Pain Management

Living smart while embracing pain.



“The state-of-the-art in pain science involves an under-standing that some patients must accept their pain and figure out how to work through it.”

PAIN IS NECESSARY, EVEN GOOD. It’s the warning signal that something is wrong. But when it lingers, pain becomes a problem — a condition rather than a symptom. Chronic pain is difficult to understand, hard to treat and nearly impossible to live with.

That’s certainly been Linda Smith’s experience. The 48-year-old St. Charles woman suffers from chronic back pain. Spinal fusion surgery didn’t do much to
alleviate her suffering, and as time went on, she learned she also had arthritis in her spine. Soon, she couldn’t work, couldn’t clean her house and, often, couldn’t get out of bed in the morning. Her doctor recommended the Pain Management Center at Washington University and Barnes-Jewish Hospital.

“ I had become a recluse,” Smith says. “I felt like I wasn’t ‘pulling my weight’ in my family. It was just so difficult because no matter what I did, it hurt. It’s just impossible for people to understand how bad the pain is until they’ve experienced it.”

The experience of pain is subjective. A painful stimulus that completely disables one person may be only a minor inconvenience for another, but that’s the nature of chronic pain.

“ The nervous system always amplifies and dampens down pain signals simultaneously,” according to Robert A. Swarm, MD, associate professor of anesthesiology, chief of the department’s Division of Pain Management, a component of the Washington University Pain Center. “So how much pain you experience is a balance, and there are a number of things that affect that balance.”

STEPP participant Linda Smith works out on the treadmill while physical therapist Jeanne Earley looks on.

For example, a person who does heavy lifting at work may experience back pain differently than someone with a desk job. The back pain for the lifter not only hurts, it also may threaten that person’s livelihood.

With chronic pain, despite the fact that many treatments exist, usually a person cannot be “cured.” Various strategies might make them feel better, but it’s unusual for a person to return to the kind of pain-free life many people take for granted.

“ From a clinical management standpoint, there are often five main treatments for chronic pain,” Swarm says. “We may recommend physical therapy, pain
medications, injections, psychological and behavioral therapies or surgical consultation.

The “injections” category includes treatments ranging from nerve block shots to high-tech spinal infusion pumps that inject medications directly into the spine. Swarm and colleagues also implant electrical spinal cord stimulators that seem to dampen the transmission of pain signals in chronic pain sufferers. But many patients still have pain, even when receiving these high-tech treatments.

“ We look for curative treatments,” Swarm says, “but the reason our clinical practice is called the Pain Management Center is that, unfortunately, in most cases we can’t cure or eliminate chronic pain. Instead, we’re limited to trying to manage these problems.”

The basis of pain

Just because there’s no pill to eliminate it doesn’t mean the understanding of chronic pain hasn’t advanced, says Swarm. In fact, work at the Washington University Pain Center is clarifying how higher cognitive functions like memory and emotion influence the perception of pain.

The center is a joint effort of the departments of anesthesiology and psychiatry that combines basic research, clinical research, clinical pain management and education. Working together, clinicians and researchers hope to make chronic pain more bearable and to provide effective treatments, if not cures.

Robert W. Gereau, PhD, chief of the Pain Center’s basic research division, studies the balance between a painful stimulus and the perception of pain. “Basically, we try to understand the molecules that change in your spinal cord and brain and to identify the differences that are associated with this change from acute pain — which is an adaptive, good thing — into chronic pain,” says Gereau, who also is associate professor of anesthesiology.

“ Morphine and drugs like it reduce pain sensation in general,” Gereau says. “What we’d like to develop would be drugs that reduce pain hypersensitivity — what I call anti-hyperalgesics — that would prevent or reverse the changes that convert normal pain into long-lasting, chronic pain.”

Gereau and colleagues have confirmed that higher brain functions are intimately involved both in perception of and reaction to pain. In mice, Gereau is studying pain response by observing an animal’s behavior following minor injury.

“ One hour after an injury to the right paw, the
left paw responds as it did before the injury,” Gereau says. “But three hours after the initial injury, the uninjured paw begins to show hypersensitivity to pressure or heat — not as much as the injured paw, but still a very significant amount.”

Gereau believes a similar process may occur in people with chronic pain. In response to prolonged back pain, a person may become hypersensitive in uninjured parts of the body so that formerly non-painful stimuli will elicit pain. Or, very light touches of injured tissue may cause a larger-than-expected pain response.

Preliminary data from the mice suggests that the amygdala, a brain structure involved in emotional memory, may play a key role in that process, implying that higher brain functions not only influence pain perception, but also help to regulate the body’s response.

Perception is reality

“ There’s a lot that goes into a person’s experience of pain,” says Beverly J. Field, PhD, instructor in anesthesiology and psychiatry, and director of the Pain Center’s STEPP (Supportive Training and Education for People with Pain) program, which combines behavioral and physical therapies for people suffering from chronic pain. “Psychological factors, such as emotions or even how a person thinks about their pain, can influence both pain perception and how well one copes.”

Other work from Gereau’s lab suggests that antidepressant drugs can alter an animal’s pain response, again suggesting that higher cognitive functions play a role in pain sensation. In other words, with pain, perception seems to be reality.

That’s a message Field can take back to her STEPP behavioral therapy group to help participants understand their pain and to explain that if their doctors prescribe antidepressants, that doesn’t mean the doctors think their pain isn’t real. On the contrary, it’s because they know antidepressants can help alleviate pain.

Gereau and Field agree that frequent contact between clinicians, researchers and clinical investigators increases their understanding of the issues their colleagues face.

Beverly J. Field, PhD, leads the STEPP program’s behavioral therapy support group.

“ It makes a huge difference to my research,” Gereau says. “Having that ‘back and forth’ helps me to see that we really can have an impact, and it makes it much more rewarding to know that what we learn in the lab can quickly affect the way that pain is managed.”

Swarm says the “state-of-the-art” in pain science involves an understanding that, at least for now, some patients must accept their pain and figure out how to work through it.

“ A lot of people have been frustrated in the last 10 or 15 years that the scientific breakthroughs in pain research haven’t directly translated into treatments that eliminate pain,” Swarm says. “I think some people had that fantasy in the past.”

Linda Smith is no longer one of those people. Her experiences with the Pain Management Center and its STEPP program have helped modify her expectations.

Along with attending Field’s behavioral therapy support group, Smith made physical therapy an important part of her personal pain management program.

Jeanne Earley, PT, MHS, a lead physical therapist at the Rehabilitation Institute, says it can be difficult to get people suffering from chronic pain to take the first step toward exercise. “They often think it will hurt worse,” she says, “but there is a difference between ‘harmful hurt’ and the muscle soreness that accompanies physical activity.”

The whole idea of exercise, she says, is to enhance the body’s physiological processes. “I tell patients that ‘If we don’t move our bodies, they don’t work as well.’”

According to Earley, within a week of beginning an exercise program, patients often begin to feel that moving is not necessarily painful — both during and after exercising, and even into the next day.

“ My goal is just to get out of bed every day and do something,” Smith says. “I still have good days and bad days, but I’ve learned my limitations and how to cope with the things that make my pain worse. If I hadn’t been through the STEPP program, I don’t know what would have become of me.”

Support group STEPPs up to sideline chronic pain

It’s a rainy winter day, the kind on which the cold, raw air goes right through a person. Despite the weather, a group of hearty souls has gathered at the Rehabilitation Institute of St. Louis to talk about pain.

Some have been in car accidents. Others have had multiple back surgeries or suffer from arthritis, fibromyalgia or migraines. What all these people have in common is pain — and most have been in pain for a long time.

The group is part of a program called STEPP (Supportive Training and Education for People with Pain). For eight weeks, its participants meet weekly for physical therapy and cognitive behavior therapy.

Through the STEPP program, Linda Smith has learned not to reach for things on high shelves. Instead of bending over to take dishes out of the dishwasher, she now sits or kneels on the floor, lifts the clean dishes up from the dishwasher to the counter and then stands to put them away. Meditation and breathing exercises help her deal with particularly intense bouts of pain.

“There are a number of reasons a person might be referred to the program,” says STEPP director Beverly J. Field, PhD. “They might not be able to work or be involved in sports or hobbies, and many will get depressed. A tremendous amount of loss is associated with chronic pain.”

Depression is just one of many factors that can influence an individual’s perception of pain. Ongoing research at the Pain Center shows that the brain’s response to pain is heavily influenced by both experience and emotion.

“During the STEPP physical therapy sessions and discussions, we formed a bond as a group,” says Smith. “Part of what helps me is thinking that if the rest of the group can do something, I can do it, too.”

The STEPP program is a multidisciplinary effort developed by the Washington University Pain Center, in association with the Pain Management Center at Barnes-Jewish Hospital and the Rehabilitation Institute of St. Louis.