Note from Editor, CHN

"Pain" as Albert Schweitzer once said, "is a more terrible lord of mankind than even death itself."  Pain is something most human beings experience to some degree in their life.  This article addresses chronic pain as a disease.  It is rare to hear or even read pain described as a disease.  The articles on pain available from SpineHealth.com provide important information for patients and doctors alike. 

Most of us become patients at one time or another.  If you have opened this page, no doubt you are more than a little familiar with pain than most.  Healthy folk avoid the discussion of pain like the plague.  It is like geriatrics, none of us want to think about becoming old until we are on the doorstep of what we accept as the age we think is "old" for us.  I have met some wonderful elderly people, who I thought earned their silver hair and wear it with distinction and beauty.  However, I have discussed age with them and discovered age is truly subjective.  For instance, a 25 year old may say "I feel like a 50 year old today."  A 50ish person might say "I feel like 80 right now."  A person in their 70's will complain of feeling like a hundred.  We always seem to equate pain with an age that is far from our actual age as if it belongs to some foreign age group. It is  rare to hear, "I'm really feeling my age today" perhaps because at what ever age we are, we can't feel age! 

Just because you are 50, 60, 70, or older, does not mean you have reached an age that doctors can say your pain is due to old age.  I recall a story about an elderly man who through most of his life was very healthy and fit finally found it necessary to see a physician.  He complained of leg pain, and that  his limping was due to the pain he was feeling in his left leg.   His doctor examined him, smiled and exclaimed, "You know you are 82, you can expect some pain at your age!"  The elderly man retorted, "And you my good doctor know both my legs are the same age yet - only my left one is aching."  

Physicians and healthcare givers must not dismiss pain as something to be expected due to age.  Tragically, before medicine had advanced in pain management, it was believed that infants did not suffer pain and therefore did not need analgesics, even after surgery.  Slowly we are seeing a change in how patients with pain are being treated.  Even a decade ago, it was not easy for a patient suffering intractable pain to receive opioids when it would have been appropriate to administer such analgesics.  

I am not convinced all doctors understand how pain actually works and how it can morbidly effect the suffering patient.  Pain from a severe sprain, is easily identified, but the kind of pain that concerns this writer are ones that are basically left untreated.  I am a chronic pain patient and know from experience what mismanaged pain can do.  I have researched euthanasia, physician assisted suicide and so - called mercy killings for over a decade and see that pain changes people.  No one wants to see someone suffer.  While not all source of pain is easily identifiable, pain that does not respond to the usual treatment, must not be dismissed.  It is unfortunate, but often patients have to buckle up and force themselves to find a doctor who will work with them.  One can't give up on oneself just because a doctor might.  Good doctors readily admit they don't have time to research all diseases, syndromes and ailments in depth, therefore they encourage the patient to find out as much as they can about their health problems. You are the one whose life is being robbed.  It may be up to you to find answers. This may seem unfair, but it is reality.  The fact that you are even reading this means you are searching for reasons behind your pain,  If you know of a journal or article that has helped you, please e-mail us and we will post the link. 

If the source of the pain can not be cured, I hope all pain patients are able to find proper pain management so that we may all once again enjoy life.  Perhaps it means learning new skills, and new hobbies, and giving up ones that frustrate us due to loss of physical ability. 

It is my hope that I will be able to add more articles like the following, that may bring you closer to why you are suffering and find the source of your pain. 

Cheryl Eckstein March 26, 2004

    

Chronic pain as a disease: Why does it still hurt?

People who suffer from severe, chronic pain know how it can utterly disrupt and damage one’s life. Pain can be cruel - making it hard to enjoy even the simplest daily activities, and certainly making it a challenge to carry out an exercise routine and other healthy activities. Moreover, chronic pain was not previously all that well understood. The medical profession used to believe that pain is always a manifestation of an underlying injury or disease. As such, doctors focused on treating the underlying cause, with the belief that once the injury or disease was cured the pain would then disappear.

If no underlying cause could be found for the pain, then the patient was told that very few treatments are available, or worse, “the pain must be in your head”. Unfortunately, some doctors still practice in this manner, having no appreciation for the unique problem of chronic pain, newer theories about pain, and the many factors that influence a chronic pain problem.

The medical community is starting to understand that if pain is no longer a function of a healthy nervous system (signaling that there is a disease or underlying injury), then the pain itself becomes the problem and needs to be treated as the primary pathology.

bulletThe Experience of Pain


Contrary to popular belief, all pain is real. This may seem like an obvious statement, but people with back pain are sometimes treated as if their pain is either imaginary or exaggerated. In some cases, they feel like they have to prove their pain to their friends, family and doctors. Some patients are told by their doctor that there is no reason for the pain and therefore “it cannot be that bad”.

Pain is a personal experience and cannot be measured like other problems in medicine, such as a broken leg or an infection. For instance, a broken leg can be confirmed by an X-ray and an infection by a blood test measuring white blood cell count. Unfortunately, there is no medical test to measure pain levels.

To make matters more challenging for the patient, for many chronic pain problems there is no objective evidence or physical findings to explain the pain. Thus, many back pain sufferers go from one doctor to the next searching for explanations. This process can lead to unnecessary evaluations and treatments, in addition to putting the patient at risk for actually being harmed or made worse by the healthcare profession.

Everyone experiences and expresses pain differently. Two people with the exact same injury will feel and show their pain in unique ways depending on a number of things such as:

bulletThe situation in which the pain occurs
bulletThoughts about the pain, such as “this is nothing serious” versus “this pain could kill me”
bulletEmotions associated with the pain, such as depression and anxiety versus hopefulness and optimism
bulletCultural influences determining whether a person is to be more stoic or more dramatic in showing pain to others

The newest theories of pain can now explain, on a physiological level, how and why people experience pain differently.

bullet

Types of pain: Acute, Chronic, and Neuropathic Pain

Understanding how pain is defined is important in order to learn how to better control it. For the purposes of research and medical practice, pain can be separated into three categories:

bulletAcute pain

bulletChronic pain

bulletNeuropathic pain

 

bulletAcute pain
Acute pain is currently defined as pain lasting less than 3 to 6 months, or pain that is directly related to tissue damage. This is the kind of pain that is experienced from a paper cut or needle prick. Other examples of acute pain include:
bulletTouching a hot stove or iron. This pain will cause a fast, immediate, intense pain with an almost simultaneous withdrawal of the body part that is being burned. More of an aching pain might be experience a few seconds after the initial pain and withdrawal.

bulletSmashing one’s finger with a hammer. This pain is similar to that of touching a hot stove in that there is immediate pain, withdrawal and then “slower” aching pain.

bulletLabor pains. The pain during childbirth is acute and the cause is certainly identifiable.

The longer pain goes on the more susceptible it is to other influences and developing into a chronic pain problem. These influences include such things as the ongoing pain signal input to the nervous system even without tissue damage, lack of exercise (physical deconditioning), a person’s thoughts about the pain, as well as emotional states such as depression and anxiety.

bulletChronic pain
There are at least two different types of chronic pain problems - chronic pain due to an identifiable pain generator (e.g. an injury), and chronic pain with no identifiable pain generator (e.g. the injury has healed).
bulletChronic pain due to an identifiable pain generator


This type of chronic pain is due to a clearly identifiable cause. Certain structural spine conditions (for example, degenerative disc disease, spinal stenosis and spondylolisthesis) can cause ongoing pain until successfully treated. These conditions are due to a diagnosable anatomical problem.

If the pain caused by these types of conditions has not subsided after a few weeks or months of conservative treatments, then spine surgery may usually be considered as a treatment option.

bulletChronic pain with no identifiable pain generator


This type of pain continues beyond the point of tissue healing and there is no clearly identifiable pain generator that explains the pain. It is often termed “chronic benign pain”.

It appears that pain can set up a pathway in the nervous system and, in some cases, this becomes the problem in and of itself. In chronic pain the nervous system may be sending a pain signal even though there is no ongoing tissue damage. The nervous system itself misfires and creates the pain. In such cases, the pain is the disease rather than a symptom of an injury.

The term “chronic pain” is generally used to describe pain that lasts more than three to six months, or beyond the point of tissue healing. Chronic pain is usually less directly related to identifiable tissue damage and structural problems. Examples of chronic pain are: chronic back pain without a clearly determined cause, failed back surgery syndrome (continued pain after the surgery has completed healed), and fibromyalgia.

Chronic pain is influenced by many factors, such as ongoing pain signal input to the nervous system even without tissue damage, physical deconditioning due to lack of exercise, a person’s thoughts about the pain, as well as emotional states such as depression and anxiety. Chronic pain is much less well understood than acute pain.

bulletNeuropathic pain


Neuropathic pain has only been investigated relatively recently. In most types of neuropathic pain, all signs of the original injury are usually gone and the pain that one feels is unrelated to an observable injury or condition. With this type of pain, certain nerves continue to send pain messages to the brain even though there is no ongoing tissue damage.

Neuropathic pain (also called nerve pain or neuropathy) is very different from pain caused by an underlying injury. While it is not completely understood, it is thought that injury to the sensory or motor nerves in the peripheral nervous system can potentially cause neuropathy. Neuropathic pain could be placed in the chronic pain category but it has a different feel then chronic pain of a musculoskeletal nature.

Neuropathic pain feels different than musculoskeletal pain, and is often described with the following terms: severe, sharp, lancinating, lightning-like, stabbing, burning, cold, and/or ongoing numbness, tingling or weakness. It may be felt traveling along the nerve path from the spine down to the arms/hands or legs/feet.


It’s important to understand neuropathic pain because it has very different treatment options from other types of pain. For example, opioids (such as morphine) and NSAID’s (such as ibuprofen, COX-2 inhibitors) are usually not effective in relieving neuropathic pain. Treatments for neuropathic pain include certain medications, nerve “block” injections, and a variety of interventions generally used for chronic pain.

When Acute Pain Becomes Chronic

It is critical for a doctor and a patient to have an understanding of the difference between acute and chronic pain. With acute pain, the pain is a symptom of injured or diseased tissue. When the injury has finished healing, the correlating pain will subside. For example, with a herniated disc, once the pressure on the nerve is alleviated the acute pain stops. For this reason, medical treatment for acute pain focuses on healing the underlying cause of the pain.

Additionally, with acute pain the severity of pain directly correlates to the level of tissue damage. This provides us with a protective reflex, such as to stop an activity when it causes pain. However, chronic pain does not serve a protective or other biological function. Treatments will be different depending on the underlying cause of the pain.

Not all pain that persists will turn into chronic pain. Pain is experienced very differently for different people. Likewise, the effectiveness of a particular treatment will often differ from person to person. For example, a particular medication or injection for a herniated disc may provide effective pain relief for some people but not for others.

One problem is that not all patients with similar conditions develop chronic pain, and it is not understood why some people will develop chronic pain. Also, a condition that appears relatively minor can lead to severe pain, and a serious condition can be barely painful at all.

As pain moves from the acute phase to the chronic stage, influences of factors other than tissue damage and injury come more into play and influences other than tissue input become more important as the pain becomes more chronic. These include such things as ongoing “pain” signals in the nervous system even though there is no tissue damage, as well as thoughts and emotions, as discussed previously.

Pain medicine and pain management as a medical specialty is relatively new. However, now that pain is becoming recognized as a primary problem, rather than always being a symptom of a disease, the specialty of pain management is starting to grow.

bulletSOURCE: http://www.spine-health.com/topics/cd/chronic_pain/chronicpain01.html

 

Please note, not all articles on pain, back pain etc., will be posted in its entirety here.  In some cases the site is too large with many diagrams or photos.  Therefore the URL will be given, and you will have to use the back button to return to CHN.  The URL's are as follows:

Management of chronic low back pain eMJA; http://www.mja.com.au/public/issues/180_02_190104/bog10461_fm.html#authors

NINDS Chronic Pain Information Page
Synonym(s):   Pain - Chronic
http://www.ninds.nih.gov/health_and_medical/disorders/chronic_pain.htm

NINDS Chronic Pain Information Page
Synonym(s):   Pain - Chronic**** A Patient's Guide to Anatomy and Function of the Spine (excellent overview of what our spine is)
http://www.umm.edu/spinecenter/anatomy/index.html

If for some reason you have trouble accessing any of the above pages, e-mail us at mailto:chn@intergate.ca  and we will do our best to provide a copy of the article for you.

 

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