CHRONIC PAIN: WHAT IT IS AND HOW PROPER TESTING HELPS

Chronic Pain in the US

Table of Contents

Chronic pain (long-term pain) affects about 40 million people in the US.​​​1  Some sources say the numbers could be as high as 100 million. Beyond the debilitating personal effects, chronic pain costs the US over $600 billion every year.​​​2 
Pain is a subjective experience. What’s painful to one person might be just a slight discomfort to another. That said, pain that lasts for long periods could be crippling, regardless of its severity.
People in the US report having more pain than people in other countries. 1 in 3 Americans reports that they experience pain “often” or “very often.” In Croatia, the proportion is only 1 in 10 people.​​​3  This is according to the International Social Survey Program.
In the US, 126.1 million adults had experienced some pain in the past three months. Among them, 10.5 million had experienced severe pain every day.​​​4 
In 2013, 178 million Americans aged 18 years and older had at least one painful condition. This was up from 120.2 million in 1997.​​​5 
chronic pain

What Is Pain?

The International Association for the Study of Pain (IASP) defines pain as
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”​​​6 
In layman’s terms, pain is an experience that causes discomfort. It may be due to an injury or to the brain’s inability to process pain signals properly. Pain may vary in severity, location, and the involvement of body parts.
Some pain may be limited to the area of injury, while some pain may affect the entire body. A headache involves only the head, and a stomachache affects only the belly.
People use different terms to describe their pain. Some of them include:

What is Chronic Pain?

Chronic pain is a type of pain that persists for at least three months. Depending on the cause, it may last up to six months or even longer.
Some examples of chronic pain are:
Chronic pain is a common complaint in older adults. A person may have more than one chronic pain condition at a time.
Examples of the conditions that cause chronic pain include:

The Effects of Chronic Pain on Physical and Mental Health

Long-term pain can seriously affect day-to-day activities, social life, and work performance. It’s common for people with chronic pain have problems with sleep, appetite, concentration, and mobility.

Moreover, they are more likely to be depressed, anxious, and irritable. Chronic pain causes a threefold increase in the risk of anxiety, and also in the risk of mood disorders such as depression.​​​7 

About 10% of people who die by suicide have chronic pain.​​​8  This may be partly because people with long-term pain have easy access to opioids.

What Makes Pain Chronic?

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”​​​6 

Pain is a complex condition. It has both physiological and psychological components.
When a person sustains an injury, damaged tissues send pain signals to the brain. This is the body’s way of preventing further tissue damage. Pain signals that reach the brain stimulate nerves, causing an unpleasant sensation called pain.

In some cases, the brain fails to process the pain signals properly and continues to feel the “pain” even after the injury has resolved. Over time, nerves that send pain signals become more efficient. It means they will send more intense signals than they should.
Many lifelong conditions, such as cancer and diabetes, cause widespread tissue and nerve damage. Both of these conditions can cause chronic pain.

Video: Re-Think Chronic Pain

Transcript: Once upon a time all the lands were fraught with persistent pain.So widespread was this affliction that one in four people experienced it. The pain lasted for more than three months it shadowed their daily lives, 00:16 held them back from everyday activities and the interventions they tried proved useless. Hey pain go away we’ve tried it all but still you stay, moving less, taking pills, knives and needles and still we’re sore we can’t take no more! No more! 00:32 But the pain remains like a loyal companion. The people’s hopes faded and they became resigned to living with the pain only now the pain was a beast. Then along came a group of researchers of which I am one. 00:46 Back off big fella! I’m professor Lorimer Moseley and I’m a pain scientist. Pain scientists are starting to think differently about pain and its causes and we’re making exciting discoveries, like how the way you think about your pain can change the way it feels. 01:01 Over the next few minutes I’ll help you to understand your pain understanding is important because it can change how much things hurt and how much your body can do and it can help you to tame the beast. First trust me about this 01:16 pain is not an accurate measure of tissue health pain is a protector by making unpleasant feelings your brain changes your behavior so you can avoid injury or your tissues can heal sometimes pain is not helpful 01:31 like phantom limb pain. You don’t expect a missing limb to ache but it does and the pain is very real. So how do we explain this? Well pain is a warning signal from your brain that depends on credible evidence to say your body needs 01:45 protecting sometimes pains too protective and you get unnecessary warning signals. Pain scientists now understand that there are many ways our nervous system ends up reducing unnecessary warning signals, take conditioning for example. Think of Pavlov’s dog every time food was offered 02:01 Pavlov rang a bell, of course the dog will salivate seeing the food. This went on for a while, eventually the dog was conditioned to salivate for the bell alone. Well conditioning is just one of the ways your body learns pain 02:15 and the longer your nervous system produces pain the better it gets at producing it, your body learns pain. So what feeds this beast? Well let’s look at how pain works, in your body’s tissues there are specific neurons which normally only respond to harmful stimuli whether mechanical, 02:33 chemical or thermal. When they are activated they send a warning signal to your spinal cord which can in turn send the signal to your brain, this activity in neurons is called nociception and it’s happening all the time, 02:47 but only sometimes results in pain, most of the time the brain protects you with other things like movement. Once the warning signal reaches the brain the brain makes sense of it based on the information arriving and a vast amount 03:02 of information already stored. If there’s good reason to think protection is required then your brain makes pain. One of our amazing discoveries is that you can have pain without any physical stimuli, thoughts and places might 03:16 activate the warning signals and the pain feels exactly the same, it’s not just your brain your spinal cord also learns how to generate unnecessary warning signals. So how do you know when your nervous system is learning pain? 03:31 You may notice if your pain spreads or comes on without warning, your body feels odd and it’s hard to move properly, your pain changes quickly with your mood and small annoyances can set it off. Old injuries start to hurt again, 03:45 you’re more sensitive to stimuli and the longer the pain goes on the more all of this occurs. The old way we understood pain could not explain these things and left many sufferers feeling like no one believed it was real or for it to hurt so badly there must be a major tissue problem, 04:03 but we now know how persistent pain happens, so how can you tame the beast? Pain is a very personal thing, there’s no one-size-fits-all solution and while you probably have well thought out coping strategies it’s time to take a new 04:17 approach to dealing with and reducing your pain, one that focuses on retraining your pain system This might mean testing yourself physically and moving more than you normally would, being honest about your 04:29 current attitudes and beliefs can also help as can asking your health professional new questions, ‘How do I know if my pain system is being overprotective?’ ‘How do I retrain my pain system to be less protective?’ ‘How do I know if I’m safe to move?’ 04:46 So be brave and have hope, because it is possible to tame the beast. Visit our website for more information and questions to ask your health professional. 04:56 tamethebeast.org

Acute Pain vs. Chronic Pain

Acute pain typically lasts three months or less. Mostly, the causes are clear. When the underlying factor, such as an injury, goes away, the pain is relieved. Once the pain is gone, the person who has been suffering from it will have no problems carrying out their daily activities.
Some common causes of acute pain are:
Chronic pain usually lasts three to six months. However, some painful conditions may persist for years. Someone may experience chronic pain long after they are injured, or without any apparent cause. In some cases, more than one factor may be involved.
Such pain causes significant problems with daily activities and can be debilitating. Chronic pain is associated with long-term conditions, such as cancer, diabetes, and arthritis.

Chronic Pain vs. Chronic Pain Syndrome

Chronic pain means any type of pain that persists for three months or longer.
Chronic pain syndrome refers to a cluster of conditions secondary to long-term pain. These conditions may make the pain worse or cause other complications, such as sleep problems, anxiety, fear of pain, or depression.

What Causes Chronic Pain?

Several conditions can cause chronic pain. The top three causes are osteoarthritis, rheumatoid arthritis, and fibromyalgia.​​​9 

Fibromyalgia

People with fibromyalgia have unexplained pain in almost every part of their bodies. No one knows what causes fibromyalgia. Nonetheless, scientists think an imbalance of certain brain chemicals may play a critical role. Fibromyalgia can cause tender spots, muscle pain, headaches, long-lasting back pain, or neck pain.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) causes persistent aching that affects more than one joint. Hands, wrists, and knees are the most commonly affected joints. People with RA have other symptoms, such as joint stiffness, swelling, and fever. Like Osteoarthritis, RA has no cure.

Osteoarthritis

Osteoarthritis (OA) causes severe intermittent or persistent aching in the knees, hips, spine, and feet. Other symptoms include joint stiffness, swelling, and limited joint mobility. There is no cure for OA. Thus, people with OA might have some level of pain throughout their lives. According to the CDC, 25% of adults with arthritis (15 million adults) have severe pain in their joints.​​​10 

Multiple Sclerosis

Multiple sclerosis (MS) is a disease of the brain and the spinal cord. In people with MS, the immune system damages the protective covering of the nerves. As a result, the brain cannot effectively communicate with the body. MS causes pain in the legs, feet, arms, and hands. People with MS report experiencing burning, prickling, or stabbing pain almost every day.​​​11 

Sciatica

Sciatica causes mild to sharp burning pain that travels from the lower back to the buttocks. Unlike acute sciatic, chronic sciatica persists for three months or longer. The condition is more common in adults aged 40 or older.

Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) causes pain and numbness in the thumb and in the index, middle, or ring fingers. The common causes include repetitive movements of the hand, rheumatoid arthritis, diabetes, and an underactive thyroid gland. Some women may have CTS during pregnancy.

Traumatic Injury

12 to 40% of cases of chronic pain have a history of physical trauma or injury. Likewise, 15% of people hospitalized after serious injury report chronic pain within the first year.​​​12  Scientists do not know how an injury can lead to persistent pain. Nonetheless, they believe several factors may increase the risk. These include pre-injury depression, anxiety, and alcohol use, as well as a history of chronic pain. Those who have sustained multiple injuries may be at a higher risk.

Back Injuries

Back injuries are one of the most common causes of chronic back pain. Heavy lifting, traffic crashes, or high-impact activities can cause back injuries. The lower back is most likely to be affected by such injuries.

Combat Injuries

Over half of war-related injuries result from explosive devices, landmines, and shrapnel. Almost all injured soldiers complain of pain, and many of them have traumatic brain injury (TBI). TBI can cause chronic headaches. Delayed wound healing and repeated injuries account for chronic pain in many injured soldiers.

Sports Injuries

Chronic pain from sports injuries is not a new phenomenon. Studies reveal that 1 in 2 retired football players experience chronic pain. Besides, they also have sleep problems and mild depression. Both of these factors can contribute to chronic pain.
An active athlete is continuously exposed to high-risk situations, such as repetitive impacts. They are always under pressure to perform well, and this can take a toll on their health.
football and chronic pain

Can Being Overweight Cause Chronic Pain?

Obesity does not directly cause chronic pain, but it can increase the risk. About 4 in 10 people who fit the definition of obese also experience chronic pain of moderate to severe intensity.13 Furthermore, people who are severely overweight are more likely to have conditions that may cause long-term pain, such as diabetes, arthritis, and fibromyalgia.

Who Suffers from Chronic Pain?

Anyone can have chronic pain. Children and teens are more likely to experience headaches, abdominal pain, and leg/hand pain. Adults usually complain of joint pain, low back pain, and neurogenic pain. That said, some people can be at a higher risk due to their age, gender, and profession.

Veterans

Chronic pain is more common in veterans than in nonveterans. According to a National Veterans Affairs Study,
Veterans, especially those who have recently served in a war, report a variety of causes for their pain, including multiple injuries, brain trauma, and injuries to the muscles and bones.

Athletes

Chronic pain is common among gymnasts, soccer players, runners, and basketball players.
All forms of sports require a high level of fitness. Athletes spend years doing activities that help maintain current fitness levels. Sadly, they are not immune to chronic pain.
The most commonly reported chronic pain conditions in athletes are:

Seniors

Increasing age is the single most significant risk factor for chronic pain. According to BMJ, 33% of people older than 65 years have long-term pain.​​​14  Studies also suggest that pain is most severe in adults aged 45 to 65 years.​​​15 
The common conditions that cause chronic pain in older adults are:

Video: Helping Older Adults Manage Chronic Pain

Transcript:00:00 geriatricians like dr. brandon verdoorn see the wide range of effects of chronic pain on older patients anything from sleep disturbance to low mood social isolation functional limitations minor 00:15 short-lived pain can be managed at home with ice heat or over-the-counter medication if you have severe pain persistent pain or pain that affects function you should see your healthcare provider to determine the underlying cause and develop a pain management plan that oftentimes involves non-medication 00:31 strategies that might mean physical therapy exercise massage or acupuncture medication strategies often are used to typically starting with lower risk approaches like to see the medicine and topical medications and reserving 00:46 high-risk medications for more difficult cases talk to your healthcare provider work with them to figure out what’s causing the pain and go through that process of trying different management strategies for the Mayo Clinic News 00:57 Network I’m Jason Outland

Women

Men and women perceive pain differently. Several factors contribute to this difference. These include hormones, menstruation, puberty, and reproductive status.
Women also have a higher risk of developing disorders that cause chronic pain. Examples of such conditions include:

How is it Diagnosed?

Diagnosing chronic pain is not easy, as there are no tools to quantify pain. Diagnosis often involves a series of tests and procedures, as well as a review of symptoms and medical history.

A doctor will first ask questions about the symptoms and factors that trigger pain. These questions may include:
Then they may order tests to identify physical causes that might be behind the pain. Some of the possible tests include:

Athletes

Blood Testing

Blood tests are useful in the diagnosis of infections and inflammation. People with infection/inflammatory disorder have high levels of white blood cells, and also of inflammatory substances such as the C-reactive protein (CRP).

A blood test can also help determine if there is the presence of rheumatoid arthritis (RA), gout, or cancer. If RA is present, the blood analysis will show positive results for specific proteins called rheumatoid factors.

Urine Testing

Urinalysis is most commonly used to check if a patient has gout. Gout is a type of arthritis that causes high blood levels of uric acid.

A doctor may also order a urine test for a patient who uses a narcotic painkiller to relieve chronic pain.

Testing Spinal and Brain Fluid

A doctor inserts a needle into the lower back and collects a sample of cerebrospinal fluid (CSF). CSF is a clear liquid that protects the brain and spinal cord.

A CSF analysis helps diagnose disorders of the central nervous system and some types of cancer.

Musculoskeletal and Neurological Exams

A musculoskeletal assessment checks the patient’s posture and joint mobility as well as looking for swellings in the affected area. It may also be used to diagnose carpal tunnel syndrome. Sometimes the test may involve a detailed spine examination to identify spinal deformities and gait abnormalities.
A neurological examination assesses muscle strength, reaction to touch, balance, and sensation. Moreover, it may also test memory, alertness, mood, and behavior.

Imaging

Imaging tests provide detailed pictures of internal organs and activities inside the body. A doctor can use these tests to:

X-Rays

X-rays are frequently used to diagnose fractures. A specific form of x-ray imaging, the arthrogram, may be used to check painful joint disorders.

MRI

An MRI scan uses a strong magnetic field and radio waves to create detailed images of internal organs. MRI helps diagnose the following conditions.

  • Chronic low back pain
  • Fibromyalgia
  • Osteoarthritis
  • Chronic migraine
  • Chronic pelvic pain
  • Peripheral neuropathy (damage to nerves that lie outside the brain and spinal cord)

Electrodiagnostic Procedures

Electromyography (EMG)

An EMG helps diagnose disorders of muscles and nerves. It records electrical activity in the muscles. Thus it helps find out how electrical signals pass from nerves to muscles.

A patient may need an EMG if they have numbness, muscle weakness, tics, or muscle pain. Electromyography may be used to identify some conditions that can cause chronic pain, such as:

  • Carpal tunnel syndrome
  • Amyotrophic lateral sclerosis (ALS)
  • Radiculopathy (pinched nerves in the spine)
  • Muscular dystrophy (a genetic disorder that causes a gradual loss of muscle mass)

Nerve Conduction Study (NCS)

A nerve conduction study measures the speed with which electrical signals pass through a nerve. NCS is a valuable tool to identify:

  • Carpal tunnel syndrome
  • Herniated disk disease, which causes low back pain
  • Abnormalities in the sciatic nerve

To confirm a diagnosis, a doctor may order both EMG and NCS at the same time.

Pain Management

Many disorders that cause chronic pain have no cure. Luckily, several treatment options are available. Pain treatment primarily focuses on treating the underlying medical condition responsible for pain.
Chronic pain has both physical and psychological dimensions. A comprehensive treatment plan addresses both physical and psychological factors that contribute to pain. For this, different health professionals work together to design a plan tailored according to individual needs. A combination of medications, lifestyle changes, and behavioral therapies is perhaps the best approach.
Chronic pain treatment aims to:

Pain Relievers

Non-Opioids

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the primary treatment for chronic mild to moderate pain. Some examples of NSAIDs are naproxen, ibuprofen, and aspirin. NSAIDs work by blocking the production of substances that cause pain and swelling.
Acetaminophen (Tylenol) is similar to NSAIDs, but it works differently. It may block the production of inflammatory chemicals in the brain.

Opioids

Opioids or narcotics are powerful pain relievers. They are used to treat moderate to severe pain. Narcotics act by blocking pain signals from reaching the brain. Opioid use has surged during the last few decades. In 2015, doctors prescribed three times as much opioid medication for chronic pain as they did in 1999.16
These drugs are highly addictive, and abuse is common. Most doctors prescribe narcotics when non-opioid pain relievers fail to provide desired benefits.
Examples include buprenorphine, fentanyl patch, hydrocodone, oxycodone, hydromorphone, methadone, morphine, and tramadol.
Depending on the patient’s needs, a doctor may use opioids, non-opioids, or some combination of these.

Anticonvulsants

Anticonvulsants or anti-epileptics primarily treat seizures. They may also relieve pain associated with nerve damage and fibromyalgia. Examples include gabapentin, pregabalin, carbamazepine, and lamotrigine.

Muscle Relaxants

When it comes to using muscle relaxants for chronic pain, expert opinions are divided. Moreover, only a few studies support their use in people with persistent pain. Thus, a person who is thinking of using any of these drugs should consult their doctor.

Corticosteroids

Corticosteroids are hormone-based drugs that reduce inflammation. They occur naturally in the body. Some corticosteroids are synthesized in the lab. Injectable steroids may help relieve chronic pain due to pinched nerves or joint disorders. In 2014, the FDA reported that injectable corticosteroids might cause paralysis and death.​​​17 

Antirheumatic Agents

Antirheumatic medications are used to control the symptoms of rheumatoid arthritis (RA). They suppress the immune system and help reduce damage to the joints. Examples include methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine.

Antidepressants

Antidepressants can lift not only mood but may also relieve chronic pain. They can be useful in treating pain due to arthritis, migraine, nerve damage, and fibromyalgia.
These medications work by increasing the levels of brain chemicals such as serotonin, dopamine, and norepinephrine. They may be used even when a person shows no signs of depression.
Examples include amitriptyline, venlafaxine, and paroxetine.

Video: Tools to Manage Chronic Pain

Transcript: I do have a headache every single day I wake up with one and I go to sleep with one for ten years Alison Fleming has endured chronic headaches the daily headaches and migraines plus pain from other medical conditions slowly eroded Alison’s quality of life it affected 00:16 everything she felt caught trapped by unyielding pain I didn’t know how I could possibly manage this amount of pain unwilling to let the pain dictate how she lived Alison went to Mayo Clinic 00:31 where she enrolled in the pain rehabilitation center a three-week outpatient intensive program designed to help people suffering from non-cancerous chronic pain regain control of their 00:43 lives you can improve your level of physical and emotional functioning and then when you improve management of chronic pain oftentimes pain severity or pain intensity will improve however that’s not the primary goal I mean dr Michael Hooton says there sometimes not cure for chronic pain so the goal of the 01:02 program is to give people the tools they need to manage it to regain controls back over their life that the chronic pain is taken away dr. Cynthia Townsend and dr. Hooten team up with physical therapists occupational therapists 01:15 nurses and other specialists to help with all aspects of chronic pain thing like group sessions exercise biofeedback and support from others going through the same thing boost confidence patients learn that they can taper off medications they can craft a plan to 01:31 turn painful days into fulfilling days they can stop pain from running their lives I’ve had people that come into this program they’re in a wheelchair or a walker they’re very difficult for them to move around and it’s a great way from 01:45 the program they’ve got their ability back they’re active they’re engaged in life they’re enjoying life they’re laughing again Alison still has a headache every day but the pain is no longer all-consuming because she’s learned how to manage it I 02:00 felt like I lost a little bit of myself over the past 10 years and now to be back to where I was is very fulfilling for Mayo Clinic News Network I’m Vivien Williams

Alternative Treatments

Alternative treatments may also help address pain. It’s always recommended to discuss any treatments with a doctor or medical professional. Remember, what works for one person may not work for another.
It’s recommended to start with the easiest alternative treatments and write down how they feel after a month of practice. If they are feeling better, they may consider continuing the treatment for an extended period.
Below are some of the alternative pain treatments to consider.

Psychological and Behavioral Treatment

Psychotherapy (talk therapy) is an integral part of chronic pain treatment. It has no direct effect on pain severity. However, it can help improve other pain-related conditions, including depression, anxiety, and fear of pain.
Two forms of psychotherapy have shown promising results in many studies. They are:

Acceptance and Commitment Therapy (ACT)

ACT is short-term psychotherapy. There are two approaches to pain perception in ACT. First, ACT teaches the patient to accept things that are beyond their control. Second, it encourages the patient to feel things as they are rather than questioning their existence.
ACT may be useful in treating lower back pain, leg pain, and neck pain.

Cognitive-Behavioral Therapy (CBT)

CBT educates people about the relationship between pain, mood, and behavior. It also teaches relaxation strategies. Patients will learn measures to replace distorted thoughts about pain with positive thoughts.
CBT is likely to be most effective in treating chronic pain caused by:

Why is Proper Testing Key to Treating Chronic Pain?

Chronic pain is a complicated disorder. There is no specific tool for diagnosis. Likewise, available treatments often fail to produce favorable results.
Untreated or undertreated chronic pain is one of the leading causes of limited mobility. Other consequences may include sleep disorders, problems with focus, and depression.
Some experts note that diagnostic tests like MRI are often overused. They fear that such tests may expose people to unnecessary radiation and increase medical expenses.
Proper testing is critical in determining the success of pain treatment. Moreover, choosing the right diagnostic strategy is key to:

Resources

  1. https://nccih.nih.gov/research/results/spotlight/Prevalence-Profile-High-Impact-Chronic-Pain
  2. https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/2351-notes.pdf
  3. https://www.theatlantic.com/health/archive/2017/12/america-experiences-more-pain-than-other-countries/548822/
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562413/
  5. https://nccih.nih.gov/news/press/02122019
  6. https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698#Pain
  7. https://www.health.harvard.edu/mind-and-mood/depression-and-pain
  8. https://www.hsph.harvard.edu/news/hsph-in-the-news/suicide-rates-chronic-pain/
  9. https://www.uspharmacist.com/article/trends-in-chronic-pain
  10. https://www.cdc.gov/arthritis/pain/index.htm
  11. https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Pain
  12. https://academic.oup.com/painmedicine/article/14/3/336/1858823
  13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676152/
  14. https://bestpractice.bmj.com/topics/en-us/694
  15. https://www.apa.org/pubs/journals/releases/amp-a0035794.pdf
  16. https://effectivehealthcare.ahrq.gov/products/opioids-chronic-pain/protocol
  17. https://www.frontiersin.org/articles/10.3389/fphar.2018.01229/full