Case Report

Shouldering the Pain

By: Cathy Guo, Biochemistry and Molecular Biology, ‘18

 

Author’s Note: “This is a reflective case study I wrote for UWP104F (Writing in the Health Profession) about a patient’s illness experience with chronic pain. After conducting an interview with the patient, I became intrigued by the controversial aspects of her ailment, and drew on research to better understand the scientific context of chronic pain. I hope that my reflection at the end raises questions that readers are also thinking, and that these questions could spur readers to learn more about the subject.”

Pain is frequently characterized as a visible symptom— a purple bruise, the “ouch” exclaimed after bumping into a table corner. We may wince simply at the sight of pain, and observing pain in action makes most of us feel empathy for its victims. Consequently, pain rarely brings to mind something invisible. But pain can go undetected by the naked eye, as exemplified by chronic pain, which is widely regarded as an invisible ailment. Patients not only battle persistent pain that lasts months to years but also cope with no visible signs of injury.

When I first learned about the subject of this reflective case study, a female student at the University of California, Davis, I was intrigued by the invisible aspect of her chronic pain condition. I decided to conduct an interview with the patient and discovered other engaging aspects of her experience. Prior to developing chronic pain, the patient described herself as a “normal college student” who strived to keep different areas of her life in balance [1]. Although she spent hours on schoolwork each day, she always made time for her hobbies and social life. Her daily routine also consisted of exercising regularly and getting enough sleep nightly.

 

This routine changed when the patient began her sophomore year in college with a heavy course workload. Feeling immense pressure to do well, the patient spent extra time to manage her studies, which often meant late nights and putting schoolwork as her sole focus. One night, she had just finished studying when she felt a dull ache spread across her shoulders. She assumed it was her stiff posture that caused the problem and didn’t think much of it, dismissing the pain easily. Her shoulders had never been injured before so she didn’t see reason to be alarmed; but the shoulder pain persisted, for weeks and then months.

When asked why she didn’t seek medical attention right away or try to alleviate her pain, the patient replied that she didn’t consider her shoulder pain to be a “serious problem” [1]. While the lack of visible injury contributed to this belief, the patient also deemed her age to be a factor. She did not think it was plausible for her nineteen-year-old self to develop a severe pain condition that is commonly associated with older adults, particularly in television commercials for pain relief medication.

The patient’s misconceptions about chronic pain are typical and have similarly caused other chronic pain patients to delay treatment and professional help. While chronic pain can develop after a major injury or illness, such as a back injury or shingles, it can also arise without a known cause [2]. Pain is the body’s way of alerting a person that something is wrong, and it is normal for the body to send pain signals to the brain when someone is injured or ill. However, pain that lingers after an injury or illness is abnormal. Chronic pain is defined as pain that extends longer than three months, and could even persist for years [2]. Anyone can develop chronic pain but it is more common in older adults [2]. It is not a normal part of aging.

Although the patient experienced chronic shoulder pain in the absence of a past injury, she believes her stress levels during sophomore year contributed significantly to her condition. The patient could manage her classes by adhering to a rigorous studying routine but her efforts took a toll on her health. It is not yet fully clear to researchers how stress and pain are related; however, evidence shows that stress and pain can influence each other dramatically [3]. Stress not only has an emotional impact on a person but can cause physical pain as well. Furthermore, studies support the conclusion that emotional processes in the brain can increase pain [4]. The brain is a key player in determining how people perceive pain because the nervous system regulates pain and its pathways [5]. The brain always tries to inhibit pain signals; however, if a person is stressed, the brain’s ability to filter these signals is hindered [5]. Consequently, the sensation of pain can actually be increased due to stress [5].

The patient suffered a year of shoulder pain before deciding to visit her physician. She realized her condition was serious when the pain became too difficult to ignore and endure; the bursts of pain gradually became more frequent, spreading to her neck during certain occurrences. Even sitting down for a short period would cause an ache to emerge in her shoulders.

 

After conducting library research, I determined that the patient’s condition can be classified as nociceptive pain, one of two generally accepted categories of chronic pain that is characterized by a dull ache [6]. Nociceptive pain “arises from actual or threatened damage to non-neural tissue” and is caused by the activation of nociceptors [6]. It’s possible that the patient’s stress posed a threat to tissue damage, thereby triggering the nociceptors. Nociceptors are sensory receptors that detect signals from damaged tissue or threat of damage in the body [7]. These sensors of the pain pathway are located in the skin, as well as in other structures such as blood vessels and tendons [8]. Tissue damage and the threat of damage trigger the activation of nociceptors, and the pain signals travel from the nociceptors, through the sensory nerves, and up the spinal cord to the thalamus in the brain, which works to relay sensory signals in the brain [8]. The pain signal is then sent to the cerebral cortex, which is the part of the brain that processes thought [8]. Nociceptors play an integral role in sounding the pain alarm in the body, in response to highly specific stimulation.

 

When the patient finally visited the doctor’s office, her physician prescribed two pain relievers– ibuprofen and acetaminophen–and provided little guidance for long-term treatment. Without a formal diagnosis from her physician, the patient came to her own conclusion that her shoulder pain was associated with stress. The patient explained that she feels the impact of her shoulder pain most aggressively before studying for exams because she is stressed out about doing well. The dull pain hits her shoulders in frequent bursts and she temporarily relieves the pain with Bengay, a type of analgesic cream used to alleviate muscle aches. She clarified that she decided not to take ibuprofen after a while because she “didn’t like taking pills all the time” [1].

 

After forming her own conclusion, the patient reigned in her unhealthy study habits, which  subsequently decreased her stress levels. She now possesses coping methods and outlets for her stress.

“I manage my stress by hanging out with friends, going to the gym to exercise, taking study breaks, and studying early for exams. I don’t stay up late anymore. I don’t think my body can handle it,” the patient explained [1]. Although she still experiences chronic shoulder pain, the frequency of pain outbursts have decreased, and the pain is now localized to her left shoulder rather than spread across both shoulders. She hopes that with time, her shoulder pain could be managed to the point that she will no longer require any treatment.

 

The patient’s experience with chronic pain raises the importance of acknowledging the invisible aspect of certain illnesses. Although she did not show any visible signs of injury, the patient still suffered pain that was real and required attention. It is interesting that what is invisible to a third party observer could be invisible to the patient as well, and patients could be just as likely to believe that their condition is not serious because they do not visibly observe that something is wrong. The patient’s initial dismissal of her condition due to preconceived ideas about chronic shoulder pain brings up the problem of harmful misconceptions in medicine. These misconceptions about certain illnesses merit attention because they have been shown to be potentially damaging to patients, and could delay timely diagnosis and treatment.

       

The relationship between stress and chronic pain in the patient’s experience demonstrates how a negative emotion like stress could manifest itself physically in the body and cause harm. It is notable that for the patient, coping with stress and learning how to manage her stress levels alleviated her chronic pain without medicinal treatment. Could self-treatment yield just as successful results in other chronic pain patients, given that pain is a very personal and subjective experience? Most certainly, the patient’s case speaks to the important relationship between the mind and the body. Because the patient managed her emotional health and actively sought to reduce her stress, her body was able to heal as well.

 

References

 

[1] Guo, Cathy (Molecular & Cellular Biology department, University of California, Davis, Davis, CA). Interview with: “The Patient”. 2016 Apr 25.

[2] WebMD.com [Internet]. New York: WebMD LLC; c2010 [updated 2011 Mar 09]. Top Causes of Chronic Pain; [about 3 screens]. Available from:http://www.webmd.com/pain-management/chronic-pain-11/causes-pain?page=1

[3] Benner, RN. Chronic pain not only hurts, it also causes isolation and depression. But there’s hope. The Washington Post [Internet]. 2015 Jan 12 [cited 2016 May 25]: Sect. Health & Science; [about 6 screens]. Available from: https://www.washingtonpost.com/national/health-science/chronic-pain-not-only-hurts-it-also-causes-isolation-and-depression-but-theres-hope/2015/01/12/db576178-7fe7-11e4-81fd-8c4814dfa9d7_story.html

[4] Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci. 2013 May 30;14(7):502-511. doi: 10.1038/nrn3516. PubMed Central PMCID: PMC4465351.

[5] Bhatia, J. Eliminating stress brings pain relief. Everyday Health [Internet]. 2013 Feb 19 [cited 2016 May 25]: Sect. Pain Management; [about 3 screens]. Available from:http://www.everydayhealth.com/pain-management/stress-and-pain.aspx

[6] Crofford LJ. Chronic pain: where the body meets the brain. Trans Am Clin Climatol Assoc [Internet]. 2015 [cited 2016 May 25];126:167-183. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530716/

[7] Dafny, N. Neuroscience Online. Houston (TX): The University of Texas Health Science Center at Houston; c1997. Chapter 6, Pain Principles.

[8] Canada.com: Health [Internet]. Toronto, ON: Mediresource Inc; c1996-2016 [cited 2016 May 25]. Chronic Pain; [about 1 screen]. Available from: http://bodyandhealth.canada.com/condition/getcondition/Chronic-Pain