Chronic pain is defined as pain that has lasted longer than three to six months, though some theorists and researchers have placed the transition from acute to chronic pain at 12 months. Others apply acute to pain that lasts less than 30 days, chronic to pain of more than six months duration, and subacute to pain that lasts from one to six months. A popular alternative definition of chronic pain, involving no arbitrarily fixed duration, is "pain that extends beyond the expected period of healing".
Nociceptive pain may be divided into "superficial" and "deep", and deep pain into "deep somatic" and "visceral". Superficial pain is initiated by activation of nociceptors in the skin or superficial tissues. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly-localized pain. Visceral pain originates in the viscera (organs). Visceral pain may be well-localized, but often it is extremely difficult to locate, and several visceral regions produce "referred" pain when damaged or inflamed, where the sensation is located in an area distant from the site of pathology or injury.
Neuropathic pain is divided into "peripheral" (originating in the peripheral nervous system) and "central" (originating in the brain or spinal cord). Peripheral neuropathic pain is often described as "burning", "tingling", "electrical", "stabbing", or "pins and needles".
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. The type of nerve fibers that are believed to propagate the pain signals are the C-fibers, since they have a slow conductivity and give rise to a painful sensation that persists over a long time. In chronic pain this process is difficult to reverse or eradicate once established.
Chronic pain of different etiologies has been characterized as a disease affecting brain structure and function. Magnetic resonance imaging studies have shown abnormal anatomical and functional connectivity, even during rest involving areas related to the processing of pain. Also, persistent pain has been shown to cause grey matter loss, reversible once the pain has resolved.
These structural changes can be explained by the phenomenon known as neuroplasticity. In the case of chronic pain, the somatototic representation of the body is inappropriately reorganized following peripheral and central sensitization. This maladaptative change results in the experience of allodynia and/or hyperalgesia. Brain activity in individuals suffering from chronic pain, measured via electroencephalogram (EEG), has been demonstrated to be altered, suggesting pain-induced neuroplastic changes. More specifically, the relative beta activity (compared to the rest of the brain) is increased, the relative alpha activity is decreased, and the theta activity both absolutely and relatively is diminished.
Complete and sustained remission of many neuropathies and most idiopathic chronic pain (pain that extends beyond the expected period of healing, or chronic pain that has no known underlying pathology) is rarely achieved, but much can be done to reduce suffering and improve quality of life.
Pain management is the branch of medicine employing an interdisciplinary approach to the relief of pain and improvement in the quality of life of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists, physician assistants, and nurse practitioners. Acute pain usually resolves with the efforts of one practitioner; however, the management of chronic pain frequently requires the coordinated efforts of the treatment team.
Psychological treatments including cognitive behavioral therapy and acceptance and commitment therapy have been shown effective for improving quality of life in those suffering from chronic pain. Clinical hypnosis, including self-hypnosis, has been shown effective not only for improving quality of life, but for direct improvement of chronic pain symptoms.
The emergence of studies relating chronic pain to neuroplasticity also suggest the utilization of neurofeedback rehabilitation techniques to resolve maladaptive cortical changes and patterns. The proposed goal of neurofeedback intervention is to abolish maladaptive neuroplastic changes made as a result of chronic nociception, as measured by abnormal EEG, and thereby relieve the individual's pain. However, this field of research lacks randomized control trials, and therefore requires further investigation.
In a recent large-scale telephone survey of 15 European countries and Israel, 19% of respondents over 18 years of age had suffered pain for more than 6 months, including the last month, and more than twice in the last week, with pain intensity of 5 or more for the last episode, on a scale of 1(no pain) to 10 (worst imaginable). 4839 of these respondents with chronic pain were interviewed in depth. Sixty six percent scored their pain intensity at moderate (5–7), and 34% at severe (8–10); 46% had constant pain, 56% intermittent; 49% had suffered pain for 2–15 years; and 21% had been diagnosed with depression due to the pain. Sixty one percent were unable or less able to work outside the home, 19% had lost a job, and 13% had changed jobs due to their pain. Forty percent had inadequate pain management and less than 2% were seeing a pain management specialist.
In a systematic literature review published by the International Association for the Study of Pain (IASP), 13 chronic pain studies from various countries around the world were analyzed. (Of the 13 studies, there were three in the United Kingdom, two in Australia, one each in France, the Netherlands, Israel, Canada, Scotland, Spain, and Sweden, and a multinational.) The authors found that the prevalence of chronic pain was very high and that chronic pain consumes a large amount of healthcare resources around the globe. Chronic pain afflicted women at a higher rate than men. They determined that the prevalence of chronic pain varied from 10.1% to 55.2% of the population.
In the United States, the prevalence of chronic pain has been estimated to be approximately 30%. According to the Institute of Medicine, there are about 116 million Americans living with chronic pain, which suggests that approximately half of American adults have some chronic pain condition. The Mayday Fund estimate of 70 million Americans with chronic pain is slightly more conservative. In an internet study, the prevalence of chronic pain in the United States was calculated to be 30.7% of the population: 34.3% for women and 26.7% for men. These estimates are in reasonable agreement and indicate a prevalence of chronic pain in the US that is relatively comparable to that of other countries.
Comorbidities and sequelae
Chronic pain is associated with higher rates of depression and anxiety. Sleep disturbance, and insomnia due to medication and illness symptoms are often experienced by those with chronic pain. Chronic pain may contribute to decreased physical activity due to fear of exacerbating pain, often resulting in weight gain. Such comorbid disorders can be very difficult to treat due to the high potential of medication interactions, especially when the conditions are treated by different doctors.
Severe chronic pain is associated with increased 10 year mortality, particularly from heart disease and respiratory disease. Several mechanisms have been proposed for the increased mortality, e.g. abnormal endocrine stress response. Additionally, chronic stress seems to affect cardiovascular risk by acceleration of the atherosclerotic process. However, further research is needed to elucidate the relationship between severe chronic pain, stress and cardiovascular health.
Those who have a tendency to "catastrophise" in response to pain report greater pain levels induced by an ice bath (Sullivan et al., 1995). A study by Crombez et al. (1998) showed that those with unhealthy catastrophising pain beliefs experienced greater impairment in performance in an auditory discrimination task when a painful stimulus was applied then those with more healthy pain beliefs. In addition there was a perception of pain at greater intensity during the experiment. This indicates that there is an increase in attention to pain at the expense of other somatosensation. Indeed Crombez et al. (2005) postulated that in chronic pain patients are thought to display a “hyper-vigilance” to pain. In addition, pain inhibited visual attention disengagement in those with a tendency to catastrophise though not in non-catastrophisers (Van Damme et al., 2004).
Two of the most frequent personality profiles found in chronic pain patients by the Minnesota Multiphasic Personality Inventory (MMPI) are the conversion V and the neurotic triad. The conversion V personality, so called because the higher scores on MMPI scales 1 and 3, relative to scale 2, form a "V" shape on the graph, expresses exaggerated concern over body feelings, develops bodily symptoms in response to stress, and often fails to recognize their own emotional state, including depression. The neurotic triad personality, scoring high on scales 1, 2 and 3, also expresses exaggerated concern over body feelings and develops bodily symptoms in response to stress, but is demanding and complaining.
Some investigators have argued that it is this neuroticism that causes acute pain to turn chronic, but clinical evidence points the other way, to chronic pain causing neuroticism. When long term pain is relieved by therapeutic intervention, scores on the neurotic triad and anxiety fall, often to normal levels. Self-esteem, often low in chronic pain patients, also shows striking improvement once pain has resolved.
Effect on cognition
Chronic pain's impact on cognition is an under-researched area, but several tentative conclusions have been published. Most chronic pain patients complain of cognitive impairment, such as forgetfulness, difficulty with attention, and difficulty completing tasks. Objective testing has found that people in chronic pain tend to experience impairment in attention, memory, mental flexibility, verbal ability, speed of response in a cognitive task, and speed in executing structured tasks. In 2007, Shulamith Kreitler and David Niv advised clinicians to assess cognitive function in chronic pain patients in order to more precisely monitor therapeutic outcomes, and tailor treatment to address this aspect of the pain experience.
- Debono, DJ; Hoeksema, LJ; Hobbs, RD (August 2013). "Caring for Patients with Chronic Pain: Pearls and Pitfalls". Journal of the American Osteopathic Association 113 (8): 620–627. doi:10.7556/jaoa.2013.023. PMID 23918913.
- Turk, D.C.; Okifuji, A. (2001). "Pain terms and taxonomies". In Loeser, D.; Butler, S. H.; Chapman, J.J. et al. Bonica's management of pain (3 ed.). Lippincott Williams & Wilkins. pp. 18–25. ISBN 0-683-30462-3.
- Main, C.J.; Spanswick, C.C. (2001). Pain management: an interdisciplinary approach. Elsevier. p. 93. ISBN 0-443-05683-8.
- Thienhaus, O.; Cole, B.E. (2002). "Classification of pain". In Weiner, R.S. Pain management: A practical guide for clinicians (6 ed.). American Academy of Pain Management. ISBN 0-8493-0926-3.
- Keay, KA; Clement, CI; Bandler, R (2000). "The neuroanatomy of cardiac nociceptive pathways". In Horst, GJT. The nervous system and the heart. Totowa, New Jersey: Humana Press. p. 304. ISBN 978-0-89603-693-2.
- Coda, BA; Bonica, JJ (2001). "General considerations of acute pain". In Loeser, D; Bonica, JJ. Bonica's management of pain (3 ed.). Philadelphia: Lippincott Williams & Wilkins. ISBN 0-443-05683-8.
- Bogduk, N; Merskey, H (1994). Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms (second ed.). Seattle: IASP Press. p. 212. ISBN 0-931092-05-1.
- Paice, JA (Jul–Aug 2003). "Mechanisms and management of neuropathic pain in cancer". Journal of supportive oncology 1 (2): 107–20. PMID 15352654.
- Hansson P (1998). Nociceptive and neurogenic pain. Pharmacia & Upjon AB. pp. 52–63.
- Vadivelu N, Sinatra R (2005). "Recent advances in elucidating pain mechanisms". Current Opinion in Anesthesiology 18 (5): 540–7. doi:10.1097/01.aco.0000183109.27297.75. PMID 16534290.
- Geha PY, Baliki MN, Harden RN, Bauer WR, Parrish TB, Apkarian AV (2008). "The brain in chronic CRPS pain: Abnormal gray-white matter interactions in emotional and autonomic regions". Neuron 60 (4): 570–581. doi:10.1016/j.neuron.2008.08.022. PMC 2637446. PMID 19038215.
- Baliki MN, Geha PY, Apkarian AV, Chialvo DR (2008). "Beyond feeling: chronic pain hurts the brain, disrupting the default-mode network dynamics". J of Neurosci 28 (6): 1398–1403. doi:10.1523/JNEUROSCI.4123-07.2008. PMID 18256259.
- Tagliazucchi E, Balenzuela P, Fraiman D, Chialvo DR (2010). "Brain resting state is disrupted in chronic back pain patients". Neurosci Lett 485 (1): 26–31. doi:10.1016/j.neulet.2010.08.053. PMC 2954131. PMID 20800649.
- May A (2009). "Chronic pain may change the structure of the brain". Pain 137 (1): 7–15. doi:10.1016/j.pain.2008.02.034. PMID 18410991.
- DA, Wideman TH, Naso L, Hatami-Khoroushahi Z, Fallatah S, Ware MA, Jarzem P, Bushnell MC, Shir Y, Ouellet JA, Stone LS (2011). "Effective treatment of chronic low back pain in humans reverses abnormal brain anatomy and function". Journal of Neuroscience 31 (20): 7540–50. doi:10.1523/JNEUROSCI.5280-10.2011. PMID 21593339.
- Jensen, M.P., Sherlin, L.H., Hakiman, S., Fregni, F. Neuromodulatory approaches for chronic pain management: research findings and clinical implications. Journal of Neurotherapy 2009, 13:196–213
- Chou, Roger; Huffman, LH; American Pain, Society; American College of, Physicians (2 October 2007). "Medications for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline". Annals of Internal Medicine 147 (7): 505. doi:10.7326/0003-4819-147-7-200710020-00008. PMID 17909211.
- Hardy, Paul A. J. (1997). Chronic pain management: the essentials. U.K.: Greenwich Medical Media. ISBN 1-900151-85-5.
- Main, Chris J.; Spanswick, Chris C. (2000). Pain management: an interdisciplinary approach. Churchill Livingstone. ISBN 0-443-05683-8.
- Thienhaus, Ole; Cole, B. Eliot (2002). "The classification of pain". In Weiner, Richard S,. Pain management: A practical guide for clinicians. CRC Press. p. 29. ISBN 0-8493-0926-3.
- Henningsen P, Zipfel S, Herzog W (2007). "Management of functional somatic syndromes". Lancet 369 (9565): 946–55. doi:10.1016/S0140-6736(07)60159-7. PMID 17368156.
- 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. doi:10.1016/j.pmr.2005.12.004. PMID 16616276.
- Sveinsdottir, Vigdis; Eriksen, Hege R; Reme, Silje Endresen (2012). "Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain.". Journal of pain research 5: 371–80. doi:10.2147/JPR.S25330. PMC 3474159. PMID 23091394.
- Castro, MM; Daltro, C; Kraychete, DC; Lopes, J (November 2012). "The cognitive behavioral therapy causes an improvement in quality of life in patients with chronic musculoskeletal pain.". Arquivos de neuro-psiquiatria 70 (11): 864–8. doi:10.1590/s0004-282x2012001100008. PMID 23175199.
- Wicksell, RK; Kemani, M; Jensen, K; Kosek, E; Kadetoff, D; Sorjonen, K; Ingvar, M; Olsson, GL (1 April 2013). "Acceptance and commitment therapy for fibromyalgia: a randomized controlled trial.". European journal of pain (London, England) 17 (4): 599–611. doi:10.1002/j.1532-2149.2012.00224.x. PMID 23090719.
- "APA website on empirical treatments". Retrieved 2009-09-01.
- Ruiz, F. J. (2010). "A review of Acceptance and Commitment Therapy (ACT) empirical evidence: Correlational, experimental psychopathology, component and outcome studies". International Journal of Psychology and Psychological Therapy 10 (1): 125–62.
- Elkins, Gary; Johnson, Aimee; Fisher, William (1 April 2012). "Cognitive Hypnotherapy for Pain Management". American Journal of Clinical Hypnosis 54 (4): 294–310. doi:10.1080/00029157.2011.654284. PMID 22655332.
- Appel, Philip R.; Bleiberg, Joseph (1 October 2005). "Pain Reduction is Related to Hypnotizability but Not to Relaxation or to Reduction in Suffering: A Preliminary Investigation". American Journal of Clinical Hypnosis 48 (2-3): 153–161. doi:10.1080/00029157.2005.10401512. PMID 16482842.
- Sachs, Lewis B.; Feuerstein, Michael; Vitale, John H. (1 October 1977). "Hypnotic Self-Regulation of Chronic Pain". American Journal of Clinical Hypnosis 20 (2): 106–113. doi:10.1080/00029157.1977.10403912. PMID 596349.
- Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D (May 2006). "Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment". Eur J Pain 10 (4): 287–333. doi:10.1016/j.ejpain.2005.06.009. PMID 16095934.
- Harstall C and Ospina M (June 2003). "How Prevalent Is Chronic Pain?". Pain Clinical Updates, International Association for the Study of Pain XI (2): 1–4.
- Institute of Medicine of the National Academies Report (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: The National Academies Press.
- A Call to Revolutionize Chronic Pain Care in America: An Opportunity in Health Care Reform. The Mayday Fund. 2009.
- Johannes C, Le T, Zhou X, Johnston J, Dworkin R (Nov 2010). "The Prevalence of Chronic Pain in United States Adults: Results of an Internet-Based Study". J Pain 11 (11): 1230–1239. doi:10.1016/j.jpain.2010.07.002. PMID 20797916.
- Pruimboom L, van Dam AC (2007). "Chronic pain: a non-use disease". Med. Hypotheses 68 (3): 506–11. doi:10.1016/j.mehy.2006.08.036. PMID 17071012.
- Ferini-Strambi L (2011). "Sleep disorders in multiple sclerosis". Handb Clin Neurol. Handbook of Clinical Neurology 99: 1139–46. doi:10.1016/B978-0-444-52007-4.00025-4. ISBN 978-0-444-52007-4. PMID 21056246.
- Torrance N, Elliott AM, Lee AJ, Smith BH (April 2010). "Severe chronic pain is associated with increased 10 year mortality. A cohort record linkage study". European Journal of Pain 14 (4): 380–6. doi:10.1016/j.ejpain.2009.07.006. PMID 19726210.
- McBeth J, Chiu YH, Silman AJ, et al. (2005). "Hypothalamic-pituitary-adrenal stress axis function and the relationship with chronic widespread pain and its antecedents". Arthritis Research & Therapy 7 (5): R992–R1000. doi:10.1186/ar1772. PMC 1257426. PMID 16207340.
- SULLIVAN, M; BISHOP, S. R. & PIVIK, J. (1995). "The Pain Catastrophizing Scale: Development and validation.". Psychological Assessment 7: 524–532. doi:10.1037/1040-35184.108.40.2064.
- Crombez, G; Eccleston, C; Baeyens, F; Eelen, P (April 1998). "When somatic information threatens, catastrophic thinking enhances attentional interference.". Pain 75 (2-3): 187–98. doi:10.1016/s0304-3959(97)00219-4. PMID 9583754.
- Van Damme, S; Crombez, G; Eccleston, C (October 2004). "The anticipation of pain modulates spatial attention: evidence for pain-specificity in high-pain catastrophizers.". Pain 111 (3): 392–9. doi:10.1016/j.pain.2004.07.022. PMID 15363884.
- Leo, Raphael (2007). Clinical manual of pain management in psychiatry. Washington, DC: American Psychiatric Publishing. p. 58. ISBN 978-1-58562-275-7.
- Fishbain, David A.; Cole, Brandly; Cutler, R. Brian; Lewis, J.; Rosomoff, Hubert L.; Rosomoff, R. Steele (1 November 2006). "Chronic Pain and the Measurement of Personality: Do States Influence Traits?". Pain Medicine 7 (6): 509–529. doi:10.1111/j.1526-4637.2006.00239.x. PMID 17112364.
- JESS,, P.; T. JESS; H. BECK; P. BECH (1 January 1998). "Neuroticism in Relation to Recovery and Persisting Pain after Laparoscopic Cholecystectomy". Scandinavian Journal of Gastroenterology 33 (5): 550–553. doi:10.1080/00365529850172151. PMID 9648998.
- Jess, P; Bech, P (1994). "The validity of Eysenck's neuroticism dimension within the Minnesota Multiphasic Personality Inventory in patients with duodenal ulcer. The Hvidovre Ulcer Project Group.". Psychotherapy and psychosomatics 62 (3–4): 168–75. doi:10.1159/000288919. PMID 7846260.
- Melzack, R; Wall, PD (1996). The Challenge of Pain (2 ed.). London: Penguin. pp. 31–32. ISBN 0-14-025670-9.
- Kreitler S; Niv D (2007). "Cognitive impairment in chronic pain" (pdf). Pain: Clinical Updates (International Association for the Study of Pain) XV (4): 1–4. Retrieved 2008-04-15.
- Chronic Pain Syndromes at DMOZ
- Chronic Pain Relief: New Treatments on WebMD
- Chronic Pain on MedicineNet
- Chronic Pain Australia
- American Chronic Pain Association
- American Pain Foundation
- International Association for the Study of Pain- IASP
- International Association for the Study of Pain- IASP
- Pain Concern (UK charity)
- Media related to pain at Wikimedia Commons