CHRONIC PAIN: WHAT IT IS AND HOW PROPER TESTING HELPS
Chronic Pain in the US
Table of Contents
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.
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.
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.
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.”
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:
- Burning
- Sharp
- Dull
- Intense
- Aching
- Cramping
- Shooting
- Stabbing
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:
- Lower back pain
- Cancer pain
- Arthritis pain
- Neurogenic pain (pain due to nerve damage in the brain or other body parts)
- Psychogenic pain (pain due to faulty processing of pain signals by the brain)
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:
- Chronic Fatigue Syndrome: Thich causes extreme fatigue and unexplained pain.
- Endometriosis: This is a painful condition in females, in which the cells that line the inside of the uterus grow outside of the uterus.
- Fibromyalgia: This causes diffuse pain throughout the body.
- Inflammatory Bowel Disease (IBD): This is a long-term disorder that can cause inflammation in any part of the digestive tract.
- Interstitial Cystitis: This causes mild to severe persistent pain in the urinary bladder.
- Temporomandibular Joint Dysfunction: This condition causes severe pain and stiffness in the jaw.
- Vulvodynia: Vulvodynia is a painful condition of females which causes unexplained pain in the areas surrounding the vaginal opening.
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 to 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.
About 10% of people who die by suicide have chronic pain.
What Makes Pain Chronic?
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
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.
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:
- Surgical or dental procedures
- Bone fractures
- Burns
- Cuts
- Labor and childbirth
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.
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.
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.
Sciatica
Sciatica causes mild to sharp burning pain that travels from the lower back to the buttocks. Unlike acute sciatica, 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.
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.
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,
- About 1 in 5 veterans in primary care have long-term pain
- 1 in 10 have severe persistent pain
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:
- Lower back pain
- Leg pain
- Stress fractures (cracks within a bone)
- Tendinitis (swelling of the tendon - a band of fibrous tissues that holds muscles and bones together)
- Diabetes
- Brittle bones
- Recurrent fractures
- Narrowed spinal canal, which presses the nerves that travel through the lower back into the legs
Seniors
The common conditions that cause chronic pain in older adults are:
- Cancer
- Arthritis and gout
- Heart disease
- Kidney disease
- Damaged nerves
- Stroke
- Shingles
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:
- Arthritis
- Brittle bones
- Migraines
- Irritable bowel syndrome (IBS), which causes mild to severe stomach cramps
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:
- When did you first begin having pain?
- How do you describe your pain? (shooting, burning, cramping, stabbing, dull, or sharp?)
- Have you had an injury in the affected part?
- Does any activity relieve your pain or make it worse?
- Do you have a history of mental illness, such as depression or anxiety?
- Where do you rate your pain on a scale of 0 to 10?
- Where do you rate your pain on a scale of 0 to 10?
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:
- Identify fractures or inflammatory changes in the bone
- Obtain details of a bone and surrounding structures
- Tell the difference between cancerous growths, infections, or fractures
- Identify nerve damage
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:
- Improve mobility as much as possible
- Maintain quality of life with the lowest possible dose of medication
- Reduce the risk of pain-related psychiatric problems such as depression and anxiety
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.
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.
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.
- Massage: This treatment may help relieve pain associated with RA and fibromyalgia
- Acupuncture: This treatment may work for pain due to osteoarthritis and fibromyalgia
- Meditation: Limited studies suggest that mindfulness meditation improves pain perception and may reduce depressive symptoms
- Hypnosis: Hypnosis may be useful in treating cancer pain and back pain
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:
- Cancer
- Chronic migraines
- Fibromyalgia
- HIV/AIDS
- Irritable bowel syndrome
- Multiple sclerosis
- Osteoarthritis
- Rheumatoid arthritis
- Spinal cord injury
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:
- Designing the most effective treatment plan
- Improving the quality of life
- Preventing potentially life-threatening complications
- Reducing the cost of diagnosis and treatment
Resources
- https://nccih.nih.gov/research/results/spotlight/Prevalence-Profile-High-Impact-Chronic-Pain
- https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/2351-notes.pdf
- https://www.theatlantic.com/health/archive/2017/12/america-experiences-more-pain-than-other-countries/548822/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562413/
- https://nccih.nih.gov/news/press/02122019
- https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698#Pain
- https://www.health.harvard.edu/mind-and-mood/depression-and-pain
- https://www.hsph.harvard.edu/news/hsph-in-the-news/suicide-rates-chronic-pain/
- https://www.uspharmacist.com/article/trends-in-chronic-pain
- https://www.cdc.gov/arthritis/pain/index.htm
- https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Pain
- https://academic.oup.com/painmedicine/article/14/3/336/1858823
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676152/
- https://bestpractice.bmj.com/topics/en-us/694
- https://www.apa.org/pubs/journals/releases/amp-a0035794.pdf
- https://effectivehealthcare.ahrq.gov/products/opioids-chronic-pain/protocol
- https://www.frontiersin.org/articles/10.3389/fphar.2018.01229/full
