pain.  In chronic pain, the protective mechanism of avoidance becomes maladaptive and counterproductive.

Achieving a happy, informed and relaxed patient, as treatment goes along is just as important as any medicine or medical procedure to ease pain / suffering.

The Western world have recognized this and “Pain management Centre/ clinic” form a busy part of the clinic / hospital. They focus of an overall detailed assessment of this persistent pain to formulate an individualized treatment regime with a combination of medicines, physiotherapy, non-surgical treatments and training on improving ability to lead an independent life. Hence reducing reliance on help from near and dear ones. The initial challenge in these setting is in unravelling the different counterproductive beliefs of a desperate patient while specific treatments are provided to achieve a happy patient at the end of the journey.

If the above article resonates with your past experience, its time you recognize it, take charge and build your road to recovery. A helping hand is always available……

Blog By

Dr. Hirachand Mutagi. (MD, FRCA, FFPMRCA)
Senior Consultant Pain Management.
SakraPain Centre.