Chronic Pain

The Basics

The Chronic Pain Coalition campaigns for pain to be seen as the “Fifth Vital Sign”: While it is common for health service professionals to measure the temperature, blood pressure, respiratory and pulse rates of their patients on a regular basis and at the earliest opportunity, if pain were routinely assessed with the same priority as the other vital signs then a great deal of unnecessary suffering, stress and anxiety could be avoided.”

We note with concern the patchy attention to pain, and especially chronic pain in the NHS and in health care in general. Many recent studies have highlighted this inattention to suffering – especially with respect to older people. It’s not good enough, it’s inhumane and it has to stop.

Anyone can have chronic pain, but it is suffered disproportionately by older people. All too often it is dealt with by giving us condescending advice and insufficient help and treatment. Chronic pain can be devastating and debilitating. Because it can’t be measured accurately like blood pressure or temperature, it’s easier to assume that in many cases it’s perhaps not really that big a deal. Chronic pain is actually a very big deal indeed. The brutal willingness to minimise and under-treat it is starting to change, but there is still a long way to go.

The Chronic Pain Coalition is an encouraging move in the right direction. They make it clear that the way we as a nation deal with chronic pain is inadequate and must be improved. The Coalition is a forum for patients, professionals and parliamentarians to develop an improved strategy for the prevention, treatment and management of chronic pain. Their website has said that: “two recent independent reports support a government commissioned survey that identified pain services in the UK as ‘variable and patchy’.

When poorly managed, conditions associated with pain can have a devastating impact on the quality of life of individuals and their families. The failure to implement an effective prevention and treatment strategy for chronic pain not only imposes an unnecessary burden on patients, but also represents an inefficient allocation of time, money and professional expertise.”

The Coalition believes that all people living with chronic pain in the UK must expect and ask for:

• Active involvement in the management of their pain
• Timely assessment of their pain
• Access to appropriate management and support
• Relevant information
• Early access to adequate resources and facilities

The following, from an article on the Age Concern website, make it clear how far we are from getting this right: “Despite the levels of pain reported, the study found that 85 per cent of people said a doctor or nurse had never spoken to them about how their constant pain could be treated.”

It is unacceptable for healthcare and nursing staff not to be actively relieving chronic pain. There is a desperate need for a more proactive approach to the management and treatment of pain by healthcare and nursing home staff’.”

It really is unacceptable that people in this country are not given appropriate help with and relief from pain as early, completely, and effectively as possible. Let’s make this completely clear by quoting the Chronic Pain Policy Coalition once again: “It is not unusual for people living with chronic pain to fall into a vicious circle of repeat doctor appointments, deteriorating physical and mental health, job loss, relationship breakdowns and depression before they receive the help they need.”

Chronic pain has consistently failed to attract the attention it deserves. A renewed focus on early assessment of pain is long overdue and could bring about significant benefits for individuals as well as their families, friends, employers and the wider economy.”

The Coalition are working to change this on the policy level. Our chronic pain self-help list gives powerful and encouraging and access to people and organisations helping to make a critical difference for sufferers.

Many of our usually helpful web resources don’t do so well when it comes to chronic pain. The sources in our chronic pain self-help list are among those which do perform. Much of our information here derives from them. With their help you can empower yourself and anyone you care for in dealing with chronic pain. The Basics we give here may help for a start. Later sections will draw on some of the best guidance about pain issues, treatments, and ways to improve your quality of life.

Chronic Pain is defined as pain that persists longer than the normal course of time associated with a particular type of injury. This constant or intermittent pain has often outlived its purpose, as it does not help the body to prevent injury.

There’s no shortage of pain in life. Much of it serves an important and necessary function. It’s a vital early warning system to say that something is causing trauma to the body. Get your finger out of that fire, get that baby born, deal with that heart attack, etc. Anything that damages or stresses us is likely to trigger the useful pain warning system. When we’ve done what we can and the warning system won’t turn off, however, it stops being useful and starts causing rather than preventing harm.

We may experience pain in a number of forms. The physical mechanism begins with an electrical impulse travelling from the affected site(s) to the spinal cord. The spinal cord acts as a sort of relay centre where the pain signal can be blocked, enhanced, or otherwise modified before it is relayed to the brain. One area of the spinal cord in particular, called the dorsal horn, is important in the reception of pain signals.

The most common destination in the brain for pain signals is the thalamus and from there to the cortex, the headquarters for complex thoughts. The thalamus also serves as the brain’s storage area for images of the body and plays a key role in relaying messages between the brain and various parts of the body.

Pain is a complicated process that involves an intricate interplay between a number of important chemicals found naturally in the brain and spinal cord. In general, these chemicals, called neurotransmitters, transmit nerve impulses from one cell to another.

There are many different neurotransmitters in the human body; some play a role in human disease and, in the case of pain, act in various combinations to produce painful sensations in the body. Some chemicals govern mild pain sensations; others control intense or severe pain.

The body’s chemicals act in the transmission of pain messages by stimulating neurotransmitter receptors found on the surface of cells; each receptor has a corresponding neurotransmitter. Receptors function much like gates or ports and enable pain messages to pass through and on to neighbouring cells. One brain chemical of special interest to neuroscientists is glutamate. During experiments, mice with blocked glutamate receptors show a reduction in their responses to pain. Other important receptors in pain transmission are opiate-like receptors. Morphine and other opioid drugs work by locking on to these opioid receptors, switching on pain-inhibiting pathways or circuits, and thereby blocking pain.

Another type of receptor that responds to painful stimuli is called a nociceptor. Nociceptors are thin nerve fibres in the skin, muscle, and other body tissues, that, when stimulated, carry pain signals to the spinal cord and brain. Normally, nociceptors only respond to strong stimuli such as a pinch. However, when tissues become injured or inflamed, as with a sunburn or infection, they release chemicals that make nociceptors much more sensitive and cause them to transmit pain signals in response to even gentle stimuli such as breeze or a caress. It has implied that receptors function like gateways and there is the possibility of closing the gates against pain.

Gate Control: The Action on Pain website tells us the “gate control theory” proposes that a “gating system” exists in the central nervous system that opens and closes to allow pain messages through to the brain or block them.

The spinal cord is made up of two types of nerve fibres; the small diameter nerve fibres which carry pain stimuli through the ‘gate mechanism’ and larger diameter nerve fibres which go through the same gate but which can inhibit the transmission activity of the smaller nerves carrying the pain signal. Chemicals released as a response to the pain stimuli also influence whether the gate opens or closes for the brain to receive additional pain signals.

An aspect of the gate control theory of pain is that the emotions, beliefs and thoughts that exist may influence the amount of pain felt from a given physical sensation. This is based on the principle that both psychological and physical factors influence how the brain receives and interprets pain signals, and how it responds to them. Many pain sufferers find that their pain is worst if they feel sad and despondent – and there is a clear mechanism whereby such feelings may open the pain gate – yet if they focus on doing something that requires attention or they find enjoyable the perception of the pain is dramatically different.

As nerve signal reaches the brain, the sensory information is handled in the context of the individual’s existing mood, state of attention, and previous experience. The combination of all this information affects the way the pain is perceived and experienced and these dictate what response takes place.

The brain’s interpretation of this information determines whether a message is sent back down the large diameter nerve fibres to “close” the gate so that the pain signals are blocked and lower pain is experienced . If the brain orders the pain gates to “open” wider then the pain signals continue to pass through and the pain intensifies. Closing or narrowing the pain gate can be approached physically in terms of brain chemistry and circuitry, and also mentally.

Let’s stop here to make an important point: mental/psychological and emotional approaches to chronic pain are not flaky side issues. They should not be used or seen as backhanded ways of telling you to pull your socks up and get over yourself. These approaches, which we’ll look at under Self-Help, are extremely practical in terms of the mechanisms of pain and the Pain Gate model.

We’ll look at what science can do in terms of both mechanics and mind under Therapies. Our abilities to work with and control our own pain through complementary/self-help techniques, and even use pain to improve our lives, will also be approached as being at least equally important.

Diagnosing Pain – There is no way to tell how much pain a person has. No test can measure the intensity of pain, no imaging device can show pain, and no instrument can locate pain precisely. Your description of what you’re experiencing is pretty much all your doctor has to start with. The point here, of course, is that some problem (or combination of problems) is causing you pain. Diagnosing the problem(s) as well as possible is obviously step one in dealing with your pain.

Doctors do have some useful tests and technologies to help find the cause of pain. Among the most common are:

Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. Information from EMG can help physicians tell precisely which muscles or nerves are affected by weakness or pain. Thin needles are inserted in muscles and a physician can see or listen to electrical signals displayed on an EMG machine. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock that stimulates the nerve that runs to that muscle. The second set of electrodes is used to make a recording of the nerve’s electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes-one set for stimulating a nerve (these electrodes are attached to a limb) and another set on the scalp for recording the speed of nerve signal transmission to the brain.

Imaging techniques, including ultrasound and CT scanning and magnetic resonance imaging or MRI, provide pictures of the body’s structures and tissues. MRI uses magnetic fields and radio waves to differentiate between healthy and diseased tissue.

Neurological examination, in which the physician tests movement, reflexes, sensation, balance, and coordination.

X-rays to look for physical / structural problems causing pain.

The Action on Pain website reminds us that knowing what’s causing your pain may not mean that your doctors can stop it. Still, this is step one: is your pain necessarily chronic, or is it a sign of something which can and should be healed? If it’s a warning to act, and if acting can heal you and stop the pain, the pain needn’t be chronic. This is pain doing its job of saying that something needs healing, and it should be relieved. If the cause of your pain cannot be definitively healed however, or dealing with the cause doesn’t end the pain, then your pain is chronic and must be managed to increase your comfort and improve your quality of life as much as possible.

Age, Gender and Pain

MedicineNet tells us: It is now widely believed that pain affects men and women differently. While the sex hormones estrogen and testosterone certainly play a role in this phenomenon, psychology and culture, too, may account at least in part for differences in how men and women receive pain signals. Many investigators are turning their attention to the study of gender differences and pain. Women, many experts now agree, recover more quickly from pain, seek help more quickly for their pain, and are less likely to allow pain to control their lives. They also are more likely to marshal a variety of resources-coping skills, support, and distraction-with which to deal with their pain.

Interestingly, Merck Medicus tells us that older people tend to tolerate and handle pain better than the young. They speculate that this may be because changes in the body decrease the sensation of pain. On the other hand, older people may simply be more stoic than younger people.

The Evaluation of Pain, as there is no actual way to test for or measure it, isn’t easy. Merck Medicus tell us that the usual approach is for doctors to ask about the history and characteristics of pain. To evaluate the severity of pain, they sometimes use a scale of 0 (none) to 10 (severe) or ask the person to describe the pain as mild, moderate, severe, or excruciating.

As well as being impossible to measure, the pain you feel may not be where the problem is. Pain felt in one part of the body can be referred pain from a problem actually happening somewhere else. Pain can be referred because signals from several areas of the body often travel through the same nerve pathways going to the spinal cord and brain. For example, pain from a heart attack may be felt in the neck, jaws, arms, or abdomen. Pain from a gallbladder attack may be felt in the back of the shoulder.

Acute or Chronic: Acute pain begins suddenly and usually does not last long. When severe, it may cause anxiety, a rapid heartbeat, an increased breathing rate, elevated blood pressure, sweating, and dilated pupils. Chronic pain persists for weeks, months or more. Merck’s definition of the term Chronic Pain is that it usually describes pain that persists for more than one month beyond the usual course of an illness or injury, pain that recurs off and on for months or years, or pain that is associated with a chronic disorder such as cancer. Often chronic pain does not affect the heartbeat, breathing rate, blood pressure, or pupils, but it may result in other problems, such as depression, disturbed sleep, decreased energy, loss of appetite, weight loss, and loss of interest in sexual activity.

Many people who are being treated for chronic pain may experience a brief, often severe flare-up of pain [our emphasis]. This is called breakthrough pain because it breaks through the regularly scheduled pain treatment. Typically, breakthrough pain begins suddenly, lasts up to one hour, and feels much like the person’s chronic pain except it is more severe. Breakthrough pain may differ from person to person and is often unpredictable.

Types of Pain

Nociceptive pain is caused by an injury to body tissues. The injury may be a cut, bruise, bone fracture, crush injury, burn, or anything that damages tissues. This type of pain is typically aching, sharp, or throbbing. Most pain is nociceptive pain. Pain receptors for tissue injury (nociceptors) are located mostly in the skin or in the internal organs. Most of the pain due to cancer is nociceptive. When a tumor invades bones and organs, it may cause mild discomfort or severe, unrelenting pain. Some cancer treatments, such as surgery and radiation therapy, can also cause nociceptive pain.

Neuropathic pain is caused by abnormalities in the nerves, spinal cord, or brain. Neuropathic pain may be felt as a burning or tingling sensation or as hypersensitivity to touch or cold. Syndromes include phantom limb pain, postherpetic neuralgia from herpes zoster (shingles), and chronic pain conditions usually occurring after an injury, like reflex sympathetic dystrophy and causalgia. Sometimes this kind of pain is made worse by activity of the sympathetic nervous system, which normally prepares the body for stressful or emergency situations—for fight or flight.

Psychogenic pain is entirely or mostly related to a psychological cause. Pain that is purely psychogenic is rare, and there are psychological factors at work in all pain. Good pain management pays great attention to the psychological as well as physical factors in dealing with chronic pain.

Tools for observing and reporting on your pain

To get the right help with chronic pain both you and the people helping you need as clear a picture as possible of what you’re dealing with. Action On Pain is very good on this subject. We edit their advice below, but do go to them for the original and all the materials they supply to help.

Assessment Tools: Proficient pain management starts with a detailed and systematic assessment which permits the health care provider to characterize the pain, clarify its impact, and consider other medical and psychosocial problems.

Pain is very subjective so only you can adequately describe what it is like and the effects that it has on your life. To enable health care providers to understand your pain better, they need to ask about the duration and location of the pain, its severity and quality, and what factors that make it better or worse. It also helps for them to comprehend what changes have occurred in your life as a result of the pain, what impact there has been on your family, social and working life. As part of the assessment a physical examination [will] be required, and it is important to discuss and evaluate all the pain treatments that have been tried, whether they are conventional, complementary or alternative treatments [our emphasis].

A detailed pain assessment will:

• Determine whether the description corresponds to a well-known pain syndrome;
• Establish [any] structural disease of the body that may help explain the pain;
• Try to understand the mechanisms (tissue damage, nerve injury, psychological processes) that maintain the pain;
• Illustrate the negative effects on physical and psychosocial functioning resulting from the pain;
• Understand the medical and emotional problems that co-exist with the pain and might need treatment at the same time.

Pain Assessment Charts: Often there are few tangible or obvious indications which enable a health practitioner to judge the severity of pain. If you have no obvious handicap you may feel that your problems are ill-understood or even that you are disbelieved. Pain Assessment Charts provide healthcare professionals with a structured and distinguishable way of gathering a clear history of your pain and appraising the nature and severity of the pain, as well as the impact that it has on daily life for you, your family and friends.

Action on Pain suggest that you may find it useful to complete an assessment chart yourself before you see your doctor so that you can clearly explain your pain and the effects that it is having on you. You can get a chart from their website. Their assessment charts and Pain Management Log are useful tools. They allow you and your healthcare providers to see clearly how things are progressing. Action on Pain also provide Pain Rating Charts and a Verbal Pain Scale to track how your pain changes and to see if treatment is having the intended effect.

Pain Diaries – It is very common for people with chronic pain to feel tense and apprehensive when faced with trying to tell their doctor about the discomfort they feel and they can forget how hard some days can get. If you are one of these people it is useful to keep a diary to help you recall and describe what happened to you whilst the pain is so bad. When telling your doctor about times when the pain was really bad, it is very helpful for them to know how it started, how it made you feel, what made it better, what made it worse.

Useful Tips for what to include in your diary include:

• Where is the pain?
• Does the pain move?
• Does the pain vary in different places?
• How does the pain feel?
• Stabbing, burning, tingling
• When did the pain start?
• When you woke up?

And then ask yourself these later in the day:

• Does the pain change during the day? – becomes sharper, duller, piercing etc
• Does anything make it better/ worse? – icepack, heat pad, tens machine.
• What medications do you take? – do they help?
• Do you use other non-drug based treatments? – e.g. acupuncture, massage, meditation
• How well do you sleep? – wake in the night, can’t get off to sleep
• Have you stopped spending time with family & friends?
• Is you appetite affected?
• How has the pain changed your life and what you enjoy?

Key points about Pain Diaries

A pain diary only requires you to note down words that sum up the pain and how you felt at the time.

You do not need to complete the diary every day, as you will not want to be focusing on your discomfort all the time- go back when you feel ready and make brief notes. If you find it difficult ask a member of the family or a friend to make a record of what you want to say.

You may like to keep a small notebook or tape recorder close at hand so that if necessary you can make notes about how you feel. You may like to use a specially designed form which provides a guide as to what to record. [Action on Pain supplies sample form]