The First Option (1996)

Chronic Pain – Definitions and Management Options

The 1990’s was officially the decade of the brain, but the science and management of pain was also receiving considerable attention. Traditionally, patients with chronic pain are difficult to manage and costly to treat (Hoffman, 1996; Bearman and Shafarman, 1999). Most experience difficulties in performing common daily activities, and many are depressed, hopeless, and without supportive family or social contacts (Cianfrini and Doleys, 2006). They are more likely to experience other clinical problems, be unemployed, and use alcohol and other drugs to excess (Weisberg and Clavel, 1999). These patients tend to be demanding of their primary care providers and generally unhappy with their health care. Providers have been frustrated with an inability to provide adequate symptom relief, and are left with few options when conventional treatment regimens fail.

Pain symptoms are a major reason for seeking health care in all industrialized nations (Smith et al., 2001). Epidemiologic data from the first National Health and Nutrition Examination Survey (NHANES-1) identified the prevalence of chronic pain in the U.S. to be about 15%. This data has been corroborated by several authors in Western Europe (Smith et al., 2001; Andersson et al., 1999; Bassols et al., 1999) and Australia (Blyth et al., 2001). The data indicate chronic pain is a common problem, impacting millions of people in terms of general health, mental health, employment, and overall functioning. Specifically, older adults, females, those of lower socioeconomic status, and the unemployed seem to be disproportionately affected (WHO, 1992).

The International Association for the Study of Pain defines pain as “an unpleasant sensory experience associated with actual or potential tissue damage or described in terms of such damage” (NIH, 1995). Pain taxonomies vary, but most authorities recognize three distinct categories of pain: acute, cancer-related, and chronic nonmalignant. Chronic nonmalignant pain may develop in response to trauma, misuse, disuse, or disease processes other than cancer, but it is primarily defined as pain that persists long after a reasonable period of healing is expected (NIH, 1995).

Chronic pain appears to be a physiologic, learned, and idiosyncratic response to a noxious stimulus (Turk and Okifuji, 1997; Weisberg and Clavel, 1999; Ruoff, 1999). As a learned response, pain is always subjective, and constitutes one of the most complex of human emotions. Pathological mechanisms are difficult to identify, and intensity is similarly difficult to quantify. Unfortunately, there are no objective biological markers of pain, and the most accurate evidence of pain is based on a patient’s description and self-report (Turk and Melzack, 1992). However, there appears to be little correlation between the intensity of pain, physical findings, and functional capabilities of those who suffer from chronic pain.

Biomedical models for the treatment of chronic pain represent an attempt to incorporate relevant principles from traditional medical disciplines. The biomedical paradigm views biologic factors as being primary in the causation and maintenance of pain. In this model, a patient’s symptoms are assumed to result from a specific disease state or biologic disorder. Testing and treatment target specific disease sites or systems, and psychological factors are considered irrelevant or secondary, as if the mind were reacting to, but is otherwise disconnected from, the body’s experience of pain (Weisberg and Clavel, 1999).

Despite the acknowledged importance of psychosocial and behavioral factors associated with chronic pain, traditional treatment strategies have focused on biomedical interventions, primarily drugs and surgery. However, many patients suffer from persistent pain that is refractory to the standard of care, and functional disability is often greater than would be expected on the basis of physical findings alone. As a result, the need for a new model has recently been acknowledged (Gatchel, 1993; Turk DC, 1996).

The biopsychosocial paradigm evolved in response to this need (Weisberg and Clavel, 1999). This model reflects the dynamics of biological, psychological, social and cultural influences hypothesized as causing, maintaining, and exacerbating chronic pain. It seems to better reflect the diversity in presentation of chronic pain symptoms, especially with regard to patient’s perception of and response to distress (e.g. severity, duration, and degree of functioning). The patient now has a treatment “team”, often represented by the specialties of neurology, anesthesiology, general medicine, physical medicine and rehabilitation, psychology, and social work. However, even when rigorously implemented, this approach leaves a significant proportion of patients dissatisfied (Astin, 1998; Eisenberg et al., 1993). Many of the dissatisfied are seeking alternatives.

In fact, the percentage of chronic pain patients seeking out alternative forms of care is increasing. In 1990 alone, 34% of Americans sampled reported visiting alternative health practitioners, often without telling their primary care physician (Eisenberg et al., 1993). These researchers estimated that Americans made 425 million visits to alternative health care providers that year, a figure that exceeded the number of visits to allopathic primary care physicians during the same period. Chronic pain was found to be a significant predictor in this study.

One alternative therapy gaining momentum and regard is the Feldenkrais Method. The Feldenkrais Method is based on our current understanding of the processes involved in learning movement skills. It is a systematic approach to improving human movement and general functioning. The Feldenkrais Method uses simple, gentle movements to reorganize posture, flexibility, strength and coordination. Named after Dr. Moshe Feldenkrais, an Israeli physicist who developed the method to treat his own sports injuries, the method offers a novel approach to pain management. By integrating mind and body, and harnessing the power of brain plasticity, Feldenkrais helps the body function more efficiently. This creates environments in which chronic pain and injuries can heal. Discover more about what Feldenkrais can do for you by reading the article “Feldenkrais FAQs“.  

About the Author

Lori L. Malkoff, MD attended the University of California at Irvine, earning her Bachelor of Science degree in 1980 with cum laude and Phi Beta Kappa honors. She completed her Medical Degree at UCIrvine, earned a Master of Public Health degree at SDSU, and completed post-graduate training in Family Medicine at UCLA. Lori Malkoff has been in private practice for 24 years.

Dr. Malkoff has taken additional post-doctoral training in the fields of physical medicine, rehabilitation, neuroscience, psychology, and nutrition. She is one of fewer than 10 Medical Doctors in the U.S. to be certified as a Feldenkrais Practitioner, and currently owns and operates The Feldenkrais Center of San Diego.

First Option (1996)

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