Why am I still hurting
Why am I still hurting?
By James N. Dillard, M.D.
Pain has come a long way. Twenty years ago, if you had lasting pain that could not be ascribed to a tissue-destroying process like cancer or rheumatoid arthritis, you were automatically considered a psychiatric case. If you had a successful surgery but it still hurt a year later, the pain was all in your head, and you were referred to a psychiatrist.
In the last two decades, pain researchers have discovered how chronic pain can take on a life of its own, independent of what is going on in the body part that hurts. And it actually is all in your head, but not the way you might think.
When you were young, you might have injured a body part, perhaps by falling on a wrist and spraining the wrist joints. The amount of tissue damage had a direct correlation to the amount of wrist pain you felt in your brain. This is still true for acute injuries and active tissue destruction. But for long-lasting pain it is not true — the pain you feel is often way out of sync with the condition of the body part.
This is enormously troubling for the pain sufferer. He or she has grown up believing that if something hurts, there is something concretely wrong in the body. In my practice as a pain and musculoskeletal specialist, I see patient after patient who is so confused about their pain. They bring in three M.R.I. scans done in the last year of the same body area because the pain persists.
But the M.R.I.s don’t make the pain go away. Even worse, doctors will point to something on the M.R.I. and tell the patient, “There — that’s where your pain is coming from.” This is almost always not true, unless they are pointing to a fracture, pocket of infection, or a spot of cancer.
X-rays and M.R.I. scans do not show pain, they show only anatomy. The vast majority of people with abnormal M.R.I. scans — arthritis, torn cartilage, bulging or even herniated spinal disks — have no pain at all. A torn cartilage in the knee found on an M.R.I. is just as common a finding for people who have no knee pain as for those who do have knee pain. Hundreds of millions of brain scans almost never explain chronic headaches.
How can it be that you can have scary-looking M.R.I. scans and be pain free? Doesn’t everybody know that M.R.I.s can show exactly what’s wrong with you? Unfortunately for so many people with persistent pain, this is not true.
Doctors who read the research have known this for years, but the truth finally hit the major media on Dec. 8, 2008. Gina Kolata, of that most respected medical journal of all, The New York Times, wrote an article for the Evidence Gap series titled “The Pain May Be Real, but the Scan Is Deceiving.”
Ms. Kolata correctly stated the poor relationship between pain and high-tech scans. What she did not explain is how pain can ramp up and remain strong for so long. And she did not mention that medical imaging is an extraordinary growth industry, doubling in just seven years to $14 billion spent per year.
Dr. Clifford Woolf, a Harvard scientist and arguably the greatest pain neurobiologist of our time, showed us back in the early 1990s how it works. If a lab rat is given one unit of discomfort in the foot, electrodes will register one unit of pain signal in the rat’s brain. There is a 1:1 relationship.
If you give the rat long-lasting noxious foot stimulation, you will see an expected long-lasting signal in the brain. But if you then give the rat one unit of discomfort in the foot, you will read 10 units of pain signal in the brain. Strong or persistent pain sensations can cause the nervous system to amplify signals, and keep amplifying them.
The phenomenon is called “central sensitization,” meaning your brain becomes more sensitive to relatively minor stimuli. I see this all the time in my office.
A woman came to see me who had recovered from shoulder surgery for a rotator cuff tear. It was a year later, but she still had disabling pain. Medication had done little for her condition. On a recent return visit to her surgeon, he looked at a new M.R.I. scan and told her the shoulder had healed up just fine. He could not explain her persistent pain.
Upon physical examination, she had a good range of motion in the shoulder and fair muscle strength, but she still could not use that arm very well. The muscles and tendons in the shoulder area were quite tender to light pressure, but the neurological examination was otherwise normal. She had abnormal enduring pain as a result of the shoulder surgery.
We have long known about pain that lasts without a good reason. During the Civil War, doctors observed that soldiers who had undergone limb amputation had persistent pain in a hand or foot that wasn’t even there. It is called “phantom limb pain” and is well documented in medical literature.
There is a spot of nerve cells in the brain that is labeled “left foot,” and those cells can actively cause pain in the left foot, even if there is no left foot. The nervous system can play many tricks on us when it comes to chronic pain.
Giving more drugs is not the answer. Well-trained pain specialists can use simple combinations of treatments to unwind the pain. Getting you better may require a selective combination of nerve-quieting medicine, good physical therapy, acupuncture, massage therapy, relaxation/stress reduction, home exercise, stretching, and a healthy diet — one that does not promote tissue inflammation.
This begs the question: “Why don’t all doctors know these things about chronic pain?” I have a fourth-year student from Harvard Medical School spending time with me in my Manhattan office as a senior elective. She will be going into general internal medicine after graduation. She has not had even one lecture at Harvard on all this research — research that most good pain docs understand.
Pain is such a misunderstood and confusing problem. Most chronic pain patients do have anxiety and depression, but that does not adequately explain what happens to them.
For the 116 million Americans who live with chronic pain, it’s bad enough to suffer all the time, but it’s even worse to have no idea what is going on, or to think it’s all in your head.