Post-trauma Pain Management: A “Back to Basics” Approach
The finding that terrorism and other forms of mass aggression can exert a potent and enduring impact on physical pain perception has only recently been confirmed.1 Acts of brutal terror such as the cataclysmic events of Sept. 11 have been reported to induce a potent exacerbation in pain intensity among people with chronic pre-existing painful ailments including arthritis and migraine.2
The tragedy that befell the world on September 11, 2001 serves as a cogent example of the devastating impact that reckless acts of terror, such as the World Trade Center and Pentagon attacks can have on physical pain perception. A retrospective multi-center study of 129 chronic pain patients reported in the March/April 2002 issue of Practical Pain Management demonstrated that average pain scores, as measured on the Visual Analog Scale (VAS) for all participants increased 27% after the Sept. 11 tragedy. Women experienced an almost two-fold increase in pain scores immediately following the event compared with men. Neither age, race or clinic location was found to be positively correlated with pain intensity.1
Chronic pain diagnoses represented in the multi-center cohort were varied and included patients with rheumatoid arthritis, degenerative arthritis, fibromyalgia as well as several other painful etiologies. Medical co-morbidities included heart disease and neurological illness. Patients with active psychological illness and cancer were excluded from the study.
A recent Robert Wood Johnson Foundation sponsored study,3 found that post-Sept. 11, Americans have become increasingly pre-occupied with chronic health concerns including arthritis, cancer, heart disease and HIV/AIDS. Since pain is a hallmark feature of many chronic illnesses, it is important to assess the impact of Sept. 11 on pain perception so that appropriate therapeutic interventions can be utilized.
Pain, Chronic Disease and Psychological Implications
Violence, mass acts of aggression and terrorism can provoke a “physiological alarm” among bystanders and those who are not directly victimized. An array of physical responses that can heighten pain can be unleashed. This can lead to a variety of somatic responses including muscle spasms, dysfunctional sleep patterns and significant pain exacerbation.
On a psychological front, it is important to recognize that chronic pain patients, who have experienced forms of trauma, may confront some very powerful emotional reactions that may cause the pain to flare and amplify. Immediately after a traumatic event, people may experience shock and denial, both of which are protective responses. As a result of Sept. 11, many people felt stunned and dazed during the immediate period after the attacks. This slowly gave way to a state of numbness and denial in which victims and bystanders failed to grasp and acknowledge the full intensity of the event. In the case of Sept. 11, many people, who were initially in utter disbelief, suddenly came to the stark realization that something awful and cataclysmic had taken place. In many cases, people suffering with chronic pain reported dramatic worsening in symptoms.
Natural, Integrative and Complementary Treatment Strategies
This article will focus on natural therapeutic and treatment modalities that can be applied to chronic pain patients who have experienced an exacerbation of their pain in the aftermath of tragedy or trauma. The reader is reminded that trauma can take many forms and is not necessarily limited to acts of terrorism and war crimes. Studies have documented that victims and observers of earthquakes, lightening storms, hurricanes and violent crimes have experienced a heightening of anxiety as well as an accompanying pain exacerbation.
Since stress and anxiety appears to have a major impact on pain intensity among victims of traumatic events, it is quite reasonable that holistic complementary medicine strategies, which place emphasis on the “mind-body connection,” be preferentially deployed. There is an abundance of recent literature profiling the gamut of integrative strategies.4-6 In the catastrophic aftermath of Sept. 11, many Americans are now emphasizing the importance of a “back to basics” approach. While most of the specific treatments offered in this overview are not necessarily specific to terror-induced pain, many can be generically applied to patients with fluctuations in their chronic pain due to various forms of trauma.
Two representative case reports will serve to highlight the importance of a multi-disciplinary program incorporating complementary strategies to help conquer the pain compounded by the Sept. 11 tragedy and other calamitous occurrences.
A 45-year-old secretary with a diagnosis of fibromyalgia sustained a significant worsening in her shoulder and neck pain following Sept. 11. Although neither she nor any of her family members were directly affected, she reported that the tension and the stress of the day contributed significantly to a pain worsening. Per the recommendation of her physician, she was started on an aerobic exercise program emphasizing swimming and brisk walking three times weekly. In addition, she was started on a yoga program and was referred for acupuncture treatment to help her deal with her anxiety and pain. After several weeks of this structured program, she reported an improvement.
A 72-year-old senior citizen with chronic pain associated with a history of Degenerative Joint Disease (DJD) — affecting her knees and hips — noted a significant worsening in her pain intensity following Sept. 11. Since one of her children was in the army, she became very anxious about his welfare and safety should he get “called up”. She also spent several sleepless nights reflecting on the tragic and unpredicted events of Sept. 11. Due to a significant pain exacerbation of her knees, the patient was started on a physical therapy regimen that consisted of quadriceps strengthening exercises, thermal modalities, ambulation exercises and a stretching program. To lessen her lingering symptoms of anxiety, she was taught a series of deep breathing exercises. In addition she received three sessions of hypnosis. The patient noted a significant improvement in her pain following a two-week period. Although the trauma of Sept. 11 would always persist, her physical pain complaints progressively improved.
A “Mind-Body” Overview
Pain management is enhanced by methods that increase the pain sufferer’s sense of mastery over his or her symptoms. It is probable that a perception of loss of control is one element in the intensification of pain symptoms experienced by chronic pain sufferers. Breathing exercises, guided imagery and yoga are practices that are likely to help individuals feel greater control of their symptomatology. Other self-empowerment activities include: attending pain support groups, participation in religious activities appropriate to the individual’s belief system and engaging in productive behaviors including working, family duties and volunteerism. Finally, it is critical to rule out major psychiatric conditions such as mood disorders, anxiety disorders, somatization disorders and psychotic disorders which must be treated to optimize pain control and remove potential confounders.