Pain and Pain Management – Interview with Rehab Psychologist Teresa

Teresa Götz

Teresa ist Reha-Psychologin in einer spezialisierten Endometriose-Reha

In our previous interview, Teresa provided valuable insights into the rehabilitation process. In this follow-up discussion, she generously imparts her extensive experience and knowledge concerning pain and its management. Thank you, sincerely!

Why does discussing pain and gaining credibility often pose challenges? Individuals with endometriosis frequently encounter situations where their pain is not acknowledged or believed.

Yes, this indeed is a significant challenge. The difficulty stems primarily from the fact that pain lacks visibility or quantifiability, unlike parameters such as high blood pressure or blood sugar levels. Assessing pain relies on subjective indicators like facial expressions or verbal descriptions, often represented by the familiar pain scale ranging from 1 to 10.

Additionally, the perception of pain varies widely among individuals. There is no universal standard; for instance, a broken leg does not consistently equate to a fixed level of pain like 6 or 8. Pain experiences differ, and factors such as gender and genetics, with redheads being more pain-sensitive, can influence this divergence.

A common misconception prevails that enduring pain toughens a person, but in reality, repeated exposure tends to heighten sensitivity. Due to the subjective nature of pain, articulating it accurately to healthcare providers becomes crucial.

Compounding the issue is the limited awareness surrounding endometriosis. Often dismissed as mere menstrual discomfort, the condition remains inadequately recognized. The invisibility of pain, particularly in the context of endometriosis, further compounds the challenge. Many affected individuals express a wish for a visible manifestation, such as a cast, to garner the seriousness their pain deserves. Unfortunately, the prevailing perception is that if pain is not visible, it is less likely to be acknowledged by others. Education plays a pivotal role in shifting this perspective in the right direction.

How does pain arise?

Simply put, we possess approximately 3 million pain receptors responsible for transmitting pain signals in the form of electrical impulses, primarily located beneath the skin.

Initially, all nerve signals travel to the spinal cord, where the first switching point determines which signals proceed and which are discarded. Pain management interventions, such as medication or electrotherapy, often commence at this juncture.

Continuing from the spinal cord, signals progress to the brain. Before reaching our conscious awareness, they traverse the second switching point, the diencephalon. The diencephalon acts like an executive secretary, deciding the significance of each signal before it reaches the cerebrum, where we perceive it as pain. This process illustrates why pain is often heightened during periods of rest. Additionally, it underscores the body’s ability to inhibit pain sensations, emphasizing a crucial starting point for pain reduction.

Importantly, conscious pain processing occurs solely in the brain. Hence, when confronted with statements suggesting that pain is psychological, it is apt to respond, “Yes, just like all other pain.” This insight allows for the integration of psychological aspects, as exemplified by phantom pains, where the absence of a body part does not eliminate the pain processed by the corresponding brain region. Acknowledging that pain is always psychological, as it is processed in the brain, offers a foundation for interventions. The positive aspect is that each of the mentioned switching points ALL pain can be influenced, providing an encouraging prospect for pain management.

Why is the distinction between chronic and acute pain important?

In the case of acute pain, such as that resulting from an injury, the pain is localized to the affected part of the body and is of short duration. This type of pain has a discernible cause and can be addressed through appropriate treatment. It serves as a crucial warning signal, compelling individuals to seek medical attention or adopt a more cautious approach.

While it might be enticing to conceive a medication that promises complete and perpetual freedom from pain, such a solution would be complicated. Acute pain, a vital warning mechanism, plays a pivotal role in survival. It prevents us from sustaining burns, handling broken glass without caution, or neglecting a broken leg. A rare gene mutation causes some individuals to experience no pain, leading to potentially life-threatening situations as they may overlook conditions like appendicitis or rib fractures, resulting in a shorter life expectancy.

Chronic pain, on the other hand, persists over an extended period, often exceeding three or six months. In scenarios where endometriosis lesions have been removed and medical assessments indicate improvement, individuals may still experience pain. In this context, the pain loses its warning function, akin to a persistent fire siren. Chronic pain can evolve into a distinct ailment, presenting more significant challenges in treatment compared to acute pain. The approach shifts from emphasizing rest to finding a delicate balance between rest and activity.

Endometriosis-related pain can potentially fall into both acute and chronic categories. However, due to factors such as delayed treatment or recurrence of lesions, the pain often transitions into a chronic state. Consequently, addressing the underlying cause AND managing the chronic pain becomes imperative.

What is the role of pain memory?

Pain memory is a common process in our brain, akin to storing things in memory, such as English vocabulary.

This process can be likened to a meadow, where each blade of grass represents a brain cell. When a child walks across the meadow once, the blades may bend but straighten up again. This is akin to experiencing pain for a few days.

However, if the child repeatedly traverses the meadow every day, a well-worn path is created, and others may start using it as well. In the context of pain, this means that other experiences, like unfamiliar movements, stress, fear, or fear of pain, can reinforce this neural pathway, intensifying the signal that reaches the cerebrum and making the pain more pronounced. In essence, the more pain experienced, the quicker and more sensitively it can be perceived—a sort of expertise in pain perception develops.

As pain memory is established, achieving rapid freedom from pain becomes challenging. It requires patience and protection from factors that contribute to this pathway. Just like allowing grass to grow over a trampled path. It involves guiding individuals down a different, healthier path.

Therefore, initial treatment goals for chronic pain focus on alleviating pain and improving the quality of life. The long-term objective is to “relearn” or “unlearn” the pain, gradually closing the neural pathway. While achieving quick relief may seem elusive, the good news is that chronic pain can be treated and overcome. This is achieved by strengthening the neural pathways associated with pleasure, well-being, and joy in the brain, effectively overwriting the pain pathways. Activities like enjoying a nice bath, receiving a massage, engaging in pleasant movements, and cultivating positive experiences contribute to this process.

While the journey may take longer than expected and seems more complex in reality, studies indicate that it can be successful.

What is the connection between physical and emotional pain, and why do they share the same neural pathways?

Various cycles of interaction contribute to the experience of pain. When pain manifests in a specific area, there is an automatic tendency to tense up, and this tension can further contribute to the experience of pain. As discussed in the previous video, individuals with endometriosis often exhibit tense pelvic floor muscles, exemplifying the interconnectedness of physical and psychological aspects.

The brain, interestingly, lacks distinct processing centers for physical and mental pain; rather, there is a unified response to all forms of stress—whether physical or emotional. The intertwining of bodily and emotional pain is evident in research utilizing a computer game, where experiences of exclusion activated brain areas associated with physical pain.

Consider a familiar scenario: a day filled with conflicts or intense stress can amplify the perception of injury compared to a day filled with happiness and love. The heightened activity in the stress center correlates with an increased sensitivity to pain.

The body’s internal pharmacy also plays a crucial role. Engaging in pleasurable activities or experiencing pride triggers the production of happiness hormones, acting as natural painkillers. However, persistent pain can deplete these resources and hinder the creation of new ones. The ongoing pain diminishes the capacity for joy and pleasure, impacting self-perception and achievement, even when the actual performance might be satisfactory. Stress hormones, such as noradrenaline, contribute to this imbalance in individuals with chronic pain, where the brain’s stress remains consistently active. The ensuing disruptions in sleep, coupled with persistent worries, create a cycle of contemplation, sleep disturbances and restlessness. This cycle may lead to withdrawal, leaving behind a landscape dominated by pain, work, and obligations.

How can these processes be intentionally harnessed to alleviate pain?

Some practical examples have already been shared on Facebook, including using painkillers, an acupressure mat, or a Tens device. Both warmth, through methods like tea, a hot water bottle, a warm bath, and cold, with the application of a cold pack, have been suggested. Physical activities such as walking, yoga, Pilates, stretching, or horseback riding, along with practices like rest, lying down, relaxation exercises, meditation, breathing exercises, or distraction, have also been recommended.

Implementing these suggestions may be challenging, and it’s crucial to experiment and identify what personally works best for you. Taking a multidimensional approach and addressing the issue from various perspectives is essential. Building a supportive team, including professionals like doctors, physiotherapists, nutritionists, osteopaths, or psychologists, can be beneficial. Additionally, having a network of family and friends or joining a support group can provide valuable support in your self-help journey.

What specific actions can you take on your own?

What specific actions can you take on your own?

  1. As a starting point, maintaining a pain diary can be beneficial. This helps recognize patterns and correlations in pain, enhancing perceived control and self-therapy.
  2. Distraction is crucial because actively redirecting attention away from pain can be more helpful than trying not to think about it. Engaging in positive activities, such as watching TV, reading, spending time with pets, or meeting friends, serves as a distraction and triggers the body’s natural painkillers.
  3. Exercise contributes to the production of happiness hormones, reducing the intensity of pain. However, individuals experiencing prolonged pain may withdraw and limit physical activities, leading to muscle breakdown and increased tension. Breaking the cycle of pain and withdrawal is vital through balanced, regular, and moderate exercise, respecting personal limits.
  4. Promoting relaxation and reducing stress is crucial for generating happiness hormones. Similar to the benefits of exercise, relaxation enhances blood circulation and facilitates the release of tension. Therefore, it is essential to establish a balance between activities such as sports and relaxation.
    Relaxation contributes to an improved sense of body awareness, allowing for early recognition of impending pain and proactive measures to counteract it. Additionally, engaging in relaxation exercises can aid in addressing sleep disorders, a prevalent concern for up to 80% of pain patients.  Lack of sleep can heighten pain sensitivity, underscoring the importance of addressing sleep-related issues in pain management strategies.
  5. Breathing exercises are beneficial, especially for those with pain who tend to breathe short and shallow. Deep breathing aids in better oxygenation of muscles, breaking the cycle of pain.
  6. Cultivating conscious enjoyment can be beneficial, Begin by acknowledging moments of joy, laughter, and pleasant experiences throughout your day. Reflecting on these positive memories triggers the release of substances in the body that alleviate pain. Consider keeping a diary for a few days, noting instances that brought you joy, creating a compilation of everyday pleasures. Actively incorporating activities that bring you joy into your daily routine, especially during challenging times, can be helpful. As pain persists, and its intensity increases, seeking diverse positive experiences becomes even more crucial.
  7. Establish clear goals and work diligently toward achieving them. Actively shape your life by prioritizing and planning your day around activities that are important and bring you happiness. Nurturing your soul with what matters to you can significantly enhance your well-being. Patience is key as you gradually notice changes, such as an improved mood or enhanced fitness, over weeks or months. Documenting your progress in a diary can serve as motivation, boosting self-confidence. In the face of setbacks, instead of giving up, reflect on the milestones you have already achieved.

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Dr. med. Nadine Rohloff