Gary A. Walco, PhD
Hackensack University Medical Center
Excerpted from The New Medicine Interviews

Defining Chronic Pain
Acute pain and chronic pain really are not just quantitatively different; they’re qualitatively different. In times past, we would say, if you have pain for greater than three months, or greater than six months, it’s now “chronic pain.” But, people with chronic pain really have a significantly different experience than acute pain – how it affects their lives; what the pain experience is like. The implications are huge.

One [implication] is, the interventions one uses for acute pain are often not so effective for chronic pain. The second is, the whole idea of rest and immobilization until you feel better may not be such a great idea, in that the pain could last a very long time. And, it may also well be the case that immobilization feeds into making a chronic pain syndrome worse, rather than better.

So clearly, it’s not like you go to bed on Day 89 with an acute-pain problem, and you wake up on Day 90 and it’s suddenly chronic. It’s really outmoded to think of chronic pain as a simple temporal extension of acute pain; they’re, they’re pretty different animals.

Perceiving Pain
Your brain does a great job of filtering. Your brain does not attend to a huge number of things going on... And that’s very adaptive. It’s your way of keeping your world sort of organized; responding to what you need to respond to…

So, for example, most of us eat, we don’t have a huge sensory experience — certainly not a painful one — of food as it’s being digested and going through the GI tract. Yet people who have various gastrointestinal pain disorders clearly do. I’ve certainly worked with kids who, literally the minute their food goes into their mouth and they start to swallow it, have an instant, fairly significant, and sometimes overwhelming pain response. That logically doesn’t make sense. That should be something that is inhibited better.

Inhibiting Pain
Inhibiting pain responses was one of the things that sort of revolutionized our whole view of pain. …[For instance] If you’re talking about somebody who’s got an injury in a war circumstance or an athlete who’s injured in playing… It may well be the case that an athlete who is so focused on the activity in which he or she is engaged can turn off, or ignore, to some degree, some of those pain stimuli. It’s only when you get a little time and distance from the immediate shock of the situation, that the pain response overwhelmingly comes through.

Or even a real simple example of the attentional component of pain: a little kid will fall down and look up at Mommy and wait to see Mommy’s response. [Mommy’s reaction] is going to have some impact on the child’s pain response. And not only the response, but their pain experience. If the reaction of people in the environment is, oh my god! You’ve fallen! That's a cue [to the child] that, wow, something’s awry here.

Treating Pain
In many cases, [medications] don’t work so well. [In those cases], we need to look at other strategies, which may include, teaching patients self-regulatory strategies like imagery and hypnosis, so they can modulate their own pain better and teach them how to lead more functional and adaptive lifestyles. The idea of being completely immobilized and withdrawing from their activities is something that we work hard on changing. So, it’s more of a rehabilitation approach.

And, I think it’s also important to point out; these are not mutually exclusive. You can use medication and work on rehabilitation and not just be wedded to one or the other.