Chronic Benign Pain

An estimated 60 million Americans suffer from chronic pain daily, contributing to high medical expenditures and disability costs. Low-back pain is the second most common reason patients see their primary doctor. Acute pain management following musculosteletal injury or surgery is predictable in scope (self-limited) and outcome (resolution with healing). Chronic pain, defined as unremitting daily pain for a minimum of six months, often progresses to chronic-pain syndrome. Chronic-pain syndrome occurs when the pain consumes the individual, interfering with work, hobbies, and interpersonal relationships. Acute pain is adaptive; it protects one from further injury, but chronic pain is maladaptive, harming the individual.

The old medical model of pain correlates the extent of injury directly with the serenity of pain. This model has been discredited in our clinical practices, since typically the patients with the most severe pain do not have the worse physical injuries, but curiously have the deepest psychological and social problems. The most striking example of these phenomena is comparing elite athletes with chronic-pain patients. Elite athletes often present with high pathology, low pain, and extraordinary function. In contrast, chronic-pain patients often present with low pathology, high pain, and dismal function. Although physical load influences who gets injured, psychosocial factors determine who recovers. The new Biopsychosocial Paradigm of pain more accurately describes what we observe in our practices.

The Biopsychosocial Paradigm integrates the nociceptive pain generator with genetic and environmental factors that effect the transmission of pain through the spinal cord to the brain, which interprets the pain. Genetic factors, including personal or family history of addiction, depression and/or anxiety; and environmental factors, including premature birth, poor child-mother bonding, and sexual, physical, or emotional abuse, can amplify a low-level nociceptive problem into crippling pain perception. The biochemical alterations in these individuals limit the nervous system’s ability to dampen pain resulting in a memory of the pain, which no longer correlates with the injury. Windup and kindling of the nervous system also occurs, resulting in a higher sensitivity to all pain.

Emory psychiatrist Dr. Charles B. Nemeroff’s publications demonstrate that women who have been exposed to physical, sexual, or emotional abuse in childhood showed exaggerated physiological responses to stressful events as adults. Women exposed to mild stress who have histories of depression and child abuse showed six times higher levels of ACTH (stress hormone) than those women without such a history. Women with a history of abuse who are not depressed also showed hypersensitivity to stress, yet to a lesser degree. Dr. Rachel Yehuda, Mount Sinai psychiatrist, has documented similar abnormal stress responses in combat veterans, rape victims, survivors of the Holocaust, and others who have endured traumatic experiences. Adult children of alcoholics are not only more likely to develop an addiction themselves, but they also would have a high incidence of developing chronic-pain syndrome.

Depression and Chronic Pain

The majority of depressed patients have chronic pain as one of their symptoms. The majority of chronic-pain syndrome patients are depressed. Of patients with chronic low-back pain syndrome, 67 percent had an episode of major depression before their low-back injury. Of these same patients, 36 percent also had a history of substance abuse before the injury occurred. The brain atrophies 10 percent in patients who have depression or chronic-pain syndrome.

These psychosocial confounding factors make it very challenging to treat chronic-pain syndrome patients. There is tremendous controversy about the care of these individuals. The anesthesia model of “blocking the pain generator” is rarely effective and actually promotes the false expectation that once the pain resolves all will be well. Inherent in chronic pain is that the pain is permanent. The focus of successful chronic- pain management involves functional restoration, involving judicious use of nonaddictive medications, aggressive treatment of psychosocial factors, behavioral modification, and setting functional goals unrelated to pain resolution. In the past decade, a deeper understanding of neuroplasticity has opened new frontiers in chronic-pain management. The central nervous system is not static as previously believed. The central nervous system responds to environmental exposures. Exercise, functional activities, and even positive thoughts can enhance healing and growth of brain cells. Disuse and depression conversely causes brain atrophy.

Medications

The treatment of chronic-pain syndrome often involves numerous medications. Long- and short-acting opiates often are used for patients with severe pain. Opiates tend to work poorly in patients with significant psychological problems and should be tapered or discontinued. The use of opiates in patients with minimal objective findings and a high number of psychosocial problems often result in a new problem involving excessive opiate use. The opiates in this population rarely provide significant long-term pain relief and should only be continued if objective improved function is observed. A recent Annals of Internal Medicine review of opiate treatment for chronic back pain (Martell, Bridget et al Vol. 146 (2), January 16, 2007 pp116-127) noted the prevalence of current substance use disorders were as high as 43 percent. Aberrant medication-taking behaviors ranged from 5 percent to 24 percent. It is essential to take a thorough medical, family, psychological, and social history prior to prescribing opiates for chronic-pain syndrome patients. A strict opiate contract needs to be adhered to. Random urine screening is necessary to ensure compliance with recommending dosing, detect diversion, and determine if any other addictive medications or illicit drugs are being used. The new opiate antagonist/agonist medications (Suboxone) are very useful in this group of patients.

Anticonvulsant medications, including Lyrica, Neurontin, Gabatril, Topamax, and Keppra, are effectively used in managing naturopathic pain. Cox1 and Cox2 nonsteriodal anti-inflammatory agents are commonly used to reduce inflammation and pain. Tricyclic antidepressants, including Nortriptyline, Elavil, and Trazadone, are helpful for sleep and neuropathic pain. Topical Lidoderm Patches are also effective. Ultram and Ultram ER, although weak opiates, are very effective in chronic-pain management since they are also weak serotonin and norepinephrine reuptake inhibitors.

Aggressive management of premorbid or reactive depression is necessary in these patients. The serotonin and norepinephrine reuptake inhibitors, Cymbalta and Effexor, are not only effective in treating depression but also reduce neuropathic pain. The traditional serotonin reuptake inhibitors, Prozac, Zoloft, Paxil, Celexa, and Lexapro, are effective in treating depression and anxiety. Wellbutrin reduces the reuptake of dopamine and norepinephrine, which is helpful in patients with addiction problems.

Reestablishing restorative sleep is often accomplished by treating the underlying depression (early morning awaking) or anxiety (inability to fall asleep). Judicious use of sleeping pills, such as Ambien, Lunesta, Sonata, and Rozerem often are required. Typically, the more effectively the pain is managed, the better the patient sleeps.

Exercise

Exercise is a therapeutic tool in managing chronic pain syndrome. In contra distinction to passive modalities like ultrasound, electrical stimulation, and endless chiropractic and massage therapy, aerobic exercise produces natural endorphins. Establishing daily aerobic exercise reduces pain, improves sleep, improves function, and increases confidence in the chronic-pain patient. Specific strengthening and flexibility exercises are useful also. Simulation of work or hobby activities in the gym hastens their restoration. The most difficult job the clinician has is convincing the chronic-pain patient that waiting for the pain to resolve prior to resuming activities is fruitless. By using exercise, the clinician can assist the patient in restoring function despite the pain. Often, once the chronic pain sufferer resumes a desired activity, the emotional suffering is reduced.

Clearly extensive psychological care is necessary in the management of this difficult condition. Patients who use coping strategies to control and decrease pain and who avoid overly negative thinking (catastrophizing) when experiencing pain have much lower levels of pain and disability. Cognitive restructuring assists the patient in self-directed problem solving. Biofeedback teaches chronic pain patients that their stress level is directly related to their pain level. Medication, yoga, and mindfulness classes also are useful. Often marriage or family counseling is necessary to facilitate understanding and break codependency tendencies in family members.

Functional restoration of chronic-pain patients is the gold standard of treatment. This involves more than 100 hours of interdisciplinary care to facilitate return to function. Functional restoration pain management programs, like SPARCMed, use physicians, psychologists, exercise specialists, nutritionists, and vocational counselors to establish lasting behavioral changes. Typically an aftercare program is provided to maintain the improvement.

Although caring for chronic-pain patients is often daunting, it also can be very rewarding. Assisting chronic suffering is one of the reasons we elected to become physicians. Rational use of typically nonaddictive medications, psychological care, exercise training, and establishing functional goals is the basis for successful treatment.

Dr. Sontag practices Physical Medicine and Rehabilitation and pain management in Redwood City.

Cognitive Restructuring

Changing one’s thinking about a situation is accomplished in psychotherapy by a process known as cognitive-restructuring, which simply means, "altering thought process." Cognitive therapy is used to change patterns of negative thoughts and self-defeating attitudes in order to generate more healthy and positive thoughts, emotions and actions.

Cognitive therapy uses three basic components:

1. Education: help in understanding behavioral and cognitive responses to pain and to stressful situations.
2. Imagery: rehearsal and practice of coping skills. Specific practices include direct-action techniques (e.g. physical relaxation, pleasant imagery, arranging "escape routes") and cognitive techniques (e.g. replacing negative self-statements with coping self-statements).
3. Logic and rational thinking:
   1. Catastrophizing: misinterpreting a minor setback as a catastrophe.
   2. Emotional reasoning: assuming that one’s negative feelings about a situation must be true.
   3. Personalization: seeing oneself as the cause of a negative event over which one actually has no influence. (Gatchel, Turk, 1999)

Pioneers in the field of cognitive therapy, such as Albert Ellis, Aaron Beck and David Burns, have pointed out that most stress and negative emotion come from distorted thinking. When we stop and listen to our inner self-talk, the thinking process, we often find patterns that distort reality in a negative direction. Catastrophizing an unfortunate event (making a mountain out of a mole hill) may exaggerate an emotional response.

Our thoughts, beliefs, worldviews, religion, social interpretations and values determine how we react to negative events or to stressors. Our view of life, habits of thinking and reactions to events are usefully viewed as a learned belief system. Like any habit, belief systems can be changed, unlearned and replaced with a better belief system. Poor motivation, negative attitudes, distressful emotions, or self-defeating thoughts can be changed. We can learn to become aware of specific beliefs and values that have been consciously or unconsciously causing personal problems.

In the book, Healing The Addictive Mind, Lee Jampolsky provides a metaphor that illustrates how thoughts may lead to pain. He writes, "Imagine that we set up a movie projector in order to view a film. The lights dim and the film begins. About ten minutes into the movie you notice that I am fidgeting and appear uncomfortable. You ask me if I am okay, and I tell you that I don’t like the movie. In fact, I get up and walk over to the screen and try to rip it. I don’t like the movie, so I try to change the screen. Jampolsky explains that the “movie projector represents the mind, thoughts are like the film," and I may add, the body is like the screen. A stressful thought can be seen on a set jaw, drawn face and tight muscles. In a general sense, life is recorded on the film, establishing a person’s self-image through programming or conditioning during the first three years of life. Psychologists agree that perhaps as much as 70% of the programming is achieved by the age of six and as much as 95% by the age of fourteen. By the mid-teen years, most of us have developed mental "habits" of responding to our environment. This early programming becomes somewhat permanent unless events in life force change. For most of us, change is frightening, and therefore usually resisted.

When fear and other defeating emotional reactions to pain are eliminated, the anguish and suffering of pain are eliminated as well. Like an engine pulling a train, thought leads the way. Opinions, beliefs and thoughts produce our moods, emotions and feelings about an event. Thoughts and behavior must change first, leading to a different interpretation of symptoms and a subsequent alteration in the pain response. The beliefs we have about pain either reduce or add to the experience of pain. For example, if we think about our body weight being placed on our tailbone while sitting in a chair, the perception of the tailbone pressing against the chair becomes more pronounced. On the other hand, as we sit in that same chair and our attention becomes focused on other events, we ignore our tailbone.

The way we think is one of the most powerful forces that influence levels of pain. Many people report that throughout the day their pain intensity ranges from perhaps a low of 4 to a high of 9 (on a scale of 10) even though they are stationary. Why does pain vary if the body is inactive? Pain varies simply because thoughts and images occur in the mind that activate or deactivate muscles and our pain perception. Keep in mind that powerful medications like morphine do not stop pain. Morphine simply inhibits nerve transmission and alters the perception of pain, causing a person to chemically enter a state of mind where he no longer cares about the pain or wants to think about it. Altering the perception of pain is the key to controlling symptoms. In other words, an emotional suffering response to an injury is due in large part to beliefs about the disability, rather than to the injured body part itself. For example, anxious individuals tend to overestimate the risk and consequences of injuries. Depressed people may actually spend time alone ruminating about their depressive symptoms, becoming more depressed about being depressed. Discouraged individuals can develop a process of thinking known as "learned helplessness" where people think they have no control or influence on the outcome of an event - no control of their own fate.

Multidisciplinary pain clinics, such as SPARCmed in Menlo Park, California, emphasize cognitive-behavioral modalities to reduce and manage pain. Pain management skills such as muscle relaxation, biofeedback, meditation and self-hypnosis are important tools. However, muscle relaxation training plus cognitive restructuring provide a long-term solution toward successfully reducing pain and suffering because removing stressful thoughts is essential to muscle relaxation. Trying to reduce muscle tension by closing the eyes and sitting in an easy chair will not work unless we also have the ability to turn off or to change stressful thoughts.

Cognitive restructuring provides a permanent alteration in our thinking that can relieve stress and suffering associated with pain and disability. Altering perceptions that cause stress and add to pain and suffering eliminates negative thought distortions. An extremely important component of pain management is adopting a positive attitude. While we cannot consciously alter tissue damage, we can alter perceptions that influence pain. The role of the behavioral component of a multidisciplinary pain program includes helping change defeated, negative attitudes. Chronic pain patients need skills to manage pain like an athlete preparing for the greatest event in life; like a football player entering the Super Bowl, focusing energy, time, intellectual, emotional, and physical resources toward one goal, winning. The way a person thinks about and copes with the experience of chronic pain largely determines functional abilities, emotional status, and compliance with treatment recommendations. A well-adjusted individual equipped with pain management skills can return to an enjoyable life even if he/she continues to experience pain.

Sharks’ Team Doctor Calls the Shots
SPARCmed physician aims for zero pain

Bill Workman
This article was published San Francisco Chronicle.

Dr. Mark Sontag is a chronic pain specialist and part owner of Sports, Pain And Rehabilitative Care (SPARCmed). Sontag is also a team doctor for the San Francisco Giants, the San Jose Sharks and the San Jose Sabercats, as well as a consulting spinal physician for the Oakland Raiders and Menlo College’s athletics programs.

In the early 1990s, he also treated San Francisco 49ers as a member to the medical group headed by the team’s longtime chief physician, orthopedic surgeon Michael Dillingham of Menlo Park.

This weekend’s schedule is an especially busy one for Sontag, with the Giants in the National League playoffs, the Sharks opening their night and the Raiders playing the 49ers on Sunday.

He’ll be behind the bench at the Sharks game and on the sidelines for the Raiders, and he is already been called on this week to examine the back injury of Giants relief pitcher John Johnstone, unfortunately confirming the team’s worst fears it’s unlikely he will be able to pitch again this season.

The 42-year-old Sontag, a longtime sports buff who grew up outside Chicago playing hockey, basketball and tennis, is said to be one of only a handful of physicians nationwide whose medical skills are serving the needs of more than two professional sports teams on a regular basis.

"What started as a hobby being a fan turned into a passion for sports medicine, and now it’s my occupation," he remarked. "I follow all the teams in the newspaper anyway, and this way I enjoy being part of an organization where my skills can have an impact on the outcome of a game or season."

For that matter, said Sontag, grinning, "I’d love to work with the Golden State Warriors and round it out" with basketball.

In July, Sontag and two colleagues, Perry Blackmon, PhD and Franklin Perry, MD opened the SPARCmed chronic pain program in Menlo Park for the treatment of chronic pain suffers. However, their patients are not elite athletes, but people with chronic pain syndrome who have under gone previous medical or surgical treatment without total pain relief. Typically, they are referred by other physicians, employers or insurance companies hoping to help them return to work and more a productive life.

Over the years, the 6-foot-3-inch Sontag, who stopped playing pickup basketball at the gym only a few years ago after injuring his knees, developed a theory about levels of pain tolerance among athletes that now inform the center’s treatment model. Medical management is combined with physical therapy, exercise, behavioral therapy and vocational counseling.

Sontag, a certified physiatrist, or doctor who specializes in rehabilitation, said neurological studies show that motion tends to block pain impulses to the brain. In the case of some star athletes, this enables them to perform at almost superhuman levels until the injury finally forces them to the sidelines for treatment.

In pursuing that theory, Sontag has established a pecking order of pain tolerance that puts hockey player at the highest pain threshold and baseball players the lowest, with football player somewhere in the middle.

He recalled that when he first went to work with the Sharks, he thought he would be following the same pregame routines of giving pain-killing injections to hockey players as the had to injured 49eers linemen who typically sought shots for shoulder problems so they could perform pain-free.

However, after waiting for more than an hour with his needles and syringes at the ready in the Sharks locker room, he was advised by the team’s trainer that "hockey players don’t take shots." The trainer was exaggerating, but it wasn’t far from the truth. Hockey players, said Sontag, "are the best conditioned and toughest athletes I’ve ever dealt with."

Eventually, he came to believe there was a correlation between pain thresholds and how much continuous movement a particular sport demands of and injured athlete. The more action, he said, "the less pain is likely to be felt, and I’ve observed that applies not only to athletes, but others, too."

For example, he noted that when the progress of a football game is analyzed, it breaks down into relatively brief bursts of action wrapped around lengthy strolls back to the huddle, timeouts and other unscheduled delays. Football players insist on being pain-free in a game, Sontag said, because any twinge could significantly affect their performance during house spurts of action.

By comparison, hockey movement is 60 minutes of almost continuous action while in baseball, players, notably outfielders hardly do much of anything other than watch. "For the most part, baseball players are standing or sitting for long stretches of time with nothing happening, but are very aware of what injury they might have, no matter how minor," said Sontag.

Even so, what differentiates most athletes from the rest of us, he says, is that when they were hurt as children, "Dad or the coach picked them up, dusted them off and told them to "get back out there," conditioning their nervous system to perform when hurt.

On the other hand, he said research shows that a high percentage of men and women who are chronic pain suffers were sexually, emotionally, and physically abused as children. "As a child they didn’t develop the coping skills of life’s challenges finding it very difficult to manage pain as an adult," Sontag said.

SPARCmed pain center is using techniques to cognitively and physically reinforce their nervous systems so the patient can at least get back to feeling pain the way most people do."