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Best Way to Measure Pain? Just Ask

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When Cynthia Toussaint went from ballerina to bed-ridden, she believes one reason was that doctors wouldn't believe her about the pain she was experiencing.

Toussaint suffered undiagnosed for 13 years with reflex sympathetic dystrophy, or RSD, a disease resulting in chronic pain due to nerve damage. She developed the condition after a minor ballet injury, and it escalated into pain so severe that she was unable to get out of bed, walk, or speak for 10 years.

"All my doctors told me that my problems were in my head. One doctor told me to shoot myself," recalls Toussaint, who has since co-founded For Grace, a non-profit organization dedicated to raising awareness about RSD. People with chronic pain, observes Toussaint, are "not believed. We're abandoned."

Now new research backs Toussaint up -- subjective response to painful stimuli is an accurate indication of pain experienced, according to a study published Monday in the Proceedings of the National Academy of Sciences .

For the study, researchers divided 17 healthy adults into two groups: those sensitive to pain stimuli and those less sensitive to the same stimuli. Using magnetic resonance imaging, brain activity was monitored in each group during application of a heat stimulus.

For pain-sensitive subjects, more frequent activity was observed in the cerebral cortex -- which plays a significant role in the pain process -- as compared to individuals less sensitive to pain.

"The hard data indicates that individuals are capable of looking into their own experience and reporting pain levels accurately," says lead author Robert C. Coghill, assistant professor of neurobiology and anatomy at Wake Forest University School of Medicine in Winston-Salem, N.C.

The Truth of 'Ouch!'

The finding should prompt physicians "to be more sympathetic to pain patients," suggests Dr. Joshua Prager, clinical assistant professor and director of the California Pain Medicine Center at the UCLA School of Medicine in Los Angeles. "Most physicians do a fairly poor job in that regard."

Pain expert Michael E. Robinson, professor of clinical and health psychology at the Center for Pain Research and Behavioral Health at the University of Florida in Gainsville, notes that often when a patient reports a high level of pain, doctors and nurses are likely to record pain at a moderate level.

"Our studies show that approximately one-third of hospitalized patients are undertreated for pain," adds Patricia L. Starck, professor and dean at the University of Texas Health Science Center School of Nursing in Houston. "This research will reinforce the fact that pain should be assessed by asking the patient, and then the treatment prescribed should match the level of pain."

Alex Zautra, author of Emotions, Stress and Health and professor of psychology at Arizona State University in Tempe concurs: "Doctors are schooled in identifying observable signs on illness or disease and then treating [them]. ... [Often] patients are in pain and no one knows why."

Zautra believes the latest finding highlights the importance of a physician's faith in a patient's pain estimation. "Indeed, the communication between doctor and patient, so often contentious on the matter of pain and its treatment, need not be so. By not doubting that the pain is real, much conflict can dissolve."

The Costs of Undertreated Pain

Doctors are sometimes hesitant to treat pain aggressively because of their reluctance to prescribe the appropriate drugs. Pain medications, such as opioids, are heavily regulated, Zautra states, adding: "The general rule has been to use as little as possible."

But undertreatment of pain results in more than just greater physical suffering, Starck contends. It can foster complications, delay recovery, and incur greater medical costs due to longer hospitalization. And undertreated pain can lead to grave consequences for mental health, Zautra adds. Not treating pain obviously hinders an individual's ability to function, work, and live, but also adversely affects mental health as it is a "source of stress the gives rise to physiological changes in the body," says Zautra.

Treating pain early and aggressively is important in preventing acute pain from developing into a chronic problem, Coghill notes. For a patient with RSD, for example, treatment in early stages can eliminate the disease, while delayed treatment of pain can preclude full recovery.

Recently enacted standards for pain management at health care facilities stipulate that health care facilities estimate patient pain accurately and treat it appropriately. "Pain is a complex, multidimensional experience that involves sensory components, emotional components, cognitive components, and even social components," Robinson explains.

As for Toussaint, she says she "wanted to talk about my pain subjectively. People with chronic pain are not making up their pain. If anything, they're trying to hide it because they're ashamed of being labeled 'sickies,' 'malingerers,' and 'drug seekers.' "

"My doctor cared about me, and he believed me," Toussaint says of the physician who finally provided her a proper diagnosis after years of agony. "That made all the difference."

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Copyright 2003 All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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