Chronic pain affects your well-being, but you can do something about it, say pain doctors.
It sometimes feels like a competitive sport when my mother and I compare our aches and pains in the morning.
She’s 89, so I let her win.
The conversation goes like this:
Mother (in a mixture of English and Teochew): My leg was so painful the whole night, I couldn’t sleep.
Me: Shall I take you to a doctor?
Mother: No need.
Me: I can’t do anything if you don’t want to see a doctor.
Mother: My leg is so painful. My fingers are also stiff. Look at them.
Me: Mum, I also have pain every day. My neck and shoulder hurt.
Mother: There’s something wrong with my stomach. I also feel it in my chest.
Me: My toe hurts all the time, and I see floaters. So do you want to go to a doctor?
Mother: No. I don’t want to go out. My head is giddy.
I’ll hold my peace at this point, lest the exchange escalates to something unpleasant.
Pain, as you can tell, is a hot topic in my household.
It intrudes on my thoughts ever so often, and I remember exactly when and how the first chronic pain descended on my body.
July 15, 2015, was the 170th anniversary of The Straits Times. The celebrations included an exhibition at the ArtScience Museum which was launched by a VIP.
Throughout the three to four hours that we waited for him to arrive, trailed him as he toured the exhibition and hung around after he left, I was tottering in narrow 7cm-high heels.
The exhibition was a success but my legs were killing me by the end of the night. I woke up to lower back, hip, knee and foot pain.
Most of it subsided, but not the pain in my right second toe.
It got so painful I went to see a specialist. An X-ray indicated osteoarthritis, a common degenerative joint disease in which the cartilage and other tissues in the joint break down over time. Years of wearing heels had worsened it, the doctor said.
I was prescribed painkillers and had to wear an orthopaedic boot on that foot. The boot caused hip pain, maybe because it was of an uneven height compared with my other footwear. I stopped after several weeks.
There is no cure for osteoarthritis. While there’s no discomfort when my foot is at rest, the pain ranges from dull and aching to sharp and pinching when I walk, worse when I run.
In the harrowing landscape of pain and suffering, I know my toe pain is minor and I ought to be more stoical about it. But pain is pain, and it is painful to me.
The easy part was weaning myself off covered, high-heeled shoes. But it has been a struggle reconciling how I must endure this pain for the rest of my life.
In the years since, I’ve had to accept and adapt to other chronic ailments.
When I developed neck and shoulder pain a year ago, I stretched, took off-the-counter painkillers and did tuina massage and acupuncture.
Nothing worked. The pain bothers me throughout the day.
When a GP’s prescription of stronger painkillers didn’t make the pain any better, I baulked.
Must I live with more chronic pain? Isn’t there anything I can do to cure it?
I decided to see a pain specialist.
When pain persists
The Pain Management Centre at the Singapore General Hospital was established in 2008 and it is the first and largest pain centre in a restructured hospital.
The multi-disciplinary set-up includes pain specialists, nurses, physiotherapists, psychiatrists and psychologists.
The clinic sees up to 6,000 patients a year, with 60 to 70 per cent of them coming in for lower back and neck pain. Others seek help for other pain conditions such as headaches, fibromyalgia (widespread pain), postherpetic neuralgia (pain after shingles), diabetic neuropathy (nerve damage from diabetes) and cancer pain.
The centre is headed by a senior consultant, Dr Diana Chan. Like most pain doctors, she is an anaesthetist with a sub-speciality in pain. She also has a diploma in acupuncture, which the centre offers as a complementary therapy. The SGH Pain Management Centre is part of the SingHealth Duke-NUS Pain Centre, which she also heads.
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”.
Pain that comes on suddenly, or acutely – what is commonly known as “acute pain” – is common with tissue damage.
Its role is protective, said Dr Chan. For example, the pain from a wound after surgery is a warning that you shouldn’t be stretching the wound or it will open up again.
Dr Diana Chan is an anaesthetist with a sub-speciality in pain. ST PHOTO: NG SOR LUAN
What happens is your peripheral nervous system sends signals to your brain, which then assesses the level of danger. If it determines that the signals require attention, it amplifies the sensation of pain until the issue is resolved. If not, the pain response is lower.
“Pain tells us that something is harmful to our body and we will then try to protect our bodies from experiencing further damage,” said Dr Chan.
Acute pain goes away when there is no longer an underlying cause for the pain. “We tell all our patients that when the wound recovers, your pain will recover.”
But if the pain persists beyond three months, what is known as wind-up and sensitisation happen, Dr Chan said.
In simple terms, what this means is that neurons – which are cells in the brain and nervous system that transmit signals to control everything the body does – undergo change.
They become more sensitive to pain and are always on high alert, amplifying pain signals and causing the body to feel pain more easily, even when the initial injury has healed.
These changes turn acute pain into chronic pain.
“The pain itself may not be protective any more, but our brain’s emotional centres light up and this can have a negative effect on the way we function,” said Dr Chan.
Acute pain, say from dental work, is usually treated with simple painkillers. With chronic pain, you need treatment, including medication that acts on the brain to reduce the sensitivity of the nerves that are transmitting pain signals.
Brain and emotions
Emotions play a big role in chronic pain, said Dr Chan.
If you are depressed, angry or anxious, you will very likely feel pain more intensely than when you are feeling calmer, she said.
Studies have shown that a large part of the perceived pain experience is contributed by emotional factors, she added.
She estimated that about 30 per cent to 40 per cent of the patients that the centre sees have underlying psychological issues such as anxiety, depression, a previous traumatic emotional experience, or “maybe they are perfectionists”.
“Whenever we are stressed or going through a very emotional event, we actually feel the pain a lot more,” she said. “That’s a reason why different people have different pain thresholds. It is shaped by their experiences and their underlying emotional well-being.”
Referring to my neck pain, she observed, accurately: “After a stressful period – maybe you are busy meeting deadlines – your neck probably is a lot more painful, right? A lot of times my patients also say that the pain coincides with their menstrual cycle.”
The scientific explanation has to do with the amygdala.
This is a small, almond-shaped cluster of neurons deep within the brain’s temporal lobe. The amygdala is involved in processing emotions, including fear and anxiety. It also plays a role in how we perceive and react to pain, by influencing our emotion to it.
When the brain interprets pain as a threat, the amygdala can heighten anxiety, fear and stress, potentially amplifying the perception of pain.
In chronic pain conditions, this emotional response can persist and worsen the experience of pain, even when the physical cause of the pain subsides.
“It is a vicious cycle,” said Dr Chan. “Pain influences our moods. The moods also affect our pain.”
But she stressed: “Every patient who walks through our door, we will acknowledge that your pain is real. You are definitely feeling the pain. It’s just how much of it is contributed by your emotional state.”
The good news is that positive emotions can significantly lower perceived pain.
Dr Chan said chronic pain management involves a multidisciplinary approach that can include interventions with a pain psychologist, physiotherapist and other disciplines.
The aim of the sessions is “to go back to a baseline where we learn to live with this pain and accept that there might be some residual pain, but that this level of pain is not going to, or will minimally, affect our function or daily activities”.
Patients fill up a questionnaire describing where they feel pain, how they rate the pain, and how much it has affected areas in their life such as their ability to walk, their mood and relationships with people.
They also fill up what is known as the Pain Catastrophising Scale, where they rate 13 statements related to pain. These include “I feel I can’t go on” and “I wonder whether something serious may happen”.
Following an examination from a doctor, treatment is recommended. This can take the form of medication, physiotherapy or procedures such as epidural steroid injections, nerve blocks, radio-frequency ablations, disc ablations, trigger point injections or more advanced procedures. Acupuncture is also offered.
Patients with high scores for negative thinking patterns – which the Pain Catastrophising Scale would have helped surfaced – might require therapy, such as cognitive behavioural therapy (CBT), to challenge such thoughts and replace them with more constructive ones.
CBT doesn’t remove residual chronic pain caused by tissue damage, such as in the case of osteoarthritis, but it can help manage the stress and anxiety that the pain brings out, which in turn worsens the pain. “It can break the vicious cycle,” said Dr Chan.
In the case of my neck and shoulder pain, she diagnosed it as a strained trapezius muscle as well as strained rotator cuff muscles, probably caused by an injury.
She said I should go for physiotherapy, and I am looking forward to starting this soon.
She didn’t prescribe psychotherapy, but from what I’ve gathered doing this story, it is clear my current attitude towards life and pain isn’t helping me.
I tend to over-think and am anxious and stressed out in some areas of my life. My Pain Catastrophising scores indicate that I harbour negative thought patterns about pain.
Learning how to be more relaxed, mindful and equable would no doubt calm my amygdala’s heightened response.
I’m also resolved to reframe those morning sessions where my mother complains about her pain.
It could well be her way of seeking comfort, expressing her fears or just sharing what’s on her mind, even if she doesn’t want to see a doctor.
Rather than trying to change her behaviour, I should change mine.
Instead of letting her remarks rile me, I could simply listen and then steer her to happier topics without bringing up my own pain, which serves only to upset me.
In a similar vein, I suppose, I can’t change how some pain will always be a part of my life.
But I have control over how much I let it play on my mind.
