About Chronic Pain

A primer for patients trying to understand their symptoms

 

Chronic pain is a life-changing disease that impacts nearly 100 million individuals, or about 1 in 3 people, according to an Institute of Medicine (IOM) report. Self-dubbed “warriors,” chronic pain patients fight symptoms ranging from nerve, joint, muscle, and burning pain, to endless fatigue and decreased functioning, every day.

Difficulty in diagnosing and treating chronic pain conditions, which often co-occur with secondary medical issues (called comorbidities), means that medications and therapeutic remedies are often approached through a trial process. The complex nature of chronic pain disease can sometimes cause friends and family members to misunderstand the severity of their condition. Chronic pain patients may therefore feel angry, confused, and depressed, and are constantly seeking relief in a return to normal life. This primer aims to provide insight and resources for those living with chronic pain, while also educating those who may have a loved one suffering from a chronic pain condition.

Who is Affected by Chronic Pain?

The number of chronic pain sufferers surpasses the incidence of those living with cardiovascular disease, diabetes, and cancer. Common pain conditions include back pain, headaches/migraine, neck pain, and arthritis and joint pain. Women are more likely to experience pain (such as neck pain or lower back pain) than men, and are twice as likely to experience migraines, severe headaches, or pain in the face/jaw, according to the Department of Health and Human Services.

Chronic pain is also prevalent among the military. According to the Veterans Health Administration, more than 50% of veterans receiving care at their facilities across the country are affected by chronic pain conditions.

Every year, chronic pain is responsible for lost workdays that take a toll both emotionally and financially on those affected, not to mention their families and coworkers. According to the IOM report, pain is a public health issue that costs $560 to $635 billion annually in healthcare fees and lost productivity in the form of missed workdays, low hours worked, and lower wages. The difficulty of living with unrelenting pain often leads to long and frequent hospital stays, and decreased ability to carry out typical activities in what is often referred to as an “invisible” disease.

Types of Chronic Pain

According to the American Academy of Pain Medicine, pain is associated with a wide range of injury and disease, and can also become a disease in of itself. Some chronic pain conditions may arise from a specific cause, such as a surgery, invasive procedure, or severe injury, while others may evolve from conditions in which pain is the primary problem, such as neuropathic pain or migraines. Below is an overview of common types of pain and why they may occur.

Acute Pain versus Chronic Pain, and Pain Chronification

Chronic pain can emerge as the result of acute pain, a normal sensation triggered in the nervous system to alert you to possible injury. You may feel acute pain, for instance, from a cut, broken bone, or stress headache. Chronic pain is more persistent and constant (pain lasting more than 12 weeks), according to the Academy of Pain Medicine. When chronic pain occurs, pain signals continue to be sent to the brain in the nervous system for weeks, months, and even years. Sometimes, there may be an initial issue that causes this excessive signaling, such as a sprained back, infection, or an ongoing inflammation caused by arthritis, cancer, or even an ear infection.

Acute pain can also transition into chronic pain, in a process known as “pain chronification” and therefore requires attention early on. An international group of doctors recently described this progression as an “imbalance between pain amplification [abnormal pain sensitivity] and pain inhibition [the ability for the pain to fade away].” A person’s genetics, personality/behavior, and environmental factors may determine the likelihood of pain chronification occurring, as well how strong and how long the transition may last. Essentially, structural changes occur in the brain’s pain control systems. Musculoskeletal pain, for example, starts out localized, and then extends regionally and spreads out more and more as time passes.

There are various types of chronic pain, and they all have distinct features:

  • nociceptive, which is divided into somatic or visceral pain, is typically pain that comes from the result of an injury (eg, broken bone, appendicitis, etc.), according to the American Pain Society. Nociceptive pain can also emerge after a surgery or traumatic event such as a car accident. Somatic pain is that which comes from joints, bones, muscles, and other soft tissues, while visceral pain is associated with the internal organs.
  • neuropathic, which is divided into centralized or peripheral pain, refers to pain signals sent from a single or group of nerves or from the central nervous system as a whole, according to the American Pain Society. Neuropathic pain can give way to paresthesias, numbness, tingling, or electrical sensations and other unpleasant stimuli. Neuropathic pain is often associated with spinal cord or brain injuries, where the central nervous system lives. Centralized pain is that which lies in the central nervous system (nerve tissues in vertebrates in the spine and brain) while peripheral pain affects the peripheral nervous system (that outside of the brain and spinal cord). According to the American Stroke Foundation, peripheral pain is often seen at the exact site of the injury, while centralized pain is a more delayed response. According to the American Academy of Pain Medicine, between 3% and 4.5% of the world’s population suffers from neuropathic pain. Prominent symptoms of neuropathic pain may include:
  • allodynia, or pain caused by something that does not usually provoke pain, such as a light touch; and
  • hyperalgesia, which is extreme pain caused by something that does usually provokes pain, such as nerve damage, according to the American Migraine Foundation and the Institute for Chronic Pain, respectively.
  • phantom pain can occur as well, when, for instance, a limb is amputated and pain lingers in that location or even another location of the body.
  • breakthrough pain or pain flare, also referred to as a flareup, is often associated with cancer and may feel like a sudden increase in pain, even when it has been stabilized or managed for some time. Breakthrough pain may occur in patients who already experience chronic pain as a result of cancer, arthritis, fibromyalgia, or other conditions, according to the National Cancer Institute. Such flares are usually severe but only lasts a short time, and are usually found in the same place as where the patient’s chronic pain lives. Stress, illness, excessive coughing, exercising, or the wearing off of pain medicine are the usual aggravators of breakthrough pain. This type of pain is typically not a symptom of a new condition, nor is it a condition that has gotten worse. According to the American Academy of Pain Medicine, 6 out of 10 patients (60%) said they experience breakthrough pain one or more times a day.
  • complex regional pain syndrome/reflex sympathetic dystrophy (CRPS/RSD) is a chronic neuro-inflammatory disorder that occurs when the nervous system and the immune system malfunction as they respond to tissue damage from trauma. The nerves misfire, sending constant pain signals to the brain, according to the Reflex Sympathetic Dystrophy Syndrome Association (RSDSA). This pain typically comes after a musculoskeletal injury, nerve injury, surgery, or immobilization. According to the RSDSA, although rare, up to 200,000 individuals experience this condition in the United States alone every year.

How Does the Sensation of Pain Work?

Imagine being stroked on the arm with a light feather, but your brain telling you that it feels like flames. This analogy was described in a TED talk by Dr. Elliot J. Krane, pediatric anesthesiologist at the Lucile Packard Children’s Hospital at Stanford University. In a presentation called “The Mystery of Chronic Pain,” Dr. Krane explained that the problem lies within the nervous system. Normally, stubbing a toe sends nerves (neurotransmitters) from your toe to your spinal cord, which sends new signals to your brain and alerts you of the pain in your toe.

However, as Dr. Krane pointed out in his discussion, the brain and nervous system are flexible (often referred to as neuroplasticity) and can change when stimulated. With chronic pain, neurotransmitters spill outside of the spinal cord and interact with other nearby cells. Called glial cells, they play a vital role in how one experiences and perceives certain sensory inputs. When the glial cells are activated and synthesize new proteins, they then spill out and interact with other close-by nerves. This causes a sort of endless loop in which pain increases and feels constant across a certain part of the body. The failing nerves and brain reception take the pain to excruciating levels, and many treatments, unfortunately, only mask the symptoms rather than treat the disease comprehensively. See also, common myths about chronic pain.

Types of Pain Doctors

Doctors for pain management range from primary care physicians, to specialists, to clinicians that help treat comorbidities (that is, when more than one condition or disease occurs in the patient) and other symptoms, such as psychosocial treatment that is sometimes needed when depression or anxiety rear their ugly heads.

  • Primary care doctors include internists, obstetricians, and gynecologists
  • Pain management specialists include rheumatologists, orthopedic surgeons, neurologists, osteopathic doctors and spine specialists
  • Physical medicine and rehabilitation specialists (PM&R, also called physiatrists) 
  • Chiropractors, acupuncturists, physical and occupational therapists
  • Neuropsychologists
  • Psychologists and psychiatrists
  • Nurse practitioners, registered nurses, and physician assistants who participate in the team care of patients with chronic pain conditions

Treatment Approaches for Chronic Pain

As noted above, most individuals with chronic pain disease often have comorbidities or secondary underlying conditions, not to mention the common roles that fatigue, depression, and anxiety may play in these conditions. Therefore, treatment is often complex and multimodal in nature, requiring a team of doctors to make a comprehensive treatment plan. Treatments may include medication as well as complementary or alternative therapies, and biopsychosocial counseling.

Common treatment approaches include:

  • Alternative treatments, such as acupuncture, herbal remedies, massage, mindfulness meditation, and yoga
  • Hormone therapy for osteoarthritis or testosterone replacement for chronic pain
  • Interventions such as injections, stimulation, and pumps. More specific interventional treatments may include: local intramuscular TPIs, diagnostic medial branch injections, therapeutic facet joint and sacroiliac joint injections, radiofrequency nerve ablations, adhesiolysis (epidural lysis of adhesions), percutaneous disc decompression, and dorsal column/spinal cord stimulator treatments
  • Medications, which can include opioids and nonopioids
  • Mental health treatments such as behavioral therapies, biofeedback, as well as counseling and/or medication for depression and anxiety
  • Nutraceuticals, or nutrition-based treatment
  • Palliative care for those with serious life-threatening illnesses
  • Physical therapy and rehab

Many patients can also use self-management strategies and portable products to help relieve day-to-day symptoms.

Continuing the Fight

For chronic pain sufferers, life is a constant jump between doctors, treatment methods, and trialing techniques for managing their disease. Add to this, the emotional and mental health battles that may warrant their own therapies. Living with chronic pain may feel like a maze. “Why am I feeling this way? What doctor do I see? Why does this treatment not work for me anymore?”

Practical Pain Management, through the patient stories, in-depth condition overviews, and insights into traditional as well as novel treatment approaches presented across this website and within our Facebook community, hopes to help individuals and their caregivers get ahead of their debilitating disease. With improved therapeutics in the pipeline and alternative treatments being studied, individuals should remain hopeful for the future of controlling their chronic pain.

We encourage readers to take a look at our Smart Patient Guide to Chronic Pain Management for a list of resources to navigate the challenging terrain of living with chronic pain, and to working with chronic pain.

 

-Reported by PPM Editorial Staff

Updated on: 04/16/18
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