October 3, 2011

The Pain that Seems Everlasting

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Joseph V. Madia, MD By:

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Chronic pain crippling effects and how to treat it

There is the kind of pain that happens when you stub a toe or slice your finger cutting vegetables. Then there is chronic pain, an enduring pain that can last for weeks, months, or even years.

Chronic pain happens for many reasons and comes in many forms. It could be triggered at first by infection or an injury like a sprained back. It is also caused by diseases like arthritis and cancer.

While chronic pain can last for a long time, it does not have to entail a lifetime of unbearable pain. There are many treatments that can dull, curb, or eliminate the many causes of chronic pain.

What is chronic pain?

Chronic pain is different than acute pain. Acute pain is a normal feeling that happens when the nervous system alerts you to a possible injury. It is the body's way of saying, "You've been hurt! Take care of yourself!"

Chronic pain, on the other hand, happens when the pain signals in the nervous system keep firing for extended periods of time. Common complaints from chronic pain sufferers include headache, lower back pain, arthritis pain, and cancer pain. Neurogenic pain (pain due to damage to the nerves or the nervous system itself) and psychogenic pain (pain caused by psychological factors) are also common.

It is not unusual for a person to have two of these chronic pain conditions conditions at once. Other conditions include:

  • rheumatoid arthritis
  • lupus
  • ankylosing spondylitis
  • fibromyalgia
  • carpal tunnel
  • spinal stenosis
  • TMJDs (temporomandibular joint and muscle disorders)
  • pinched nerves
  • growing pains
  • osteoarthritis

Depression is also closely linked with chronic pain. Pain can be depressing, and depression can make pain even worse. People with depression are more likely to experience pain than those without depression. People with chronic pain are more likely to become depressed than those without chronic pain.

What conditions lead to chronic pain?

Chronic pain is not a disease of its own. It is a general term used to describe persistent pain. There are many diseases that cause chronic pain. The type of pain a patient has will depend on the disease that patient is suffering from. In many patients, treating pain means treating their disease.

Here are a few examples of diseases that cause chronic pain and their treatments:

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease, meaning the body's immune system attacks healthy tissue by mistake. The cause of RA is unknown. However, patients are well aware of the pain it produces.

RA leads to inflammation of the joints (where two or more bones make contact) and the tissues surrounding those joints. The most commonly affected joints are wrists, fingers, knees, feet, and ankles.

When these joints become inflamed, patients can experience a number of painful symptoms, including:

  • morning stiffness, in which the joints may feel warm, fragile, and stiff if they are not used for an hour
  • deformity and the loss of the normal range of motion
  • pain in the same joint on both sides of the body (e.g. left wrist and right wrist)

In addition to joint pain, RA patients may suffer from other symptoms such as:

  • dry eyes and mouth
  • burning eyes
  • itching
  • chest pain when taking a breath
  • tingling, numbness, or burning in the hands and feet

Over time, RA can weaken patients to the point at which doing day-to-day tasks is a struggle. Patients may feel discomfort and fatigue that can make most physical activities unbearable.

The good news is there are ways to reduce the symptoms and pain of this disease. There are many types of drugs used to treat RA, including disease-modifying antirheumatic drugs (DMARDs), anti-inflammatory drugs, and corticosteroids.

DMARDs do more than treat the symptoms of RA. They fight against the underlying processes that cause the disease. Some common DMARDs include:
Rheumatrex (methotrexate), Arava (leflunomide), and Azulfidine (sulfasalazine).

Anti-inflammatory drugs include aspirin, ibuprofen, and Celebrex (celecoxib). However, Celebrex comes with strong warnings about the risk of heart disease and stroke.

Corticosteroids work by lessening joint swelling and inflammation. These drugs are known to have long-term side effects. For this reason, it is recommended that patients take corticosteroids only for a short time and in low doses.

In some cases, surgery is an option for repairing badly damaged joints. One surgery - called synovectomy - involves removing the joint lining. In the most extreme cases, patients may need their joints entirely replaced. Such surgeries include total knee replacement, total hip replacement, ankle replacement, and should replacement among others.

The cheapest and easiest way to treat RA is through exercise and other physical activities. The general kinds of exercises for RA include:

  • flexibility exercises, which are used to increase the range of motion in affected joints
  • strengthening exercises, which are designed to increase muscle strength to give more support to affected joints
  • aerobic exercises (e.g. walking, aerobic dance, water exercises, and bicycling)
  • body awareness exercises, which are designed to improve posture, balance, a sense of joint position, coordination, and relaxation

It is important to talk to your doctor before starting an exercise program. You can work with your doctor and physical therapist to find what exercises will work best for you.

Ankylosing Spondylitis

Ankylosing spondylitis is a form of arthritis that affects the spine. It causes swelling between the vertebrae (the discs that make up the spine) and between the spine and pelvis. Over time, ankylosing spondylitis causes to bones in the spine to fuse together.

In the beginning, patients with ankylosing spondylitis may experience lower back pain that comes and goes. Patients may lose motion in their lower spine, or find that they cannot fully expand their chest if the rib joints are affected.

Patients can also experience:

  • fatigue
  • eye inflammation
  • heel pain
  • hip pain
  • loss of appetite
  • fever
  • weight loss

The treatments for ankylosing spondylitis are fairly similar to those for RA. Doctors may prescribe anti-inflammatory drugs to lessen pain and swelling. Corticosteroids are also used.

A class of drugs called TNF-inhibitors also have been shown to reduce the symptoms of this painful disease. They work by blocking a protein that causes inflammation. These drugs include Enbrel (eternacept), Humira (adalimumab), and Remicade (infliximab).

Just as it is for patients with RA, exercise can help reduce the pain of ankylosing spondylitis.

Surgery is an option in cases of severe joint damage and pain. However, surgery often involves more risks than other treatments.

Fibromyalgia

Fibromyalgia is a common condition that affects the whole body. Patients may feel pain and weakness in their joints, muscles, tendons (tissue that connects muscle to bone), and other soft tissues.

Like many painful diseases, the cause of fibromyalgia is not known. It is possible that the condition is set in motion by a few different triggers, including:

  • physical trauma
  • emotional trauma
  • abnormal responses to pain because of faulty areas of the brain
  • sleep problems
  • infection, even though no specific infection has been linked to fibromyalgia

Although fibromyalgia does not directly affect the joints, patients may feel like the pain is coming from their joints. The pain can come as a deep ache or a shooting, burning pain. All of the painful areas in fibromyalgia patients are called 'tender points.' These tender points are in the soft tissue in the shoulders, chest, elbows, lower back, hips, knees, and shins. Pain may start out in these spots, but then spread from there.

Almost all patients with fibromyalgia experience fatigue, trouble sleeping, and a depressed mood.

When treating fibromyalgia, the main goal is to reduce pain. At first, a doctor may recommend physical therapy, exercise programs, or ways to relieve stress like massage or relaxation techniques.

If those treatments do not do the job, then a doctor may prescribe medications. These medications often include antidepressants and muscle relaxants. The point is to help patients get better sleep and relieve pain. The main drugs used to treat fibromyalgia are Cymbalta (duloxetine), Lyrica (pregabalin), and Savella (milnacipran). It is recommended that these drugs be used in combination with exercise and behavior therapy.

Other drugs used to treat this condition include anti-seizure drugs, pain relievers, and sleeping aids.

Eating a healthy diet, staying away from caffeine, and practicing a good sleep schedule are a few other simple ways to manage the pain of fibromyalgia.

Depression

Chronic pain is no laughing matter. It can affect more than your body. It can also have a huge impact on your emotional state and overall mood.

Depression is extremely common among people suffering from chronic pain. In fact, it appears that chronic pain and depression feed off one another. In other words, pain leads to depression and depression leads to pain.

Research has shown that patients are more likely to have depression or other mood problems as the amount of pain and the amount of painful places increases.

Chronic pain patients with depression commonly report symptoms such as:

  • trouble sleeping
  • less sexual activities
  • family stress
  • work problems
  • legal problems
  • financial worries
  • less self-confidence
  • fear of getting injured

So, where does this connection between depression and pain come from? One explanation is that depression and suffering of pain are found in the same part of the brain. Similarly, pain and mood are controlled by the same chemical messengers in the body.

Treating chronic pain caused by depression involves treating the depression. To do this, doctors may prescribe drugs. They may also recommend cognitive-behavioral therapy (a type of mental health counseling), relaxation techniques, hypnosis, biofeedback (learning to control bodily functions like heartbeat using your mind), supportive counseling, and family counseling.

Depression is not a sign of weakness. It is a chemical imbalance in the brain. That is why it is important to treat depression, especially if it is causing physical pain.

What is happening in the world of research on chronic pain?

The best way to help patients with chronic pain is to increase our understanding of the various conditions that lead to chronic pain. The more knowledge we have about the underlying causes of chronic pain, the more targets for treatment will become available.

Scientists are hopeful that the current advances in neuroscience (the study of the nervous system) will lead to an increasing number of better treatments for chronic pain.

Researchers have recently found that chronic pain patients often have lower levels of endorphins (peptides that are produce of feeling of well-being) in their spinal fluid. Some studies have involved using acupuncture with electricity to produce more endorphins.

Other studies are looking at how stress has an impact on chronic pain. Scientists have are also making new types of painkillers and finding that some drugs - which are not normally used for pain - can actually be used to curb chronic pain.

There are so many causes of chronic pain, and so many avenues researchers can go down in their efforts to find better treatments. It seems a daunting task to find relief for patients. However, as research grows, chronic pain patients get closer and closer to having a normal, mobile life once again.  

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Reviewed by: 
Joseph V. Madia, MD
Review Date: 
September 30, 2011

Last Updated:
October 31, 2011