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Knee Pain Blurred
by Johnna Marcus, LICSW
The National Institutes of Health (NIH) defines chronic pain as “pain that lasts more than several months (longer than ‘normal healing’).” Alongside the pain itself, people with chronic pain are vulnerable to “worse health, used more health care and had more disability than those with less severe pain” (National Institutes of Health, 2021). Additionally, as anyone who has experienced pain before knows, anxiety, depression, and panic can be effects of the condition, as well.
For many patients, chronic pain “has a severe detrimental effect on their social and family environment, as well as on health care services” (Dueñas et al., 2016, p. 7). It can be all-consuming. In the very definition of chronic pain, being outside of “normal healing” can also make someone feel like an outsider from society, isolated in their experience.
The National Center for Health Statistics (a division of the CDC) reports that in 2019, “20.4% of adults had chronic pain that frequently limited their life or work activities in the last three months” (Zelaya et al., 2020). The determination of what constitutes chronic pain targets the frequency of pain (how many days in the past week/month did you experience pain?), as well as the effects or severity of the pain (did the pain limit life or work activities?).
Despite the validity of the diagnosis of chronic pain, it is a condition that is scrutinized and questioned not only in general society, but in the medical community. Dr. Diane Monsivais, a nurse and researcher, explains, “Cultural and social norm in the United States is the expectation for objective evidence (such as an injury) to be present if a pain condition exists” (2013, p. 3). In addition to the pain of the condition, the invalidating response to pain adds another layer of complexity. This is relevant when engaging with patients in treatment.
In this case study of a man in his 60s with chronic pain (“Corey”)[1], we examine the importance of acceptance and hope through clinical interventions to alleviate distress and greater engagement.
Patient Care and Challenges
I began working with Corey for assistance with his longstanding pain while a social worker in the addiction psychiatry division of a large hospital. Initially, I felt an impulse to help or fix his condition, not unlike many practitioners feel when hearing about chronic pain, or any pain, for that matter. I wanted to find ways he would feel alleviation from severe, often debilitating pain.
Corey had had an accident years earlier, leaving him with longstanding pain that has had some instances of improvement over the years, but has stayed significantly distressing affecting movement and quality of life. It is very difficult for him to find a comfortable position. After realizing some limitations of medication treatment options for chronic pain, I read about “complementary health approaches,” such as acupuncture, manipulation, massage therapy, and relaxation techniques such as meditation and mindfulness (Nahin et al., 2016, p. 6).
Parks outlines the importance of exploring a “multidisciplinary approach to treatment” such as a combination of psycho-behavioral approaches, procedural and other manual therapies, and procedural or interventional techniques (Parks, 2017). At this point, I was supposed to feel hopeful about these interventions, accepting the fact that there was no easy answer nor specific timeline to healing. Instead, I felt much like Corey had felt earlier in his recovery—frustrated and stunned. There was no one surgery or intervention, no clear timeline nor specific pill for alleviation. It felt uncertain and unknown.
Acceptance and Hope
I found the “chronic” aspect of chronic pain challenging in terms of conceptualization. Where does chronic pain fit in the framework of treatment planning and prognosis? Our medical system is comprised of cures and timelines for healing. There often isn’t much space for acceptance of pain, and there is often a tendency to question the legitimacy of chronic pain. Although tempting to try to find new ways of “fixing” the pain, I was brought into a clinical space of acceptance and aligning with my patient.
Part of this process is understanding the effects of the stigma of chronic pain and working to break down the pain it causes. Goldberg (2017) reports that “ameliorating such stigma is an ethical imperative, and yet most approaches eschew even an attempt to trace connections between historical attitudes, practices and beliefs towards pain and the stigmatization so many pain sufferers currently endure.” Increased acceptance of patients’ experience of pain combined with clinical alignment with patients can improve interventions for chronic pain. This can translate to alleviation of suffering for patients even outside of the clinical setting.
Regarding work with Corey, there are two types of pain we focus on. The first and most obvious is the physical sensation of pain. The second is perhaps more difficult to grapple with, but just as significant—his reaction to the chronic pain. A patient’s reaction to pain is complex—emotional, psychological, or traumatic.
According to Harvard Health Publishing (2010):
The overlap of anxiety, depression, and pain is particularly evident in chronic and sometimes disabling pain syndromes such as fibromyalgia, irritable bowel syndrome, low back pain, headaches, and nerve pain. Psychiatric disorders not only contribute to pain intensity but also to increased risk of disability.
Coping with anxiety resulting from pain and feelings of being a “victim” of pain are key aspects of treatment that can be explored in a therapeutic setting. Corey and I work together to explore the interconnected nature to sensations of pain and these challenging feelings.
I have moved from a place of clinical uncertainty to a questioning of how else we can explore next steps in care. I have learned the importance of being present without “fixing things.” Social workers, for the most part, like fixing. A patient may need rides to medical appointments, better relationships with family, food resources—these interventions have clear indicators of success. By exploring a patient’s experience—asking questions, wondering out loud with patients why they may have more pain lying on their back rather than their side, and investigating adjunctive therapies such as movement analysis or deep breathing exercise—the therapeutic relationship can be enhanced. This can lead to acceptance of certain aspects of the patient’s condition while moving forward to ask questions about how treatment can be enhanced.
It can be important for a treatment team to “emphasize the need to adopt a comprehensive and multidisciplinary approach to improve the patient’s condition and circumstances, contemplating both pharmacological treatments and non-pharmacological measures” (Duenas et al., 2016, p. 10) to give patients like Corey multiple avenues of possibility and hope.
Redefining Treatment
I work with teams of people who fix problems. Medication adjustments that have been made by the medical team have undoubtedly saved my patients’ lives. How do I gauge progress made within clinical sessions with patients who have chronic pain without the idea of fixing? Should I have them rate their pain weekly? if so, how many weeks do I hear a high pain rating until I feel hopeless? It can be difficult to “be in the trenches” with my patient, knowing that he is in this space of pain in the minutes, hours, and days after our session ends.
I have become more present in these weekly sessions—not looking to find a solution or plan a timeline for change to occur. Our time together distracts him from pain at times and takes focus off some of the distressing sensations. Instead of discussing “cures,” we discuss how pain fits into Corey’s life.
He feels pain when getting out of bed, but he endures it. He goes outside for some gardening if he can and finds joy in seeing bunnies in his yard. We talk about some everyday frustrations (riding in a car) and some extraordinary frustrations (riding in a car on a bumpy road). We discuss politics, the economy, and movies. He appreciates companionship, kindness, and laughter. He has found a way for pain to fit in his life while still moving forward. I have respect for the magnitude of this struggle and the stamina he must have to endure it.
There is power in feeling the pain instead of fighting it. Talking about pain during sessions can help him manage the anxiety he feels in response to it. My hope is that our interventions of acceptance translate into his daily life outside of sessions, as well. His consistency in engaging in weekly sessions would suggest that alleviation of distress transfers into his everyday life.
Next Steps
I still want to be able to treat patients with more concrete and prescriptive answers. It still gives me goosebumps when our medical staff comes up with the exact medication regimen to alleviate a patient’s immediate distress. I have seen patients feel as though they are “losing their minds” and get significant alleviation with the use of medications and treatments. There is no mistaking the beauty in the science in this work.
I am learning more about the trial-and-error side, too—the intangibles, and the things for which I have no frame of reference. I hope the interventions are beneficial and that change may be possible. This may mean that we expand the definition of what “change” and “progress” mean in treatment planning.
In a recent session, I found myself looking at images of where Corey feels pain, using diagrams of the nervous system we found online. He pointed to specific areas that have pain and the movements and positions he can move into to provide alleviation.
“Even just talking about these things takes some of the pain away—it kind of blurs it a bit.” At this point in my work with Corey, I can say, “I understand how that helps.”
References
Dueñas, M., Ojeda, B., Salazar, A., Mico, J. A., and Failde, I. (2016, June 28). A review of chronic pain impact on patients, their social environment and the health care system. Journal of Pain Research, 9, 457-67. doi: 10.2147/JPR.S105892. PMID: 27418853; PMCID: PMC4935027.
Goldberg, D. S. (2017, December). Pain, objectivity and history: Understanding pain stigma. Medical Humanities, 43(4), 238-243. doi: 10.1136/medhum-2016-011133. Epub 2017 Feb 21. PMID: 28228477.
Harvard Health Publishing, Harvard Medical School. (2010). The pain-anxiety-depression link. https://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection
Monsivais, D. B. (2013). Decreasing the stigma burden of chronic pain. Journal of the American Association of Nurse Practitioners, 25, 551-556. https://doi.org/10.1111/1745-7599.12010.
Nahin, R. L., Boineau, R., Khalsa, P. S., Stussman, B. J., and Weber, W. J. (2016, September). Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clinic Proceedings, 91(9):1292-306. doi: 10.1016/j.mayocp.2016.06.007. PMID: 27594189; PMCID: PMC5032142.
National Institutes of Health. (2021, April). Chronic pain: In depth. https://www.nccih.nih.gov/health/chronic-pain-in-depth
Parks, T. (2017, February 24). 3 critical factors to help guide your management of chronic pain. https://www.ama-assn.org/delivering-care/overdose-epidemic/3-critical-factors-help-guide-your-management-chronic-pain
Zelaya, C. E., Dahlhamer, J. M., Lucas, J. W., and Connor, E. M. (2020). Chronic pain and high-impact chronic pain among U.S. adults, 2019. NCHS Data Brief, no 390. National Center for Health Statistics.
Johnna Marcus
Johnna Marcus
Johnna Marcus, LICSW, is a licensed social worker at Beth Israel Deaconess Medical Center in the Addiction Psychiatry Department. She received her master’s in social work from the University of Pennsylvania in Philadelphia, PA.
[1] Name and identifying information have been changed to protect anonymity.