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'''Editor-in-Chief:''' Steven D. Feinberg, M.D. Adjunct Clinical Professor, Stanford University School of Medicine, Board Certified, Physical Medicine and Rehabilitation, Board Certified, Electrodiagnostic Medicine, Board Certified, Pain Medicine, Qualified Medical Evaluator (QME); '''Associate Editor-in-Chief:''' {{MUT}}
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'''Editor-in-Chief:''' Steven D. Feinberg, M.D. Adjunct Clinical Professor, Stanford University School of Medicine, Board Certified, Physical Medicine and Rehabilitation, Board Certified, Electrodiagnostic Medicine, Board Certified, Pain Medicine, Qualified Medical Evaluator (QME)
 
'''Associate Editor-in-Chief:''' {{MUT}}
 
 


==Overview==
==Overview==

Revision as of 17:16, 18 September 2014

Chronic Pain Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Epidemiology and Demographics

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Case Studies

Case #1

Chronic pain On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Chronic pain

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Chronic pain

CDC on Chronic pain

Chronic pain in the news

Blogs on Chronic pain

Directions to Hospitals Treating Chronic pain

Risk calculators and risk factors for Chronic pain

Editor-in-Chief: Steven D. Feinberg, M.D. Adjunct Clinical Professor, Stanford University School of Medicine, Board Certified, Physical Medicine and Rehabilitation, Board Certified, Electrodiagnostic Medicine, Board Certified, Pain Medicine, Qualified Medical Evaluator (QME); Associate Editor-in-Chief: M.Umer Tariq [1]

Overview

Chronic pain was originally defined as pain that has lasted 6 months or longer. More recently it has been defined as pain that persists longer than the temporal course of natural healing, associated with a particular type of injury or disease process.[1]

The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."[2] It is important to note that pain is subjective in nature and is defined by the person experiencing it, and the medical community's understanding of chronic pain now includes the impact that the mind has in processing and interpreting pain signals.

As a summary;

  • Chronic pain is defined as pain that continues beyond the recognized time for the body to heal (usually 4-6 weeks)
  • Historically, chronic pain is underdiagnosed, and therefore undertreated
  • Chronic pain becomes a disease state itself without a physiologic role
  • Depending upon the distribution of symptoms, the pain can be categorized as regional or diffuse
  • High rates of psychiatric co-morbidities exist with these conditions

Functional Anatomy

The anatomy of the nociceptive system can be grossly divided into the peripheral and central nervous system. The peripheral nervous system consists of small myelinated and unmyelinated nerve fibers. These nerve fibers converge into a region of the spinal cord referred to as the dorsal horn. The dorsal horn is the first relay station in pain signal transmission. The next element of pain transmission includes nerve fibers that then travel to the thalamus. From the thalamus the next order of neurons ascend to the limbic system and sensory cortex. This accounts for the affective elements and discriminative of pain respectively.[3][4]

Nociception

The experience of pain biologically is referred to as nociception. Nociception occurs in any tissue or organ in which pain signals arise secondary to a disease process or trauma. The nociception can also occur if there is dysfunction or damage to nerves themselves.[2]

The Pathophysiology of Chronic Pain

Under persistent activation nociceptive transmission to the dorsal horn may induce a wind up phenomenon. This induces pathological changes that lower the threshold for pain signals to be transmitted. In addition, it may generate nonnociceptive nerve fibers to respond to pain signals. Nonnociceptive nerve fibers may also be able to generate and transmit pain signals. In chronic pain this process is difficult to reverse or eradicate once established.[5]

Classification

Nociception (pain) may arise from injury or disease to visceral, somatic and neural structures in the body. More broadly pain is described as malignant or non-malignant in origin.[4]

Diagnoses

Pain may be a response to injury or any number of disease states that provoke nociception. Advances in imaging studies and electrophysiological studies allow us to gain a deeper insight into the characteristics and properties associated with the phenomenon of chronic pain.[6][7][8]

History and Symptoms

  • Detailed surgical and medical history
  • Previous treatments/medications
  • The effects the symptoms have on the patient's life
  • Symptom history should include:
    • Location
    • Onset
    • Character
    • Intensity
    • Duration
    • Radiation
    • Associate symptoms
    • Alleviating factors
    • Aggravating factors

Physical Examination

  • Thorough physical examination with special attention paid the areas where the symptoms are present (both soft-tissue regions and joints)
  • Comprehensive mental status examination:
    • Mood of patient
    • Affect
    • Insight
    • Ideation
    • Individual system evaluation

Laboratory Findings

Electrolyte and Biomarker Studies

Other Imaging Findings

  • Similar to lab studies, imaging is symptom specific and should be condition-specific
  • Electromyogram (EMG) may be considered depending upon the presentation of symptoms

Chronic Pain Syndrome

Chronic pain may generate other adversities including affective symptoms of depression and anxiety. It may also contribute to decreased physical activity given the apprehension of exacerbating pain.[9] Conversely it may itself have psychosomatic or psychogenic component to its cause.[10]

Differential Diagnosis of Causes of Chronic Pain

Cancer Pain

Headache

Low Back Pain

Musculoskeletal

Neuropathic

Pelvic/Abdominal

Psychiatric

Miscellaneous

Complete Differential Diagnosis of the causes of Chronic pain

(In alphabetical order)


Complete Differential Diagnosis of the Causes of Chronic pain

(By organ system)

Cardiovascular

Behcet's disease, Budd-Chiari syndrome, Buerger's disease, Cholesterol Emboli Syndrome, Cholesterol pericarditis, Chronic Stable Angina, Deep vein thrombosis, Dilated cardiomyopathy, Peripheral artery occlusive disease, Raynaud's phenomenon, Varicose veins, Vasculitis,

Chemical / poisoning

Lead poisoning,

Dermatologic

Cellulitis, Pilonidal cyst, Plantar fasciitis, Pyoderma gangrenosum,

Drug Side Effect

Opioid-induced hyperalgesia,

Ear Nose Throat

Aphthous ulcer, Otitis media, Plummer-Vinson syndrome, Sinusitis,

Endocrine

Diabetic neuropathy, Hyperthyroidism, Hypothyroidism,

Environmental No underlying causes
Gastroenterologic

Alcoholic Hepatitis, Anal fistula, Ascending cholangitis, Autoimmune Hepatitis, Autoimmune pancreatitis, Barrett's esophagus, Celiac disease, Cholangiocarcinoma, Cholangitis, Cirrhosis, Colorectal cancer, Crohn's disease, Esophageal cancer, Fructose malabsorption, Functional bowel disorder, Fundic gland polyposis, Gallbladder cancer, Gallstone Disease, Gastroesophageal reflux disease, Hemorrhoids, Intestinal pseudoobstruction, Irritable bowel syndrome, Ischemic colitis, Peptic ulcer, Ulcerative colitis, Viral Hepatitis ,

Genetic

Cystic fibrosis, Familial dysautonomia, Hurler's Syndrome,

Hematologic

Acute intermittent porphyria, Acute myeloid leukemia, Atheroembolic disease, Erythromelagia, Leukemia, Post-thrombotic syndrome, Sickle-cell disease,

Iatrogenic

Graft-versus-host disease,

Infectious Disease

Ascaris infection, Chlamydia infection, Dientamoebiasis, Poliomyelitis,

Musculoskeletal / Ortho

Achilles tendinitis, Ankylosing Spondylitis, Baker's cyst, Carpal tunnel syndrome, Chondromalacia patellae, Degenerative disc disease, DeQuervain's syndrome, Dermatomyositis, Exostosis, Frozen Shoulder, Gout, Juvenile idiopathic arthritis, Myofascial pain syndrome, Myotonic dystrophy, Osteoarthritis, Osteochondroma, Osteomalacia, Paget's Disease, Pelvic myoneuropathy, Polymyalgia Rheumatica, Polymyositis, Reactive arthritis, Sciatica, Spinal disc herniation, Spinal Stenosis, Spondylolisthesis, Synovial osteochondromatosis, Temporomandibular Joint Syndrome, Tendinitis, Tennis elbow,

Neurologic

Alexithymia, Amyotrophic lateral sclerosis, Arachnoiditis, Cerebellar Infarction, Cervical radiculopathy, Chronic inflammatory demyelinating polyneuropathy, Guillain-Barre syndrome, Migraine, Multiple Sclerosis, Neurofibromatosis type I, Schwannomatosis, Syringomyelia,

Nutritional / Metabolic

Beriberi, Farber disease, Gaucher's disease, Metabolic bone disease,

Obstetric/Gynecologic

Chronic pelvic pain, Endometrial cancer, Endometriosis, Pelvic inflammatory disease, Polycystic ovary syndrome,


Oncologic

Cancer Pain, Desmoplastic small round cell tumor, Multiple myeloma, Nasopharyngeal carcinoma, Lymphangiomatosis, Pancreatic cancer, Paraneoplastic syndrome, Sacrococcygeal teratoma,

Opthalmologic

Keratoconjunctivitis sicca, Tolosa-Hunt syndrome,

Overdose / Toxicity No underlying causes
Psychiatric

Conversion disorder, Psychogenic rheumatism,

Pulmonary

Acute Chest Syndrome, Caplan's Syndrome, Chronic bronchitis, Lung abscess, Lung cancer, Malignant Mesothelioma,

Renal / Electrolyte

Gout, Hypophosphatemia, Interstitial nephritis, Pyelonephritis, Renal osteodystrophy,

Rheum / Immune / Allergy

Angioedema, Ankylosing Spondylitis, Churg-Strauss syndrome, Henoch-Schonlein purpura, Periodic fever syndrome, Reactive arthritis, Rheumatoid arthritis, Sarcoidosis, Sjogren's Syndrome, Systemic lupus erythematosus,

Sexual Epididymitis,
Trauma

Chronic wound,

Urologic

Interstitial cystitis, Obstructive uropathy,

Miscellaneous Anxiety,

Benign fasciculation syndrome, Chronic Fatigue Syndrome, Chronic functional abdominal pain, Cluster headache,

Treatment

  • Occupational and physical therapy is helpful for most conditions associated with chronic pain
  • Psychiatric evaluations (and therefore treatment) may be required for patients with co-morbidities and psychiatric conditions
  • If necessary, refer patient to a pain specialist

It is rare to completely achieve absolute and sustained relief of pain. Thus, the clinical goal is pain management. Pain management is often multidisciplinary in nature. A recent journal article by Gatchell and Okifuji recognizes the importance of comprehensive pain programs(CPPs) in the management of chronic pain. They summarize their findings as follows: "CPPs offer the most efficacious and cost-effective treatment for persons with chronic pain, relative to a host of widely used conventional medical treatment." [11][12]

Pharmacotherapy

Pharmacotherapies

Opioids

Opioid medications provide short, intermediate and long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectal, transdermal, intravenously, epidurally and intrathecally. In chronic pain conditions that are opioid responsive a combination of a long acting or extended release medication is often prescribed in conjunction with a shorter acting medication for break through pain (exacerbations). Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are efficacious analgesics in chronic malignant pain and modestly effective nonmalignant pain management. However, there are variable associated adverse effects, especially during the commencement or change in dosing and administration. When opioids are used for prolonged periods drug tolerance, chemical dependency and (rarely) addiction may occur. Chemical dependency is ubiquitous among opioid therapy after continuous administration; however, drug tolerance is not well studied in patients on long term opioid therapy. Addiction rarely occurs as a result of opioid prescription, but they are abused by some individuals, which can cause concern to health care providers. Diversion of opioid medications is another concern for health care providers.

Non-steroidal anti-inflammatory drugs

The other major group of analgesics are Non-steroidal anti-inflammatory drugs (NSAID). This class of medications includes acetaminophen which may be administered as a single medication or in combination with other analgesics. The alternatively prescribed NSAIDs such as ketoprofen and piroxicam, have limited benefit in chronic pain disorders and with long term use is associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization.[13][14]

Antidepressants and Antiepileptic drugs

Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome.[15] Drugs such as Gabapentin have been widely prescribed for the off-label use of pain control. The list of side effects for these classes of drugs are typically much longer than opiate or NSAID treatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of seizure.

Interventional therapy

Injections, Neuromodulation and Neuroablative Therapy may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nerves conveying nociception from the structures implicated as the source of chronic pain.[16][17][18][19][20]

Rehabilitation

Further information: Physical medicine and rehabilitation

As alluded to earlier there are other modalities used in the treatment of chronic pain. These include: physical modalities such as thermal agents and electrotherapy. Complementary and alternative medicine, therapeutic exercise and behavioral therapy are also utilized autonomously or in tandem with interventional techniques and conventional pharmacotherapy. This is most often structured in a multidisciplinary or interdisciplinary program.[21]

Controversy

Pain.com UN-INCB

Chronic pain patients are often misdiagnosed. Patients are often ignored, and their pain dismissed as imaginary. Patients, particularly the ones prescribed opioids, are often labeled as drug addicts. Furthermore, chronic pain patients in the United States and other countries, continue to encounter problems caused by their governments' war on illegal drugs (examples include but are not limited to: red tape in applying for/renewal of special prescription pads; government-mandated limits and excessive regulations for hospitals and drugstores; etc.).

References

  • Carol A. Warfield: Principles & Practice of Pain Management 1st edition, McGraw-Hill Professional 2004
  • John D. Loeser: Bonica's Management of Pain 3rd edition, Lippincott Williams & Wilkins 2001

Footnotes

  1. ↑ Shipton EA, Tait B (2005). "Flagging the pain: preventing the burden of chronic pain by identifying and treating risk factors in acute pain". European journal of anaesthesiology. 22 (6): 405–12. PMID 15991501.
  2. ↑ 2.0 2.1 Merskey H (1994). "Logic, truth and language in concepts of pain". Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. 3 Suppl 1: S69–76. PMID 7866375.
  3. ↑ Romanelli P, Esposito V (2004). "The functional anatomy of neuropathic pain". Neurosurg. Clin. N. Am. 15 (3): 257–68. PMID 15246335.
  4. ↑ 4.0 4.1 Vanderah TW (2007). "Pathophysiology of pain". Med. Clin. North Am. 91 (1): 1–12. PMID 17164100.
  5. ↑ Vadivelu N, Sinatra R (2005). "Recent advances in elucidating pain mechanisms". Current opinion in anaesthesiology. 18 (5): 540–7. PMID 16534290.
  6. ↑ Dunckley P, Wise RG, Fairhurst M, Hobden P, Aziz Q, Chang L, Tracey I (2005). "A comparison of visceral and somatic pain processing in the human brainstem using functional magnetic resonance imaging". J. Neurosci. 25 (32): 7333–41. PMID 16093383.
  7. ↑ Geha PY, Apkarian AV (2005). "Brain imaging findings in neuropathic pain". Current pain and headache reports. 9 (3): 184–8. PMID 15907256.
  8. ↑ Turton AJ, McCabe CS, Harris N, Filipovic SR (2007). "Sensorimotor integration in Complex Regional Pain Syndrome: a transcranial magnetic stimulation study". Pain. 127 (3): 270–5. PMID 17011705.
  9. ↑ Pruimboom L, van Dam AC (2007). "Chronic pain: a non-use disease". Med. Hypotheses. 68 (3): 506–11. PMID 17071012.
  10. ↑ Sarno, John et. al. (2006). The Divided Mind: The Epidemic of Mindbody Disorders. New York: ReganBooks. pp. 11–18. ISBN 0-06-085178-3.
  11. ↑ Henningsen P, Zipfel S, Herzog W (2007). "Management of functional somatic syndromes". Lancet. 369 (9565): 946–55. PMID 17368156.
  12. ↑ Stanos S, Houle TT (2006). "Multidisciplinary and interdisciplinary management of chronic pain". Physical medicine and rehabilitation clinics of North America. 17 (2): 435–50, vii. PMID 16616276.
  13. ↑ Munir MA, Enany N, Zhang JM (2007). "Nonopioid analgesics". Med. Clin. North Am. 91 (1): 97–111. PMID 17164106.
  14. ↑ Ballantyne JC (2006). "Opioids for chronic nonterminal pain". South. Med. J. 99 (11): 1245–55. PMID 17195420.
  15. ↑ Jackson KC (2006). "Pharmacotherapy for neuropathic pain". Pain practice : the official journal of World Institute of Pain. 6 (1): 27–33. PMID 17309706.
  16. ↑ Varrassi G, Paladini A, Marinangeli F, Racz G (2006). "Neural modulation by blocks and infusions". Pain practice : the official journal of World Institute of Pain. 6 (1): 34–8. PMID 17309707.
  17. ↑ Meglio M (2004). "Spinal cord stimulation in chronic pain management". Neurosurg. Clin. N. Am. 15 (3): 297–306. PMID 15246338.
  18. ↑ Rasche D, Ruppolt M, Stippich C, Unterberg A, Tronnier VM (2006). "Motor cortex stimulation for long-term relief of chronic neuropathic pain: a 10 year experience". Pain. 121 (1–2): 43–52. PMID 16480828.
  19. ↑ Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L (2007). "Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain" (PDF). Pain physician. 10 (1): 7–111. PMID 17256025.
  20. ↑ Romanelli P, Esposito V, Adler J (2004). "Ablative procedures for chronic pain". Neurosurg. Clin. N. Am. 15 (3): 335–42. PMID 15246341.
  21. ↑ Geertzen JH, Van Wilgen CP, Schrier E, Dijkstra PU (2006). "Chronic pain in rehabilitation medicine". Disability and rehabilitation. 28 (6): 363–7. PMID 16492632.

See also

External links

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