4.1 A Holistic Approach to Chronic Pain Management

By Julie G. Pilitsis, MD, PhD (USA)

[Neurosurgeon Julie Pilitsis reminds us that chronic pain is a tridimensional experience that involves sensation, cognition, and emotion. Neurosurgeons address the sensation. As neurosculptors, we need to address the cognitive and emotional components.]

“The only thing you can really control is how you react to things out of your control.”

Better advice has probably never been given to any of us. It is relevant to the numerous roles I play in my life and something that I consider multiple times a day. As a surgeon, I often face an unexpected set of circumstances in the operating room such as a new team or a different piece of equipment. As a mother of former toddlers and now tween/teens, plans often do not go the way I had envisioned. As a patient, I often do not know how a new medication dispensed by my local pharmacy will affect my body.

Chronic pain affects people in many different ways, and there are many variables that may limit control over the condition. Physicians focus on the sensory experience and its treatment. They ask patients to evaluate their pain using the Numerical Rating Scale (NRS). “On a scale of 0 to 10, with 0 meaning ‘no pain’ and 10 meaning ‘the worst pain imaginable,’ what is your pain level?” Physicians use the reported pain level to assess response to treatment. Thus, the focus on sensation continues. Physicians and patients are less apt to consider other markers of success. More relevant questions perhaps are the following:

• Could you stand a minute longer than you did the day before?
• Were you able to do the dishes?
• Were you able to ride in a car?
• Were you able to sleep better?
• Did your mood improve?
• Were you able to enjoy time with family?

Why do we still use the NRS? Historically, its use goes back to the well-meaning idea of considering pain as the fifth vital sign, which, unfortunately, had the unintended consequence of contributing to the opioid epidemic. The NRS resonated with physicians by treating abnormal vital signs as something with which they were familiar. If blood pressure is high, providers give medications to reduce the value. The same is true for treating NRS values, and thus the focus on sensation continues. Although this approach may work for acute pain (e.g., a broken arm), for patients who have chronic pain, defined as more than three months of pain in the same area, it does not. Chronic pain goes beyond sensory changes alone as the brain’s plasticity is altered.

In fact, chronic pain is a tridimensional experience that involves sensation, cognition, and emotion. However, there is a lack of guidance and adherence by both providers and physicians to treating components of pain that are not related to sensation. Why is this? For physicians not specializing in mental health, we often focus on fixing values like those reported using the NRS. We may advise our patients to limit their stress, but without concrete guidance on how to do that or integration of stress-reducing options into the formal treatment plan, patients rarely succeed on their own. Compounding the issue, patients with chronic pain have often been passed from physician to physician, and because of a lack of objective signs and/or a lack of response to treatments, they may have been told that the pain is just in their heads. This statement marginalizes what patients are experiencing. Further, it makes patients less accepting of any cognitive or emotional components of their pain and of future treatment strategies designed to treat those aspects of their disease. Indeed, chronic pain is a disease and something that people will have to learn to manage. That is not to say that people must suffer, and in fact, they should not. However, expecting to be pain-free for a lifetime is likewise an unreasonable expectation.

We need to consider how living in pain may affect our thoughts, our behaviors, and our moods. While we wait for our provider to aid in diagnosis and treatment, it is important to keep ourselves in the best physical and mental space possible to modulate our reactions and empower ourselves to keep moving forward. Much as we have to make good lifestyle choices when living with diabetes, we have to do the same with chronic pain. We may have to change certain behaviors. We may have to add meditation and yoga, a healthy diet that reduces inflammation, and good sleep hygiene to our lives. Changing our cognitive and emotional response to chronic pain is essential to our well-being. When working through the process of limiting pain, controlling our reactions is empowering.

In 2021, as I watched Phil Mickelson, a soon-to-be 51-year-old, win the PGA championship, I was struck by the fact that this man who suffers from psoriatic arthritis was able to achieve these goals. It was obvious that he was thinner and had worked on his swing. What was less obvious was what he had shared with interviewers: the role of meditation and yoga in his life over the previous few years. He truly had optimized his mind–body connection to accomplish the previously impossible. If we all did that, just think what we could do!