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What Causes Chronic Pain?
There are many different factors that
cause chronic pain. Often conditions that accompany aging may affect
bones and joints in ways that cause chronic pain. Other common causes
are nerve damage and injuries that fail to heal properly.
Some kinds of chronic pain have numerous causes. Back pain, for
example, may be caused by a single factor, or any combination of these
factors:
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Years of poor posture
-
Improper lifting and carrying of heavy
objects
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Being overweight, which puts excess
strain on the back and knees
-
A congenital condition such as
curvature of the spine
-
Traumatic injury
-
Wearing high heels
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Sleeping on a poor mattress
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No obvious physical cause
Disease can also be the underlying cause
of chronic pain. Rheumatoid arthritis and osteoarthritis are
well-known culprits, but persistent pain may also be due to such
ailments as cancer, multiple sclerosis, stomach ulcers, AIDS, and
gallbladder disease. In many cases, however,
the source of chronic pain can be a very complex and even mysterious
issue to untangle. Although it may begin with an injury or illness,
ongoing pain can develop a psychological dimension after the physical
problem has healed. This fact alone makes pinning down a single course
of treatment tricky, and it is why health care providers often find
they have to try a number of different types of curative steps.
What Are the Treatments for
Chronic Pain?
The treatments for chronic pain are as
diverse as the causes. From over-the-counter and prescription drugs to
mind/body techniques to acupuncture, if one approach doesn't work,
another one might. But when it comes to treating chronic pain, no
single technique is guaranteed to produce complete pain relief. Relief
may be found by using a combination of treatment options.
Drug Therapy: Nonprescription and
Prescription
Milder forms of pain may be relieved by
over-the-counter medications such as Tylenol (acetaminophen) or
nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and
Aleve. Both acetaminophen and NSAIDs relieve pain caused by muscle
aches and stiffness, but only NSAIDs can also reduce inflammation
(swelling and irritation). Topical pain relievers are also available,
such as creams, lotions, or sprays that are applied to the skin in
order to relieve pain from sore muscles and arthritis.
If over-the-counter drugs do not provide relief, your doctor
may prescribe stronger medications, such as muscle relaxants,
anti-anxiety drugs (such as Valium), antidepressants, prescription
NSAIDs such as Celebrex or Bextra, or a short course of stronger
painkillers (such as Codeine, Fentanyl, Percocet or Vicodin). A
limited number of steroid injections at the site of a joint problem
can reduce swelling and inflammation. Note:
NSAIDs such as
Celebrex and
Bextra, as well as
Aleve,
may increase your risk of heart attack or stroke. Consult with your
doctor before taking anti-inflammatory drugs on a regular basis.
Patient-controlled analgesia (PCA) is another method of pain
control. By pushing a button on a computerized pump, the patient is
able to self administer a premeasured dose of pain medicine. The pump
is connected to a small tube that allows medicine to be injected
intravenously (into a vein), subcutaneously (just under the skin), or
into the spinal area. This is often used in the hospital to treat
pain. Sometimes, a group of nerves that
causes pain to a specific organ or body region can be blocked with
local medication. The injection of this nerve-numbing substance is
called a nerve block. Although many kinds of nerve blocks exist, this
treatment cannot always be used. Often blocks are not possible, are
too dangerous, or are not the best treatment for the problem. You
doctor can advise you as to whether this treatment is appropriate for
you.
Trigger Point Injections
Trigger point injection is a procedure
used to treat painful areas of muscle that contain trigger points, or
knots of muscle that form when muscles do not relax. During this
procedure, a health care professional, using a small needle, injects a
local anesthetic that sometimes includes a steroid into a trigger
point. With the injection, the trigger point is made inactive and the
pain is alleviated. Usually, a brief course of treatment will result
in sustained relief. Trigger point injection
is used to treat muscle pain in the arms, legs, lower back, and neck.
In addition, this approach has been used to treat fibromyalgia,
tension headaches, and myofascial pain syndrome (chronic pain
involving tissue that surrounds muscle) that does not respond to other
treatment.
Surgical Implants
When standard medicines and physical
therapy fail to offer adequate pain relief, you may be a candidate for
a surgical implant to help you control pain. There are two main types
of implants to control pain:
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Intrathecal Drug Delivery.
Also called infusion pain pumps or spinal drug delivery systems. The
surgeon makes a pocket under the skin that's large enough to hold a
medicine pump. The pump is usually about one inch thick and three
inches wide. The surgeon also inserts a catheter, which carries pain
medicine from the pump to the intrathecal space around the spinal
cord. The implants deliver medicines directly to the spinal cord,
where pain signals travel. For this reason, intrathecal drug
delivery can provide significant pain control with a fraction of the
dose that would be required with pills. In addition, the system can
cause fewer side effects than oral medications because less medicine
is required to control pain.
-
Spinal Cord Stimulation
Implants. In spinal cord stimulation, low-level electrical
signals are transmitted to the spinal cord or to specific nerves to
block pain signals from reaching the brain. In this procedure, a
device that delivers the electrical signals is surgically implanted
in the body. A remote control is used by the patient to turn the
current off and on or to adjust the intensity of the signals. Most
people describe the feelings from the simulator as being pleasant
and tingling. Two kinds of spinal cord stimulation systems are
available. The unit that is more commonly used is fully implanted
and has a pulse generator and a non-rechargeable battery. The other
system includes an antenna, transmitter, and a receiver that relies
upon radio frequency. The latter system's antenna and transmitter
are carried outside the body, while the receiver is implanted inside
the body.
TENS
Transcutaneous electrical nerve
stimulation therapy, more commonly referred to as TENS, uses
electrical stimulation to diminish pain. During the procedure,
low-voltage electrical current is delivered through electrodes that
are placed on the skin near the source of pain. The electricity from
the electrodes stimulates the nerves in an affected area and sends
signals to the brain that "scramble" normal pain signals, offering
short-term pain relief. While effective in the short-term, long-term
effectiveness of TENS remains questionable.
Bioelectric Therapy
Bioelectric therapy relieves pain by
blocking pain messages to the brain. Bioelectric therapy also prompts
the body to produce chemicals called endorphins that decrease or
eliminate painful sensations by blocking the message of pain from
being delivered to the brain. Bioelectric
therapy can be used to treat many chronic and acute conditions causing
pain, such as back pain, muscle pain, headaches and migraines,
arthritis, TMJ disorder, diabetic neuropathy, and scleroderma.
Bioelectric therapy is effective in providing temporary pain
control, but it should be used as part of a total pain management
program. When used along with conventional pain-relieving medications,
bioelectric treatment may allow pain sufferers to reduce their dose of
some pain relievers by up to 50%.
Physical Therapy
Physical therapy helps to relieve pain by
using special techniques that improve movement and function impaired
by an injury or disability. Along with employing stretching and
pain-relieving techniques, a physical therapist may use, among other
things, TENS to aid treatment.
Exercise
Although resting for short periods can
alleviate pain, too much rest may actually increase pain and put you
at greater risk of injury when you again attempt movement. Research
has shown that regular exercise can diminish pain in the long term by
improving muscle tone, strength, and flexibility. Exercise may also
cause a release of endorphins, the body's natural painkillers. Some
exercises are easier for certain chronic pain sufferers to perform
than others; try swimming, biking, walking, rowing, and yoga.
Psychological Treatment
When you are in pain, you may have
feelings of anger, sadness, hopelessness, and/or despair. Pain can
alter your personality, disrupt your sleep, and interfere with your
work and relationships. In turn, depression and anxiety, lack of
sleep, and feelings of stress can all make pain worse. Psychological
treatment provides safe, nondrug methods that can treat your pain
directly by reducing high levels of physiological stress that often
aggravate pain. Psychological treatment also helps improve the
indirect consequences of pain by helping you learn how to cope with
the many problems associated with pain.
A large part of psychological treatment
for pain is education, helping patients acquire skills to manage a
very difficult problem.
Alternative Therapies
In the past decade, strong evidence has
accumulated regarding the benefits of mind-body therapies,
acupuncture, and some nutritional supplements for treating pain. Other
alternative therapies such as massage, chiropractic therapies,
therapeutic touch, certain herbal therapies, and dietary approaches
have the potential to alleviate pain in some people. However, the
evidence supporting these therapies is less concrete.
Mind-Body Therapies
Mind-body therapies are treatments that
are meant to help the mind's ability to affect the functions and
symptoms of the body. Mind-body therapies use various approaches
including relaxation techniques, meditation, guided imagery,
biofeedback, and hypnosis. Relaxation techniques can help alleviate
discomfort related to chronic pain.
Visualization may be another worthwhile pain-controlling technique.
Try the following exercise: Close your eyes and try to call up a
visual image of the pain, giving it shape, color, size, motion. Now
try slowly altering this image, replacing it with a more harmonious,
pleasing -- and smaller -- image. Another
approach is to keep a diary of your pain episodes and the causative
and corrective factors surrounding them. Review your diary regularly
to explore avenues of possible change. Strive to view pain as part of
life, not all of it. Electromyographic (EMG)
biofeedback may alert you to the ways in which muscle tension is
contributing to your pain and help you learn to control it.
Hypnotherapy and self-hypnosis may help you block or transform pain
through refocusing techniques. One self-hypnosis strategy, known as
glove anesthesia, involves putting yourself in a trance, placing a
hand over the painful area, imagining that the hand is relaxed, heavy,
and numb, and envisioning these sensations as replacing other, painful
feelings in the affected area. Relaxation
techniques such as meditation or yoga have been shown to reduce
stress-related pain when they are practiced regularly. The gentle
stretching of yoga is particularly good for strengthening muscles
without putting additional strain on the body.
Acupuncture
Acupuncture is thought to decrease pain
by increasing the release of endorphins, chemicals that block pain.
Many acu-points are near nerves. When stimulated, these nerves cause a
dull ache or feeling of fullness in the muscle. The stimulated muscle
sends a message to the central nervous system (the brain and spinal
cord), causing the release of endorphins that block the message of
pain from being delivered to the brain.
Acupuncture may be useful as an
accompanying treatment for many pain-related conditions, including
headache, low back pain, menstrual cramps, carpal tunnel syndrome,
tennis elbow, fibromyalgia, osteoarthritis, and myofascial pain.
Acupuncture also may be an acceptable alternative to or may be
included as part of a comprehensive pain management program.
Chiropractic Treatment and
Massage
Chiropractic treatment is the most common
nonsurgical treatment for back pain. Improvements of people undergoing
chiropractic manipulations were noted in some trials. However, the
treatment's effectiveness in treating back and neck pain has not been
supported by compelling evidence from the majority of clinical trials.
Further studies are currently assessing the effectiveness of
chiropractic care for pain management.
Massage is being increasingly used by
people suffering from pain, mostly to manage chronic back and neck
problems. Massage can reduce stress and relieve tension by enhancing
blood flow. This treatment also can reduce the presence of substances
that may generate and sustain pain. Available data suggest that
massage therapy, like chiropractic manipulations, holds considerable
promise for managing back pain. However, it is not possible to draw
final conclusions regarding the effectiveness of massage to treat pain
because of the shortcomings of available studies.
Therapeutic Touch and Reiki
Healing
Therapeutic touch and reiki healing are
thought to help activate the self-healing processes of an individual
and therefore reduce pain. Although these so called "energy-based"
techniques do not require actual physical contact, they do involve
close physical proximity between practitioner and patient.
In the past few years, several reviews
evaluated published studies on the efficacy of these healing
approaches to ease pain and anxiety and improve health. Although
beneficial effects with no significant adverse side effects were
reported in several studies, the limitations of some of these studies
make it difficult to draw definitive conclusions. Further studies are
needed before the evidence-based recommendation for using these
approaches for pain treatment can be made.
Nutritional Supplements
There is solid evidence indicating that
glucosamine sulfate and chondroitin sulfate relieve pain due to knee
osteoarthritis. These natural compounds were found to decrease pain
and increase mobility of the knee and were well tolerated and safe.
Other dietary supplements, such as fish oils, also show some
evidence of benefit, although more research is needed.
Herbal Remedies
It has been difficult to draw conclusions
about the effectiveness of herbs. If you decide to use herbal
preparations to better manage your pain, it is of critical importance
to share this information with your doctor. Some herbs may interact
with drugs you are receiving for pain or other conditions and may harm
your health.
Dietary Approaches to Treating
Pain
Some people believe that changing dietary
fat intake and/or eating plant foods that contain anti-inflammatory
agents can help ease pain by limiting inflammation.
A mostly raw vegetarian diet was found helpful for some people
with fibromylagia, but this study was not methodologically strong. One
study of women with premenstrual symptoms suggested that a low-fat
vegetarian diet was associated with decreased pain intensity and
duration. Weight loss achieved by a combination of dietary changes and
increased physical activity has been shown to be helpful for people
suffering from osteoarthritis.
Still, further research is needed to
determine the effectiveness of dietary modifications as a pain
treatment.
Things to Consider
Alternative therapies are not always
benign. As mentioned, some herbal therapies can interact with other
medications you may be taking. Always talk to your doctor before
trying an alternative approach and be sure to tell all your doctors
what alternative treatments you are using.
Other Options: Pain Clinics
Many people suffering from chronic pain
are able to gain some measure of control over it by trying many of the
above treatments on their own. But for some, no matter what treatment
approach they try, they still suffer from debilitating pain. For them,
pain clinics -- special care centers devoted exclusively to dealing
with intractable pain -- may be the answer. Some pain clinics are
associated with hospitals and others are private; in either case, both
inpatient and outpatient treatment are usually available. Pain clinics
generally employ a multidisciplinary approach, involving physicians,
psychologists, and physical therapists. The patient as well should
take an active role in his or her own treatment. The aim in many cases
is not only to alleviate pain but also to teach the chronic sufferer
how to come to terms with pain and function in spite of it.
Various studies have shown as much as 50% improvement in pain
reduction for chronic pain sufferers after visiting a pain clinic, and
most people learn to cope better and can resume normal activities.
Medially updated November 2004.
SOURCES: The Cleveland Clinic Spine
Center, The Center for Integrative Medicine at The Cleveland Clinic,
and The Cleveland Clinic Department of Physical Medicine and
Rehabilitation. Chronic Pain Network.
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