The Last Word - SHINGLES: A Case Study

Mira Steranka

My name is Mira Steranka, I am in my sixties and live in Mississauga. My story began a week after abdominal surgery in March of 2005. I woke up one morning with a bloody left eye. I was referred to an ophthalmologist (eye doctor) who was on call for emergencies, just to be told that I had shingles on the cornea of my left eye. I was prescribed four or five different eye drops that I had to administer almost every hour. Every couple of days I had to go for a follow up because the pressure in my eye was so high, that I could have gone blind if not treated properly. My eye was very sensitive to light and this made me extremely nauseous. I had to wear sunglasses even indoors.

Several weeks went by before I was able to sit and look at a computer screen. When I went on the internet and this is what I found:

“Shingles is a painful skin rash. It is caused by the varicella zoster virus. Shingles usually appears in a band, a strip, or a small area on one side of the face or body. It is also called herpes zoster.

Shingles is most common in older adults and people who have weak immune systems because of stress, injury, certain medicines, or other reasons. Most people who get shingles will get better and will not get it again. But it is possible to get shingles more than once.

Shingles occurs when the virus that causes chickenpox starts up again in your body. After you get better from chickenpox, the virus "sleeps" (is dormant) in your nerve roots. In some people, it stays dormant forever. In others, the virus "wakes up" when disease, stress, or aging weakens the immune system. Some medicines may trigger the virus to wake up and cause a shingles rash. It is not clear why this happens.”

As my luck would have it, when I was a small child I almost died due to a very bad case of chicken pox. Unfortunately, the virus “awakened” when my immunity dropped significantly due to the stress of my long abdominal surgery.

It took almost six weeks for my eye to get better. Imagine that you have an eyelash or sand in your eye and it is there 24/7 week after week. Some days the pain was so bad that I cried, because I did not know how to stop it. I thought that I would gouge my eye out just for the pain to stop. My eye eventually got somewhat better, but new outbreaks kept happening three to four times every year since. During an outbreak, blisters return to the cornea, my eye gets bloodshot, and the pain intensifies. The morning is the worst. The pressure in the eye is so high that it feels as if someone is pushing my eye out of the socket. When the pain is bad it makes me very nauseous. Under conditions of stress, outbreaks take much longer to go away. By now, my cornea is deeply scarred, I developed severe dryness, my eye tears constantly, and I have double vision. I have to use drops several times a day, which are not covered by insurance, as they are over the counter medications.

I changed my diet to include food with a high content of lysine and tried to alleviate stress but the outbreaks kept reoccurring. I was already on disability due to the chronic pain caused by a previous motor vehicle accident, and this additional pain was making my life even more miserable.

Four years ago, a night before my regular annual check-up, I saw a TV advertisement for shingles vaccine Zostavax. During the check up my family doctor mention the Zostavax vaccine to me. I immediately accepted his offer to receive the injection and ever since then the outbreaks have decreased significantly to one or two per year. I found out that the shingles vaccine (Zostavax) is an injection of a weakened form of the chickenpox virus that reduces the chances of getting shingles by about 50%. The vaccine also helps prevent the spread of the virus.

From my personal experience, I can tell you that the vaccine is the best way to reduce the chance of developing shingles or, in case shingles occurs to reduce chances of long-lasting pain (Post Herpetic neuralgia). The vaccine is available in pharmacies and doctors' offices. 


HOT OF THE PRESS
The Ontario Government in their budget on February 25, 2016 announced New Funding for Shingles Immunization. The government aims to make the shingles vaccine available to Ontario seniors between the ages of 65 and 70, free of charge. The investment will save eligible seniors about $170 in out-of-pocket expenses for the vaccine, and reduce emergency room visits and hospitalizations for vaccinated seniors


Dr. Angela Mailis

Dr. Angela Mailis

DOCTOR’S CORNER

Mira’s experience with Herpes Zosters (HZ) is a bad one. To under- stand the magnitude of the problem, let’s talk numbers. One out of three Canadians will experience an episode of HZ in their life- time. The numbers are one out of two for those aged 85 years and older. Complications that can severely affect the patient’s quality of life are:

  • Acute HZ pain (due to Shingles) causes loss of work and low quality of life
  • Post Herpetic Neuralgia occurs in 10-22% of those afflicted with acute HZ and can have several complications such as eye problems; scarring; and super infections (infections other than HZ). * Stroke

HOT NEW INFORMATION

HZ is a risk factor for Stroke (particularly in the first two weeks after HZ infection)

On the other hand, factors that increase the risk to develop HZ are:

  • Family History with blood relatives having HZ. One blood relative increases the risk 3-5 times. The risk is much higher with multiple blood relatives suffering from HZ.
  • COPD
  • Diabetes
  • Use of statins (such as Lipitor and other drugs that reduce blood lipids).

The National Advisory Committee on Immunization (NACI) has made the following recommendations in 2013 as to who should be vaccinated against HZ:

A) AGE GROUPS

HZ vaccine is recommended for the prevention of HZ and its com- plications in persons 60 years and older without contraindications, and may be used in patients aged 50-59

B) PREVIOUS VARICELLA ZOSTER VIRUS (VZV) HISTORY

HZ vaccine may be administered to individuals less than 50 years of age with a prior history of HZ.

C) In regards to a SECOND DOSE
for healthy persons previously
vaccinated with the HZ vaccine,
National Advisory Committee on
Immunization (NACI) states that
duration of protection remains unknown beyond five years; it is also not known whether booster doses of vaccine are beneficial.

D) IMMUNOSUPPRESSED PERSONS

Individuals with HIV, post-organ or hematopoietic stem cell trans- plant, or in those receiving high-dose corticosteroids, chemother- apy or immune-suppressing medications: If patients are going to be initiated on immunosuppressive medications, administration of HZ vaccine prior to immunosuppression should be considered. A period of four weeks should be allowed to elapse between vaccine administration and initiation of immune-suppressing medications or treatments. If the immune-suppressing medication is discontinued, a period from three days to greater than one year, depending on the specific medication, should elapse before vaccination with live attenuated vaccine such as HZ vaccine can be considered.

Individuals on low-dose immunosuppressive therapy: NACI recommends that it is reasonable to consider HZ vaccine in patients on lower doses of immunosuppressive agents: low-dose prednisone (< 20 mg/day), methotrexate ≤ 0.4 mg/kg/week, azathioprine ≤ 3.0 mg/kg/day and 6-mercaptopurine ≤1.5 mg/kg/day.

Individuals on anti-TNF biologics (such as those used in rheumatoid arthritis), may receive the HZ vaccine after review with an expert in immunodeficiency.

With these new guidelines it is easier for family doctors to guide patients when and whether they should have the vaccine.


Angela Mailis MD, MSc, FRCPC (PhysMed)
Director, The Pain & Wellness Centre, Vaughan
Consultant CIPP/UHN
Adjunct Professor, University of Toronto
Chair ACTION Ontario 

What if “I Can’t Afford My Prescription Medications?”

I’d hazard a guess that most of us with chronic pain have used or are using prescription pain medications. Without a health insurance plan, the costs can be huge, especially if our income drops! Even with a drug Insurance Plan, the costs can be a burden!

The Trillium Drug Program (TDP) is a provincial government program for residents of Ontario who spend a large part of their income on prescription medications. The TDP provides benefits for prescription medications when drug costs are higher than approximately 4% of the total household net income.

TDP is intended to offer prescription drug coverage for residents in Ontario who have high out of pocket prescription drug expenses in relation to their income. If you don’t have drug insurance coverage or when you exhaust your private plan (or have reached the annual dollar maximum for your drug plan,) Trillium can help by covering the drugs that you need.

Application forms for the Trillium Drug Program are available at pharmacies, clinics, and online. You can apply for Trillium at any time during the year and the application process can take anywhere from two to four weeks for your registration to be completed.

You will only have to apply to TDP once. Each program year, your enrolment in the TDP will be automatically renewed. If your file cannot be renewed for some reason, you will receive a pre-renewal notification letter requesting required documentation.

How do I know if Trillium will cover the medications I’m taking? The TDP covers over 3,800 prescription drug products and 450 Limited Use Drug products on the Provincial Drug Formulary. You can ask your pharmacist and/or your physician if the medications you are currently on are covered by TDP.

If you have any questions regarding your TDP application, you may contact TDP at: 416-642-3038 (calling in the Toronto area) or toll free at: 1-800-575-5386. Alternately, you can also contact TDP via e-mail at: trillium@ontariodrugbenefit.ca 

Benefits of a Chronic Pain Support Group

Across both Ontario and Canada there are support groups that bring together people suffering with chronic pain. Many of these groups are members of the Chronic Pain Association of Canada (CPAC). Their Mission is to improve the quality of life and daily function of people who suffer from pain, through education and awareness of community resources. Members share experiences and advice about the life changes that they are going through, while offering one another emotional comfort and moral support.

While group therapy is a formal type of mental health treatment under the guidance of a trained health care provider, these pain support groups are facilitated by volunteers, often a lay person. They offer free admission. Usually the only requirement for attendance is that the activities discussed in the group are kept confidential. While members meet for mutual support and learn about financial, social, medical and other needed resources, they also learn that each person with chronic pain is different. The latter is a very important lesson! 

Benefits of participating in support groups may include:

  • Feeling less lonely, isolated or judged
  • Talking openly and honestly about your feelings
  • Reducing distress, depression or anxiety
  • Developing a clearer understanding of what to expect with your situation
  • Getting practical advice or information about treatment options
  • Comparing notes about resources, such as doctors and medications
  • Learning about the types of financial and legal assistance that may be available
  • Meetings others who are successfully living with yours or a similar condition
  • Gaining a sense of empowerment and control

Most of all, support groups offer HOPE. Living with chronic pain sometimes means living a life at less than full strength. Life can still be rich when lived like this. The members of support groups can help show us how to manage our pain and adapt our lives suc- cessfully.

The Chronic Pain Association of Canada has a list of peer led chronic pain support groups from across Canada, including Ontario. The link is http://redirect.hp.com/svs/rdr? TYPE=4&s=webslice&tp=iefavbar&pf=cnnb&locale=en_us&bd=pavi lion&c=103

Non Medical Pain Therapies

We asked Dr. Sean Sutton, a chiropractor at The Pain & Wellness Centre in Vaughan to provide us with some explanations of different therapies used in pain management. Many of these treatments and therapies can be done by manual therapists such as chiropractors and physiotherapists, but some of these techniques require special training. Here is Sean’s “Glossary”: 

Active Release Therapy ® is a soft tissue system based massage technique that treats problems with muscles, tendons, and ligaments. ART is helpful at relieving pain, spasm and adhesions in tight muscles, which are often a result of overuse injuries. 

Acupuncture is a technique in which a fine disposable needle is inserted into the skin and tissues of the body to reduce and/or relieve pain, improve muscle function and stimulate the body to produce its own natural pain relieving chemicals called endorphins. Be aware there are more than one kind of acupuncture techniques.

Chiropractic Adjustments, also known as “Manipulations”, are a therapeutic technique used to treat conditions involving jointsofthespineandextremities. A gentle but fast thrust is directed towards a joint with the goal of improving movement, decreasing muscle spasm and relieving pain. There may be an accompanying audible release of gas (“pop”) that is a combination of oxygen, nitrogen and carbon dioxide, which releases joint pressure. 

Spinal Mobilizations are used similarly to chiropractic adjustments in that they aim to restore or enhance joint function. Unlike a chiropractic adjustment, mobilizations often involve slow oscillatory passive movement, usually to the end of a joints range of motion, to mobilize a joint.

Exercise Therapy consists of a plan of physical activities designed and prescribed with specific therapeutic goals in mind. An exercise therapy plan may be used to restore normal musculoskeletal function, reduce pain caused by injury, or build endurance to protect against further harm. 

Aqua Therapy uses water-based exercises for therapeutic intent, in particular for relaxation, fitness, and physical rehabilitation. Exercise is performed while floating, partially submerged, or fully submerged in a pool. These programs are beneficial for conditions where limited or non-weight bearing movement isdesirable, or where normal functioning is limited by inflammation, pain and muscle spasm.

Electrical Therapies such as Transcutaneous Electrical Nerve Stimulation (TENS) or Interferential Current (IFC) use varying frequencies of electrical current for pain relief. Electrodes are placed on the skin around the injured body part and the device transmits electrical impulses to the under- lying tissues to relieve pain through the production of endorphins, and reduce muscle spasm caused by inflammation.  

Cold Laser Therapy or Low level Laser Therapy (LLLT) utilizes specific wavelengths of light to interact with tissue and is thought to accelerate the healing process, eliminate pain, decrease swelling, and reduce muscle spasm.

Ultrasound Therapy is a method of stimulating the tissue beneath the skin’s surface using very high frequency sound waves. Ultrasound may be helpful in speeding up healing by increasing blood flow in the targeted area, and decreasing pain from the reduction of swelling.

Shockwave Therapy involves the application of short, frequent, and high intensity
bursts of mechanical energy (in the form of a shockwave) into tissues that are injured, scarred, painful, or inflamed. Shockwave can increase local blood flow, improve healing, break apart scar tissue, reduce muscle spasm and decrease pain. 


Dr. Sean Sutton, BSc, DC
Acupuncture Provider
Diplomat of the Canadian Academy of Pain Management (CAPM)
Certified Strength Coach (CSC)

The Pain & Wellness Centre
2301 Major Mackenzie Dr. West
Vaughan, ON L6A 3Z3
email: seansutton1010@gmail.com
tel: 416-587-0512
fax: 1-844-358-9308 

The Ontario Pediatric Pain Network

In Canada one in five people live with chronic pain. This includes children.

Drs. Jennifer Stinson & Fiona Campbell

Drs. Jennifer Stinson & Fiona Campbell

Access to specialized pain care from a multidisciplinary team is the gold standard for people with debilitating pain, both adults and children. However, there are not enough specialized chronic pain clinics and most clinics have a one to two year waiting list. When it comes to children, until recently there were only eight pediatric multidisciplinary chronic pain clinics in Canada with several provinces having no access to these services. There has been also lack of intensive rehabilitation programs for those children most severely disabled by their pain. Some pediatric patients go to the United States to receive care. This is challenging for families and expensive for society. This problem is made even worse because health care providers in the community don’t get enough training in the assessment and management of chronic pain in general, including the appropriate prescribing and monitoring of opioids.

Consumer groups, such as ACTION Ontario and People with Neuropathic Pain (PNP) have been actively lobbying the provincial government for more chronic pain services for both adults and children. Put together, all of these factors helped raise awareness about chronic pain and the need for better healthcare services. In Ontario specifically, there has been a fair amount of progress as the Ministry of Health and Long Term Care (MOHLTC), the Ontario Medical Association, and healthcare providers from the pediatric and adult health centers in Ontario have come together to form the Chronic Pain Advisory Network. 

A subgroup of this Chronic Pain Network is the Pediatric Academic Chronic Pain Advisory Network. It was developed in 2013 to advise on developing a provincial strategy for managing pediatric chronic pain. This network is being co-chaired by Drs. Fiona Campbell and Christina Lamontagne, together with Dr. Garry Salisbury, Senior Medical Advisor Health Services Branch (MOHLTC). This group also includes sub-committees focused on research and evaluation, education, and clinical care agendas. A pediatric Network study found that children and youth seen at a tertiary referral chronic pain clinic used other healthcare services far less than those who didn’t. This positive finding led to MOHLTC investment in pediatric chronic pain programs; this investment will lead to better access to more pain services for children and their families in Ontario.

The Pediatric Network has so far received funding for, two new chronic pain programs at the Children’s Hospital of Western Ontario in London and at McMaster Children’s Hospital in Hamilton, the enhancement of two existing programs at SickKids in Toronto and Children’s Hospital of Eastern Ontario in Ottawa, and the creation of the first intensive inpatient program in Ontario between SickKids and Holland Bloorview Kids Rehabilitation Hospital, with a second to be established in Hamilton. 

The Pediatric Network has developed and is piloting a pediatric chronic pain registry at SickKids led by Dr. Jennifer Stinson. This national registry collects a variety of information about patients across the country. The data can be compared and shared to help inform decision-making. It can also be used to inform research questions. Due to the size of the registry, research questions will be more meaningful and the answers will be more useful to pediatric patients and healthcare providers. The information being collected will also help researchers and policy makers to understand the impact of pediatric pain on society. Such as; Who is at risk? What does pain cost the healthcare system? Finally, the pediatric pain registry will also help the MOHLTC and other funding bodies make decisions about how best to support children and young adults with chronic pain, such as funding more multidisciplinary pediatric chronic pain clinics and pediatric pain networks across provinces.

It is hoped that the Adult Academic Pain Network under the umbrella of MOHLTC will follow in the successful steps of the Pediatric Network. 


Fiona Campbell BSc, MD, FRCA Staff, Department of Anesthesia and Pain Medicine Co-director, SickKids Pain Centre The Hospital for Sick Children, Toronto Associate Professor, Department of Anaesthesia Faculty of Medicine, University of Toronto 

Home: 416-813-7451
Fax: 416-813-7543
Email: fiona.campbell@sickkids.ca 

Jennifer Stinson, RN-EC, PhD, CPNP Mary Jo Haddad Nursing Chair in Child Health Senior Scientist, Child Health Evaluative Sciences Nurse Practitioner, Chronic Pain Program The Hospital for Sick Children Associate Professor, Lawrence S. Bloomberg, Faculty of Nursing, University of Toronto

Phone: (416) 813-7654 ext. 304514
Fax: (416) 813-8501
Email: jennifer.stinson@sickkids.ca 

Retiring on a Low Income?

Many of us with chronic pain are receiving some form of income replacement such as WSIB or disability insurance. These usually end at age 65, if not before, with the result that our retirement incomes will be quite low [compared to our former employment income]. Do you think that YOU might have to retire on a low income? Will your income be low for a long time BEFORE you retire? Then maybe you need to start planning NOW!

Reducing housing costs takes both advance planning and strategy! There are both seniors’ & co-operative non-profit apartment buildings across the province, where the rent only increases to cover expenses. Some of these have long waiting lists but others are available with only a few months’ notice! Rent-geared-to-income apartment buildings [RGI] often have waiting lists of five to seven years but heh; you’re going to age anyways, so why not apply now. [These RGI buildings usually charge a max. 35 % of income.] There are specialized disability apt. units as well, fully accessible for those using scooter, wheelchairs and other assistive devices. The means test for these apartment units are based on an individual’s or family’s INCOME, not their ASSETS. 

There is one excellent web site designed for those of us ‘Retiring on a Low Income’ and that is “OPEN POLICY On- tario by John Stapleton” [www.openpolicyontario.com/retiring-on-a-low-income-3]. I recommend that everyone read it. It gives much practical advice for those of us cur- rently on low incomes. Its strength lies in advising us how to prepare properly for our future retirement! 

The following is an example from this website. Financial advisors are constantly advising people to put money into an RRSP but this is bad advice for those who expect to receive the Guaranteed Income Supplement [GIS] when they retire. The reason: money taken out of an RRSP is taxed as income for that year, reducing or eliminating the GIS. Money taken from a Tax Free Savings Account [TFSA] does NOT affect the GIS. Also please visit www.health.gov.on.ca for information regarding the Trillium drug/health benefit plan. 

Other topics that he tackles are: 1. Maximizing the G.I.S. 2. The advan- tages of taking Canada Pension at age 60. 3. The smartest way to save before age 65 4. The smartest way to save after age 65. 

News From: The Ontario Pediatric Pain Network

In Canada one in five people live with chronic pain. This includes children.

Access to specialized pain care from a multidisciplinary team is the gold standard for people with debilitating pain, both adults and children. However, there are not enough specialized chronic pain clinics and most clinics have a one to two year waiting list. When it comes to children, until recently there were only eight pediatric multidisciplinary chronic pain clinics in Canada with several provinces having no access to these services. There has been also lack of intensive rehabilitation programs for those children most severely disabled by their pain. Some pediatric patients go to the United States to receive care. This is challenging for families and expensive for society. This problem is made even worse because health care providers in the community don’t get enough training in the assessment and management of chronic pain in general, including the appropriate prescribing and monitoring of opioids.

Consumer groups, such as ACTION Ontario and People with Neuropathic Pain (PNP) have been actively lobbying the provincial government for more chronic pain services for both adults and children. Put together, all of these factors helped raise awareness about chronic pain and the need for better healthcare services. In Ontario specifically, there has been a fair amount of progress as the Ministry of Health and Long Term Care (MOHLTC), the Ontario Medical Association, and healthcare providers from the pediatric and adult health centers in Ontario have come together to form the Chronic Pain Advisory Network.

A subgroup of this Chronic Pain Network is the Pediatric Academic Chronic Pain Advisory Network. It was developed in 2013 to advise on developing a provincial strategy for managing pediatric chronic pain. This network is being co-chaired by Drs. Fiona Campbell and Christina Lamontagne, together with Dr. Garry Salisbury, Senior Medical Advisor Health Services Branch (MOHLTC). This group also includes sub-committees focused on research and evaluation, education, and clinical care agendas. A pediatric Network study found that children and youth seen at a tertiary referral chronic pain clinic used other healthcare services far less than those who didn’t. This positive finding led to MOHLTC investment in pediatric chronic pain programs; this investment will lead to better access to more pain services for children and their families in Ontario.

The Pediatric Network has so far received funding for, two new chronic pain programs at the Children’s Hospital of Western Ontario in London and at McMaster Children’s Hospital in Hamilton, the enhancement of two existing programs at SickKids in Toronto and Children’s Hospital of Eastern Ontario in Ottawa, and the creation of the first intensive inpatient program in Ontario between SickKids and Holland Bloorview Kids Rehabilitation Hospital, with a second to be established in Hamilton.

The Pediatric Network has developed and is piloting a pediatric chronic pain registry at SickKids led by Dr. Jennifer Stinson. This national registry collects a variety of information about patients across the country. The data can be compared and shared to help inform decision-making. It can also be used to inform research questions. Due to the size of the registry, research questions will be more meaningful and the answers will be more useful to pediatric patients and healthcare providers. The information being collected will also help researchers and policy makers to under- stand the impact of pediatric pain on society. Such as; Who is at risk? What does pain cost the healthcare system? Finally, the pediatric pain registry will also help the MOHLTC and other fund- ing bodies make decisions about how best to support children and young adults with chronic pain, such as funding more multidisciplinary pediatric chronic pain clinics and pediatric pain networks across provinces.

It is hoped that the Adult Academic Pain Network under the umbrella of MOHLTC will follow in the successful steps of the Pediatric Network. 


Fiona Campbell BSc, MD, FRCA Staff, Department of Anesthesia and Pain Medicine Co-director, SickKids Pain Centre The Hospital for Sick Children, Toronto Associate Professor, Department of Anaesthesia Faculty of Medicine, University of Toronto Phone: 416-813-7451 Fax: 416-813-7543 Email: fiona.campbell@sickkids.ca 

Jennifer Stinson, RN-EC, PhD, CPNP Mary Jo Haddad Nursing Chair in Child Health Senior Scientist, Child Health Evaluative Sciences Nurse Practitioner, Chronic Pain Program The Hospital for Sick Children Associate Professor, Lawrence S. Bloomberg, Faculty of Nursing, University of Toronto Phone: (416) 813-7654 ext. 304514 Fax: (416) 813-8501 Email: jennifer.stinson@sickkids.ca 

You Are Not Allowed To Be Negative!!!

I had just come back from attending the Canadian Pain Society annual conference in Winnipeg. I go to this conference every year to present some of my research work, see the research work of other colleagues and acquire new knowledge. Such conferences as well provide opportunity to meet with colleagues around the country and network.

The night before the end of the conference, I was having a bite to eat with a colleague, a mature female physician looking after pain patients for many years, while discussing stories that we thought were unusual or unique. I now feel compelled therefore, to share with you one of my colleague’s recent encounters with a 38-year-old woman who had been hurt in the performance of her duties as a nurse and had developed a chronic pain condition. Let’s call my colleague Dr. M and the patient RN.

RN walks to the doctor’s office visibly upset and agitated. Dr. M asks her to explain exactly what her problem was. RN speaks loud and fast, giving details about her workplace accident and making unflattering comments about her work supervisor and the care she received from her doctors. After 10 minutes of incessant talking, RN paused realizing that Dr. M who has remained totally silent, is scribbling some vertical lines on her note pad.

RN: What are you doing Dr. M?
Dr. M: I am drawing a line every time you use a negative word such as pain, anger, upset, insensitive, not understanding etc. So far in these 10 minutes I marked 38 negative words.
RN: You must be kidding! I find this very rude.
Dr. M: 39!
RN: You certainly seem to be insensitive to my pain!
Dr. M: 40, 41!
RN. This is a joke. You seem to ridicule my pain. I think you are worse than all the other ignorant doctors I saw so far.
Dr. M: 42, 43, 44, 45!
RN: Can you tell me why you use this approach with me?
Dr. M: You are overloaded with negative and angry feelings. These can only feed and increase your pain. Have you discussed with your family how they feel when you come across always so angry and negative?
RN: Leave my family alone. They proved to be indifferent, insensitive, selfish and uncaring anyway.
Dr. M: 46, 47, 48, 49!
RN: Enough! Next you will hear from me, it would be when I file a complaint against you with the College of Physicians (RN storms out of the room).
Dr. M: 50! 

I was amazed. In our line of work, we see a few disgruntled patients who are always dissatisfied with our care, obnoxious, verbally abusive towards us as physicians but also the support staff (secretaries etc), and complain about the care we give them. This type of patients takes a real toll on physicians’ emotions as we have to undergo lengthy processes to exonerate ourselves.

I admire you, I said to my colleague. How did you manage to get through this whole encounter? This is a definite recipe for disaster with a sure complaint to the College of Physicians and Surgeons (the provincial body that grants our license to practice).

Dr. M. nodded. I thought for sure, she was going to file a complaint but I could not resist pointing out her constant negativity. Nevertheless, nothing happened for a couple of months.

And then, I asked with great curiosity. Did she file a complaint?

No, Dr. M. replied. To the contrary, she asked to see me again. I was not happy at all given our previous consult and I expected another shouting encounter. But strangely, it did not happen. To the contrary, I saw a calm woman, coming into my office, sitting in a chair opposite to me and greeting me with a smile. I was stunned. I reciprocated the greeting and asked her what happened.

RN: When I left your office a few weeks ago, I was extremely angry with you for pointing out that I was negative. I went home and asked husband and kids to tell me frankly what they thought of my pain and my general mood. To my surprise, they let me know that they find me angry, negative and complaining all the time.
Dr. M: So, what did you do after you had this talk with the family?
RN: I decided to mark down all my negative thoughts every waking hour of the day for a few days. I then realized with disgust that I could not last longer than five minutes before an angry thought or feeling would pop into my head, which I had to write down. I became very aware of my negative feelings. I am now ready to ask you to help me, so that I can harness my thoughts and maybe I can somehow control my pain.

To make the long story short, Dr. M. worked with RN on her medications for pain and to set objectives and targets for therapy and her recovery. RN responded well to structured goals and also joined a Mindfullness Based Stress Reduction program, to learn to relax. Today, she has returned part time to work on modified duties and works towards her goal to return to full time nursing duties soon.

The story is very didactic and I use it to talk to other pain patients regarding negative feelings and thoughts. Learn to control and curtail negative thoughts and for sure, your pain perception will decrease substantially. Trained professionals, such as pain physicians, psychologists, social workers etc., can very much help you to navigate the sea of negative emotions and restore your emotional balance. 


Angela Mailis, MD, MSc, FRCPC(PhysMed) CIPP/UHN Consultant Adjunct Clinical Professor, Dept. of Medicine University of Toronto, Director, The Pain & Wellness Centre, Vaughan, ON Chair ACTION Ontario

Helping Your Brain Cope With Chronic Pain

Over the years, many researchers and health care professionals alike have come to understand that pain is not a solitary central nervous system (CNS) process; that is, what you feel is not pain alone. Other CNS processes play a role in our experience and sensation of pain. These include areas of the brain involved in fear and anxiety; attention and vigilance; and memory and past experiences. As the pain becomes more chronic, these other processes take on a more prominent role. Someone in constant pain will become more vigilant and attentive to his/her symptoms so that pain always feels in the forefront of their lives. As well, being more aware of your pain along with fear/anxiety of causing further pain with physical activity (based on experience), makes many people feel that they have to restrict and limit their activities to avoid more pain. Feeling constant pain, being restricted by pain, and having at times to make dramatic changes to one’s lifestyle to accommodate pain can make people feel more anxious, stressed and depressed. They do not feel in control of their pain, their feelings or their lives. Pain is therefore a WHOLE person problem, an interplay of both the mind (our emotions) and the body.

Psychologists who specialize with chronic pain patients understand the interplay between the mind and body. By the time we see a pain patient, he/she has undergone multiple medical assessments and treatments with minimal to some relief of symptoms. Psychologists understand that emotions, thoughts and vigilance play a role in “amplifying” the pain experience. Have you ever noticed that when you are feeling very stressed, angry or depressed that your pain seems worse? Or that your pain seems less intense when you are caught up in an activity that grabs your attention or makes you feel happy? Psychologists, like myself, focus on teaching patients more effective ways to cope and manage their pain by helping them to change negative thoughts and feelings, reducing stress, improving sleep, and setting goals to engage in more positive daily activities. Making positive changes to these areas serve to lower the “amplification” of pain. This is accomplished through various psychological strategies.

For example, Cognitive-Behavioral Therapy (CBT) is often used to help patients become more aware of their negative thoughts and feelings and to develop alternative ways to look at problem areas (including pain) so that the patient can resolve them without getting caught up in them. Patients learn relaxation training and/or mindfulness meditation to teach them ways to reduce muscular tension through the body and to relax the mind, which helps to

reduce stress levels. Helping patients resume some of their daily activities is accomplished by utilizing the various skills acquired in sessions, setting small goals that are achievable and gradually increasing the level of activity while staying in control of pain. A pain psychologist will tailor the strategies to the needs of each patient and treatment goals are discussed at the very beginning so that the patient and psychologist are on the same page in terms of the patient’s needs and expectations.

Research has consistently shown that psychological counseling is one of the most effective treatment strategies for chronic pain. If you have been struggling with depression, anxiety, stress, and/or anger because of chronic pain, then it may be time to contact a pain psychologist to help lessen your emotional suffering and to get you on a more positive path to living a good life with pain. 


Karen Spivak is a registered Psychologist by the College of Psychologists of Ontario since 1990. She received her Ph.D. in Psychology from Concordia University in Montreal in 1987 and pursued post-doctoral training at the Addiction Research Foundation and the Clarke Institute of Psychiatry. Since 1992, Dr. Spivak has maintained a private practice, providing psychological assessments and treatment for chronic pain, depression, anxiety, stress and post-accident adjustment difficulties In addition, she is a consultant with the Comprehensive Interdisciplinary Pain Program at the Toronto Rehabilitation Institute, and she provides counselling to pain patients as part of the interdisciplinary team at the Pain and Wellness Centre in Vaughan, Ontario.

Karen Spivak, Ph.D. C.Psych Comprehensive Interdisciplinary Pain Program @ Toronto Rehab Institute & Pain and Wellness Centre, 2301 Major Mackenzie Dr. West Vaughan, ON L6A 3Z3 email:karenspivak@rogers.com tel: 416-587-0512 fax: 1-844-358-9308