Pain and Stress

Pain and Stress

Postby timbj » Thu Jul 03, 2008 3:33 pm

Hello Fellow Survivors and Carers

Here is another of my draft chapters from an unpublished book with the working title of "Cancer: The Challenge of a Lifetime" - based on my own experience and research.

This one is basically about pain management.

Chapter Nine – The importance of getting off your back

Outline of topics covered in this chapter

• The importance of getting off your back
• Understanding the nature of pain
• Managing your own pain
• Mind over matter
• Avoiding stress
• A place for humour, music and exercise

The importance of getting off your back

One of the curious things about hospitals is that the beds are much more comfortable than the seating. Yet the whole purpose of the hospital is directed towards getting you off the bed and into the chair! We are not advocating for a change in the furniture budget but you have to see the act of getting off your back and sitting in the chair as one of the early milestones in your journey to a full recovery, should you require treatment in hospital.

This simple physical sequence of movements is one of the most important things you will do in hospital and you should aim to achieve it as soon as possible after surgery or other forms of treatment. It will reinforce your sense of control over your situation and you will feel that you have taken a big step on the way to a full recovery. In addition to the psychological aspect, there is a very practical and physical benefit. The longer you lie in bed, the more likely you are to develop a chest infection and bedsores.

At the time, though, it might be the last thing in the world that you feel like doing. You might be feeling very weak or be in considerable pain so you may have to use your mental resilience to push yourself through that resistance. Getting off your back is an affirmation that you are not going to be beaten down by cancer. You have to fight cancer one step at a time, though, and this is one of the important early victories if you have had surgery or if some other treatment has put you on your back.

What might slow down or even stop you from attempting to get off your back is the fear of pain or perhaps a state of depression. You might not be thinking clearly because of the stress of your situation. Pain, stress and depression can go hand in hand with cancer. If you are going to survive cancer, you will need to use your mental resilience to fight off these side effects as well as the main illness. A deeper knowledge of these side effects will help you to stay in control and focussed on your recovery.

Understanding the nature of pain

Like every other hurdle you will meet along your journey, pain is something we need to understand if we are to overcome it and move on. You may have a good idea what pain is like already. If so, you will want to learn more about how to raise the level of your pain tolerance and deal with the mental aspect of pain management so that you can reduce its potential to have an overwhelming impact on your situation.

When contemplating the consequences of a diagnosis and likely therapies for most forms of cancer, it will not be long before our thoughts turn to the likelihood of pain and suffering. Perhaps this is why so many people avoid thinking about cancer or to put it another way, why so few people spend much time thinking about avoiding cancer.

There are hundreds of books and thousands of articles which deal with the subject of pain. And almost as many drugs, ointments, oils, quack medicines and therapies designed to deal with it. As a visitor to the planet, you might be forgiven for thinking that, as a species, we are obsessed by pain – or rather the avoidance of it! Far from it, we would argue, for the onset of searing and continuing pain – chronic pain - is an event that no-one in their right mind would willingly seek out. If we are unfortunate enough to experience severe pain, we want to be rid of it by whatever means we can.

This view of pain as unwanted and dreadful is understandable but unhelpful if you are standing on the steps of the hospital entrance, shortly to undergo an operation or process that you anticipate will involve a lot of pain. That will simply raise your stress levels and stress is not helpful in your recovery. To avoid that stress, you need to know about pain, what to expect and how to deal with it. You will recall our thoughts in Chapter Six about the importance of “knowing your enemy”. Knowledge of the nature of pain and about the moderating effect of our thoughts and emotions on our perception of pain will help to lessen our fear of pain. Incidentally, we will see later that stress and pain are closely related phenomena.

Pain and suffering are the stuff of biblical tales and, it seems, inextricably linked to our common human heritage. Why is it that a species as sophisticated and highly evolved as homo sapiens should still retain such a limiting aspect of our bodies’ biochemistry? The answer is that pain is a much more sophisticated process and a subtler defence mechanism than we often give credit it for. Before we consign it to the redundant mechanisms heap, let us dig a little deeper into its nature and physiology.

As is our habit, let us be clear at the outset about our use of the term pain and contrast it to its all too frequent bedfellow, suffering. By pain, we mean the physical sensation and discomfort caused by the response of our nervous system to an external stimulus, for example a hot saucepan or a sharp needle touching our skin. By suffering, we take the discomfort onto a different level – into our thoughts. Suffering can be of an emotional nature or predominantly mental (cognitive) anguish or the result of social isolation or, indeed, any of those in combination.

Of course, physical pain can be the cause of suffering but suffering can be just as real even if it is not associated with physical pain. Suffering is our mental response to pain and to other events which cause us to feel unhappy. There may be no physical pain at the root of our suffering but the very process of suffering, for example through grief or depression, can bring on physical symptoms of pain and side-effects such as gastric upset and headaches. Thus, there is a two-way cause and effect mechanism at work whenever pain and suffering intrude into our lives.
Just as there are varying degrees of pain, so there is a spectrum of suffering ranging from mild unease through to states close to insanity. “It’s driving me out of my mind” we will say of our nagging toothache or agonising muscular pain, though we may be exaggerating for effect. Even the adjectives we use about pain are framed in terms of its impact on our scale of suffering.

Pain has its uses as a signalling system, as Descartes commented, but it can be misleading.

I also discovered error in judgments founded on the external senses; and not only in those founded on the external, but even in those that rested on the internal senses; for is there aught more internal than pain ? And yet I have sometimes been informed by parties whose arm or leg had been amputated, that they still occasionally seemed to feel pain in that part of the body which they had lost, --a circumstance that led me to think that I could not be quite certain even that any one of my members was affected when I felt pain in it.

Descartes – Meditations

What is worth investigating, given our (more or less) common anatomy, is why some people should be able to withstand much higher levels of pain than others. Is this because of variations in the pain mechanism in different individuals or is it the way in which different people use their mind to moderate the impact of pain on their sense of normality? Why should the mood we are in affect the way we perceive pain?

Although pain has been studied by physicians for many hundreds of years, it is only in the last couple of decades or so that researchers have come closer to understanding the biological mechanisms involved. Our dim recollections of school science will require a polish and some updating as a result. We recall the basic understanding of human physiology we acquired through our school science classes and remember being taught that specialised, elongated cells called nerves are located throughout our bodies and, through their organisation as nerve fibres, act as a communication system between our skin, muscle, bones, internal organs and the brain.

This communication system was, until fairly recently, thought to involve the two-way passage of messages up and down the nerve fibres, analogous to the electric wiring running around modern houses. The biology of the nerve fibres themselves and in particular the process of neural transmission was known to be a little more complex than passing electric current backwards and forwards along a copper wire! There are, for example, many different types of nerve fibres with different speeds of impulse transmission. But in essence, for much of the first half of the twentieth century, the sensation of pain was thought to be simply the brain’s response to the messages it was receiving from the nerve endings in an area of burnt skin, bruised muscle or in a damaged organ. It was seen, essentially, as a problem wholly within the medical domain and its treatment involving blocking out pain using pain-killing drugs like aspirin and powerful opioids, like morphine.

Let us put some labels on the structures and processes involved in pain. There are two broad classes of pain: nociceptive pain and non-nociceptive pain. These derive their group names according to whether or not they are caused by the triggering of nociceptive receptors. These nociceptors (as they are referred to) are a family of sensors which are specialised to react to one of a range of noxious stimuli, normally of a chemical, thermal or mechanical origin.

We have lots of these specialised pain receptor cells in our skin, subcutaneous layers, muscles, joints, ligaments and internal organs (viscera) and they serve as a vital protective system, alerting us to the danger of tissue damage. The nociceptors send a signal through nerve fibres via the structures in the spinal cord and then upwards to the brain. This produces the sensation known as nociceptive pain and the overall process is called nociception. Sometimes nociceptive pain is sharp but transient (acute pain) but if the damage, for example to the skin and underlying structures, is significant, the pain can be long-lasting or chronic.

Nociceptive pain is further subdivided into somatic pain and visceral pain, according to the locus of the pain. Somatic pain finds its source in the skin, muscle, bones, joints and related structures and is sometimes referred to as musculo-skeletal pain. The types of nociceptors involved include those sensitised by heat, cold, pressure, stretching, inflammation and oxygen deprivation. Somatic pain is usually well localised – we can tell where the pain is coming from – and we usually describe it as a sharp pain. Surgical incisions are an example of somatic pain.

Visceral pain originates in the internal organs, found in the three principal body cavities of the thorax (heart and lungs), abdomen (spleen, pancreas, liver, kidneys and intestines) and the pelvis (bladder and reproductive organs). The types of nociceptors involved are triggered by stretching, pressure, inflammation and oxygen deprivation. Unlike somatic pain, visceral pain is often difficult to pinpoint with accuracy. We might feel a deep seated ache and sometimes it produces a sensation like cramp or squeezing. Often, it produces a secondary locus of pain in the back muscles, called referred pain, and the location of this referred pain laterally corresponds with the abdominal cavity affected.

The second broad class of pain, non-nociceptive pain, originates in the nervous system itself. There are no receptor cells involved in this class of pain, which is subdivided into neuropathic pain and sympathetic pain. Neuropathic pain can have its locus in the peripheral nervous system, that is, the nerves which run between tissues and the spinal cord; or it can occur in the central nervous system itself, being the nerves in the spinal cord and connecting it to the brain. It can be caused by pressure on a nerve, viral infections which affect nerve cells (like shingles), nerve inflammation and degeneration of nerves (as in multiple sclerosis). Some forms of cancer treatment, like radiation, chemotherapy and surgery, can cause neuropathic pain as a result of damage to the nervous system.

The sensation of neuropathic pain is caused by the malfunctioning of the nerve cells themselves and so can be spasmodic in nature and extremely intense, like a faulty electrical transformer sending high voltage spikes along a transmission cable. It may be characterised as shooting or lancing pain and may be associated with hyper sensitivity of surrounding tissue to heat or cold or touch. There may be feelings of numbness or tingling sensations and it sometimes triggers a sensation of pain in unrelated areas as happens in sciatica, where pain originating in a spinal disc can irritate adjoining nerves supplying distant sites like a leg or toe, creating the sensation of pain in those locations.

The fourth type of pain is sympathetic pain. This is believed to be caused by an over reactive sympathetic nervous system (which controls processes like dilation of blood vessels) perhaps operating in conjunction with the peripheral and central nervous systems. It occurs most frequently after bone fractures and soft tissue injuries in the limbs. It is characterised by extreme hypersensitivity in the skin around the injury and may lead to a condition known as complex regional pain syndrome in which the use of the limb affected is absolutely avoided by the individual affected. This can eventually lead to muscle wastage and osteoporosis in the affected bone.

Of these four types of pain, cancer patients are frequently affected by somatic and visceral pain and less often (about 20% of cases) by neuropathic pain. Tumours that develop close to neural structures tend to cause the most severe pain that cancer patients experience. Somatic, visceral, and neuropathic pain can all be felt at the same time or one at a time and at different frequency of occurrence. Identifying these different types of pain correctly allows the medical team to apply the appropriate pain relieving drugs – each responds differently to the commonly used pain management therapies. Generally speaking, somatic and visceral pains are easier to manage than neuropathic pain.

Usually, pain management therapies involve a chemical interference in the process of signal transmission along nerve fibres or in the spinal cord. A brief diversion into the history of medical science is helpful to explain the complex mechanism involved. The insight into the mechanism of chemical neurotransmitters, operating in the microscopic space between the ends of adjacent nerve cells, was said to have occurred to their German-born discoverer, Otto Loewi, in a dream. In 1921, Loewi’s in vitro experiments with the hearts of frogs led to his discovery of acetylcholine, the first neurotransmitter to be identified. The amazing finding that this complex molecule acted as a “dumb” messenger across nerve synapses led to his receiving the Nobel Prize in 1936,

We now know that the biochemistry of the process of neural transmission is astonishing in its complexity and speed. Over fifty such neurotransmitters have now been identified. But that understanding of signal transmission in nerves is only part of the story of our response to pain. We all have pretty much the same nociceptors and signal transmission system but why do some people seem able to tolerate pain better than others? Experiments show that people can differentiate quite readily between the strength of a pain and their own tolerance of it. It is pain tolerance which varies considerably between individuals rather than the perception of pain strength.

Our individual experience of pain is dependant upon our pain tolerance. Our pain tolerance in turn is affected by a multiplicity of factors that, individually, amplify or diminish our sensitivity to and reaction to pain.

The following table lists some of the most frequently occurring influences on our pain tolerance level.

    Increased Pain Tolerance ******Reduced Pain Tolerance
    Sleep ****** Insomnia
    Physiotherapy****** Physical discomfort
    Relaxation ****** Fatigue
    Explanation and Support ******Anxiety, Fear
    Understanding/Empathy ****** Social Abandonment
    Diversionary Activity ****** Anger, Boredom
    Companionship/Listening****** Mental Isolation
    Happiness ****** Sadness
    Understanding of the meaning
    and significance of pain
    ****** Depression
    Relief of Symptoms ****** Introversion

These factors influence what we commonly call our mood, being a set of dominant feelings at any one time – often expressed on a spectrum ranging from euphoria to depression. Why should our mood influence our overall reaction to pain? The answer seems to be because of what happens when the transmitted pain signal is handled by the brain.

Pain signals are not dealt with by a single pain receptor site in the brain. In fact, modern brain imaging techniques can track the activation of many regions in the brain which are triggered by a single painful stimulus. With apologies for some of the long names, these centres include the primary and secondary somatosensory cortices (concerned with receiving general sensations like touch and pressure), the anterior cingulate cortex (where older or lifelong memories are stored), the insular cortex (believed to play a role in emotional and attention aspects of human behaviour), and regions of the frontal cortex (which controls a huge range of behavioural and cognitive processes). It is beyond the scope of this book to delve too deeply into the complex interactions involved and, in any event, this is still largely uncharted territory even for neurologists.

What is known for certain is that there are affective (emotional) and sensory components of pain which are encoded in different structures in the brain. There is clear evidence that the activation of the primary somatosensory cortex (thankfully often abbreviated to S1) is often moderated by what we are thinking at the time. Our cognitive processes and our previous experience of pain can alter the perception of pain by our brain. Many studies on humans have shown that teaching people how to think about their evaluation of pain and modify their behaviour and mood can help them to diminish their experience of pain. This type of therapy is called cognitive behaviour therapy and is increasingly used as part of the total pain management regime in most hospitals.

Managing your own pain

The beauty of this aspect of pain management is that we don’t have to wait for a therapist to lead us through the process. We can do it ourselves – in fact, as a thinking person, you will have been using at least some of the techniques since childhood. Lest you think that this is a bit too much like voodoo magic, we can explain some of the science involved.

In 1972, a post-graduate researcher called Candace Pert discovered the existence of the opiate receptor in the brain. For years, scientists had theorised about the existence of such a centre in the brain and it was thought to hold the key to understanding how drugs like opium and morphine worked. A trained pharmacist working on her post-graduate doctorate, Dr Pert was the first to identify the existence of receptor sites in the limbic brain.

These sites on the surface of cells could be triggered by particular chemicals called peptides, which are short chains of amino acids. The “lock and key” characteristics of these receptor sites provided the means for molecules in the fluid surrounding cells to alter the chemical balance and promote, slow or stop particular activities within the cells, without in some cases actually entering the cell. These receptor sites were later discovered to exist on cell surfaces around the body, not just in the brain. This threw new light on scientists’ understanding of biochemical feedback loops within the body.

Soon after Candace Pert’s discovery, researchers in Scotland and the USA discovered the existence of encephalins and endorphins, which are morphine-like molecules which the brain itself can create. The discovery of these natural pain killers, more accurately described as opioid neuropeptides, opened the door to a whole new science. Specialised nerve cells in the brain, called neurons, were found to be the site of many receptor sites on their outer membranes. Neurons linked to their neighbours to form chains or neural pathways, though it became clear that a simple neurotransmitter device could not explain the many feedback loops and connections to other structures in the brain.

A flood of more discoveries of different peptides and the medium of television science programmes brought the cutting edge of cell biochemistry into our living rooms. We became aware of “new” chemicals creeping into our vocabulary, like serotonin, noradrenalin and dopamine, though of course they had been swimming around in the human brain for millions of years.

Exactly how these self-generated opioids work in the control of pain is still only partially understood. The widely accepted “gate control theory of pain” was first published in 1965 by Ronald Melzack and Patrick Wall. In the original gate control theory, the experience of pain depended on a complex interaction between the central nervous system and the peripheral nervous system as they each processed pain signals in their own particular way. When a tissue is injured, pain messages originate in the adjoining nerves and flow along the peripheral nerves to the spinal cord and on up to the brain. According to the gate control theory, these pain messages encounter “nerve gates” in the dorsal horns of the spinal cord that open or close depending upon a number of factors.

One of the factors is nerve signals from the brain – coming in the opposite direction down the spinal cord and triggering the closure of local nerve gates. This is known as a descending inhibitory system. When the nerve gates are open, pain signals arrive undiminished in the brain and may be experienced as intense pain. When the nerve gates close, pain messages are filtered and perhaps prevented from reaching the brain, thus a stimulus may not even register as a sensation of pain.

It is now known that there are several descending inhibitory systems. The one we know most about is mediated by our natural pain killers, the endogenous opioids, particularly involving serotonin and acting on neurons in the dorsal horn of the spinal cord. In many experiments, it has been shown that we can induce the release of these natural pain killers just by creating a mental image of a painful situation or, the converse, when we summon up a mental image of a pleasurable experience, promoting the release of serotonin which acts as an inhibitor to the transmission of pain signals and creates a sensation of happiness and well-being.

Thus science has provided a rudimentary explanation of the calming effects of the mind in activities such as meditation and visualisation. We can produce the same serotonin release through exercise, by listening to music and by enjoying a good laugh. We are literally prescribing our own self-manufactured and self-administered opioids. Through ongoing research using PET imaging, it will not be long before scientists unlock further mysteries of “mind over matter” phenomena, which many ancient healing practices and religions have been actively tapping into for thousands of years. For now, it is enough to know that what we think and what we feel, emotionally, can influence the biochemistry of pain. This is no mere illusion or self-deception.

Armed with this understanding, we can apply our minds to the self-management of our pain. We know, too, that our moods can alter our biochemistry and we because we can choose to think our way out of a mood state or emotional reaction, we can also think our way out of pain.

Mind over matter

Looking back over the development of medical science in the hundred years up to 2020 – (it ought to be a great year for clarity of vision!) - the next generation of historians will see a strong thread emerging. Gradually, as we approached the new millennium, the long-held construct of our brain as centre of the human mind and the body as a collection of discrete physiological systems, was increasingly undermined. Over the next fifteen years, the distinction may disappear altogether. The mind may be shown to be distributed through the body as Candace Pert speculates in her book “Molecules of Emotion”.

The separation of mind and body was first postulated by the ancient Greeks but refreshed for the modern era by the French philosopher Rene Descartes in the sixth part of his Meditations, which he wrote in 1641.

Although I certainly do possess a body with which I am very closely conjoined; nevertheless, because, on the one hand, I have a clear and distinct idea of myself, in as far as I am only a thinking and un-extended thing, and as, on the other hand, I possess a distinct idea of body, in as far as it is only an extended and unthinking thing, it is certain that I, [that is, my mind, by which I am what I am], is entirely and truly distinct from my body, and may exist without it.

Descartes – Meditations

The construct of a separation of mind and body had been sustained by Western scientific method rather than traditional Eastern wisdom. Not for the first time, modern science had destroyed its earlier map of our physiological landscape and replaced it with a more accurate and colourful representation of reality. The new science of psycho-neuro-immunology (quite a mouthful and understandably referred to as PNI) embraced these developments in cell to cell communication and gave us a model for understanding how the activities in the brain could result in a measurable effect in our immune system.

It is now only at marginal risk to their reputation for some physicians to see a convergence of Western medicine with the ideas of ancient Eastern health practices handed down from generation to generation over thousands of years. Their confidence is boosted by western scientists “discovering” the biochemical mechanism for a number of ancient medicine procedures. For example, in 1997, researchers were able to demonstrate the effect of acupuncture needles being inserted at some sites in the body through measurement of the consequential release of endorphins.

Those in the vanguard of this “integrated” approach, spanning conventional, complementary and alternative therapies see a possible scientific explanation emerging through the study of the magnetic and electrical properties of cellular matter. When compressed or stretched, almost all tissues in the human body produce a tiny electrical field and different organs produce their own trademark oscillating electrical field. That physics has long since accepted that matter can have both particulate and waveform properties has somehow been pushed to one side in Western medicine’s push for biochemical explanations of illness and acceptable treatments.

Some say that this is because of the tyranny of the international drugs companies who have a vested interest in selling ever more expensive “miracle” drugs to an increasingly pressured health system. Whatever the truth of that, it is time for governments and scientists to collaborate better to ensure a corresponding injection of research time and effort into the biophysics of the human body and for the genius of science to facilitate the emergence of new tools and techniques to study and measure the micro-energy fields which traditional ancient medicine may have been unwittingly manipulating for thousands of years.

For us, the attitude and approach of the Bristol Cancer Centre is to be commended. Their holistic, “Integrated Medicine” approach is more concerned with applying what works, rather than what science has proven, through analysis and clinical trials, to work. If you are suffering with cancer, we understand the sense of urgency. You haven’t got the time to wait for science to provide all the answers which are still outstanding on some complementary and alternative treatments. There are meditative and herbal therapies from those complementary and alternative sources that you can tap into to promote your own recovery.

You can also reinforce your mental resilience with some mind control over your mood and hence pain tolerance. We are thinking in particular of the work of the psychologist Martin Seligman, who is Director of Clinical Training at the University of Pennsylvania in Philadelphia. Seligman is famous for creating the concept of “learned optimism” and has written a book with that title.

Seligman developed an Attributional Style Questionnaire (ASQ) which he used to rank individuals on an optimism-pessimism scale. In one of his studies of school children, which spanned several years, those who scored highest for pessimism were most likely later to suffer depression. He also found that high scores for optimism were predictive of excellence in a wide range of activities- ranging from sport to life-insurance sales. He also used the concept of optimism, rather more frivolously, for predicting the outcome of elections in the USA, based on the extent of optimism shown in candidates’ campaign speeches.

Though the finding is not reproduced across all studies, Seligman believes that optimists tend to be more resistant to infectious illness and to chronic diseases. In one study, Seligman and his colleagues followed the progress of 96 men who had suffered their first heart attack. Within eight years, 15 of the 16 most pessimistic men died of a further heart attack, but only five of the 16 most optimistic men died.

Seligman’s “learned optimism” techniques involve choosing to summon up positive images and thoughts when we encounter negative outcomes or opinions. It taps into our remarkable ability to choose how we think and what we want to think about. Pessimistic people tend to tell themselves that they are hopeless – “I’ll never get it right” or “That’s typical – I never get a break”. In this style of thinking, they label themselves as hopeless cases. It becomes a self-fulfilling prophesy over time.

The learned optimism approach is to speak to ourselves in a more kindly and forgiving way, the way a close friend might do. When things go wrong, the pessimist can learn to be optimistic by changing the way they manage their inner speech. They might say to themselves 'Things didn't go as well as I had hoped today, but I learned a lot from the experience. I am confident that I will do better tomorrow.'

Seligman’s advice for overcoming pessimism extends to not dwelling on failures but instead doing something totally different – a fun activity – in order to induce positive thoughts and a happy mood. It may seem strange to do this at first but it works. By getting into a habit of consciously creating a positive mood and lifting their self-esteem, people can learn not to be pessimistic. Seligman says that it may take most people a few weeks to get the hang of the technique but that, once it is learned, the less likely they will be to revert back to their old pessimistic habits.

We will not attempt to assess all the kinds of self-healing methodologies and practices which are available through individuals and institutions of greater or lesser authenticity and credibility. What will work for one individual may not work for another. We suggest you check through the resources listed in Dr Rosy Daniel’s “Cancer Directory” and see which might appeal to you. You can, if you do not do so already, use visualisation techniques or so-called guided imagery to good effect without involving anyone else. There are many self-help books available – perhaps that by Dr Martin L Rossman entitled “Guided Imagery for Self-Healing” is one of the best.

Avoiding Stress

In the final part of this Chapter, we will look at the complex issue of stress, our reaction to the pressure of circumstances, events and behaviours we encounter and sometimes our own thoughts, which push us outside our comfort zone and into increasing levels of mental discomfort. In the context of a cancer diagnosis, it does not take much of a leap of imagination to visualise extremely high levels of stress arising very quickly, leaving us de-motivated and de-energised. This is not a good starting point for your recovery drive.

Possibly, you will have a good understanding of your level of resistance to stress. Even if you are highly resistant to work pressures, your coping mechanisms will be severely tested by the news that you have cancer. This is a much more significant moment in your life than almost any other. Potentially, it can overwhelm even the toughest of characters before they have a chance to gather themselves and take control of their reactions.

If you are not well versed in the nature of stress and its damaging effects, both psychologically and physiologically, you need to improve your understanding of stress and how you can use your thinking ability to lower your stress levels. If you do not pay particular attention to the impact of the diagnosis on your state of mind, you can be sure that it will soon start to manifest in a poorer physical condition. Like a boxer stepping into the ring, you need to be properly focussed or else you will get a battering. Cancer is a dangerous opponent and, if you do not watch out, it can sap your mental strength as well as your physical resilience long before it significantly damages your body’s physiology.

Stress in any context has been defined as a condition or feeling experienced when a person perceives that demands exceed the personal and social resources that the individual is able to mobilize. The Health and Safety Executive in the UK, with one eye on the workplace, define stress as the adverse reaction people have to excessive pressure or other types of demand placed on them. As we all know from experience, different people react to the same level of pressure in different ways. Time and again we observe that what produces stress in one individual does not do so in someone else.

Sometimes, you will hear people claim that some levels of stress are good for us. That is to confuse pressure with stress. Stress is an adverse reaction and is to be avoided if at all possible. On the other hand, pressure to achieve or to perform at a particular level, for example, is a positive thing and helps with our motivation - if we can handle that pressure.

Research carried out on behalf of the HSE estimated that around five million people in the UK are “very or extremely” stressed by their work. Of those five million, half a million say that the level of stress they are experiencing is making them feel ill. Whilst we acknowledge that stress is an increasingly frequent visitor to the workplace, it is also an intrinsic part of the world of ill-health – and of cancer.

Some of the physical symptoms of long term stress include a feeling of tiredness, even first thing in the morning; an itchy skin; constipation; indigestion; high blood pressure; migraines; asthma attacks and even heart attacks. We must learn to recognise the first signs that stress is taking a grip on our physiology. These include an increased heart rate and increased rate of breathing. We might notice that our mouth feels dry or that we start to perspire or our hands feel clammy, even though the temperature of our environment would not normally produce such an effect.

An interesting point about stress is that it is a mechanism which is rooted in our instincts for self-preservation. Though we made not feel too close to our cavemen ancestors’ plight in fighting off woolly mammoths and sabre-toothed tigers, our stress mechanisms in responding to the pressures of modern life find their evolutionary basis in the well known fight or flight response. This ability to react to life-threatening danger almost instantaneously has extended the lives of many of our ancestors but its very reactivity may be our undoing in the modern day equivalent life-threatening situation of a cancer diagnosis.

Two parts of our body systems come into play when we become aware of a threatening situation. The first of these is the triggering of the sympathetic part of our non-voluntary, autonomic nervous system (ANS). Unlike the parasympathetic part of the ANS, which controls the normal state of our physiology (like heart rate), the sympathetic system is only called into play when activated by a threatening situation. It prepares both mind and body for rapid action and it does this by stimulating the secretion of hormones, which travel around the body in the blood, and by direct neural impulses.

The “stress hormones” are released into the blood stream by the adrenal glands, stimulated by the sympathetic part of the ANS. These stress hormones are adrenaline, noradrenalin and cortisol. Of these, adrenaline is the most powerful and its effects include raising the heart rate, increasing blood pressure to offset the dilation of the arteries and an increase in the rate of breathing. In combination, these changes result in increased oxygen levels in the blood being pumped to the main muscle groups. In addition, adrenaline stimulates the conversion of glycogen, stored in the liver and muscles, into glucose which is the cellular fuel.

There are many other physiological responses activated in the body but we have described the most important ones. They are also to an extent the most unfortunate ones, particularly where the body does not require sudden releases of glucose and an accelerated heart rate to deal with the stressful stimulus. They are unfortunate because the hormonal boost in our bodies does not diminish anything like as quickly as it arises. As a result, we have a sharp spike in our blood sugar levels which is pumped rapidly to all parts of the body yet finds no outlet for its energy.

It is well established that high blood sugar levels create the environment for a number of serious threats to our health, including cardiovascular disease, cancer and type 2 diabetes. It is also known that cancerous cells proliferate most quickly when they have access to high levels of blood sugar.

In his book Managing Pressure for Peak Performance, Stephen Williams provides a simple but nevertheless useful model for thinking about the relationship between pressure and stress. He suggested that pressure is like a downward force on one end of a seesaw. The plank of the seesaw is our well-being, balanced on a fulcrum. Williams suggested that the position of that fulcrum is determined by our personality. We would refine that notion by suggesting that it is our stress tolerance which is the key factor at work here.

Let us complete Williams’ explanation of how different people respond in different ways to the same level of pressure. If we have a calm, unflappable personality, our fulcrum is closer to the point where pressure is applied so that it dampens the leverage which the pressure applies to our sense of well-being. If we have a tense, reactive kind of personality, the fulcrum can be at some distance from the point of pressure, resulting in an increased leverage effect.

The opposing force on the other end of the seesaw is our coping mechanism. This is the personal and social resources we can bring to bear to avoid the plank of our well-being shooting upwards – and hence giving bigger readings on our personal “stress-ometer”. In this way, Williams illustrates the moderating or amplifying influence of “personality” on the degree of stress experienced.

The model allows for positive or negative feedback from our perception of how well we are handling the pressure, which in turn influences the amount of pressure we perceive being applied. If we feel we are handling pressure well, this produces a feel good factor which reinforces the power of our coping mechanism. On the other hand, if the pressure gets too much to handle, we can start to feel stressed. That awareness of stress, of itself, can add to the pressure we experience. It can quickly become a downward spiral leading to self-doubt, a lack of confidence and even depression.

There are many aspects of emotional intelligence that can help us to strengthen our coping mechanisms. The first of these is self-awareness- we need to learn to recognise the symptoms of stress in ourselves at an early stage and summon up our coping mechanisms before we get too much out of kilter. We also need to understand that our perceptions of pressure, the natural positioning of our fulcrum point and our choice of behaviour and lifestyle can all be altered under our conscious control.

A final comment about Williams’ model is that it also subtly reminds us that we need a certain amount of pressure (or urge to achieve) in our lives. In the absence of that pressure, we can start to experience stress through feeling that our talents and other resources are being under-used. There is no outlet for the energy of our coping mechanisms. As with our body’s balancing mechanisms, we need to maintain a balance between pressure and achievement.

When people talk about managing stress what they really mean is managing pressure and our reactions to it. Ideally, we should avoid stress not manage it. There are many excellent sources of information and advice on how to do that and we list some at the end of this Chapter. For now, we will have to limit ourselves to a brief list of useful techniques which we know will work as stress-busters for most people.

Five tips for beating off stress

1. Slow down!

Don’t try to do too much in any one day. It is easy to be swept along by the manic pace and relentless change in the workplace and in society as a whole. Wherever you can, eliminate meaningless deadlines. Don’t over-schedule your day with meetings or other commitments. Save some time (ten minutes or so) morning and afternoon when you can just empty your mind and let your heart and mind slow down to a normal pace.

2. Relax using breathing exercises

This is a very quick and effective stress-buster and it doesn’t cost anything! Take time out to breathe deeply every day or just when you feel stressed. Practise deep-breathing techniques such as slowly inhaling while counting to five. Hold your breath for five seconds and then breathe out slowly. Try to focus and think only about your breathing. Repeat this cycle 10 times and you will feel an instant benefit. Follow it with gentle stretching exercises and you will feel the tension loosen its grip on your neck muscles.

3. Exercise regularly

You don’t have to become a fitness freak or a gymnasium junkie! Just 30 minutes of brisk walking on three days a week is enough to keep yourself in reasonable trim. If you can’t manage that at the outset, build up to that target slowly, starting with five minutes then ten minutes the next week and so on. This will help to keep your heart and lungs in good condition as well as reducing your stress levels.

4. Get a life!

Take up an interest outside your work or domestic role. It doesn’t matter much what it is – gardening, fishing, hang-gliding, walking – anything is better than nothing. It will give you time to relax and to think about the important things in life. And it will give you a perspective on your life and current situation.

5. Don’t take on the worries of the world.

You are just one of six billion inhabitants of planet earth. You are not Flash Gordon and it is not your role to save the earth (or your company, or your boss or your team). Be realistic about what constitutes a fair day’s work. Don’t shirk or cheat but equally, don’t worry yourself to death. Lying on their death-bed, no-one ever wished they had spent more time in the office wrestling with the contents of their in-tray.

A place for humour

In places like hospital wards, the appropriate use of humour is a real skill to have and can create an aura of well-being which spreads to other patients. In Chapter Five, you will have read how, as fellow patients, Richard and Tim had to balance their banter and natural tendency to make each other laugh, with sensitivity to the others in the ward who were coping with pain at the time. When Tim was mobile after his operation, he could wander around the ward and include the other four patients in the Richard and Tim Laughter Show. It made people feel better and it visibly lifted their spirits. It seemed to work because the other patients knew that the two comedians suffered considerable pain too and, in that sense, the laughter became part of a shared experience.

So, whilst we can point to many examples from our own experience where laughter has played a crucial role in lowering stress levels and promoting a sense of well-being, we wondered whether there is an underpinning of our empirical observations by a body of scientific study. The biochemistry of laughter has not been studied as intensively as the biochemistry of pain. We find this surprising, given the frequently quoted maxim that laughter is the best medicine.

Researchers into the science of laughter, like Robert Provine, remind us that, given the universality of the sound of laughter, our ignorance about its purpose and meaning is remarkable. Why is it that we know when to laugh and (usually) when not to laugh? Why do we laugh more in the company of others than we do when alone? After more than ten years of research, Provine concludes that laughter is “primarily a social vocalization that binds people together”. He believes that it is not learned through social conditioning but is an instinctive behaviour, genetically programmed.

There are gender differences in how much we laugh too. Women apparently laugh more than men do, according to author Deborah Tannen, who described gender differences in speech in her book, “You Just Don't Understand” (Ballantine, 1991). She found that in mixed gender conversations, females laughed 126% more times than their male counterparts. Other studies provide evidence that the laughing phenomenon is not culturally dependent. Given that we tend to laugh on cue, does this mean that there is a “survival of the species” factor which determines that women should do the most laughing while alpha-males focus on providing the laughter opportunities? Perhaps there is more to laughter than we think!

Why we laugh when others laugh may have its explanation in the complex pathways of brain activity. Provine speculates that there is a neurological mechanism of laughter detection. The fact that laughter is contagious, leads Provine to suggest that we all have a specialised neural circuit in the brain that responds exclusively to laughter. Once triggered, the laugh detector activates a laugh response mechanism, a neural circuit that causes us in turn to produce laughter. Such a mechanism is clearly self-sustaining.

Some researchers believe there are three main brain components involved in producing the laughter response to the telling of a joke. Firstly, cognitive areas, such as sections of the frontal lobe near the forehead, help you to analyse the content and context of the words and hence understand the joke. Another brain component involved in the processing is the supplementary motor area which triggers the muscle movements related to smiling and laughing. Last, it is thought that an emotional component is added from structures in the mid-brain and result in the feelings of happiness associated with a funny experience.

From our own experience, we have observed that laughter helps to unite a group and create team bonding and we have deliberately used the technique to good effect on many team building courses. Furthermore, the resulting social support in a group setting has been shown in studies to improve mental and physical health. Provine, however, speculates that the presumed health benefits of laughter may be entirely coincidental. They may be a side effect rather than its primary social purpose which is, he believes, to bring people together.

Regardless of the neurological mechanism within the brain, sustained laughter is a physical and energetic activity that raises our heart rate and blood pressure. However, even these physiological effects are not fully researched and their medicinal benefits are even less certain. Lennart Levi, of the Karolinska Institute in Stockholm, proposed that laughter activates the body's "fight or flight" system, and demonstrated increased catecholamine levels in urine, as a biomarker of activation and stress. Other studies have shown the complete opposite effect.

As we can testify from our own experience, coping with pain appears to be one of laughter's most valuable applications. Rosemary Cogan, Ph.D., a professor of psychology at Texas University, showed that patients who laughed at a comedy video or underwent a relaxation procedure were able to tolerate more discomfort than other patients. Other studies have shown that laughter may help us to moderate the impact of severe pain. Dr James Rotton, of Florida International University, reported that orthopaedic surgery patients who watched comedy videos requested fewer pain killers and tranquilizers than a control group that watched dramas.

The late Norman Cousins, a distinguished American writer and editor, is perhaps one of the most celebrated case studies of the use of humour in overcoming a life-threatening illness. Popular reporting of his astonishing recovery attributed his success to his refusal to conform to the normal medical interventions. He booked himself out of hospital and into a hotel, where he devised his own therapy, which included large doses of vitamin C and watching films by the Marx Brothers. Perhaps tired of the way his positive patient attitude had been characterised as a “laughing cure”, he later wrote a book entitled “Anatomy of an Illness: As Perceived By The Patient” in which he described his rather more sophisticated approach.
Cousins successfully applied the same approach when he suffered a major heart attack some years later. He commented “The newspaper accounts had made it appear that I had laughed my way out of a serious illness. Careful readers of my book, however, knew that laughter was just a metaphor … Hope, faith, love, will to live, cheerfulness, humour, creativity, playfulness, confidence, great expectations – all these I believe had therapeutic value.” Perhaps it is Cousins’ legacy to us all that we are no longer regarded as “funny” if we decide to include humour as part of our stress coping mechanisms and, should we be ill enough to require hospital treatment, as a healing option which changes our mood, boosts our immune system and motivates us to get off our back.

The contribution of humour in fighting cancer is probably more to do with creating a mood of optimism and reinforcing our will to live than to any specific physiological changes which can have a direct effect on cancer cells. In our view, the importance of laughter and happy feelings are not diminished by this assessment, for happiness is what we strive for in our lives when we are well. When we are not well, it is all the more important to hang onto the link with “feeling normal” that laughter can provide. If humour can indeed strengthen our will to live, we should regard it as a crucial ingredient in our self-prescribed “fighting chance therapy” and absorb as much as we can of its mood-uplifting properties.

A place for music

If you are looking for mood enhancing or mood changing therapy, you could not do better than listening to the kind of uplifting music which suits your personal taste. Music therapy is finding a place in modern cancer treatments and its effects are positive and measurable. It is a flexible tool as well. You can listen to music alone or with others, be passive or take an active role in the creation of the music. All these ways of accessing music have been shown to benefit cancer patients both psychologically and physiologically.

A place for exercise

The final word in this chapter is about exercise. You can start to exercise even before you are strong enough to get out of bed after surgery or before you have finished chemotherapy or radiotherapy. Exercise needs to be carefully planned and integrated into your recovery plan. So you should always follow the advice of your medical team on what you should and should not attempt at any particular stage. You will find the book written by Anna Schwartz, entitled “Cancer Fitness”, to be valuable and stimulating in this aspect of your mental resilience. It is written from by an expert viewpoint by an oncology nurse and former athlete who also has a personal history of living with cancer.

Summary of key learning points

• When you are flat on your back in hospital, the best thing to focus on is getting up and sitting in a chair. It might be the biggest journey you will ever make.

• Pain is a complex subject. By adding to our understanding of it, we are better placed to moderate its impact on our state of mind and stay positive in the course of our treatment.

• Stress is a part of the cancer package – if you allow it to be. You can’t deny the pressure imposed by a cancer diagnosis but you can develop a mindset which stops the pressure raising your stress levels and causing deep depression.

• Laughter may not be the best of all medicines but it can be accessible at all times. Even in desperate situations, don’t be afraid to laugh. It can lighten your mood, help you to stay positive and strengthen your will to live.

• Music and exercise have a place in the scheme of things too. Both can lighten your mood and boost your energy levels, putting you into the right frame of mind to carry on the fight.

Useful books for further reading

Guided Imagery for Self-Healing, by Dr Martin L Rossman, published by H J Kramer, 2000 ISBN: 0-915811-88-X

Learned Optimism: How to change your mind and your life, by Martin Seligman, published by Pocket Books ISBN: 0-6710-1911-2

Managing Pressure for Peak Performance, by Stephen Williams, published by Kogan Page, 1994 ISBN: 0-7494-1239-9

Anatomy of an Illness: As perceived By the Patient, by Norman Cousins, published by W W Norton & Company, 1979 ISBN: 0-3930-4190-5

Cancer Fitness, by Anna L. Schwartz, published by Fireside,2004 ISBN: 0-7432-3801-X

As always, I'm very pleased to have any constructive criticism of the text - my sole aim is to help others treading the same path.


Pain Management - Intrathecal Pump

Postby Nicolai » Fri Aug 15, 2008 10:35 am

I have finished most of my recovery from the installation of my intrathecal pump. Here are two links that may be useful: and I am providing my insights for others evaluating an intrathecal pump for pain management.

At this point, I have to recommend this device to anyone who is experiencing severe pain. The pain relief is beyond description: complete and thorough. I am still on oral medication, and have not completely switched over to the intrathecal medication. Explore this option if you want relief from severe pain; however, note the possible side effects. Choose wisely.

As background, I have pancreatic cancer with bone metastasis in the spine. I have severe abdominal, spinal, and neuropathic pain, and I required roughly 1,500mg of Oxycontin daily, with extra immediate release medication during rough spots.

The installation consists of a trial insertion, evaluation, and then a permanent insertion of the pump. After the permanent insertion, switch from oral medication to intrathecal medication over time.

The trial insertion evaluates the catheter (a small flexible hollow tube) for efficacy. Catheter position and narcotic combination are evaluated. The test insertion left me in the hospital for several days, during that time I realized that the pump worked great (complete relief from my cancer pain), however I was prone to severe pain from pressure of the catheter onto the spinal cord. I was awake during the trial surgery. The threading of the catheter is challenging on my psyche: I felt nerve roots being pressed by the catheter. When the catheter pressed the spinal cord, I experienced more surreal pain. The surgeon used this feedback to back off and to insert the catheter in a different manner. The fear of paralysis made the feedback process challenging.

During hospitalization, the surgeon and nursing staff examined me for side effects of the intrathecal narcotic, and I evaluated the intrathecal narcotic for efficacy. We also evaluated surgical issues. I experienced severe pain in my kidneys when I tried to bear down. A temporary pump, the size of a small purse, injected narcotic into my intrathecal space. Through the intense kidney pain, I could feel all of my cancer pain dissipating, during private moments I grieved for the volume of pain I endured, as I was now aware of how poorly oral narcotics manage chronic pain for me. Then after several days the catheter is removed.

After the first surgery process was complete, I met with my pain surgeon and explained that the pressure of the catheter onto the spinal cord negated the benefit from the relief. My spine received radiation treatment in the insertion area, and there are many metastases in the vertebrae where the catheter had to travel. Insertion was at space between T10/T11, and the catheter was advanced to T8. The surgeon modified the insertion procedure for the second surgery.

During the second surgery, the insertions were more severe in sensation. During several moves up the spine, my leg felt on fire and being electrocuted. Life challenges us for every reward. After the catheter placed, I was placed under general for the insertion of the pump, and treading of the catheter to the pump. Overall, the surgery is minor in nature; the pump is secured under the skin, the catheter insertion is the most challanging aspect.

The pump is completely covered by skin. Nothing is exposed.

Then I started reducing my oral medications as the intrathecal narcotics were increased. I then hit my withdrawal wall, and vomited for a week while I found the exact level of the oral narcotic level I needed to avoid profuse vomiting.

The information I needed was how fast I clear oral narcotic, and the level of narcotic I need to avoid withdrawal. With these two metrics, I can reduce the oral narcotic, and then wait 6 days for the oral narcotic to clear my system. Then I can reduce the oral narcotic again. Apparently, the level of withdrawal and the rate of clearance are individual.

Friends who meet me noted how more alert I look, and how more alive I look. My face color seems better. I'm now interested in sex again! How wonderful!

For me, as a patient, the largest upside is relief. I have more complete pain relief. The spine pain is gone, the abdominal pain is gone.

I am so pleased to be able to have more "insurance against pain" available to me.

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