"The pain is all in your head." I remember being a newly minted doctor and hearing that statement in one of the first clinics where I worked out of residency training. It would be a common refrain I would hear time and time again over the next few years, as this idea was all the rage in the '80s and '90s. After I had examined a few hundred patients in pain, I knew intuitively that this conceptualization that pain was a psychological problem was ridiculous. The idea is still out there, despite study after study showing that while pain is in the brain and it impacts psychology, it's quite real. Not a figment of someone's imagination, but more like the brain's physical reaction to something bad. This morning I'll review one of those new studies showing that pain can now be "seen" impacting how the brain works.
Crazy or Lazy
I'll never forget my experiences with "chronic pain programs" as a young doctor. This contraption was a multidisciplinary team of physicians, therapists, and psychologists who would see patients continuously over one to two weeks for eight hours a day. The idea was that since the patients' chronic pain wasn't real and was instead a figment of their imagination, patients could be talked out of pain. Also, since they were deconditioned and this was also causing their pain, we could work the laziness out of them by bombarding them with physical and occupational therapy. The idea was that these patients would, of course, exit these programs with less pain and as productive members of society ready to go back to work lifting stuff. However, in reality, despite these programs costing tens of thousands of dollars, this never seemed to happen. While every once in a while we would meet a patient who did figure out what we wanted to hear and would tell us that to escape his or her special version of treatment hell, for the most part, patients exited "the program" still in pain, but maybe a little more knowledgeable.
While my colleagues at the time bought into this idea that pain was just another psychological diagnosis, the idea didn't hold water for me. Why? After examining the first 100 patients, I realized they all hurt in the same places, and distinct patterns of exam findings began to emerge. I remember thinking to myself, either these patients are all meeting up at night telling each other exactly when to say ouch as I palpate this or that spot, or this is a real medical diagnosis with predictable pathology. Hence, it wasn't long before I viewed the doctors running chronic-pain programs as crazier than the patients they were treating.
New Research Emerges that Changes Everything
Sometime around the turn of the millennium, we began to see our first images of how the brain worked. New technologies began to let us not only accurately measure things on standard MRIs but also use special tools, like functional MRI, to "see" the brain processing information. Sure it was crude at first, but scientists began to publish the first papers showing real physical changes in the brain in patients with chronic pain
. More such studies followed and put to rest the idea behind a chronic-pain program. In fact, the community hospital where I live just finally axed the last vestiges of its program, which had morphed over the years from a psychological focus to a medication-based one.
Imaging Your Brain and Pain
The new study was performed in eleven patients who had chronic pain from failed back surgery and normal control patients. Using a high-resolution functional MRI, the authors were able to image how the various parts of the brain talked to each other. They noted alterations in the pain-processing parts of the brain and other areas involved in perceiving sensation and controlling movement. They hypothesized that these real alterations in brain function were caused by real pain signals and that this temporary brain rewiring likely gave rise to the psychological changes we observe. Basically, that chronic pain patients seem crazy and lazy because of their pain.
The upshot? I'm glad that chronic-pain programs have died off like the dinosaurs. While we can't always solve every patient's chronic-pain problem, the fact that we ditched the "crazy or lazy" model means that we're now applying resources to why patients hurt and how to fix that rather than trying to convince them it's all in their head!