In western orthodox medicine, we generally do well with the treatment of acute, or sudden onset diseases, like asthma or a heart attack, surgical conditions like appendicitis, trauma, and infections for which we happen to have effective anti-microbials. Chronic disease outcomes, on the other hand, are often way less favorable, and sometimes frankly poor. Part of the problem for this is that most medical treatment is dominated by medication, while there is still a lot else that someone can do to optimize their situation and to effect recovery.

Over the years, there have been several landmark discoveries in biology. These include Cell theory, Darwinian natural selection theory, and the discovery and decoding of DNA. A relatively more recent, but important subcategory is Epigenetics, which refers to how other factors can change the way that our genes are expressed, without changing the DNA sequence. These factors may be related to disease, aging, environmental changes, and lifestyle changes.

The important point here is that this vital information requires a whole mindset change, in that we now no longer need to feel that out genetic makeup alone determines our outcomes, but that other factors also play a key part. Along with this, there are a group of health-associated behaviors, thinking patterns, internal and external environments and areas of focus that are essential for good health as well as recovery in chronic physical and mental disease. Clearly, we cannot just assume that these helpful and healthful behaviors are all epigenetic, as associations are way more easily made, while proving causality requires robust investigation, and far more work and evidence. 

To remain healthy, we firstly need to be mindful. Mindful that we have made a   commitment that requires daily effort. No surprise here, as whatever we may turn our mind to invariably requires constant effort. Whether it is to be a happy or a good person, we must think, position ourselves and behave in ways that will make us makes happy or good. A good person isn’t simply the driver and agent of good thoughts, words, and deeds; it is rather that these activities over time confer goodness upon the person and qualifies them as such. Cutting to the chase, it all starts with the work. 

Too many who listen to this hear ‘toil’ instead of work. Whenever we start something new, we meet with at least some resistance or inertia, making it challenging at first. Moving to something where there previously wasn’t anything, or very little, is rarely easy. An analogy from physics is that static friction is way greater than sliding (moving) friction, requiring more energy to overcome it.

However, the good news is that with time and the accumulation of many small advantages, sound diligence is more easily accomplished, rather than requiring more or even the same effort. This applies whether you are trying to maintain your already good health and resilience or moving to a better place when ill with chronic physical or mental disease. By exercising healthful self-help techniques to maximise your overall treatment plan, you can secure or at least improve your health outcomes.

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When we consult with a physician, a history is taken before examination, which is the way it should be. With simpler, more recent onset problems, the history is usually shorter and simple. Complications can occur with chronic conditions that are longstanding and that impact many areas of our lives. These have a complex and lengthy narrative.

We see this in chronic pain, where we tend to cluster our many questions, symptoms, and problems in order to inform our physicians when the opportunity presents. However, there is usually so much to cover and present-day physician consults are so brief, that we understandably tend to focus on the most pressing and frustrating problems, hoping for clarity and reassurance during these short sessions.

But what we do not see is that the usually bleak, sometimes overwhelming negative history then becomes the overarching narrative we also tell our family and friends, whenever they express concern regarding our condition. This is then repeated as their narrative when others ask them how we are doing.

With time, the repetition and reach of the story may result in our social circle having a more unrealistically negative picture of our condition, and they may treat us accordingly, expressing it through over-concern, coddling and other unhelpful behaviors.

But even that is not the end of it.

Through repetition and focus, the dominant themes become a staple or mantra for our own negative internal dialogue, and here the problem becomes obvious. Endless reflection and rumination trap us in the most negative cycles of our experience, to the point where, rather than character becoming destiny, as the old saying cautions, narrative may become destiny.

So how do we get around it?

Firstly, we need to become aware of this potential problem. Then we need to attempt, when speaking to friends, family and even physicians, to try and include some even mildly positive points as well as some things that may have improved even slightly, or by including newly gained coping skills, so that the detail does not become an overly negative spiral. No-one is expecting you to tell a story that you cannot relate to, but it is vital to inform family and friends that not everything is entirely bleak and sad.

There are often small gains that can be expanded through focus and we do see this in clinical practice.

You can easily temper certain aspects of your challenges by reframing things. For example, instead of saying that “pain always wakes me up at night,” you can say “for now, the pain seems to be waking me frequently.” Rather than “nothing works,” perhaps state that you have yet to find a reliable treatment approach. Not only will this make others worry less and you feel better, but it may crack open further possibility and recovery potential. A very least it will make you feel less trapped in the pain cycle.

First comes awareness, followed by initial effort and the accumulation of small advantages, and then time spent in this healthier mode may well secure significant change and shifts for the better.

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“So what, aren’t we all? “ is a common, less than helpful sentiment we hear when we mention our stress.

We possess an autonomic nervous system that is not fully under our control. When we are out of danger, safe and relaxed, we are in parasympathetic mode which is appropriate for re-charging our bodies after a day’s work, physically or mentally.

This nourishes our body and aids digestion, socialization, immune function, and reproduction, making sure that our bodies are not prematurely worn down by the demands of everyday life.

In times of danger, threat, or confrontation on the other hand, we are in sympathetic mode that prepares us for either doing battle…. or running away. Issues like digestion and ‘non-essential’ functions are downgraded for the time being, and we become ‘wired, hypervigilant, jittery, with a rapid heartbeat and breathing rate ready to act swiftly or to run away fast.

Everything else in the body is put on hold until we can again find a safe place and are not in a state of anxiety or stress.

In fact, stress negatively effects every chronic disease.

Prolonged time in the sympathetic zone is known to be harmful to our health. High circulating levels of stress hormones like cortisol and adrenaline take their toll on our bodies and this is particularly true in chronic pain and other chronic diseases.

Therefore exercise, especially while in nature, meditation, adequate sleep, and activities like yoga, creative and other pursuits are important to help us get back into the relaxation mode.

But here’s the take-home message…

We have this long tradition of trying to fight chronic diseases which does not really make a good deal of sense because fighting constantly drives us into sympathetic mode which is not an internal environment that can promote recovery.

That is why I am not supportive of fighting chronic pain.

Rather than fighting pain, we should first try and understand what pain is, and then learn to outwit or outsmart it.

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The key issue here is this could be one of your most important techniques for reducing daily stress. It is also literally cost- free once you know what to do, completely portable (of course) and accessible. It can be performed in 15 to 20 minutes either privately or even in public. I nearly always meditate on flights and have done so waiting at medical and dental offices.

It is also almost free of all adverse effects unless you have had severe trauma, in which case you need to check with your physician before commencing.

You can easily learn the technique even though many mistakenly regard it as a skill that takes a while to develop. Rather than viewing meditation as some sort of achievement, know that there is no right or wrong way as long as you remain awake, aware, and don`t obstruct or dwell on your thought flow.

I like to think of it more as going back to a previous time in your life, pre-school, when you probably while playing alone, drifted into a quiet state, still awake and aware, but not over-focused.

The major benefits are an almost immediate reduction in your stress level as well as (later) more control over your thoughts. You come to view your thoughts for what they truly are…. thoughts…and not reality. Some of your thoughts can be helpful, but when feeling unwell, many can be completely unhelpful and disruptive, delaying your recovery. While meditating, you try not to oppose thoughts that may surface, you merely view them passing you like leaves blown by the wind.

Meditation also slows you down and with time you realize that you were previously perhaps acting immediately, almost reflexively in response to stressful situations. With practice, your range of response possibilities expands and also whether or not you want to react in the minute…. or even at all.

Meditation obviously works best with a daily routine, say 20-30 minutes. Do not feel that it is not working if at the start you skip some days, as this is a new discipline for you. What usually happens is that once you see the benefit, you become way more motivated to continue on a daily basis.

Initially, it may feel quite strange because we are so used to cramming a tremendous amount into one day and are strangely at ease with our minds constantly racing. Once in a meditation routine, you may become surprised at how you coped effectively before meditating.

Some learn meditation through disciplines like yoga, or after exercise or aerobics sessions, and others are self-taught through books, Internet videos and apps.

Meditation is at heart a quiet practice that often stretches the novice’s belief how something so simple could possibly be so effective,…. but it can be a game-changer!

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From a medical standpoint, we view pain reduction or elimination as only one of the parameters for recovery. A good deal of importance is also placed on increasing functionality, or the ability to do more than usual physically, with improvement of the activities of daily life, whatever the current level of pain. A further consideration is improvement in quality of life. These two factors are therefore also important metrics in order to assess recovery. This is all completely in keeping with the recommended bio-psychosocial approach to chronic pain, where the psychological and social issues also need to be factored into the overall health status.

So, we really need to evaluate all three. As we have seen in previous articles, what we focus on expands or grows in our life, and in the case of pain focus, this is also one of the early predictors and triggers of chronic pain. However, by rather focusing on increased functionality and quality of life, these two, rather than the pain is likely to expand with the increased awareness and attention.

The central nervous system has neuro- modulators, specific nerve cells and circuits that use various chemicals that can affect other circuits to change different types of nerve activity including pain levels. They act like ‘volume knobs’ for the pain, either increasing or decreasing the pain level. When your quality of life and/or functionality increases, these factors can actually reduce the level of pain experience, much like a good night’s sleep, an improved mood, or a more positive outlook may achieve.

Therefore, there is good reason to make every effort not to place too much focus on the pain level, even though pain itself is admittedly hard to ignore. These modifications may seem simple though challenging to adhere to, but their effect is profound.

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There are some drawbacks however, two of which I will detail.

Technology was predicted to reduce our stress levels, expand, and simplify our lives, and potentially free hours off our daily toil. However, the complication of keeping up with changes in technology in a rapidly expanding discipline, remains stressful, as do security issues and the physiological stressors arising from screen gazing, excessive virtual time, and prolonged compromising postures. 

We are increasingly dependent on our mobile phones, many of us constantly checking emails and social media and the latest array of e-novelties and delights. For many, phone gazing has become the default mode whenever there are a few spare minutes to spare. It is also completely normal these days for couples and family members to be seemingly happily involved with their own phones for extended periods even while sitting together after dinner. 

It has been widely discussed that immersion and over-involvement in social media can make one feel down, given the fact that “friends” often tend to selectively broadcast their successes and achievements, some appearing not to ever quite put a foot wrong. We generally hear a lot less about their failures and disappointments than we do about their prosperity stream. 

We already know that excessive phone and computer screen time can have a depressogenic (mood-lowering) effect on one, just as much as excessive TV watching does. Living a large part of one ‘s life virtually, is almost like reducing it to a spectator sport. 

This having been said, social media is a valuable asset enjoyed and used in a helpful, positive way by many millions of consumers. For the more isolated and the aged, it has variously been described as a lifeline or godsend.

The message in all of the above is, beware of the potential negative effect of long periods of TV/computer/mobile phone time, especially with chronic pain when already you are hardly feeling your best. 

The second potential problem concerns unhelpful medical research by those desperately seeking answers but having limited subject knowledge. Incessant scouring of the internet for medical information or advice is an important but particularly difficult habit to break. British researchers showed several years ago that people conducting internet research tend to select studies and articles that support their initial opinions and biases, even if they have subject knowledge. 

It seems that most consumers look at the first three pages of offerings of the search engine results on chronic pain, often spending much of the time on the most sensational articles about the most severe conditions within the category. This usually increases their anxiety and sense of dread, especially since they are seldom able to discern whether or not the source is reliable.

It is advisable to first seek out the most reliable and reputable health websites before browsing. Here one ‘s family physician can often be of help.

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Once you understand what is going on regarding your condition, you need to review and consider which behaviors and habits you need to drop, which helpful behaviors you have to re-adopt or expand, as well as whether any of your thinking patterns are holding you back and keeping you stuck.

The second aspect of acceptance can be made when you learn of some advice or treatment that can become easily incorporated into your day and that will help change your situation for the better. It should be evidence-based, helpful, and plausible (making sense), as well as be endorsed by your physician. This can improve your situation greatly. For example, hypertension and diabetes can be greatly improved by losing excess weight, even if you still need medication. Chronic conditions work this way.

It is not only what you are given (medication, injections, physical therapies) that helps, but also what you do, and the unhealthy habits you put on hold.

And then this brings us to the importance of and need for meaning. Meaning, as it applies not only to your condition, or what is going on in the body, but also what your condition means to you personally in the way that it impacts most areas of your life, as happens with chronic pain.

I will discuss the importance of meaning in a subsequent posting.

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We then considered the importance of acceptance in chronic disease, which helps you recognize that you need to make certain lifestyle changes because of chronic disease. This can only be done once you know what you are agreeing to or accepting. Chronic pain is not merely the persistence of pain symptoms, it is a disease or disorder in its own right, and we can see brain changes on special imaging scans such as fMRI.

Why would meaning be so important?

For two reasons, because it is hard to plan when you do not know what you are up against, and, in order to know what you are to accept, you must have a clear idea of what you are buying into. As important as the above is that once we understand the “why’ of something, the ‘how to’ (or how to deal with it) becomes more obvious and easier to address. Meaning also affects our motivation level, and ultimately our resilience, and our ability to persist with our efforts. History is filled with people who did amazing things through their commitment against all odds, based on the meaning and value that they placed on their quest or goal.

Now the following challenges remain. 

What is chronic pain? 

And what does it mean to you?

This will be outlined in another posting.

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Multimodal merely means that the treatment may include various modalities or types, such as physical interventions, medication, injection therapy, to name but a few. This is what we often see and can be said to be true in most cases.

Bio-psychosocial is merely a long-winded way of saying that the psychological and social issues of chronic pain should be addressed at the same time as the medical problems.

Experts then go on to say that it is unlikely for recovery to occur without including this approach, and yet, alarmingly this is what is most often missing from treatment programs.

How did this happen?

There are a number of reasons for this, such as poor undergraduate chronic pain training for physicians and present- day medical appointment times that are way too short, with about 15 minutes or so at one’s own physician, but often less than 10 minutes at a walk-in clinic, in order to do the required education and work.

But there is a less frequently discussed, even bigger problem behind it. It is a medical system that has somehow helped create the unrealistic expectation that we can always rely on rapid and effective ‘solutions’, mostly in the form of chemical compounds, even in the case of chronic conditions such as chronic pain. We still see the effects of this notion in the ongoing opioid crisis.

So clearly, that’s not how things work.

It is also why our treatment outcomes for chronic disorders are relatively poor compared to other diseases and conditions such as acute (recent onset) disease like pneumonia, surgical conditions like appendicitis, and the treatment of traumatic injuries.

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