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Pain Management and the Mind
Different people have different experiences in relation to pain. Some have a great threshold,
while others cannot stand the slightest pain. A recent experiment of brain scans reveals that this
is in fact true. The same pain stimulus can produce a different effect on different people.
"We saw a huge variation between responses to the same stimulus," says project leader Bob
Coghill of the Wake Forest University School of Medicine in Winston-Salem, North Carolina.
"The message is: trust what patients are telling you." Coghill tested the pain tolerance of 17
healthy volunteers by applying heat to the back of their calves. He varied the heat from around
body temperature to 49 °C, the temperature of very hot washing-up water. Volunteers asked to
rate the pain on a scale of zero to 10 showed huge variations. One resilient volunteer rated pain
at the hottest temperature at just over one, whereas another could scarcely bear it at all, rating
it at almost nine. Then Coghill repeated the experiment when the volunteers were in MRI brain
scanners. The scans revealed stark differences that reflected each individual's sensitivity to pain.
The volunteers least able to bear pain showed more activity in the cerebral cortex, the region of
the brain associated with higher cognitive function. Specific areas activated included the
prefrontal cortex - linked with attention, working memory and emotion - and the anterior
cingulate cortex, a region already linked with pain. Finally, the "leg" region lit up on the
primary somatosensory cortex - a pain "map" of the body. None of these areas lit up in the
resilient individuals. But an area called the thalamus, which receives pain messages from the
spinal cord and peripheral nerves, was active in all 17 volunteers. This suggests that the pain
signal was not dampened on its way to the brain in any of the volunteers, so all the differences
must be down to what happens in the brain itself. "Once the signal arrives, the cerebral cortex
interprets and colours the information based on prior experience, emotion and expectation, and
that's when the differences kick in," says Coghill [1].
Physical and emotional stress has been linked to a gene which makes a protein important for
brain chemistry. The gene makes catechol-O-methyl transferase (COMT), an enzyme vital for
mopping up the dopamine brain chemical linked with sensing pain. Jon-Kar Zubieta and his
team at the University of Michigan and The National Institute of Alcohol and Alcoholism,
Rocksville, Maryland, tough people who carry a particularly active form of COMT and not so
tough ones carry a far less active form of COMT. Those who carry both forms from each
parent, can react moderately to pain. Zubieta said "This is the first time that a gene has been
linked to particular changes both to the chemical systems of the brain and behaviour."2
The COMT gene exists in two forms which make copies differing by a single amino acid only -
either valine or methionine. This small variation has a big effect on the activity of COMT, say
the researchers. People with the laziest form of the gene – who, have two copies of the
methionine version - make enzymes three- to four-fold less effective than the other variants
contained just valine or one of each. The team used brain imaging or positron emission
tomography to examine the brain activity of 29 people who were subjected to a "tolerable" pain
over 20 minutes. The volunteers were given a salt water injection into their jaw muscles to
simulate a condition called temporomandibular joint pain disorder. They rated their own level
of pain every 15 seconds during the brain imaging. Zubieta predicted correctly that those people
who were able to metabolise dopamine best because both copies of their gene were of the valine
form would feel least pain. "Depending on the genotype you got - which had lowest,
intermediate and highest activity - people had a gradation in response," said Zubieta. In people
with two copies of the methionine form of COMT, the dopamine is not cleared fast enough. If
this becomes chronic the uncleared dopamine also acts on a second brain pathway regulating
pain and stress. Zubieta said a quarter of the population would be pain sensitive types, a quarter
would be more stoic types, and half would be in between [2].
Research on the relationship between health status and positive, as opposed to negative, states
or moods has led to intriguing findings in several domains. Positive states have been linked to
reduced perceptions of pain or symptoms. Induced positive moods reduced reported experiences
of general bodily pain, although induced negative moods had no effect. In a sample of subjects
who were currently ill with a cold, those induced to feel a positive or neutral mood reported
fewer aches and pains and less discomfort than those induced to feel a negative mood.
However, Watson found that daily levels of physical complaints were related to negative but not
positive affect [3].
The PSOM (Positive State of Mind) Scale has also been used successfully in a study of
collegiate athletes. The authors' theoretical model proposed that stress, through increased
tension and attentional disruption, is related to athletic injuries. They expected that diminished
ability to achieve positive states of mind would provide a sensitive indicator of stress and could
predict vulnerability to injuries. The scale had acceptable internal consistency in this population
(Cronbach's alpha for the six items was 77) and principal components factor analysis revealed
two distinct factors: "Focused on task," and "Enjoyment of the ordinary." Athletes who scored
higher on the first factor, "Focused on task," at the beginning of the athletic season were less
likely to suffer an athletic injury during the course of that season than low-scoring athletes 3.
Peace of mind is a powerful adjuvant for pain relief. Peace of mind may be defined as freedom
from fear, anger, and guilt. Pain is generally amplified by the presence of any of those
emotions. Whenever pain is causing distress or interfering with baseline functioning, the
transcendent domain should be explored for sources of suffering [4].
In a study conducted by Meagher, et al, on Effects of Affective Picture Modulation, viewing
fear and disgust slides decreased pain intensity and unpleasantness thresholds, but only the fear
slides decreased pain tolerance. In contrast, viewing erotic, but not nurturant, slides increased
pain intensity and unpleasantness threshold ratings on the visual analog scale in men, whereas
neither nurturant nor erotic slides altered pain tolerance. It is unclear why the disgust slides,
which were rated as more unpleasant than the fear slides, did not affect pain tolerance. One
explanation may be the greater level of physiological arousal evoked by the fear slides. Higher
levels of arousal may lead to heightened activation of the aversive system, resulting in
prolonged sensitization of pain. Alternatively, fear may unambiguously prime the aversive
motivational system, whereas disgust may evoke a more complex array of emotions, including
pity, which elicits an approach disposition to help others. When complex affects elicit dual
motives, the behavioral outcome is determined by the relative level of activation of the aversive
and appetitive motivational states. Supporting this, disgust slides receive high pity ratings and
produce less startle potentiation compared with fear slides. Although we did not obtain pity
ratings, disgust slides received higher sadness ratings than either the fear or neutral slides,
suggesting that the disgust slides evoked a more complex emotional state. Despite the higher
valence ratings of the nurturant slides, only the erotic slides altered pain threshold ratings in
males [5].
These results are consistent with the priming hypotheses, which predicts that pleasant and highly
arousing stimuli should lead to greater pain inhibition than pleasant and calming stimuli.
Although the results do not seem to support the view that pleasant and calming emotions reduce
pain, the lack of an effect of the nurturant slides may be due to the rapid decay of the affective
state. This seems plausible because highly arousing stimuli produce more persistent and vivid
emotional memories than less arousing stimuli. Indeed, arousal may contribute to the analgesic
properties of pleasant stimuli by producing prolonged activation of the appetitive motivational
system. Thus, it may be helpful to present pleasant and calming stimuli during the pain to alter
pain perception, a common practice in pain management settings [5].
Changes in pain sensitivity were more often observed for pain threshold than for tolerance.
Differential sensitivity across measures may reflect the decay of the emotional state over time:
Threshold ratings occurred early in the session when the affective state was greatest, whereas
tolerance occurred later after the emotion declined. Thus, the lack of an effect of the erotic
slides on tolerance may be attributable to low physiological arousal and the consequent decay of
this emotion over time. In contrast, the fear slides induced significant physiological arousal that
maintained the activation of the aversive system, long enough to influence tolerance. Finally, it
could be argued that our cold-pressor instructions ("remove your hand when the pain becomes
intolerable") created a negative expectancy that counteracted the effect of the pleasant slides on
tolerance [5].
Psychological approaches
A range of psychological techniques has been shown to be beneficial in management of chronic
pain, particularly in improving function and perceived quality of life, reducing depression and
health service use (visits to the doctor and use of medications). There is a difficulty of
attributing apparent gains to specific psychological approaches when these form part of a wider
program. Communication is a key issue when considering psychological approaches to the
management of chronic pain. Although from a professional perspective there is now recognition
that dualistic distinctions between mind and body are unhelpful, people experience pain as
fundamentally physical and will discuss it in these terms. Although some people may recognize
the role of stress or other psychological or social factors in their experience of pain, the
suggestion of psychological approaches to management could be interpreted as a suggestion that
the pain or the patient is not genuine. It is important therefore to explain clearly the specific
aims of any psychological approach intervention, and careful selection of vocabulary is
crucial. A substantial strand of the psychological literature subdivides chronic pain patients
into two groups: those in search of relief or cure, and those who have accepted their pain, the
latter being more likely to benefit from psychological intervention. There is now evidence to
suggest that this is another unhelpful distinction, and many people whom professionals would
assess as coping well and getting on with their lives would still be hoping that the pain might go
away. Broader psychological research on the relationship between realism and depression or
conversely self-deception and positive thinking points to the need to avoid crude distinctions
about ‘facing reality’ or ‘seeking a cure’ [6].
Three principal psychological techniques are summarized: behavioral, cognitive and relaxation
therapy. Behavioral (operant) therapies are based on a theory of learning (operant conditioning
or instrumental learning). According to this theory, behaviors are learned and maintained
because of their consequences. Behaviors can be learned unconsciously and can include
psychological responses as well as social behavior and the taking of medications. The broad aim
of behavioral therapies is to reduce behavior associated with pain and disability while
reinforcing behavior associated with health and activity. Behavioral approaches may include
periods of activity and rest on specified or time-contingent schedules, and goal-setting and
pacing. They include techniques such as bio-feedback (feedback on measures of physiological
responses such as electromyographic activity) to train patients to control apparently involuntary
negative responses, such as the tensing of muscles in response to pain. Partners are often
included in behavioral therapy on the grounds that behavior occurs in a social context, and
partners or other close family members may be maintaining or reinforcing certain behaviors.
Behavioral approaches make no explicit attempts to address the cognitive and affective aspects
of pain. Cognitive therapies address sufferers' attitudes, thoughts and beliefs relating to pain
and its effects, including their sense of self-worth or self-efficacy. Approaches include education
about pain mechanisms, challenging the idea of pain as harm, positive thinking, avoidance of
negative thinking such as ‘catastrophizing’, and the development of effective coping
mechanisms including communication assertiveness training. A large area of research and
practice is based on the importance of positive thinking and positive coping skills, and
inevitably ideas about these two areas form an important part of professionals' approach to
their work with patients. Work in this area involves the difficult balance of being positive but
realistic, and acknowledging the real difficulties that people face in their everyday life, whilst
encouraging and supporting them in developing their own management strategies instead of
labeling people as non-copers. Relaxation training combines many of the above theoretical
approaches and is based on the close relationship between physical and psychological stress and
the distress associated with chronic pain. Many different relaxation techniques may be used,
including progressive relaxation, bio-feedback, autogenic training, hypnosis, meditation and
yoga [6].
TCM View of Meditation, Exercise, and a Healthy and Pain Free Life
In TCM pain is considered as qi and blood stagnation. Practices such as qigong and tai chi,
are considered TCM treatment modalities to promote health. Tai chi although traditionally was
a martial arts practice, is a form of Chinese gentle exercise for the promotion of health in
TCM. These forms of exercise regulate the qi and restore balance. There is an aspect of the
mind and meditation that is a part of these forms. Meditation therapy in the practice of qigong
and tai chi is based on the belief that a person’s mind is capable of regulating qi. As with other
TCM modalities, qi is directed along the channels and meridians of the body, and moves the
blood. When the qi and blood are regulated and maintained in a harmonious balance, the body
stays healthy and pain free.
Health and longevity promoting exercises involving meditation have existed under many names
throughout the Chinese history. There has been names such as Dao Yin, Fu Qi, Zuo Chan, Tu
Na, and so on, based largely on the origin of the exercises and on their different emphasis on
movement, breathing and intentionality. The first chapter of the Yellow Emperor’s Classic of
Internal Medicine, the emperor states “I have heard that in early ancient times, there were the
Enlightened People who could master the Yin and Yang in the universe, breath in the essence of
qi, meditate, and their spirit and body would become whole, and their longevity could therefore
be endless". This quote refers to self meditation practices generally called “life nurturing
practices” or Yang Sheng Fa in ancient times. These practices were based on the concept that
those who know how to nourish themselves know the way to regulate qi. Self meditation
practices were one of the ways to regulate qi. They were performed as a part of a self healing
discipline and focused on health maintenance and disease prevention [7].
References:
1. Coghlan A, (2003) Pain really is 'all in the mind', NewScientist.com news service,
http://www.newscientist.com/article.ns?id=dn3861
2. Bhattacharya S, (2003) Tiny gene changes means big differences in pain, NewScientist.
com news service, http://www.newscientist.com/article.ns?id=dn3423
3. Adler N, et al, Additional Validation of a Scale to Assess Positive States of Mind
Psychosomatic Medicine 60:26-32 (1998)
4. Bope E, et al, Pain Management by the Family Physician: The Family Practice Pain
Education Project, The Journal of the American Board of Family Practice 17:S1-S12 (2004)
5. Meagher M, et al, Pain and Emotion: Effects of Affective Picture Modulation,
Psychosomatic Medicine 63:79-90 (2001)
6. Smith BH, Hopton JL, Chamber WA, Chronic Pain In Primary Care, Family Practice
Vol. 16, No. 5, 475-482 (1999)
7. Schlitz M, Amorok T, Micozzi M, Consciousness and Healing Integral Approaches to
Mind Body Medicine, Elsevier Churchill Livingstone, USA (2005)
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