Left jab, right cross, left hook: Hannah Terrell pummels a punching I bag in full-out fury, her red boxing gloves set off by a pink T-shirt and pearl earrings. No, this isn't a gym, and Terrell isn't training for a shot at Laila Ali. The Vanderbilt University sophomore is a patient at the Cleveland Clinic's Chronic Pain Rehabilitation Program, where hitting the big bag is part of her therapy—a way of purging half a lifetime's worth of anger and frustration. Since shattering her left ankle in a fall 10 years ago, Terrell, now 20, has endured five surgeries and physical anguish so punishing that she sometimes could not stand upright for more than a few minutes. Last fall "I was crying all the time," she says. "I skipped classes because I was knocked out by medications. My body was out of control."
Her suffering is all too common, for Terrell is among millions of Americans tormented by chronic pain. A recent study published in the Clinical Journal of Pain shows that the majority of patients receive inadequate treatment. In part this is because all too few physicians are trained specifically in pain management. Even excellent doctors tend to regard pain as a byproduct of illness or injury; they try to treat it with drugs, from aspirin to opiates. "All of us would rather have someone take away our pain with an injection than be taught how to live with it," says Dr. Edward Covington, director of the Cleveland Clinic program. But meds often offer only brief or partial relief, and when prescribed improperly their side effects (ulcers from analgesics; dopiness from narcotics) can be nasty.
Covington, 56, is helping to pioneer a more comprehensive—and, experts say, effective—approach. "Ed is a leader in his field," says Dr. Jeffrey D. Rome, medical director of pain rehabilitation at the Mayo Clinic in Rochester, Minn. The Cleveland program is one of a handful in the U.S. that attack intractable pain not only with carefully calibrated pharmaceuticals but also with exercise, biofeedback, self-hypnosis, psychological counseling and family therapy. That regimen is based on a growing body of research showing that pain is "intensely affected by emotions, fears and beliefs," says Covington, and that treating it as a mere symptom is not always enough. In chronic cases, says Covington, pain can cause permanent neurological changes. "Pain becomes an evolving, perpetuating problem," he explains. "A disease."
That was certainly the case for Terrell. An athletic girl who loved field hockey, she was 10 when she plunged 15 ft. off a zip line—a backyard cable ride strung between two trees. Despite years of operations, nerve damage set in and her agony became unbearable. Painkillers (Celebrex and Percocet, among others) worked only intermittently. "Pain defined her, it ruled her life," says her mother, Sally, 45, a homemaker. By last fall the child-development major was falling behind in her classes and dropping out of campus social life. "I missed my old self," Terrell says. "I felt helpless."
She discovered the Cleveland Clinic in December, after years of shuttling from specialist to specialist in several states. Told by a surgeon that she needed yet another operation, Terrell consulted a California pain counselor, who suggested that she try a new strategy—one available just a few miles from the Chagrin Falls, Ohio, home she shares with her mother and her father, Steve, 46, a financial consultant. "It was really my last resort," Terrell says. "I'd tried everything."
So have most patients at the Cleveland Clinic's all-day program, which offers a three-to-four-week course to a dozen sufferers at a time. They learn that the mind-body phenomenon of pain can be modified by psychological or external events. An adrenaline rush, for example, can minimize pain. "That's what allows you to score a touchdown with a broken leg," says Covington, a psychiatrist and married father of three who got his medical degree at the University of Tennessee and came to the Cleveland Clinic in 1979. On the other hand, he notes, brain-imaging studies show that fear or anxiety increases pain. "Some areas of the brain reflect the sensory component—the 'ouch' factor," he says. "Others reflect emotional suffering."
Covington "understands that you can't be in pain for any significant period and not become depressed or anxious," says Dr. Hubert Rosomoff, medical director of the University of Miami's pain rehab center. Former patients agree. Spinal fusion surgery had left Darlene Davis, 46, with severe pain in her limbs, back and head, forcing her to quit her nursing job. "I was so depressed, it was like living inside myself in a hellhole," she recalls. Thanks to Covington, Davis is working at her family's window company and now makes the clinic sound like Lourdes on Lake Erie. "A woman came in with a cane and dumped it the second day," she says. "A woman in a wheelchair was walking. But it isn't the physical transformations that are so amazing, it's the emotional ones. You see people become alive again."
For Terrell that process was not easy. At Cleveland the staff pushed her to be more active—learning to put into practice the philosophy of "working through your pain." By the end of the first week she was jogging, swimming and lifting weights. "It wasn't that she did not have pain but that her pain didn't get worse once she started to work out," says physical therapist Maribeth Gibbon. "Her confidence in her body increased." Along with counseling, exercise helped her clear a major barrier: fear. "One of the most important things we do is send people to the gym, where they find themselves doing things they didn't think they could do," says Covington. "They think, 'Maybe I'm not quite as helpless as I thought I was.' "
But during her second week Terrell suffered a setback during a session in which 50 ex-patients discussed how they managed their pain. The dispiriting word was "managed." Though many who spoke were upbeat ("I have such a desire for life that I did not have," said one woman who suffers from excruciating cluster headaches), the reality that their pain—and hers—might never disappear made Terrell slump lower and lower in her seat. A few hours later, in a family therapy session, she broke down. "My pain is not going to go away," she sobbed. "I can't deal with it."
By the end of the third week, however, she had righted herself. And on Jan. 17 she was discharged to return to school. Covington prescribed a battery of medications—including an antidepressant, two anti-epileptic drugs known to fight pain, and Ultram, an analgesic. But she was also assigned activities such as walking, yoga and relaxation exercises.
"I'm still in pain, but when I find myself slipping back, I can catch myself and try to calm down," she says. "We talked in the program about how you have to allow yourself a bad day every once in a while." Now the good days are more frequent. Terrell regularly walks to class. Not only does she stand and schmooze at parties, but she has been known to dance. "It's nice," she says, "to feel a little bit more normal."
Giovanna Breu in Cleveland
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