About Chronic Pain

As a chronic pain sufferer, I am confident that there are very few people who are not able to describe pain and the damaging and negative effects that can follow. At some point in our lives, practically all of us have the misfortune to experience some kind of physical pain and discomfort, although usually this is no more severe than an occasional headache or the after-effects of over indulgence.

However for a significant number of people, pain does not 'go away' and they live with chronic Pain on a constant basis. this website is dedicated to such people.

Because pain cannot be seen, it's therefore difficult to 'measure'. There are no lab tests or x-rays that can accurately convey to your General Practitioner (GP) how and what you are feeling. in fact even when pain is severe, many people struggle to accurately find words to describe it to their GP. if this happens to apply to you, try to organize your thoughts by asking yourself these questions:

where is the pain and for how long have you been in pain?
How bad is your pain? try and use descriptive words to explain it to your GP. Is the pain shooting, stabbing, numbing, throbbing, aching, or is it a burning, radiating or tingling? Is it constant or does it come and go? Can you describe what triggers it?
What do you think caused your pain? Tell your GP about any injuries, illnesses or activities that you think may be related to the onset of the pain.
What medications or other pain relief methods (including alternative or herbal therapy) have you tried? How effective where they?
Besides this pain, do you have any other medical conditions? Are you taking medication for any of these conditions?
How has the pain affected your daily life? Be sure to describe the emotional changes in your life as well as the physical ones.

I have taken the liberty of including a pain chart for you to copy and paste in into a word processor. This may be useful for some people, as it can show at a glance overall levels of pain. To be taken to the link, please click here

Definition of pain

Whilst compiling this website, my thoughts were drawn to an actual definition of pain. It appears that this is actually difficult to define, as 'pain' means different things to different people. no doubt a SAS combat soldier would have a different threshold to and interpretation of pain as would a confused elderly man.

many chronic pain sufferers find that their pain is worst when they feel depressed and anxious, and is more tolerable when they are focused on doing something that demands attention or is enjoyable. Although in both cases, the physical cause of pain may be identical, the actual person's perception of pain can be dramatically different. this can be partly explained by an understanding of the role of distraction and endorphins.

however may people don't seem to realize that pain is a medical problem, and therefore treatment is available. Subsequently, it is important to differentiate between 'acute' or 'chronic' pain.

Acute pain is not related to an ongoing condition and declines when there is recovery from the illness, injury, or surgery thst initially caused the pain . Acute pain usually lasts for no longer than it takes to heal.
It is generally accepted by the medical profession that the following definition can be applied. chronic pain is a condition which persists for one to three months beyond the time that an expected acute pain or acute injury should subside or is associated with a chronic pathological process.

unfortunately chronic pain tends to defy logic and it would be unwise to simply consider chronic pain to be just an extended version of acute pain. The original injury causing the pain may have healed some considerable time prior, so why dose it still hurt? In simple terms, this is because the injured nerves don't just die off and disappear. when nerves are injured, they can become irritated, inflamed and retaliate with sever pain messages. In addition, if the pain is not treated effectively, and it can hurt in areas that are not connected with the original injury, it can be far more painful than the original injury, and it can become impossible to determine exactly where the pain originates. It is this potential danger that people must come to terms with through the process of pain management in order to promote and maintain a quality of life.

A word of caution, remember the longer the pain is untreated or under-treated the more likely the pain will cause destructive and permanent changes in the nervous system of the person experiencing the pain.

Prevalence of chronic pain

Although comprehensive information is not readily available, chronic pain is clearly a very widespread condition. In fact the most widespread chronic pain condition, such as low back pain, arthritis and recurrent headache (including migraine) are common - they are often seen as a normal and unavoidable part of life. One of the better quotes I have come across is, 'although few people die of pain, many die in pain, and even more live in pain'.

It is estimated over 80 per cent of the population in the United Kingdom take pain killers (analgesics) on a regular basis, and 10 per cent or more of the population of UK suffer from chronic pain.
In a prevalence study of persistent pain in Denmark, researchers found that approximately 38% of the general population suffers from chronic pain. (Andersen and Worm-Pedersoen 1989).
An epidemiological survey of chronic pain in Sweden found that 45% of all adults have experienced recurrent or persistent pain 8% severe persistent pain (Von Korff et al 1990)
Neuropathic pain effects 25-50% of patients attending most pain in the Grampian region of the UK found that 50% of those surveyed reported chronic pain or discomfort including 16% with back pain 16% with arthritis. In 16% of those surveyed chronic pain was severe. (Elliott et al. 1999).
The finding of a study in the Netherlands indicate that chronic pain is also a common complaint in childhood and adolescence (Perquin et al. 2000).

Physical and psychological changes through pain

Chronic Pain takes a psychological as well as physical toll, which can greatly increase the burden on the sufferer, carer, family and friends.

These include such aspects as:

Anxiety, fear, hopelessness, bitterness, irritability, frustration, depression, decreased activity and suicide.
Immobility and the consequent wasting of muscles, joints etc- leading to disability.
Depression of the immune system and increased susceptibility to disease.
Disturbed sleep and sleep patterns leading to constant tiredness.
Poor appetite and nutrition - leading to weight loss.
Potential dependence on medication - although estimates suggest only 0.1% of people prescribed opioid medication actually become addicted. This is partly due to the fact that people with legitimate pain do not get that "high" feeling when they take these drugs. Therefore there is no "reward" for taking the medicine for any reason other than keeping the pain at bay.
Over-dependence on family and other caregivers - potential marital problems.
Overuse and inappropriate use of professional healthcare systems.
Poor performance on the job or inability to work, unemployment and financial problems. Isolation from society and family, turning inwards.

Social and economic costs of chronic pain

While acute pain is by definition a brief process, chronic pain can easily dominate the life and concerns of the sufferer, and often also family, friends and other caregivers. In addition to the severe erosion in quality of life and those around him/her, chronic pain imposes severe financial burdens on many levels.

These include:

Costs of healthcare services and medication.
Job absenteeism and disruption in the workplace, loss of income.
Non-productivity in the economy and in the home.
Financial burden on family, friends and employers.
Worker compensation costs and welfare payments.

It is suggested that the overall financial costs of chronic pain to society is in the same range as cancer and cardiovascular disease. A study of the socio-economic costs of pain syndromes in the UK estimated that the yearly costs of back pain and sciatica are approximately £9 billion, with £1 billion spent each year on direct health case costs (Waddell 1996). However, this direct cost is insignificant compared to the cost of informal care and the production losses related to it, which total £10.7 billion. Overall, back pain is one of the most costly of all medical conditions (Maniadakis and Gray 2000).

Typical Chronic Pain Conditions

Low back, shoulder and neck pain.
Headache including migraine and Trigeminal neuralgia.
Rheumatoid arthritis.
Osteoarthritis.
Neuropathic and Neurogenic pain.
Cancer pain.
Herpes zoster (shingles) and post-herpetic neuralgia.
Myofascial pain syndrome.
Fibromyalgia and Fibromyostitis.
Post-laminectomy, post-mastectomy and post-thoracotomy pain.
Sympathetically mediated pain.
Stump and phantom limb pain.
Raynaud's disease.
Trigeminal neuralgia.
Diabetic neuropathy.
TMJ (Temporomandibular Joint Disorder).
Angina pectoris.
CPS (Chronic Pain Syndrome).

Distraction

Often when we have injured a part of the body, we instinctively rub that area to soothe it. By rubbing the area, our brain has something else to focus on rather than the pain that has been inflicted on it. This distraction / refocusing actually helps reduce the number of pain messages sent from the brain. How often have you seen a hurt small child run up to mummy saying "kiss it and make it better"? How many times does a soothing kiss, work? For the child, the nurturing and comforting sensation overrides the pain.

The Gate Control Theory of Pain

For many hundreds of years it was accepted that pain was strictly a result of injury or illness in the body, and that lingering pain was probably psychosomatic in nature. However the Gate Control Theory changed the way scientists looked at chronic pain. According to this theory, our thoughts, beliefs, and emotions affect the levels of pain experienced from a given physical sensation. The basis for this theory is that psychological as well as physical factors guide the brain's interpretation of painful sensations and response. This can be appreciated when considering how many athletes do not experience pain during intense activity, though it appears to come from nowhere when they have finished.

The gate control theory was first proposed in 1965 by psychologist Ronald Melzack and anatomist Patrick Wall (1988). They suggested that there is a "gating system" in the central nervous system, which opens and closes to let pain messages through to the brain or to block them.

Here's how the gate control theory works:-

Sensory messages travel from stimulated nerves to the spinal cord, where they are reprocessed and sent through open 'gates' to the thalamus. Once the nerve signal reaches the brain, the sensory information is processed. The brain's response to this information will determine the extent of pain. If the brain sends a message back down to close the gate, the pain signals to the brain are blocked and we experience lower levels of pain. (That message may be carried by endorphins.) If the brain orders the pain gates to open wider, the pain signal intensifies and increased levels of pain can be felt.

Endorphins

Within this site several references are made to pain existing where there is no apparent physical causation, such as phantom limb pain. In the same way that firing nerves are able to 'create' pain, the brain can balance the effects by the production of endorphins. These behave like and are chemically very similar to opiate drugs such as morphine. The result is they produce a natural analgesia and function as an internal mechanism for controlling pain sensations. They are responsible for the euphoria experienced by athletes during exercise, they can cause a temporary loss of pain in stressful situations and they are also released during orgasm. These endorphins may explain how someone severely wounded in battle can continue to fight or have the strength to save someone else.

In 1975, researchers were attempting to find out how morphine worked, and after injecting morphine into laboratory rats, they found that morphine molecules fitted perfectly into receptor sites in the brain. This led to the question of why these receptor sites existed unless the body itself also produced compounds that fitted, and the eventual discovery of a natural morphine-like substance that is produced by the body. It was named endorphin, or endogenous morphine, i.e. morphine coming from within. These discoveries have allowed scientists to produce analgesics that are less addictive, have greater potencies and fewer side effects.

Unfortunately by the very fact that people with chronic pain suffer, it means that such people do not manufacture enough endorphins, which causes two problems. One is that the body is sending inappropriate pain messages and not releasing endorphins to protect against pain, and also a lack of sufficient endorphins causes hypersensitivity to pain.

However there are ways to increase our endorphins naturally and with medication. Endorphin research suggests that there is a link between our emotional state and the health and well-being of our immune systems. So a potentially effective method of pain management would be to find a way of increasing our levels of endorphins and therefore help our body to fight pain through it own natural chemicals.

Naturally occurring endorphins are available through

Exercise.
Biofeedback, meditation.
Sex, massage.
Laughter.

Biofeedback and mediation. Biofeedback operates on the concept that people have the innate ability and potential to influence the automatic functions of their bodies through the exertion of will and mind. Biofeedback has recently been shown to give us what had previously seemed an impossible degree of control over a variety of physiologic events. By slowing our minds down we open ourselves to our inner strength, our god energy, and our endorphins are released.

Many studies again have shown that therapies such as massage will cause the body to release endorphins. As already indicated sexual activity can help in the release of endorphins.

The old cliché of laughter is the best medicine has been around for too long to be glibly dismissed. It seems like some of the best things in life are actually the best things for us.

Endorphins can also be released through

Pain Definitions

Analgesia Treatment given in an attempt to reduce levels of pain.

Causalgia A syndrome of sustained burning pain, allodynia, and hyperpathia after a traumatic nerve lesion, often combined with vasomotor and sudomotor dysfunction and later trophic changes.

Central Pain Pain initiated or caused by a primary lesion or dysfunction in the central nervous system.

Dysesthesia An unpleasant abnormal sensation, whether spontaneous or evoked.

Hyperalgesia An increased response to a stimulus which is normally painful.

Hyperesthesia Increased sensitivity to stimulation, excluding the special senses.

Hyperpathia A painful syndrome characterized by an abnormally painful reaction to a stimulus, especially a repetitive stimulus, as well as an increased threshold.

Hypoalgesia Diminished pain in response to a normally painful stimulus.

Hypoesthesia Decreased sensitivity to stimulation, excluding the special senses.

Neuralgia Pain in the distribution of a nerve or nerves.

Neuritis Inflammation of a nerve or nerves.

Neurogenic pain Pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in the peripheral or central nervous system.

Neuropathic pain Pain initiated or caused by a primary lesion or dysfunction in the nervous system.

Neuropathy A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy.

Nociceptor A receptor preferentially sensitive to a noxious stimulus or to a stimulus which would become noxious if prolonged.

Noxious stimulus A noxious stimulus is one which is damaging to normal tissues.

Pain threshold The least experience of pain which a subject can recognize.

Pain tolerance level The greatest level of pain which a subject is prepared to tolerate.

Paresthesia An abnormal sensation, whether spontaneous or evoked.

Peripheral neuropathic pain Pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system.

References

Andersen S, Worm-Pedersen J. (1987) The prevalence of persistent pain in a Danish population. Pain, S4:S332.

Becker N, Bondegaard TA, Olsen AK, Sjorgren P, Bech P, Eriksen J (1997) Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center. Pain 73:393-400.

Bowsher, D, Rigge, M, Sopp, L (1991) Prevalence of chronic pain in the British population: A telephone survey of 1037 households. Pain Clinic 4:223-230.

Bowsher, D (1991) Neurogenic pain syndromes and their management. Brit. Med. Bull, 47:644-666.

Brattberg G, Thorslund M, Wilkman A (1989) The prevalence of pain in a general population. The results of a postal survey in a county of Sweden. Pain 37:215-222.

Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA (1999) The epidemiology of chronic pain in the community. Lancet 354:1248-1252.

Leboeuf-Yde C, Lauritsen JM (1995) The prevalence of low back pain in the literature: A structured review of 26 Nordic studies from 1954 to 1993. Spine 19:2112-2118.

Maniadakis N, Gray A (2000) The economic burden of back pain in the UK. Pain 84:95-103.

Melzack R, Wall PD (1998) The challenge of pain (2nd ed) London: Penguin books.

Perquin CW, Hazebroek-Kampschreur AAJM, Hunfeld JAM, Bohnen AM, van Suijlekom-Smit LWA, Passchier J, van der Wouden JC (2000) Pain in children and adolescents: a common experience. Pain 87:51-58.

Von Korff M, Dworkin SF, Le Resche L. (1990) Graded chronic pain status: an epidemiologic evaluation. Pain 40:279-291.

Waddell G (1996) Low back pain: A twentieth century health care enigma. Spine 21:2820-2825.