Chronic pain
Encyclopedia
Chronic pain has several different meanings in medicine
. Traditionally, the distinction between acute
and chronic pain
has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the initiation of pain, though some theorists and researchers have placed the transition from acute to chronic pain at 12 months. Others apply acute to pain that lasts less than 30 days, chronic to pain of more than six months duration, and subacute to pain that lasts from one to six months.
A popular alternative definition of chronic pain, involving no arbitrarily fixed durations is "pain that extends beyond the expected period of healing."
(caused by damage to or malfunction of the nervous system).
Nociceptive pain may be divided into "superficial somatic
" and "deep", and deep pain into "deep somatic" and "visceral
". Superficial somatic pain is initiated by activation
of nociceptors in the skin or superficial tissues. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly-localized pain. Visceral pain originates in the viscera (organs). Visceral pain may be well-localized, but often it is extremely difficult to locate, and several visceral regions produce "referred" pain when injured, where the sensation is located in an area distant from the site of pathology or injury.
Neuropathic pain is divided into "peripheral" (originating in the peripheral nervous system
) and "central" (originating in the brain or spinal cord). Peripheral neuropathic pain is often described as “burning,” “tingling,” “electrical,” “stabbing,” or “pins and needles.” Bumping the "funny bone" elicits peripheral neuropathic pain.
Chronic pain of different etiologies has been characterized as a disease affecting brain structure and function. Magnetic Resonance Imaging
studies have shown abnormal anatomical and functional connectivity, even during rest involving areas related to the processing of pain. Also, persistent pain has been shown to cause grey matter
loss, reversible once the pain has resolved.
Pain management
(also called pain medicine) is that branch of medicine employing an interdisciplinary approach to the relief of pain
and improvement in the quality of life
of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapist
s, and nurse practitioner
s. Acute pain usually resolves with the efforts of one practitioner; however, the management of chronic pain frequently requires the coordinated efforts of the treatment team.
(MMPI) are the conversion V and the neurotic triad. The conversion V personality, so called because the higher scores on MMPI scales 1 and 3, relative to scale 2, form a "V" shape on the graph, expresses exaggerated concern over body feelings, develops bodily symptoms in response to stress, and often fails to recognize their own emotional state, including depression
. The neurotic triad personality, scoring high on scales 1, 2 and 3, also expresses exaggerated concern over body feelings and develops bodily symptoms in response to stress, but is demanding and complaining.
Some investigators have argued that it is this neuroticism
that causes acute pain to turn chronic, but clinical evidence points the other way, to chronic pain causing neuroticism. When long term pain is relieved by therapeutic intervention, scores on the neurotic triad and anxiety
fall, often to normal levels.
Self-esteem, often low in chronic pain patients, also shows striking improvement once pain has resolved.
Conditions related to pain
:
Drugs:
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Other approaches in Physical medicine and rehabilitation
(Physiatry):
Alternative therapies:
Surgery:
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Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
. Traditionally, the distinction between acute
Acute
Acute may refer to:* Acute accent* Acute angle* Acute * Acute * Acute toxicity...
and chronic pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the initiation of pain, though some theorists and researchers have placed the transition from acute to chronic pain at 12 months. Others apply acute to pain that lasts less than 30 days, chronic to pain of more than six months duration, and subacute to pain that lasts from one to six months.
A popular alternative definition of chronic pain, involving no arbitrarily fixed durations is "pain that extends beyond the expected period of healing."
Classification
Chronic pain may be divided into "nociceptive" (caused by activation of nociceptors), and "neuropathic"Neuropathic pain
Neuropathic pain results from lesions or diseases affecting the somatosensory system. It may be associated with abnormal sensations called dysesthesia, which occur spontaneously and allodynia that occurs in response to external stimuli. Neuropathic pain may have continuous and/or episodic ...
(caused by damage to or malfunction of the nervous system).
Nociceptive pain may be divided into "superficial somatic
Somatic
The term somatic means 'of the body',, relating to the body. In medicine, somatic illness is bodily, not mental, illness. The term is often used in biology to refer to the cells of the body in contrast to the germ line cells which usually give rise to the gametes...
" and "deep", and deep pain into "deep somatic" and "visceral
Viscus
In anatomy, a viscus is an internal organ, and viscera is the plural form. The viscera, when removed from a butchered animal, are known collectively as offal...
". Superficial somatic pain is initiated by activation
Activation energy
In chemistry, activation energy is a term introduced in 1889 by the Swedish scientist Svante Arrhenius that is defined as the energy that must be overcome in order for a chemical reaction to occur. Activation energy may also be defined as the minimum energy required to start a chemical reaction...
of nociceptors in the skin or superficial tissues. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly-localized pain. Visceral pain originates in the viscera (organs). Visceral pain may be well-localized, but often it is extremely difficult to locate, and several visceral regions produce "referred" pain when injured, where the sensation is located in an area distant from the site of pathology or injury.
Neuropathic pain is divided into "peripheral" (originating in the peripheral nervous system
Peripheral nervous system
The peripheral nervous system consists of the nerves and ganglia outside of the brain and spinal cord. The main function of the PNS is to connect the central nervous system to the limbs and organs. Unlike the CNS, the PNS is not protected by the bone of spine and skull, or by the blood–brain...
) and "central" (originating in the brain or spinal cord). Peripheral neuropathic pain is often described as “burning,” “tingling,” “electrical,” “stabbing,” or “pins and needles.” Bumping the "funny bone" elicits peripheral neuropathic pain.
Pathophysiology
Under persistent activation nociceptive transmission to the dorsal horn may induce a wind up phenomenon. This induces pathological changes that lower the threshold for pain signals to be transmitted. In addition it may generate nonnociceptive nerve fibers to respond to pain signals. Nonnociceptive nerve fibers may also be able to generate and transmit pain signals. In chronic pain this process is difficult to reverse or eradicate once established.Chronic pain of different etiologies has been characterized as a disease affecting brain structure and function. Magnetic Resonance Imaging
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
studies have shown abnormal anatomical and functional connectivity, even during rest involving areas related to the processing of pain. Also, persistent pain has been shown to cause grey matter
Grey matter
Grey matter is a major component of the central nervous system, consisting of neuronal cell bodies, neuropil , glial cells and capillaries. Grey matter contains neural cell bodies, in contrast to white matter, which does not and mostly contains myelinated axon tracts...
loss, reversible once the pain has resolved.
Management
Complete and sustained remission of many neuropathies and most idiopathic chronic pain (pain that extends beyond the expected period of healing, or chronic pain that has no known underlying pathology) is rarely achieved, but much can be done to reduce suffering and improve quality of life.Pain management
Pain management
Pain management is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists,...
(also called pain medicine) is that branch of medicine employing an interdisciplinary approach to the relief of pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
and improvement in the quality of life
Quality of life
The term quality of life is used to evaluate the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare, and politics. Quality of life should not be confused with the concept of standard of...
of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapist
Occupational therapist
An occupational therapist is trained in the practice of occupational therapy. The role of an occupational therapist is to work with a client to help them achieve a fulfilled and satisfied state in life through the use of "purposeful activity or interventions designed to achieve functional...
s, and nurse practitioner
Nurse practitioner
A Nurse Practitioner is an Advanced practice registered nurse who has completed graduate-level education . Additional APRN roles include the Certified Registered Nurse Anesthetist s, CNMs, and CNSs...
s. Acute pain usually resolves with the efforts of one practitioner; however, the management of chronic pain frequently requires the coordinated efforts of the treatment team.
Epidemiology
In a recent large-scale telephone survey of 15 European countries and Israel, 19% of respondents over 18 years of age had suffered pain for more than 6 months, including the last month, and more than twice in the last week, with pain intensity of 5 or more for the last episode, on a scale of 1(no pain) to 10 (worst imaginable). 4839 of these respondents with chronic pain were interviewed in depth. Sixty six percent scored their pain intensity at moderate (5–7), and 34% at severe (8–10); 46% had constant pain, 56% intermittent; 49% had suffered pain for 2–15 years; and 21% had been diagnosed with depression due to the pain. Sixty one percent were unable or less able to work outside the home, 19% had lost a job, and 13% had changed jobs due to their pain. Forty percent had inadequate pain management and less than 2% were seeing a pain management specialist.Comorbidities and sequelae
Chronic pain is associated with higher rates of depression and anxiety. Sleep disturbance, and insomnia due to medication and illness symptoms are often experienced by those with chronic pain. Substance abuse is highly prevalent in some segments of the chronic pain population such as those with chronic headache. Chronic pain may contribute to decreased physical activity due to fear of exacerbating pain.Personality
Two of the most frequent personality profiles found in chronic pain patients by the Minnesota Multiphasic Personality InventoryMinnesota Multiphasic Personality Inventory
The Minnesota Multiphasic Personality Inventory is one of the most frequently used personality tests in mental health. The test is used by trained professionals to assist in identifying personality structure and psychopathology....
(MMPI) are the conversion V and the neurotic triad. The conversion V personality, so called because the higher scores on MMPI scales 1 and 3, relative to scale 2, form a "V" shape on the graph, expresses exaggerated concern over body feelings, develops bodily symptoms in response to stress, and often fails to recognize their own emotional state, including depression
Depression (mood)
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...
. The neurotic triad personality, scoring high on scales 1, 2 and 3, also expresses exaggerated concern over body feelings and develops bodily symptoms in response to stress, but is demanding and complaining.
Some investigators have argued that it is this neuroticism
Neuroticism
Neuroticism is a fundamental personality trait in the study of psychology. It is an enduring tendency to experience negative emotional states. Individuals who score high on neuroticism are more likely than the average to experience such feelings as anxiety, anger, guilt, and depressed mood...
that causes acute pain to turn chronic, but clinical evidence points the other way, to chronic pain causing neuroticism. When long term pain is relieved by therapeutic intervention, scores on the neurotic triad and anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
fall, often to normal levels.
Self-esteem, often low in chronic pain patients, also shows striking improvement once pain has resolved.
Effect on cognition
Chronic pain's impact on cognition is an under-researched area, but several tentative conclusions have been published. Most chronic pain patients complain of cognitive impairment, such as forgetfulness, difficulty with attention, and difficulty completing tasks. Objective testing has found that people in chronic pain tend to experience impairment in attention, memory, mental flexibility, verbal ability, speed of response in a cognitive task, and speed in executing structured tasks. In 2007, Shulamith Kreitler and David Niv advised clinicians to assess cognitive function in chronic pain patients in order to more precisely monitor therapeutic outcomes, and tailor treatment to address this aspect of the pain experience.See also
- SufferingSufferingSuffering, or pain in a broad sense, is an individual's basic affective experience of unpleasantness and aversion associated with harm or threat of harm. Suffering may be qualified as physical or mental. It may come in all degrees of intensity, from mild to intolerable. Factors of duration and...
Conditions related to pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
:
- ArthritisArthritisArthritis is a form of joint disorder that involves inflammation of one or more joints....
- Temporomandibular joint disorderTemporomandibular joint disorderTemporomandibular joint disorder , or TMJ syndrome, is an umbrella term covering acute or chronic inflammation of the temporomandibular joint, which connects the mandible to the skull. The disorder and resultant dysfunction can result in significant pain and impairment...
- Back painBack painBack pain is pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine.The pain can often be divided into neck pain, upper back pain, lower back pain or tailbone pain...
- CancerCancerCancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
- Chronic Fatigue SyndromeChronic fatigue syndromeChronic fatigue syndrome is the most common name used to designate a significantly debilitating medical disorder or group of disorders generally defined by persistent fatigue accompanied by other specific symptoms for a minimum of six months, not due to ongoing exertion, not substantially...
- Clinical depressionClinical depressionMajor depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
- Complex Regional Pain SyndromeComplex regional pain syndromeComplex regional pain syndrome is a chronic progressive disease characterized by severe pain, swelling and changes in the skin. It often affects an arm or a leg and may spread to another part of the body.Though treatment is often unsatisfactory, early multimodal therapy can cause dramatic...
- FibromyalgiaFibromyalgiaFibromyalgia is a medical disorder characterized by chronic widespread pain and allodynia, a heightened and painful response to pressure. It is an example of a diagnosis of exclusion...
- HeadacheHeadacheA headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the...
- Irritable Bowel SyndromeIrritable bowel syndromeIrritable bowel syndrome is a diagnosis of exclusion. It is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic cause. In some cases, the symptoms are relieved by bowel movements...
- Myofascial Pain SyndromeMyofascial pain syndromeMyofascial pain syndrome , also known as chronic myofascial pain , is a syndrome characterized by chronic pain caused by multiple trigger points and fascial constrictions...
- Post-Vasectomy Pain SyndromePost-Vasectomy Pain SyndromePost-vasectomy pain syndrome is a chronic and sometimes debilitating genital pain condition that may develop immediately or several years after vasectomy. Because this condition is a syndrome, there is no single treatment method, therefore efforts focus on mitigating/relieving the individual...
- Restless Leg Syndrome
- SciaticaSciaticaSciatica is a set of symptoms including pain that may be caused by general compression or irritation of one of five spinal nerve roots that give rise to each sciatic nerve, or by compression or irritation of the left or right or both sciatic nerves. The pain is felt in the lower back, buttock, or...
- Lumbar spinal stenosis and cervical spinal stenosisCervical spinal stenosisCervical spinal stenosis is a bone disease involving the narrowing of the spinal canal at the level of the neck. It is frequently due to chronic degeneration, but may also be congenital. Treatment is frequently surgical....
Drugs:
- Analgesia
- Antiepileptics
- GabapentinGabapentinGabapentin is a pharmaceutical drug, specifically a GABA analogue. It was originally developed for the treatment of epilepsy, and currently is also used to relieve neuropathic pain...
- PregabalinPregabalinPregabalin is an anticonvulsant drug used for neuropathic pain and as an adjunct therapy for partial seizures with or without secondary generalization in adults. It has also been found effective for generalized anxiety disorder and is approved for this use in the European Union. It was designed...
- Levetiracetam
- TopiramateTopiramateTopiramate is an anticonvulsant drug. It was originally produced by Ortho-McNeil Neurologics and Noramco, Inc., both divisions of the Johnson & Johnson Corporation. This medication was discovered in 1979 by Bruce E. Maryanoff and Joseph F. Gardocki during their research work at McNeil...
- LamotrigineLamotrigineLamotrigine, marketed in the US and most of Europe as Lamictal by GlaxoSmithKline, is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. It is also used as an adjunct in treating depression, though this is considered off-label usage...
- ZonisamideZonisamideZonisamide is a sulfonamide anticonvulsant approved for use as an adjunctive therapy in adults with partial-onset seizures for adults; infantile spasm, mixed seizure types of Lennox-Gastaut syndrome, myoclonic, and generalized tonic clonic seizure.-History:...
- Gabapentin
- Antidepressants
- Local anesthetics
- KetamineKetamineKetamine is a drug used in human and veterinary medicine. Its hydrochloride salt is sold as Ketanest, Ketaset, and Ketalar. Pharmacologically, ketamine is classified as an NMDA receptor antagonist...
- Ketamine
- Acetaminophen (Paracetamol)
- NSAIDs
- Opioids
- Medical cannabisMedical cannabisMedical cannabis refers to the use of parts of the herb cannabis as a physician-recommended form of medicine or herbal therapy, or to synthetic forms of specific cannabinoids such as THC as a physician-recommended form of medicine...
- Other agents:
- ClonidineClonidineClonidine is a sympatholytic medication used to treat medical conditions, such as high blood pressure, some pain conditions, ADHD and anxiety/panic disorder...
- Ziconotide
- TizanidineTizanidineTizanidine is a drug that is used as a muscle relaxant. It is a centrally acting α2 adrenergic agonist. It is used to treat the spasms, cramping, and tightness of muscles caused by medical problems such as multiple sclerosis, spastic diplegia, back pain, or certain other injuries to the spine or...
- Clonidine
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Other approaches in Physical medicine and rehabilitation
Physical medicine and rehabilitation
Physical medicine and rehabilitation , physiatry or rehabilitation medicine, is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. A physician having completed training in this field is referred to as a...
(Physiatry):
- CryotherapyCryotherapyCryotherapy is the local or general use of low temperatures in medical therapy or the removal of heat from a body part. The term "cryotherapy" comes from the Greek cryo meaning cold and the word therapy meaning cure...
- Exercise
- Hot pack
- Occupational therapyOccupational therapyOccupational therapy is a discipline that aims to promote health by enabling people to perform meaningful and purposeful activities. Occupational therapists work with individuals who suffer from a mentally, physically, developmentally, and/or emotionally disabling condition by utilizing treatments...
- Physical therapyPhysical therapyPhysical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
- TENS
Alternative therapies:
- AcupunctureAcupunctureAcupuncture is a type of alternative medicine that treats patients by insertion and manipulation of solid, generally thin needles in the body....
- ChiropracticChiropracticChiropractic is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. It is generally categorized as complementary and alternative medicine...
- Massage therapy
- HypnosisHypnosisHypnosis is "a trance state characterized by extreme suggestibility, relaxation and heightened imagination."It is a mental state or imaginative role-enactment . It is usually induced by a procedure known as a hypnotic induction, which is commonly composed of a long series of preliminary...
- Behavioral therapy
- ProlotherapyProlotherapyProlotherapy is also known as "proliferation therapy" or "regenerative injection therapy." involves injecting an otherwise non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening weakened connective tissue...
- Structural Integration
Surgery:
- Spinal cord stimulation
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External links
- Chronic Pain Syndromes at the Open Directory ProjectOpen Directory ProjectThe Open Directory Project , also known as Dmoz , is a multilingual open content directory of World Wide Web links. It is owned by Netscape but it is constructed and maintained by a community of volunteer editors.ODP uses a hierarchical ontology scheme for organizing site listings...
- Chronic Pain Australia
- American Chronic Pain Association
- American Pain Foundation
- Patient consumer web page sponsored by the APS
- International Association for the Study of Pain- IASP