Once you decide to give radiotherapy a chance, you will need to make an appointment with a radiation oncologist. He or she will give you several options depending on your stage of disease.

The staging of prostate cancer is broken down into three important distinctions. First is the size of the cancer and if it has broken through the capsule and/or invaded local organs. TI is the earliest and smallest cancer. With T2 the cancer involves about half of either the right or left lobe of the prostate up to both lobes. T3 extends through the capsule and into the seminal vesicles. T4 invades surrounding structures such as the rectum or bladder.

The next markers for staging are the lymph nodes and/or any chance of distance spread. This is checked by CT scans and bone scans done after the diagnosis is made.

After diagnosing prostate cancer, the pathologist studies the differentiation (maturity) and growth pattern of the population of the cancer cells. This shows the aggressiveness of the disease. The Gleason grading system is used for this with 2 being the least aggressive and 10 being the most. For example, after a man has all of his pre-staging work-ups completed, he might have a stage of T2; No (lymph nodes are negative), Mo (no distance spread), Gleason 6, PSA12. These are the numbers that the doctors should use to determine the form of treatment.

Now that the staging is done and you’ve made your appointment with a radiation oncologist, what can you expect to hear?

In radiation therapy, high-energy rays are used to damage cancer cells and stop them from growing. The radiation is directed at the prostate and can be delivered in a variety of ways. The patient and the radiation oncologist should decide the type of radiation therapy used. Based on the patient’s stage of disease and the chance of extracapsular involvement, the following choices are available.

External Beam Irradiation: This consists of daily radiation therapy for about eight weeks. The treatments are Monday through Friday and take about 20 minutes a day. Diarrhea and bladder irritations are frequent side effects. Complications may include ulcerations of the rectum, but this happens in less than three percent of patients. New conformal therapies maximize the radiation to just the prostate and spare the rectum even more. Incidences of impotence are around 10 to 30 percent. Doses delivered are about 7000cGy.

External Beam Irradiation and Temporary Brachytherapy: This procedure consists of six weeks of external beam irradiation. Then the doctor temporarily places radioactive material into the prostate. This can be done using high doses of radiation over a few hours or lower doses over a few days. While in the hospital for either, trans-rectal ultrasound guides the doctor in placing long hollow needles into the prostate. This is done under anesthesia. After the needles are placed in the prostate, either low dose or high dose ribbons of radioactive material are slid into the needles thereby irradiating the prostate. Because the treatment is tailored to correspond to the location of the disease, local control rates (controlling cancer inside the prostate) of 90 percent can be achieved. Impotence rates drop to 10 percent. The side effects of diarrhea and bladder irritation and rectal damage are reduced. The dose to the prostate is increased to be biologically equivalent to 10,000 cGy without any additional external to the surrounding organs.

Note: If your doctor has hyperthermia it can be used during this procedure. Hyperthermia is a unique heating treatment that works very well on large prostatic tumors. It also works for benign prostatic hypertrophy (BPH). Many men have both prostate cancer and an enlarged prostate. While an enlarged prostate is benign by nature, it can still disrupt the flow of urine and can be addressed while the doctor is treating the cancer. The biological equivalent of an implant with hyperthermia is approximately 12,000 cGy to the prostate.

Permanent Iodine Seed Implant: Before deciding on this procedure, make sure to review the Partins Table with your doctor. (See the discussion later in this article.) This procedure was all the rage some years ago, but fell out of favor because of poor local control. Today, because of better diagnostic work-up, it is being offered again. But it should only be for men with T1 or T2a lesions with Gleason < 6 and a PSA of <10. The biological equivalent is 11,000 cGy.

For this procedure, the doctor will use ultrasound to permanently place very low levels of radioactive seeds into the prostate. Its main advantages are that it doesn’t require any external beam irradiation and is an easy outpatient procedure. However, you must be wary of any doctor who offers it to all of their patients. Only the earliest stage patients should have this procedure. It will not adequately treat any disease that extends beyond the capsule and if it does those patients will not be cured by seed implants alone.

To summarize, deciding a course of treatment needs to be based on the patient’s stage of disease, not the doctor’s specialty. Make sure to talk to both a surgeon and a radiation oncologist before deciding on a treatment. If, because of scheduling problems or insurance delays (or your just too confused to decide which way to go) and the treatment isn’t going to happen soon, there is a third option that can buy you some time. As mentioned before the prostate is fed by testosterone. If you take away this hormone, the prostate cancer will starve and rapidly shrink. It DOES NOT cure the disease, but hormone therapy takes three months to be delivered, and while it is shrinking your prostate cancer, you’ll have three months to decide what to do. Of course, there are side effects with the hormones, so discuss this option with your doctor. But you must eventually decide. Nothing, of course, is black and white. Different stages of disease need different treatments. I would love to be able to tell you exactly which treatment option to choose, but without specific details that would be impossible. I have, however, talked to hundreds of men with prostate cancer and have heard all of the pros and cons of the treatments out there, and I would definitely choose radiation over surgery.

Before discussing radiation therapy for prostate cancer, let’s discuss the prostate itself. The prostate is a gland and is responsible for producing some of the seminal fluid that feeds the semen.

The prostate needs the male hormone, testosterone, to function. The prostate is about the size of a walnut and is located in the front of the rectum, behind the base of the penis and below the bladder. The prostate surrounds the upper part of the urethra. The urethra is the tube that carries urine and semen out of the penis. A thin membrane known as the capsule surrounds the prostate.

Cancer can begin in any portion of the prostate, but most seem to occur on the posterior portion adjacent to the rectum. The first tests to rule out prostate cancer are usually the digital rectal exam and the PSA. Digital rectal exams are important because physicians can feel approximately 80-percent of all palpable tumors.

The other important tool in diagnosing prostate cancer is the Prostatic Specific Antigen (PSA) blood test. This test measures a substance emitted by both normal prostate tissue and prostate cancer. Very little escapes the normal prostate so the PSA usually measures 0-4. When the PSA begins to rise it can be a sign that prostate cancer is present. If cancer is suspected, an ultrasound-guided biopsy is performed and the cancer is diagnosed.

Once cancer has been diagnosed the headache really begins. Anyone who has ever talked to a man newly diagnosed with prostate cancer will find someone confused and frustrated, AND RIGHTFULLY SO! How can a patient decide on a course of treatment when the medical community cannot even agree? Each medical specialty — surgeons, radiation oncologists etc., favor their own approach. Consultations are filled with one specialist politely refuting in faux-respectful terms, the advice of the previous specialist. Surgeons want to operate, and radiation oncologists push for radiotherapy. Each may be a viable option, but it is ultimately up to the patient to decide their course of treatment.

My goal is to educate you on radiation therapy. Radiation therapy always took a back seat to surgery in the treatment of prostate cancer. Early studies show clearly that patients who underwent surgery fared better than patients receiving radiation therapy when compared at five years post-treatment. In fact, studies went so far as to say that the radiotherapy accelerated the cancer because the radiotherapy patients had much more metastases (distance spread) after treatment. The studies haunted radiation oncologists for years until the patient’s pretreatment stages were studied more closely. The patients that were given surgery had the earliest stages of the disease. Of course, these patients did well because the disease hadn’t broken through the capsule. The group of patients that were placed in the radiation therapy protocol had stages II to IV with greatly elevated PSAs. Some PSAs were as high as 200! Obviously, the study was slanted towards surgery and many men had it performed when it would not have been indicated.

In fact, radiotherapy is a valuable tool in the fight against prostate cancer, and recent advances have made it equal to surgery for early-stage cancers and the treatment of choice for later stages.
to be continued…

The person is said to be depressed when feelings of sadness and despair interfere with daily activities. In addition to sadness and despair, other symptoms may include:

* Loss of appetite or overeating
* Problems sleeping (not sleeping or oversleeping)
* Lack of energy
* Loss if interest in ordinary activities
* Difficulty concentrating, remembering, making decisions
* Irritability
* Excessive crying
* Aches and pains for no apparent reason
* Alcohol abuse
* Thoughts of suicide

What can be done to help?

The following are things you can do to help yourself or the person with cancer during depression:

* Avoid alcoholic beverages, as they have a depressive effect.
* Plan enjoyable activities with other people.
* Set reasonable and attainable goals.
* Encourage participation in a support group.
* Encourage prayer or other spiritual support.

Things to remember:

* Depression is common. You should not feel embarrassed to talk about your feelings. Everyone deals with the disease process differently, and a depressed person should not be ‘forced’ to talk about it if they are not ready to talk. Finding or creating a supportive atmosphere in which you or the person with cancer feels comfortable expressing feelings is an important way to open the door to talking.
* Finding someone who can just listen without giving advice or making judgments is essential, often times a person just wants and needs their deepest feelings to be heard and accepted. Sometimes they aren’t looking for an answer, just a chance to voice their feelings, their fears, their regrets, and their dreams.
* If the patient is depressed, just let them know you are here to listen. Let them know you care. Let them know that because they are depressed, voicing their feelings will not make you feel bad. Often the depressed patient feels they are a burden to their caregivers, and talking about their depression just adds to that burden.
* Take thoughts and discussion about suicide seriously. Your doctor and health care team can and should be involved in helping in such situations. There are also many community resources to help you deal with suicidal thinking, either your own or the patient’s.

Anxiety

Anxiety is a response to stressful situations. When people are diagnosed with cancer, they often are afraid, nervous and even feel overwhelmed. Sometimes they can’t even ‘define’ how they feel. Often there is the fear of medical procedures, the fear of being a burden and the fear of pain and discomfort. These feelings are not only real, they are normal.

Caregivers often feel this anxiety themselves. Whether it’s the fear of not being able to cope, or feeling that they can’t give the proper care and support to the patient.

Signs and symptoms of anxiety may include:

* Verbal expression of anxiety
* Verbal denial of obvious tension or anxiety
* Difficulty solving problems
* Feeling excitable
* Increased muscle tension (appears tense)
* Trembling and shaking
* Headaches
* Getting angry

If more than one of the above symptoms exist, call a doctor or other member of the health care team. You can also help by:

* Determine what thoughts are causing the anxiety.
* Talking to someone who has been through the situation causing the anxiety.
* Seek the help of a social worker, support group, chaplain or rabbi, or psychologist.
* Increase pleasant, distracting activities
* Increase companionship and time spent with friends and family who care.
* Relieve physical symptoms such as pain or other side effects
* Encourage relaxation techniques, such as medication, music therapy, mild exercise, etc.

When the only proof you have that a product works is from a number of other peoples’ statements or testimonials. A few of the people interviewed may have benefited from the product, but many may have been paid a sum of money for giving a positive testimonial. Often people giving a statement are identified only by their initials or first name, which should raise some suspicion.

If you are already taking a prescribed medication and a practitioner tells you to stop all your prescribed medication and start taking this alternative therapy, this should bring up a red flag in your mind. You should always discuss with your prescribing doctor your desire to stop or change your medication. Stopping some medications abruptly can be very dangerous to your health.

Another situation that should raise suspicion is if a practitioner tells you to severely restrict your diet. This is not merely lowering your caloric level, but eliminating whole food groups or fasting for long periods of time. If you believe that certain food groups are creating your problem the best person to contact is a registered dietitian. They can help with regulation of your dietary needs.

This one is commonly used in magazines. You need to send in your money and then they will send out the product. Many times it will be a situation where they will automatically keep sending it to you each month until you notify them to stop. You get started on this plan and they make it hard for you to cancel. Also, there is no way to monitor whether this product is helping you or what it is doing to or for you.

The provider of whatever substance you are trying should be able to provide you with some proof of why their product does what they say it does. If they cannot sight any scientific studies or other reputable means of proof that the product will do what they claim, then you should be suspicious.

The last one is not heard of too often, but it is when the prescribing practitioner tells the patient that there isn’t a need to tell the regular physician about this new treatment. Most reputable practitioners will welcome the opportunity to work right along side with a person’s regular physician.

Now that you have an idea of what to look out for, it is time to talk just a little about how you work with your regular doctor and at the same time another practitioner of alternative therapy. The statistics are high (about two-thirds) for the number of people who use alternative therapy and do not report it to their doctors. The main reason they don’t report it is they believe there regular physician will disapprove or even stop treating them. To some degree the patient is right; not all Western physicians believe in or want to work with complimentary medicine. The fact remains, it is in the patient’s best interest to disclose all information to all doctors who are treating them. If you are having difficulty communicating with your health-care providers, whether they are complimentary practitioners or Western medical doctors, here are some tips that might get you started in the right direction.

It doesn’t matter what kind of doctor you are seeing, always tell them everything you are taking, including over-the-counter vitamins, herbs, mineral and nutritional supplements.

If you have been seeing a doctor over a period of time, then discuss with him/her your desire to seek out the advise of a complementary medicine practitioner. Try to stay neutral and don’t assume your doctor will automatically be against the idea. Sometimes they will welcome the opportunity and actually have some names of good practitioners in the area.

If you are considering a new medical therapy, take the information you have to your doctor and listen to what he has to say about it before making your final decision.

If for some reason your doctor is negative about you taking a certain medicine, then ask him/her to explain to you why they are against it. Most of the time they will also have information on that particular medicine that they can share with you and help you make up your mind about trying it.

If you decide to go to both your regular doctor and seek the help of a complimentary practitioner, you should expect the same cooperation from the complimentary practitioners as you would your regular doctor. They both must work together and with you to develop the best treatment program.

This should give you some ideas about how to work with a complimentary practitioner as well as your regular doctor. Hopefully you now have a better understanding of the different kind of practitioners and what they do. Open up the lines of communication with your own doctor and together explore all the possibilities for treatment. You might just find a magic combination that works for you.

For the most part these kinds of therapies seemed to be the only ones doctors relied upon for symptom relief. This approach has proven beneficial for many thousands of people for decades, but there have been a number of people who, for one reason or another, cannot take medicine or utilize these other forms of therapy. This other sector of people with arthritis has looked beyond what we call conventional therapy and has explored the world of alternative therapies. In the last few years more and more attention is being focused on alternative therapies. Part of the reason for the increased interest is people who have arthritis are not realizing the results they want from the conventional forms of therapy. As patients assume more responsibility for their own healthcare, they are looking beyond conventional treatments and have a desire to incorporate all kinds of therapy into their treatment program. In this article I hope to help you understand some of these alternative treatments and how you can go about deciding whether they are something you want to add to your treatment program.

Alternative Medicine: Refers to medical practices or remedies used in place of mainstream Western medicine.

Complementary Medicine: These are therapies that are used along with or in support of mainstream Western medicine.

Western Medicine, Allopathic Medicine: Medical treatments and therapies — drugs or otherwise — accepted by U.S. mainstream medicine, taught in medical schools, prescribed by doctors and used in hospitals.

Holistic Medicine: Refers to a way of treating the patient, taking into consideration their physical, mental, emotional and spiritual health when designing or planning a person’s healing process.

Integrative Medicine: This is an approach that integrates complimentary therapies into Western medical practice to individualize a person’s treatment plan.

Preventive Medicine: This medical practice focuses on educating and treating a patient to help prevent health problems from occurring, rather than treat the problem once it develops.

Unconventional Medicine: This form of therapy is described as being any treatment or therapy — drugs or otherwise — that does not fall within the conventional or Western medicine category.

One other topic, the dangers of using alternative therapy, is also important to know before we get into the specific alternative therapies. Some patients get irritated at their healthcare providers when they seem not to be at all interested in hearing about alternative therapies. As a patient, and one who likes to be the center of his/her own care, it is important that doctors keep an open mind and try to help that person understand why or why not to incorporate alternative therapies into their existing treatment plan. If a physician is not willing to do that, many times the patient will go out on their own and start using alternative therapies without disclosing that to his/her doctor. This can be a very dangerous approach to treatment, especially if the person is taking prescribed medication along with the alternative therapy. If you are one of those people who fall into this category then please read this next paragraph carefully.

There are many danger signals that all of us should be aware of when deciding whether a therapy, especially medical, is appropriate for us. Here are some claims we should question:

A salesman or practitioner who cannot disclose the secret way the treatment works. If it had a scientific base, then the information would be available to the scientific community for review and evaluation.

The claim of a cure or a miraculous breakthrough without scientific data to back it up is always something to be cautious about. Big discoveries are few in number. Most of the time when we do have one, a scientist is very cautious about claiming it as a cure.

If the only way you have heard about the treatment is on an infomercial, on the back page of magazine, over the phone or by direct mail, this should raise some question in your mind. Usually treatments that have been researched are identified in medical journals or other reputable publications.
to be continued…

If you are planning a day or half-day of shopping then you also need to set some time aside for rest when you return. Plan this right into your schedule just as you would another task you need to do when returning home. That way you won’t feel like you are taking time away from chores that need to be done. A short half-hour rest with your feet elevated and in a relaxed position is all you need. You don’t need to go to bed for a couple of hours. The main thing is to make sure you are comfortable, warm and not disturbed. It is also important to get the proper amount of sleep at night during the holiday season. Oftentimes our regular schedules have to altered to meet the increase in social activities during the holiday season. Socializing is important, but not at the expense of lost sleep. Our bodies do repair work while we are sleeping, and if we don’t allow enough time for sleep there is no time for this to happen. If that happens night after night our entire body starts to react by feeling fatigue and an increase in symptoms. So, enjoy your social activities, but also pay attention to the amount and quality of sleep you are getting.

Another survival tactic is staying on schedule with your regular medical therapy. If you are routinely taking medication for the treatment of your arthritis, then you must not miss doses or take medicine in a way that wasn’t prescribed for you. Trying to combine over-the-counter medication with prescription medication for an occasional flare-up from overdoing things can disrupt how your body reacts to the normal course of treatment. The ideal situation is to prevent yourself from getting into situations that will cause unusual fatigue, pain and stiffness. If you can do a little preventative work, then you won’t have to over-medicate yourself. Most medical therapy taken for the treatment of arthritis is designed to work most effectively when taken without adding or subtracting medication that isn’t prescribed.

Traveling over the holidays can become a big obstacle for people who have arthritis. If at all possible it is important to travel when your medication is at a level most beneficial to you. Choose a means of transportation that you will feel the most comfortable. Pick the shortest route. If you must travel for long periods of time, stop every hour and stretch or walk around. (If you are in an airplane keep moving your legs and ankles around and get up often and walk through the aisles.) Change positions often and keep the circulation moving. Also always stay well-hydrated during travel. It may mean a few more stops in the car or trips down the aisle to the bathroom in the airplane, but your body needs to be hydrated even while sitting. You might even consider breaking up your trip into a couple of days instead of trying to travel a long distance all at once. This will prevent your joints from becoming stiff and swelling up. Take items that will insure your comfort while away from home. Taking your own pillow and having certain grooming tools that will make getting ready for the day easier will help insure a good night’s sleep and a great start to the day. If you are going to help with food preparation, you might want to take along some favorite kitchen utensils with built-up handles or double-handled pans. If you are accustomed to sitting while preparing food, then ask if you can do your job seated. Just because the person you are staying with does all her/his work standing up, doesn’t mean you have to. It is also very important to have grab bars, raised toilet seats (if needed), and a bench in the bathtub. Trying to keep your environment safe and stress off your joints will make for a much more enjoyable trip.

Stay safe while traveling. When you are traveling to an unfamiliar location, try to travel during the day. Make sure someone has your complete travel itinerary. If at all possible make arrangements ahead of time for assistance at the airport if you need it. Don’t ruin your vacation by straining something while lifting bags that are heavy. When making your travel plans, allow for enough time in between flights or connections of any kind, so that you don’t have to hurry to get to the next destination. This will increase your stress level and also increase your chances of falling or injuring yourself in some way. Try to pack light. Limit the weight of your purse. Even a purse that is carried properly can aggravate a shoulder, arm, hand or back if carried for prolonged periods of time. Change positions of your purse often and try to use the biggest muscles to carry the load.

Changing your diet and consuming too much alcohol can increase arthritis symptoms. People with arthritis who are taking anti-inflammatory medication need to take food with their medication. Most people find that certain foods agree with them more than others. If they are away from home and don’t have control over their diet this could complicate their regular regime of how they control the side effects of certain medications. You might want to take along some “comfort” foods just incase they aren’t available where you are going. Drinking too much alcohol is never a good idea, but it becomes even more important if you are taking medication for arthritis. Most of the disease modifying medications specifically state not to drink alcohol while taking the medication. Alcohol in excess impairs coordination and balance, which can increase your risk for falling and injury.

People with arthritis do best when they can keep their lives simple and their routines constant day after day and week and week. Change, even for a few days can cause an increase in symptoms that can last for weeks. So, staying in control of your activities, diet, medication and sleep will enable you to get through this holiday season without increasing your symptoms.

Some of the best advice I ever got was from a drunken Englishman, who was trying to talk me into running off with him (this was back in my younger, firmer days). In his thickest Cockney, he said, “You only go around once, gull…gawd-damnit! Live it!”

I took his advice. I turned down his offer. Still, it’s hard to “seize the day” when it feels as if your body has “seized” you. Morning stiffness and pain flatters the couch and makes the TV seem very appealing. We all have days like that…and during major flares, rest may be the only answer.

But every once in a while it happens: you are awakened by the alarm clock and not by pain. Cautiously, you sit up and place your feet on the floor without any problem. Not only can you walk without a cane, you are walking, not limping! Sure, there is some pain, some discomfort—perhaps a “3” on a scale from 1-10—but for the most part, you feel like…well, you. This day is special, so don’t take it for granted!

Remember the Bad Days

This is when keeping a journal can really come in handy. Find the entry of your last flare. Chances are, you will have either written about what you wish you could do or what you weren’t able to do at the time. Now is your chance!

Tend the Neglected

Who is the friend that you’ve canceled out on the most? Call him or her up and make plans to go shopping, see a movie, throw darts at his favorite pub…and if at all possible, make it your treat. Patient friends are rare and deserve to be acknowledged.

Quality Time With the Kiddies

There are so many times when our kids want us to toss the ball around or help them make cookies and we have to say no. During your flares, keep a list of all the projects your children ask you to do…and then save them for days like this!

Quality Time With Your Partner

To put it as delicately as possible, RA can make us too sore for physical intimacy. After you’ve finished putting that model car together for your kids, send them to bed and show your partner just how well you feel!

Get That Chore Over With

That unpainted room…the ripped sash on the bedroom window…that leaky faucet…chores that you’ve been putting off until you felt better. Go ahead and get them over with—tending your responsibilities improves your self-esteem, which, some feel can actually improve your health. On the other hand…

Leave Some Time to Play

Sure, it’s nice to cross those chores off of your list, but if you don’t have any fun, you’ll be sorry later on…unless you are one of those freaks who actually enjoys housework/home improvement (and if so, come see me…my house will leave you in a state of ecstasy).

Tell Others How Well You Are Feeling

Even the bravest of us complain from time to time…probably a lot more than we realize. Do your friends and family a favor by telling them when you are feeling well, too.

Help Someone Who is Not Having a Good Day

Go visit someone who is sick or out of sorts. Because of your own experiences, you’ll probably be able to empathize with them better than the average person…and you’ll feel good about yourself, too.

Get Outside!

Unless there is a hurricane, a tornado, an ice storm/blizzard or some other nasty act of God, try to get outside at some point during the day. After repeated flares, staying inside can become an unhealthy habit; it is also an ideal breeding ground for depression. Go outside and just look at the sky…even on gray days, its sheer beauty can make you glad you’re alive.

Return to your Journal

Write, in detail, of how well you feel and of all the things you were able to accomplish. The next time you are having a flare that feels like forever, flip back to this entry to remind yourself that flares—like most things—are temporary.

Because pain is relative to the individual it does not lend itself to easy or accurate measurement. This may lead to a misinterpretation of the pain an individual is experiencing, particularly when others cannot relate the experience to themselves. During a typical medical consultation, the patient is asked to describe their own symptoms, which in turn acts as the most accurate measure for the physician to work with. The judgement as to the nature and type of pain relief to be used is guided by the adjectives the patient uses to describe its intensity (stabbing, dull, crushing, etc). The patient may also be questioned regarding its duration, location and what, if anything, they are doing to relieve the symptoms and its effectiveness. Of course if pain is then associated with a clinical condition then treatment of the condition will help to reduce or stop pain.

Once treatment is administered, the healthcare worker relies on feedback from the patient. This feedback comes directly (nurse I’m still in pain), and indirectly, e.g. from relatives or from an observation of body language. Developing a full appreciation of pain experience can be a time consuming issue. For example, Karoly (1985) states that six key elements contribute to how we perceive pain. These are:

1. Sensory (intensity, duration, location, etc)
2. Neurophysiological (heart-rate, blood pressure, EEG, etc)
3. Emotional / Motivational (anxiety, depression, anger, etc)
4. Lifestyle (relationships, sexual behaviour, marriage etc)
5. Behavioural (exercise, work, previous history)
6. Information Processing (coping style, health beliefs and knowledge, etc)

More commonly, questionnaires or scales are used. One of the simplest measures is the use of the Visual Analogue Scale (VAS) The VAS is a small plastic ruler about 12 cm long, along which the patient can slide a marker. At each end of the ruler a statement is printed. The patient is asked to slide the marker to a point that represents their level of pain. Once done, the healthcare worker simply turns the ruler over and can obtain a rough numerical guide as to how the patient feels. VAS scales, despite their simplicity, are quite accurate forms of self-reporting. Over time, the healthcare worker can establish whether or not pain is diminishing, remaining stable, or getting worse.

Pain relief then, can come from a variety of sources. Drugs, such as opiates in the form of morphine, or salicylates like aspirin or ibuprofen, are standard and effective methods. Surgery is reluctantly used as pain often re-occurs after neural pathways have been severed. Physical methods such as massage, heat or cold packs, ultra-sound or TENS machines, serve to disrupt the pain in a manner similar to changing the wavelength on a radio. Psychologists encourage new ways of thinking, particularly with chronic pain, where dwelling on pain serves to make it feel worse. Relaxation and more focused ways of thinking are acknowledged to increase effective coping skills.

Our interpretation of pain seems to vary over time and across cultures. Pain, it seems, is a very personal experience and does not always need to relate to physical or pathological factors. In a previous article (”The Nature of Pain”) it was pointed out that even when physical trauma occurs it may not equate with the sense of pain and in some cases may not even appear at all.

Because of its variable nature attempts to explain pain from a theoretical perspective have not always met with success. Descartes (1664) likened pain to the ringing of a bell at the end of a rope. As the rope is pulled, so at the almost the same instant, the bell rings (prick your finger, you feel the pain). The idea of specific pathways for pain was to remain for a further 300 years. Theories became more elaborate as ideas about pain ‘spots’ over the skin (von Frey, 1894) were superseded by ideas involving different types of pain fibre and pain receptors. Whilst the specificity model has illuminated information about neural pathways, its main weakness is the fact that it cannot explain how or why sensations of pain varies so much according to individuals and circumstances. In such a model we should all perceive pain the same.

As a result of Beecher’s research with wounded servicemen (1959) it appears that psychological aspects play a crucial role in how we perceive pain. Severely wounded men will often complain of very little pain. One idea is that the relief that follows removal from a combat zone acts as analgesia, but it is also possible that the bodies own natural opiods may also have such an effect.

One of the most influential alternatives to specificity theory is a model of pattern theory developed by Melzack and Wall (1965). The ‘Gate Control’ Theory as it is known, is also a prime example of the biopsychosocial model in that it attempts to encompasses biological, psychological and social aspects into our understanding of pain:

According to the model, a system exists within the spinal cord in which messages to and from the brain serve to open or close the ‘gate’. So, if I bang my knee, a neural message is passed to transmission cells in the spinal cord which in turn alert the brain to my discomfort. The physical injury has opened the gate via small & large diameter nerves. My psychological state also has an effect on opening the gate. If I’m anxious for example, or if I dwell on the injury, the longer the chance I will perceive discomfort. The gating system is a two way process however. Conditions that help to close the gate are counter-stimulation (rubbing it better), or taking an aspirin, or being distracted by something more important than the injury.

Does this mean we understand how pain works? Well, not quite. Even though the Gate Control Theory provides an elegant way in which to conceptualise the pain / analgesia process, there are one or two issues still to be addressed. The first is that, to date, no gating mechanism has actually been found. Secondly, the theory still assumes an organic basis for pain and although an attempt has been made to link mind and body it is still the case that physical states are seen to influence psychological states and vice versa. Therefore the theory provides a mind-body overlap, rather than a truly integrated model.

Wouldn’t it be great if we couldn’t feel pain?

Well, no it wouldn’t. Our ability to perceive pain has evolved as a sophisticated response to our environment. Pain warns us that physiological damage is happening or has happened. It helps us to learn about situations and events likely to cause damage and even if we are injured pain serves to identify limit our activities until we have recovered. We do however have an insight into what our worl would be like without pain. In rare cases of congenital universal insensitivity to pain (CUIP), people are born with an inability to feel pain. Miss C, a Canadian and sufferer of CUIP, helped with experiments to try and understand the condition. Despite exhaustive investigations no cause could be found. Miss C died at the age of 29, after developing infections due to joint injuries which she could not feel. Even after death her post-mortem revealed no physiological abnormalities. CUIP remains a mystery to this day.

The case of Miss C is actually only one of several puzzles about pain. The sudden loss of a limb may result in a state known as episodic analgesia. Here the victim is perfectly aware of what has happened, but feels no pain at the site of the injury. The onset of analgesia (pain relief) is instant but only lasts for a limited time. This can result in the curious effect of the victim whincing at the minor pain of a tetanus injection whilst being unaffected, at least for a time, by the severity of limb loss.

Sometimes pain occurs after injury to the body has repaired itself. Neuralgia, for example, is a sudden intense pain that follows the track of a nerve. It is associated with nerve damaging diseases like shingles although, curiously, the pain starts after the disease has ended.

The vast majority, if not all people, suffer at some time with headaches. Headaches are a familiar if unwelcome feature of life and can often be traced to stressful events, over indulgence of alcohol, staring at this screen for too long and so on. Yet relatively little is known about the mechanism of headaches such as migraine which were originally thought to be due to dilation of blood vessels. However, it is now known that blood vessel changes are a result, not a cause of migraine. Headaches however stand as the prime example of how we experience pain without injury.

Whilst we tend to associate pain with the severity of injury this is not always the case. Certain cancers cause profound injury to the body but produce little pain until quite advanced. Yet, a paper cut on the finger can cause immediate discomfort. Likewise a damaged dental nerve can produce agonising levels of pain.

So-called phantom pains occur after the loss of a limb. People may try to walk on a phantom leg for example because it still feels so real. Phantom arms may feel as if they are hanging by the persons side. People with spinal injuries may also experience phantoms and may report the fatiguing sensation of cycling movements with their legs. Phantom limbs can appear to get stuck in awkward position and around 70 per cent of phantoms have a wide range of sensations such as heat, cold, itchiness and pain. An explanation for this is that the brain contains a kind of neural map of the body. When a limb is lost, the brain still regards it as being in place and tries to accommodate messages from nerves in way it can make sense of. This results in the sensation of limbs being intact.

Whilst a lot is known about pain it is clear that a great deal remains unknown. In the second of the articles on pain we explore psychological models that have been constructed to help explain the pain process. The third article looks at options in the treatment of pain.