Chronic Pain

August 5, 2011

Chronic pain is a complex medical syndrome. Any episodic pain problem, including low back pain, neck pain, and migraine headaches, as well as many common medical problems such as diabetes can cause chronic pain. Chronic pain is any pain that, despite appropriate medical and surgical treatment, persists for 6 months or longer. Acute pain denotes tissue damage or injury, whereas chronic pain can develop insidiously from an acute problem. Many times the cause of the chronic pain cannot be determined. in these instances, chronic pain becomes the disease itself. Many people cope well with chronic pain; however, oftentimes, a chronic pain syndrome may develop.

The chronic pain syndrome has been defined by the Social Security Administration as intractable pain of 6 months or greater duration, which is associated with depression and anxiety that affects every aspect of a person’s life. Vocational, recreational, and family relationships become altered and there is a marked restriction in daily activities. Sleep disorders are common. There are frequent visits to physicians. Patients have a history of multiple tests, treatments, and surgeries without alleviation of the pain. There is excessive use of medications, and frequent use of a variety of medical services including emergency room services is common.

Back and neck pain are the most common causes of chronic pain syndromes and are associated with significant workers’ compensation costs. Back-related disability approaches 2% of the workforce at any given time. Lifetime prevalence for a significant episode of low back pain is 30-90%. The duration of an individual episode of low back pain is 2 weeks or more in 13% of individuals. The lifetime prevalence of neck pain is 40-70%. There are currently 28 million migraine sufferers worldwide, with more than 12 million in the United States. Twenty-one million of these sufferers are women and seven million are men. One in four households has at least one migraine sufferer. Other chronic medical problems which can produce chronic pain include rheumatoid arthritis (1%), diabetes (6%), and osteoarthritis (7%) (U.S. statistics).

Why should a single episode of illness, episodic pain problems, and chronic medical problems produce a chronic pain syndrome? Chronicity is determined not by the disease state alone, but by psychological and social factors. Certain psychological factors which predispose to a chronic pain problem include “catastrophic thinking” with interpretations of pain as mysterious or life threatening. Correlations between avoidance of an unpleasant situation such as working in a low-paying job or monotonous job or trying to avoid an unhappy marriage can lead to illness behavior which increases without a direct correlation to the pain itself. Fear of repeat injury and kinesiophobia (fear of movement) lead to deconditioning, which then produces a cycle of prominent susceptibility to strains/sprains and reinjury. Psychiatric illnesses such as depression (10-83%) share a high comorbidity with chronic pain. Situational or reactive depression may be associated with the pain, but endogenous depression can also be exacerbated by an episode of illness. This can lead to a lack of response to rehabilitation since depressed individuals do not rehabilitate well. Anxiety increases pain by causing an increase in release of stress hormones. Muscle contraction which produces chemicals such as lactic acid is also increased during anxiety. This can lead to a vicious cycle of chronic pain/anxiety/depression. Addictive disorders can also lead to chronic pain. However, meditation dependency may not be the initial presenting problem; patients in their attempts to alleviate their pain may increase the amount and frequency of their pain medications so that a dependency syndrome is produced. Lastly, personality disorders may predispose to chronic pain. There is a significant association of prior physical, sexual, or emotional abuse in patients with chronic pain.

The medical evaluation of chronic pain includes taking an appropriate history and performing a detailed physical examination. An evaluation of the specific pain problem should be undertaken if not previously done to ensure that no further testing or surgery is indicated. In addition, management of chronic pain requires a psychological evaluation to decide if someone is appropriate for self-management. Once it has been determined that all tests are complete, that no further assessment is required, and that medication adjustment alone will not alleviate a patient’s pain, a comprehensive self-management program is imperative. Patients should be both medically and psychologically appropriate. Individuals must be motivated for rehabilitation and be willing to be active participants in their own health care. Any type of active thought disorder or dementia will not allow a patient to participate in self-management. The goal of chronic pain management is just that, “management” and not a cure. Some pain relief may ascertained, but a cure, in most instances, is not possible. Individuals who are satisfied with their current sedentary lifestyle and inability to function in society will not benefit from active participation in a pain management program. In general, the best indication of a patient’s suitability for any type of self-management program is compliance with treatment instructions. Daily diaries to assess levels of activity including ability to sit, stand, walk, or lift before pain increases, amount of “up time” (time doing daily activities), and amount of “down time” (time spent resting or in bed) must be documented. Family and friends should be encouraged to participate in treatment. Family members need to provide support without excessive caretaking.

Chronic pain is a significant problem, which affects an individual’s ability to function and be productive.

Pain and disability is multifactoral and involves medical, emotional, and socioeconomic factors. It is a complex problem, which requires comprehensive treatment. Evidence is substantial that patients who have failed individual therapies will benefit from a comprehensive pain management program and have an excellent outcome with regard to ability to function within society.

SEE ALSO: Addiction, Anxiety disorders, Arthritis, Depression, Migraine, Osteoarthritis, Sleep disorders

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Category: C, Chronic Pains