Dr. Aruna

People who suffer from severe, chronic back pain know how it can utterly disrupt and damage one's life. Chronic back pain can be cruel-making it hard to enjoy even the simplest daily activities, and certainly making it a challenge to carry out an exercise routine and other healthy activities. Moreover, chronic pain was not previously all that well understood. The medical profession used to believe that pain is always a manifestation of an underlying injury or disease. As such, doctors focused on treating the underlying cause of the pain, with the belief that once the injury or disease was cured the chronic pain would then disappear.

If no underlying cause could be found for the pain, then the patient was told that very few treatments are available, or worse, 'the pain must be in your head'. Unfortunately, some doctors still practice in this manner, having no appreciation for the unique problem of chronic pain, newer theories about chronic pain, and the many factors that influence a chronic pain problem.

The medical community is starting to understand that if pain is no longer a function of a healthy nervous system (signaling that there is a disease or underlying injury), then the chronic pain itself becomes the problem and needs to be treated as the primary pathology.

The Experience of Chronic Pain

Contrary to popular belief, all pain is real. This may seem like an obvious statement, but people with chronic pain are sometimes treated as if their chronic pain is either imaginary or exaggerated. In some cases, they feel like they have to prove their chronic pain to their friends, family, and doctors. Some patients are told by their doctor that there is no reason for the chronic pain and therefore 'it cannot be that bad'.

Chronic pain is a personal experience and cannot be measured like other problems in medicine, such as a broken leg or an infection. For instance, a broken leg can be confirmed by an X-ray and an infection by a blood test measuring white blood cell count. Unfortunately, there is no medical test to measure chronic pain levels.

To make matters more challenging for the patient, for many chronic pain problems, there is no objective evidence or physical findings to explain the pain. Thus, many chronic pain sufferers go from one doctor to the next searching for explanations. This process can lead to unnecessary evaluations and treatments, in addition to putting the patient at risk for actually being harmed or made worse by the healthcare profession.

Everyone experiences and expresses pain differently. Two people with the exact same injury will feel and show their pain in unique ways depending on a number of things such as:

• The situation in which the pain occurs
• Thoughts about the chronic pain, such as 'this is nothing serious' versus 'this pain could kill me'
• Emotions associated with the chronic pain, such as depression and anxiety versus hopefulness and optimism
• Cultural influences determining whether a person is to be more stoic or more dramatic in showing pain to others

The newest theories of chronic pain can now explain, on a physiological level, how and why people experience pain differently.

Types of Back Pain: Acute Pain, Chronic Pain, and Neuropathic Pain

Understanding how pain is defined is important in order to learn how to better control it. For the purposes of research and medical practice, pain can be separated into three categories:

-Acute Pain
-Chronic Pain
-Neuropathic Pain

Acute Pain

One common type of pain is acute pain, currently defined as pain lasting less than 3 to 6 months, or pain that is directly related to tissue damage. This is the kind of pain that is experienced from a paper cut or needle prick. Other examples of acute pain include:

• Touching a hot stove or iron. This pain will cause a fast, immediate, intense pain with an almost simultaneous withdrawal of the body part that is being burned. More of an aching pain might be experiencing a few seconds after the initial pain and withdrawal.
• Smashing one's finger with a hammer. This pain is similar to that of touching a hot stove in that there is an immediate pain, withdrawal and then 'slower' aching pain.
• Labor pains. The pain during childbirth is acute and the cause is certainly identifiable.

The longer pain goes on the more susceptible it is to other influences and developing into a chronic pain problem. These influences include such things as the ongoing pain signal input to the nervous system even without tissue damage, lack of exercise (physical deconditioning), a person's thoughts about the pain, as well as emotional states such as depression and anxiety.

Chronic Pain

There are at least two different types of chronic pain problems - chronic pain due to an identifiable pain generator (e.g. an injury), and chronic pain with no identifiable pain generator (e.g. the injury has healed).

Chronic pain due to an identifiable pain generator

This type of chronic pain is due to a clearly identifiable cause. Certain structural spine conditions (for example, degenerative disc disease,spinal stenosis and spondylolisthesis can cause ongoing pain until successfully treated. These conditions are due to a diagnosable anatomical problem.

If the pain caused by these types of conditions has not subsided after a few weeks or months of conservative (nonoperative) treatments, then spine surgery may usually be considered as a treatment option.

Chronic pain with no identifiable pain generator
This type of pain continues beyond the point of tissue healing and there is no clearly identifiable pain generator that explains the pain. It is often termed 'chronic benign pain'.

It appears that pain can set up a pathway in the nervous system and, in some cases, this becomes the problem in and of itself. In chronic pain, the nervous system may be sending a pain signal even though there is no ongoing tissue damage. The nervous system itself misfires and creates the pain. In such cases, the pain is the disease rather than a symptom of an injury.

The term 'chronic pain' is generally used to describe the pain that lasts more than three to six months, or beyond the point of tissue healing. Chronic pain is usually less directly related to identifiable tissue damage and structural problems. Examples of chronic pain are: chronic back pain without a clearly determined cause, failed back surgery syndrome (continued pain after the surgery has completed healed), and fibromyalgia.

Chronic pain is influenced by many factors, such as ongoing pain signal input to the nervous system even without tissue damage, physical deconditioning due to lack of exercise, a person's thoughts about the pain, as well as emotional states such as depression and anxiety. Chronic pain is much less well understood than acute pain.

Neuropathic Pain

Neuropathic pain has only been investigated relatively recently. In most types of neuropathic pain, all signs of the original injury are usually gone and the pain that one feels is unrelated to an observable injury or condition. With this type of pain, certain nerves continue to send pain messages to the brain even though there is no ongoing tissue damage.

Neuropathic pain (also called nerve pain or neuropathy) is very different from pain caused by an underlying injury. While it is not completely understood, it is thought that injury to the sensory or motor nerves in the peripheral nervous system can potentially cause neuropathy. Neuropathic pain could be placed in the chronic pain category but it has a different feel then the chronic pain of a musculoskeletal nature.

The neuropathic pain feels different than musculoskeletal pain and is often described with the following terms: severe, sharp, lancinating, lightning-like, stabbing, burning, cold, and/or ongoing numbness, tingling or weakness. It may be felt traveling along the nerve path from the spine down to the arms/hands or legs/feet. It's important to understand neuropathic pain because it has very different treatment options from other types of back pain. For example, opioids (such as morphine) and NSAID (such as ibuprofen, COX-2 inhibitors) are usually not effective in relieving neuropathic pain. Treatments for neuropathic pain include certain medications, nerve 'block' injections, and a variety of interventions generally used for chronic pain.

When Acute Pain Becomes Chronic Pain

It is critical for a doctor and a patient to have an understanding of the difference between acute pain and chronic pain. With acute pain, the pain is a symptom of injured or diseased tissue. When the injury has finished healing, the correlating pain will subside. For example, with a herniated disc, once the pressure on the nerve is alleviated the acute pain stops. For this reason, medical treatment for acute pain focuses on healing the underlying cause of the pain.

Additionally, with acute pain, the severity of pain directly correlates to the level of tissue damage. This provides us with a protective reflex, such as to stop an activity when it causes pain. However, chronic pain does not serve a protective or other biological function. Treatments will be different depending on the underlying cause of the pain.

Chronic Pain Development

Not all pain that persists will turn into chronic pain. Different people experience chronic pain very differently. Likewise, the effectiveness of a particular treatment for chronic pain will often differ from person to person. For example, a particular medication or injection for a herniated disc may provide effective pain relief for some people but not for others.

One problem is that not all patients with similar conditions develop chronic pain, and it is not understood why some people will develop chronic pain. Also, a condition that appears relatively minor can lead to severe chronic pain, and a serious condition can be barely painful at all.

As pain moves from the acute phase to the chronic stage, influences of factors other than tissue damage and injury come more into play and influences other than tissue input become more important as the pain becomes more chronic.

Pain medicine and pain management as a medical specialty is relatively new. However, now that chronic pain is becoming recognized as a primary problem, rather than always being a symptom of a disease, the specialty of pain management is starting to grow.