What is pain? Chronic pain is pain that continues after an injury has healed.

Transcription

1 What is pain? Pain is defined as an unpleasant sensry and emtinal experience assciated with actual r ptential tissue damage. (Internatinal Assciatin fr the Study f Pain) Chrnic pain is pain that cntinues after an injury has healed. Pain is the bdy s alarm system, warning us that ur tissues are under threat, usually by injury r illness (fr example, an acute back strain r appendicitis). The human bdy and especially the brain and spinal crd have evlved ver millins f years t amplify pain alarm signals (a bit like a hi-fi system) s we dn t ignre pain when we are injured. This is usually a gd thing which helps us t survive. Peple brn with the rare cnditin f pain insensitivity die at a yung age because they dn t realize they ve been injured until it s t late. Unfrtunately, in sme peple wh develp chrnic pain, this alarm system keeps n ringing even thugh the injury (such as a back strain) has well and truly healed. We nw have an alarm system that hasn t switched itself ff! This ccurs because f changes in the nervus system (called pain sensitizatin ) and the bdy s respnses t stress, injury and illness, which amplifies and prduces a memry f the riginal pain signals in the brain and spinal crd, even thugh the injury that caused the pain in the first place has healed. Nerve cells becme super-sensitive when a persn has chrnic pain this interferes with activity, sleep and hw yu feel. In this state, the nerve cells that detect tissue damage keep sending a lt mre messages than usual t the brain. This explains why ften there ften isn t a clear link between pain and tissue damage. This desn t mean there s anything wrng with yur brain r spinal crd if yu have chrnic pain (there s n prblem with the hardware ); it s mre like a glitch in the sftware prgramme that prcesses pain signals in the bdy. Chrnic pain can als develp as part f the bdy s respnse t stress: Expsure t stress such as injuries (e.g. whiplash, brken bnes), illness (e.g. glandular fever virus, cancer, arthritis) r life-event (e.g. depressin, anxiety, wrk r relatinships prblems) causes changes in the bdy s nervus, immune and hrmne systems, prducing a sickness respnse (exactly like a dse f the flu ), which smetimes desn t switch-ff as expected, but cntinues ver the lng-term (especially if stress cntinues). This sickness respnse t stress nt nly prduces chrnic pain in varius parts f the bdy (like the aching muscles yu feel when yu re sick in bed with flu), but many f the ther symptms that g hand-in-hand with pain, like chrnic fatigue, pr sleep, lack f energy and mtivatin, difficulty thinking, pr memry, depressin, anxiety, sensitivity t varius sensatins (cld r bright lights), pr appetite and libid. In sme peple this is called fibrmyalgia syndrme. 1 E.J. Visser V All rights reserved: D nt reprduce withut written permissin. Disclaimer: Generic advice nly-nt intended as specific clinical directin. Authrs r institutins cannt take respnsibility fr any adverse cnsequences assciated with this infrmatin.

2 Pain is a whle-persn experience: Pain affects a persn s general health, ability t wrk, incme, travel, relatinships, all aspects f life. That s why we need the help f a team f health care prfessinals such as psychlgists r physitherapists t treat the big picture f smene s pain experience. Pain is als an unpleasant emtinal experience: Fifty percent f patients with chrnic pain suffer with anxiety r depressin. Pain is assciated with increased levels f anxiety and fear. Pain and fear develped tgether during evlutin as a means f ensuring survival when primitive man was threatened by injury (such as an attack by a tiger). Brain scans als shw the parts f the brain cntrlling fear, depressin and pain are clsely linked tgether. Pain, depressin and anxiety interact in a vicius cycle. When yu experience pain, yu may get anxius r depressed, which in turn makes it harder t cpe with the pain. This is quite understandable: there are few things as stressful as living with cnstant pain. That s why we pay a great deal f attentin t peple s emtins and stress levels when treating chrnic pain. Physitherapy and exercise are a vital part f pain management. Back pain is a classic example. Peple wh stp exercising their back because f pain becme de-cnditined, weakening the scaffld f supprting muscles and ligaments, which in turn makes the back pain wrse. Exercise bsts yur immune system and yur bdy s natural pain killers called endrphins : This nt nly helps t ease pain but als makes a persn feel better, just like the high runners describe after jgging. Exercise is als very effective fr treating stress, depressin, chrnic fatigue (fibrmyalgia) and a whle hst f pain-related prblems. Hwever peple with chrnic pain can easily verd their exercises and becme exhausted, disheartened, avid further exercise and get even mre unfit; a vicius cycle. Pacing f physical activities, by gradually building-up stamina and endurance a little each day, is a key pain management strategy that physical therapists can teach. Prcedures and pills Althugh prcedures and pain medicatins play a valuable rle in pain management, mre ften than nt, a magic injectin, peratin r drug that cures chrnic pain is nt available. Gals f prcedures and pills: Prcedures and pain medicatins prvide a windw f imprved pain cntrl, during which yu can wrk n the lng-term gals f pain management such as imprving self-management, physical functin, fitness, md, cping and reducing stress and medicatin-use. Fr mst pain-relieving prcedures r medicatins, abut 1 in 5 patients reprt satisfactry pain relief. 2 E.J. Visser V All rights reserved: D nt reprduce withut written permissin. Disclaimer: Generic advice nly-nt intended as specific clinical directin. Authrs r institutins cannt take respnsibility fr any adverse cnsequences assciated with this infrmatin.

3 Mst spinal injectins (e.g. epidurals, facet jint injectins, nerve rt sleeve injectins) and pain medicatins (e.g. mrphine, paracetaml, antidepressants, gabapentin, anti inflammatry drugs) reduce pain in abut 1 in 5 patients, and they all have ptential side effects. Mrphine-like pain killers (called piids ) include; mrphine (MS Cntin, Ordine ), xycdne (Oxycntin CR, Oxynrm, Endne ), methadne, hydrmrphne (Jurnista, Dilaudid ) cdeine (Panadeine frte, Nurfen plus ), fentanyl (Durgesic patches), buprenrphine (Nrspan patches, Temgesic ) and tapentadl (Palexia ). Tramadl is a special kind f pain medicatin that has mixed piid and antidepressant pain relieving prperties. It is especially effective fr nerve pain (1 in 4 patients) and is less cnstipating, less addictive and less likely t slw dwn breathing. It may interact with sme antidepressants and can be assciated with blackuts r seizures in rare cases. Effectiveness f piid pain (mrphine-based) medicatins Only abut 1 in 5 patients btain effective pain relief with piid (mrphine-based) pain medicatins, withut majr side effects. A successful respnse includes nt nly a decrease in pain severity, but mre imprtantly, an imprvement in physical functin (walking, exercise, wrk etc). As yu can see, nt all patients respnd t piid pain medicatins, despite them being very ptent, and piids can actually increase pain in sme cases! The human bdy is nt designed t have high levels f (piid) pain medicatins flating arund in the bld stream. When the bdy detects high levels f piids in the bldstream, it prduces chemicals which actually increase the pain signal, t cunteract these medicatins. This increases pain sensitivity and is called piid induced hyperalgesia. Yur bdy may als becme used-t (tlerant) t pain medicatins, meaning yu cntinually need a larger dse t get the same pain relief. This leads t a vicius cycle the higher the dse, the mre side effects develp and wrse the pain becmes. The way t deal with these prblems is a gentle reductin in yur pain medicatin t reset the chemical balance f yur brain and reduce yur pain. If an piid pain medicatin is ging t be effective it will d s at lw-t-mderate dses ging ever-higher in dse will nt reduce pain further. Sme peple s pain simply wn t respnd t piids, whatever the dse! In these cases, the piid medicatin shuld either be changed, r tapered and ceased. Patients shuld be reviewed every 3 mnths t see if the dse f pain medicatin can be reduced r ceased. Pain relieving medicatin such as piids, pregabalin, gabapentin, anti-inflammatries (e.g. ibuprfen, diclfenac, celecxib) and antidepressants (e.g. amitriptyline, dulxetine) shuld be reduced at regular intervals (under medical supervisin nly) in an attempt t see if the underlying pain has imprved. Very ften after a few mnths f treatment, the pain actually imprves and patients need less f their pain medicatin, r it can even be stpped. 3 E.J. Visser V All rights reserved: D nt reprduce withut written permissin. Disclaimer: Generic advice nly-nt intended as specific clinical directin. Authrs r institutins cannt take respnsibility fr any adverse cnsequences assciated with this infrmatin.

4 Opiid pain medicatins may cause the fllwing side effects (sme f which yu may nt even ntice): Restrictins in breathing: Accidental r deliberate verdse f piid pain relievers can slw dwn r even stp a persn s breathing leading t death, especially in peple with excessive snring r wh are verweight (bstructive sleep apnea), r when mixed with ther pain medicatins, sleeping tablets such as diazepam (Valium ), alchl and drugs. Addictin (getting hked ) in up t 15% f pain patients: these patients need a sympathetic apprach including careful management f their medicatins and ther lifestyle factrs. Reduced hrmne levels, like teststerne and estrgen: This can cause lw energy, changes in md (depressin) and reduced sex drive. Brittle bnes (steprsis). Impaired brain functin and changes in the structure f yur brain: increasing the risk f psychlgical prblems such as anxiety, depressin, pr memry and insmnia. Reduced immune system functin: pssibly resulting in a higher risk f infectins and cancer. Antidepressant pain-relievers: Amitriptyline (Endep ), Nrtriptyline, Dulxetine (Cymbalta ) and pssibly Venlafaxine (Efexr ) may be effective in treating nerve pain (e.g. shingles, diabetic pain, spinal nerve cmpressin), fibrmyalgia and sme chrnic headaches in arund 1 in 3 patients. Pregabalin (Lyrica ) r gabapentin are anti-epilepsy drugs which may be effective in treating nerve pain and fibrmyalgia in abut 1 in 5 patients. Disappintments and frustratins What many peple wh live with chrnic pain realize is that despite ur best attempts with injectins, peratins r medicatins, the cmplex and whle-persn experience f chrnic pain may nt respnd t using medical techniques in islatin. The chrnic pain experience can be very frustrating lts f dctrs, therapists, scans and prcedures, cnflicting infrmatin, disappintments and failures, ften leading t a lss f faith and hpe and even anger. Why isn t this pain getting better? Managing the whle-persn in pain T manage chrnic pain successfully, the whle-persn needs t be engaged in a wide range f therapies, prvided by a team f experts, including the persn-in-pain. 4 E.J. Visser V All rights reserved: D nt reprduce withut written permissin. Disclaimer: Generic advice nly-nt intended as specific clinical directin. Authrs r institutins cannt take respnsibility fr any adverse cnsequences assciated with this infrmatin.

5 There is gd scientific evidence that pain management prgrammes imprve physical functining, energy levels, fitness, cping skills, sleep, md, quality f life (wrk, scial, family), and reduce medicatin and healthcare use and t sme extent pain levels, in many peple with chrnic pain. Effective pain management prgrammes shuld include; Educatin and infrmatin (which prmtes self-management and the ability t make infrmed chices abut pain management strategies; prmtes an understanding f pain and its mechanisms, thereby taking away sme f the mystery, fear and threat assciated with pain). Psychlgical techniques (stress management, relaxatin, mindfulness, hypnsis). Physical therapy techniques (activity pacing, fitness, spinal cre stability). Brain pwer training techniques (mirrr bx, virtual reality, placeb). Lifestyle management (sleep, medicatin use, wrkplace and hme, relatinships). Medical treatments (prcedures and medicatins). Strategies t deal with pain flare-ups (the bad days). Mdern pain management fcuses n helping yu take cntrl and using yur whle-bdy s resurces t deal with yur pain. The treatment apprach is t manage yur pain s that yu can imprve yur functining in areas f yur life that are imprtant t yu. Althugh this may nt sund easy, with help and supprt it is pssible. Everyne s pain experience is unique. That is why yu are the mst imprtant persn in successfully managing yur pain. 5 E.J. Visser V All rights reserved: D nt reprduce withut written permissin. Disclaimer: Generic advice nly-nt intended as specific clinical directin. Authrs r institutins cannt take respnsibility fr any adverse cnsequences assciated with this infrmatin.