THE BURDEN OF CHRONIC PAIN

Pain is a common sensation, experienced by most of us at some point in our lives. When the discomfort lasts more than 12 weeks, it is classified as chronic, experienced by about 20 percent of the population. 50 million US citizens live with it…..but how much do we really know about chronic pain? The answer may lie in how well we (don’t) deal with it.

Most people when asked will say pain is an undesirable sensation, which is an understandable sentiment. Yet, this is not always the case: pain has numerous functions in the human body. The pain experienced from  trauma to our skin is optimal since we need to be informed there has been an injury. The unpleasant sensation motivates us to address the wound in some fashion (ideally utilizing appropriate wound care techniques!).

Pain has been defined as an “unpleasant sensory and emotional experience” which says nothing about the character of the pain. Is it sharp, often cited as the classic example? Far too many assume if some sensation they have isn’t sharp, then it isn’t painful. This is wholly inaccurate since pain comes in many forms and flavors, from an uncomfortable ache, right through the alphabet of adjectives, to the unpleasant ‘zinging’ sensation. Simply put, if it isn’t normal and not pleasant, it can be thought of as pain.

Pain is a mysterious sensation, resulting from a complex interaction of nerves and neurotransmitters, chemical messengers and mental health. There are many situations in which the pain experienced is not informative and not beneficial. When some component of our sensory system is sufficiently disturbed, abnormal or inappropriate pain may be experienced. Such is the nature of painful diabetic neuropathy, although a majority of individuals with diabetes don’t get the classic burning pain. Or, if they once did, any such sensations resolved, to be left with numbness as the nerve changes of diabetes progress, as they do in the great majority of people.

Ask anyone suffering from fibromyalgia, a relatively common condition causing pain to the afflicted individual that is not related to an injury or traumatic event. Those so afflicted also experience sleep disturbances and fatigue, although it is not an inflammatory disease like rheumatoid arthritis. There is much about fibromyalgia we don’t understand, but it would seem the nervous system processes pain signals abnormally leading to heightened sensitivity. 

Another mysterious condition, termed complex regional pain syndrome (CRPS), causes severe and enduring pain and results from some seemingly insignificant injury. Surgical procedures can be such a cause or even a minor sprain. Pain develops far out of proportion to the trauma which becomes entrenched and intractable with time, untouchable with the strongest opioid pain relievers. As with many neurologic conditions, there must be some mechanism, but we simply don’t understand the “why’s and how’s” of CRPS.

An important part of this discussion is our inability to accurately measure pain. It’s a very individual sensation: our tolerances and the experience itself seems to vary wildly. The only method in use is that of self-reporting, in which a person describes verbally its intensity, the pain’s character, and obviously changes following any treatment. Numerous rating systems of pain allow us, albeit very imprecisely, to rate the pain experienced by a single individual. But we have no means of comparing accurately the pain experienced by different people.

A recent discovery may change that, providing potentially the ability to accurately evaluate and measure different types of pain. Scientists have developed a new technology  allowing us to potentially distinguish between types of chronic pain. The potential benefits are great. Measuring the changes with some therapy or being able to differentiate between pain caused by fibromyalgia versus peripheral neuropathy would allow us to guide treatment more precisely.

The structure responsible for generating someone’s pain can be hard for them to localize. A physician will typically stress a tendon or joint, via manipulation or palpation, but this examination still relies on the patient feeling and then verbalizing the discomfort produced by the physical exam. Too often, the patient’s own imaginings are taken as gospel and the exam is cursory. Treating the wrong problem leads to ineffective therapy.

An ultrasound exam of a painful tendon can precisely evaluate the amount of edema resulting from inflammation, but that is different than pain. With orthopedic trauma, we see clearly on an MRI  the tendon tear, but often its simply not that obvious. Pain has been a difficult sensation to quantify, to measure precisely, but even an imprecise method would be an advance.

Pain is a complex, multifactorial experience that comprises multiple elements. The perception that something hurts includes sensory features like its intensity, quality and location. But chronic pain is a whole other animal and leads to distress and disability. It can impair basic functional activities, like the all-important ADL’s, the Activities of Daily Life.

Objective measures, reproducible person to person, are lacking. This deficit makes the study of pain inexact, imprecise, and prone to guesswork. We simply don’t know enough about pain, but the same can be generally said for the field of neurology. We need better solutions for chronic pain, new directions like encouraging healing rather than addressing symptoms.

Too often, pharmacologic methods provide some measure of pain relief but at what cost? In addition, it’s often only a palliative approach. We need more research on non-pharmacologic methods, as well as new medication options. Many long-suffering individuals would agree, it would be better to somehow correct the root of the problem than to mask the symptoms.  Expect a discussion of therapies for chronic pain soon.