Chronic Pain

Chronic pain is defined as pain that lasts longer than six months. Chronic pain can be mild or extremely painful, episodic or continuous, merely inconvenient or utterly debilitating.With chronic pain, signals of pain remain active within the nervous system for months or even years on end. This can take both a physical and emotional toll on a person.

The most common sources of pain stem from headaches, backaches, pain from injury and joint pain. Other kinds of chronic pain include:

• Tendinitis
• Sinus pain
• Carpal tunnel syndrome
• Pain affecting specific parts of the body, such as the shoulders, pelvis, and neck

Generalized muscle or nerve pain can also progress and develop into a chronic condition.

Chronic pain may originate with an initial trauma/injury or infection, however there may be an ongoing cause of pain. Some people suffer chronic pain in the absence of any past injury or evidence of bodily harm.

The emotional toll of chronic pain can also make pain much worse. Anxiety, stress, depression, anger, and fatigue interact in complex ways with chronic pain and may decrease the body’s production of natural painkillers; moreover, such negative feelings may increase the level of substances that amplify sensations of pain, causing a vicious cycle of pain for the person. Even the body’s most basic defenses can be compromised: There is substantial evidence that constant, unrelenting pain can suppress the immune system.

Because of the mind-body links associated with chronic pain, effective treatment requires addressing both the psychological and physical aspects of the condition.

SYMPTOMS OF CHRONIC PAIN

The symptoms of chronic pain include:

• Mild to excruciating pain that does not ease
• Pain that may be described as aching, burning, shooting or electrical
• Feeling of discomfort, soreness, tightness, or stiffness

Pain is not a symptom that exists alone. There are other problems associated with pain that can include:

• Fatigue
• Sleeplessness
• Withdrawal from activity and increased need to rest
• Changes in overall mood including hopelessness, fear, depression, irritability, anxiety, and stress
• Disability
• Weakening of the immune system

TREATMENT OPTIONS AVAILABLE FOR CHRONIC PAIN

The treatments for chronic pain are as diverse as itS causes and can range from over-the-counter and prescription drugs to mind/body techniques to acupuncture, and so on. But when it comes to treating chronic pain, no single technique is guaranteed to produce total pain relief. Often relief may be found by using a combination of treatment options.

The goal of pain management is to improve overall function, enabling individuals to work, attend school, or participate in other day-to-day activities. Patients and their physicians have a number of options for the treatment of pain; some are more effective than others. Sometimes, relaxation and the use of imagery as a distraction can provide some relief. These methods can be powerful and effective, according to those who advocate their use. Whatever the treatment regime, it is important to remember that pain is treatable, with the following treatments being among the most common.

• Acetaminophen: This is the basic ingredient found in Tylenol® and its many generic equivalents. It is sold over the counter as a prescription — strength preparation, and in combination with codeine (also by prescription).
• Analgesic: This refers to the class of drugs that includes most painkillers, such as aspirin, acetaminophen, and ibuprofen. The word analgesic originates from ancient Greek and means to reduce or stop pain. Nonprescription or over-the-counter pain relievers are generally used more for mild to moderate pain, whereas prescription pain relievers, sold through a pharmacy under the direction of a physician, are used for more moderate to severe pain.
• Anticonvulsants: These are used for the treatment of seizure disorders but are also sometimes prescribed for the treatment of pain. Carbamazepine is used very often to treat a number of painful conditions, including trigeminal neuralgia. Another antiepileptic drug, gabapentin, is currently being studied for its pain-relieving properties, especially as a treatment for neuropathic pain.
• Antidepressants: These are sometimes used for the treatment of pain and, along with lithium and neuroleptics, belong to a category of drugs called psychotropic drugs. In addition, anti-anxiety drugs called benzodiazepines also act as muscle relaxants and are sometimes used as pain relievers. Physicians usually try to treat the condition and lessen the amount of discomfort with analgesics before prescribing these drugs.
• Antimigraine drugs: These include the triptans – sumatriptan (Imitrex®), naratriptan (Amerge®), and zolmitriptan (Zomig®) – and are used specifically for migraine headaches. They can have serious side effects in some people and therefore, as with all prescription medicines, should only be used under the care and supervision of a doctor.
• Capsaicin: This is a chemical found in chili peppers that is also a primary ingredient in pain-relieving creams.
• Chemonucleolysis: This is a treatment in which an enzyme called chymopapain, is injected directly into a herniated lumbar disc in an effort to dissolve material around the disc, thus reducing pressure and pain. This procedure’s use is extremely limited, in part because some patients can have a life-threatening allergic reaction to chymopapain.
• Chiropractic care: Chiropractic care can ease back pain, neck pain, headaches, and musculoskeletal conditions and involves “hands-on” therapy designed to adjust the relationship between the body’s structure (mainly the spine). Chiropractic spinal manipulation includes the adjustment and manipulation of the joints and their adjacent tissues. Such care may also involve therapeutic and rehabilitative exercises.
• Cognitive: Cognitive or behavioral therapy involves a wide variety of coping skills and relaxation methods to help prepare for and cope with pain. It is used for postoperative pain, cancer pain, and the pain of childbirth.
• Counseling: Counseling can give a patient suffering from pain some much needed support, whether it is from their family, a group, or from individual counseling. Support groups can provide an important adjunct to drug or surgical treatment. Psychological treatment can also help patients learn about the physiological changes produced by pain.
• COX-2 inhibitors: These may be effective for individuals with arthritis. For many years scientists have wanted to develop a drug that works as well as morphine but without its negative side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) work by blocking two enzymes, cyclooxygenase-1 and cyclooxygenase-2, both of which stimulate the production of hormones called prostaglandins, which in turn cause inflammation, fever, and pain. The newer COX-2 inhibitors primarily block cyclooxygenase-2 and are less likely to have the gastrointestinal side effects often produced by NSAIDs.
• Electrical stimulation: Electrical stimulation, including transcutaneous electrical stimulation (TENS), implanted electric nerve stimulation, and deep brain or spinal cord stimulation, is the modern-day extension of age-old practices in which the nerves of muscles are subjected to a variety of stimuli, including massage or heat. Electrical stimulation, regardless of what form, involves a major surgical procedure and is not for everyone, nor is it 100 percent effective. The following techniques each require specialized equipment and highly trained personnel:

TENS :

• TENS uses tiny electrical pulses, delivered through the skin to nerve fibers, to cause changes in muscles, such as contractions or numbness. This in turn produces temporary pain relief. There is also evidence that TENS can activate subsets of peripheral nerve fibers that can block the transmission of pain at the spinal cord level, in much the same way that shaking your hand can reduce pain.

Peripheral nerve stimulation:

• This uses electrodes placed surgically on a carefully selected area of the body. The patient is then able to deliver an electrical current as needed to the affected area, using an antenna and transmitter.

Spinal cord stimulation:

• Thisuses electrodes surgically inserted within the epidural space of the spinal cord, allowing the patient to deliver a pulse of electricity to their spinal cord using a small box-like receiver and an antenna taped to the skin.

Deep brain or intracerebral stimulation:

This is considered an extreme treatment and involves surgical stimulation of the brain, usually the thalamus. It is used for a limited number of conditions, including extreme pain, central pain syndrome, cancer pain, phantom limb pain, and other neuropathic pain.

• Nerve blocks: These employ the use of drugs, chemical agents, or surgical techniques to interrupt the relay of pain messages between the brain and specific areas of the body. There are many different names for the procedure, depending on the technique or agent being used. Types of surgical nerve blocks include neurectomy; spinal dorsal, cranial, and trigeminal rhizotomy; and sympathectomy, also called sympathetic.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): Aspirin and ibuprofen are widely prescribed and sometimes called non-narcotic or non-opioid analgesics. They work by reducing inflammatory responses in tissues. However, many of these drugs are known to irritate the stomach and for that reason are usually taken with food. Although acetaminophen may have some anti-inflammatory effects, it is generally distinguished from the traditional NSAIDs.
• Physical therapy and rehabilitation: These techniques date back to the ancient practice of using methods such as heat, cold, exercise, massage, and manipulation, for the treatment of certain conditions. These may be applied to increase function, control pain, and speed the patient towards a full recovery.
• Surgery: Although this is not always an option, it may be required to relieve pain, particularly pain caused by back problems or serious musculoskeletal injuries. Surgery may take the form of a nerve or may involve an operation to relieve pain from a ruptured disc. Surgical procedures for back problems include discectomy or, when microsurgical techniques are used, microdiscectomy, in which the entire disc is removed; laminectomy, a procedure in which a surgeon removes only a fragment of the disc, gaining access by entering through the arched portion of a vertebra; and spinal fusion, a procedure where the entire disc is removed and replaced with a bone graft. In a spinal fusion, the two vertebrae are then fused together.
  
  Although this procedure can cause the spine to stiffen, resulting in lost flexibility, it serves one critical purpose: protection of the spinal cord. Other operations for pain include rhizotomy, in which a nerve close to the spinal cord is cut, and cordotomy, where bundles of nerves within the spinal cord are severed. Cordotomyis is an operation generally used only for the pain of terminal cancer that has not responded to other therapies. Another operation for pain is the dorsal root entry zone operation, otherwise known as DREZ, in which spinal neurons corresponding to the patient’s pain are surgically destroyed. Because surgery can result in the formation of scar tissue that may cause additional problems, patients are well advised to seek a second opinion before proceeding.
  Occasionally, surgery is carried out with electrodes that selectively damage neurons in a targeted area of the brain, however, these procedures rarely result in long-term pain relief. Both physician and patient may decide that the surgical procedure will be effective enough that it justifies the expense and risk. In some cases, the results of an operation are remarkable. For example, many individuals suffering from trigeminal neuralgia who do not respond to drug treatment have had wonderful success with a procedure called microvascular decompression, in which tiny blood vessels are surgically separated from the surrounding nerves.

DIAGNOSING CHRONIC PAIN

• Consult with the doctor & physical examination: Your doctor will discuss with you about your symptoms and inquire about your history of illness, injury or surgery. You may be asked to fill out a questionnaire to assess the intensity and location of your pain.Pain is a very personal and subjective experience and as such, there is no test that can measure and locate pain with precision. So, health professionals rely largely on the patient’s own description of the type, location and timing of the pain. Defining pain as sharp or dull, constant or on-and-off, or burning or aching may give the best clues to its origin. These descriptions are part of what is called the pain history, taken during the start of the evaluation of a patient with pain. Your doctor will also perform a physical examination, and may order multiple blood tests or X-rays.
• CT or CAT scan: Computed tomography (CT) or computed axial tomography (CAT) scans use X-rays and computers to produce an image of a cross-section of the body. During the test, you will be asked to lie down on a table as still as possible. The table will then move through a large, donut-shaped scanning device. Sometimes, an intravenous (injected into a vein) contrast material is required for a CAT scan and in such cases, you may have a blood test before the CAT scan appointment. Most CAT scan procedures take 15-60 minutes.
• MRI: Magnetic resonance imaging produces very clear pictures of the body without the use of X-rays. This test uses a large magnet, radio waves and a computer to produce images. Generally, an MRI takes 40 to 80 minutes, during which time several dozen images may be obtained. Certain MRI exams require an injection of a contrast material called gadolinium, which helps to highlight certain anatomic structures on the images. Due to the magnets used in the study, some people (like those who have pacemakers) should avoid having an MRI.
• Discography: During discography a contrast dye is injected into the spinal disc that is thought to be causing back pain. This dye outlines the damaged areas on X-rays taken following injection. This procedure may be recommend for people who are considering surgery or IDET (intradiscalelectrothermal treatment).
• Myelograms: As in discography, during the myelogram procedure, a contrast dye injected into the spinal canal to enhance the diagnostic ability of the X-ray. Doctors are then able to see on X-ray, the image of the spinal cord and can identify whether there is any nerve compression caused by herniated discs or fractures.
• EMG: This procedure allows doctors to evaluate the activity of the muscles. This procedure involves inserting very fine needles into the muscles to measure the muscles response to signals from the brain or spinal cord.
• Bone scans: Bone scans are used to diagnose and monitor infection, fractures, or other disorders in the bone. During a bone scan, a small amount of radioactive material is injected into the bloodstream, which will then collect in the bones, particularly in areas with any abnormalities.Scanner-generated images are sent to a computer to identify specific areas of irregular bone metabolism or abnormal blood flow.
• Ultrasound imaging: Also referred to as ultrasound scanning or sonography, this test uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image.