What Is Chronic Pain
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In 2020 the IASP introduced a revised definition of pain, the result of a two-year process that the association hopes will lead to revised ways of assessing pain.
“IASP and the Task Force that wrote the revised definition and notes did so to better convey the nuances and the complexity of pain and hoped that it would lead to improved assessment and management of those with pain,” said Srinivasa N. Raja, MD, Chair of the IASP Task Force and Director of Pain Research, Professor of Anesthesiology & Critical Care Medicine, Professor of Neurology, Johns Hopkins University School of Medicine.
The definition is: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” and is expanded upon by the addition of six key Notes and the etymology of the word pain for further valuable context.
Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
Through their life experiences, individuals learn the concept of pain.
A person’s report of an experience as pain should be respected.
Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.
A multi-national, multidisciplinary Task Force developed the revised defintion with input from all potential stakeholders, including persons in pain and their caregivers.
This type of pain can be nociceptive, or can be neuropathic i.e. handled by a dysfunctional nerve or cluster of nerve signals. People living with chronic pain often report hyperalgesia (increased sensitivity to pain), allodynia (heightened pain response to usually non-painful stimuli) or dysaesthesia (unpleasant abnormal sensations). Chronic pain can also arise from other types of pain.
Chronic Primary Pain
Chronic primary pain represents chronic pain as a disease in itself. Chronic primary pain is characterized by significant functional disability, or emotional distress and is not better accounted for by another diagnosis of chronic pain. Here you find chronic widespread pain, chronic primary musculoskeletal pain previously termed “non specific” as well as the primary headaches and conditions such as chronic pelvic pain and irritable bowel syndrome. They are recognised as a group of chronic pain syndromes for the first time in ICD-11.
Chronic Secondary Pain
Chronic cancer-related pain is chronic pain that is due to cancer or its treatment, such as chemotherapy. Represented in ICD-11 for the first time see here.
Chronic postsurgical or post-traumatic pain is chronic pain that develops or increases in intensity after a tissue trauma (surgical or accidental) and persists beyond three months. It is also part of the ICD for the first time see here
Chronic secondary musculoskeletal pain is chronic pain in bones, joint and tendons arising from an underlying disease classified elsewhere. It can be due to persistent inflammation, associated with structural changes or caused by altered biomechanical function due to diseases of the nervous system. See here
Chronic secondary visceral pain is chronic pain secondary to an underlying condition originating from internal organs of the head or neck region or of the thoracic, abdominal or pelvic regions. It can be caused be persistent inflammation, vascular mechanisms or mechanical factors. See hee
Chronic neuropathic pain is chronic pain caused by a lesion or disease of the somatosensory nervous system. Peripheral and central neuropathic pain are classified here. These diagnoses are also newly represented in the ICD. See here
Chronic secondary headache or orofacial pain contains the chronic forms of symptomatic headaches (those termed primary headaches in the ICHD-3 are part of chronic primary pain) and follows closely the ICHD-3 classification. Chronic secondary orofacial pain, such as chronic dental pain, supplements this section. See here
Causes of Chronic Pain
Headache and/or Migraine
- Alcohol
- Cluster Headaches
- Drug or Substance overuse or misuse
- Giant cell (temporal) arteritis
- Glaucoma
- Migraine
- Smoking
- Temporo-mandibular joint dysfunction
- Trigeminal neuralgia
Musculoskeletal
- Ankylosing spondylitis
- Carpel Tunnel Syndrom
- Chronic or repetitive overuse
- Fractures
- Mechanical low back pain
- Muscular strains
- Myofascial diseases
- Osteoarthritis
- Osteomyelitis
- Osteoporosis
- Polymyalgia rheumatica
- Polymyositis
- Rheumatoid arthritis
Neurological
- Alcoholism
- Brachial plexus traction injury/compression
- Complex regional pain syndrome
- Diabetic sensorimotor polyneuropathy
- Infections (e.g., HIV, Hepatitis C, post-herpetic neuralgia Herpes Zoster also know as Shingles)
- Multiple Sclerosis
- Pernicious anaemia (impaired absorption of Vit. B12)
- Spinal stenosis
- Thoracic outlet syndrome (blood vessel/nerve compression)
- Thyroid disease
- Polyneuropathies (damage affecting peripheral nerves)
- Polyradiculopathies (damage to serval nerve roots)
Psychological causes
- Anxiety,
- Depression,
- Personality disorder
- Sleep disturbances.
Medical or Generalised Disease processes
Chronic Pain may arise from general medical or disease conditions. Regional pain includes:
- Abdominal (e.g. peptic ulcer, irritable bowel syndrome, pancreatitis, hernias, diverticular disease)
- Cardiovascular (e.g. ischaemic heart disease, coronary heart disease, angina, peripheral vascular disease, etc)
- Gynaecological (e.g. endometriosis)
- Obstetric (e.g. symphysis pubis dysfunction)
- Urological (e.g. interstitial cystitis)
Chronic Pain which results from disease processes includes:
- Endocrine – i.e. diabetes, joint pain etc.
- Infectious – i.e. hepatitis C, HIV Post-herpetic neuralgia
- Malignancy – cancer and post-treatment pain (e.g. chemotherapy, radiation or surgery)
- Rheumatological – i.e. fibromyalgia, rheumatoid arthritis, osteoarthritis etc
Referral to Healthcare Professional
If you think that you may have chronic pain, it is important that you seek the appropriate help and the first step is speaking to your GP.
It is important that you are prepared and able to give your GP as much information as possible during your visit. If you are anxious that you might forget something, write it down and bring it with you and you can also bring someone in with you. It will be helpful if you can inform your GP of the following:
- When pain began
- Was the onset of pain gradual, sudden, result of event/, trauma, accident
- Description of your pain (see section what is chronic pain LINK)
- Region(s) of your body that you are experiencing pain
- Does it radiate (e.g. starts and spreads to another location in your body)
- Describe how severe the pain can be on a daily, weekly basis, does it vary
- When you are most affected (is it worse in the morning / night)
- How often the pain occurs, is it constant, frequent, does it come and go
- How intense is your pain (how would you rate it 1 – 10 with ten being worst)
- If pain is affecting your ability to work, socialise or is it affecting your private / family life
- If pain is causing sleeplessness, poor concentration or low mood
Your GP may also ask you to use a Pain Diary which involves recording your level of pain (on a pain scale) several times a day over the period of a week. A useful online tool can be found at https://www.changepain.com/en/pain-toolkit
You will be asked to note activities or other things that seem to increase pain, and note when taking any medication the effect it has on your pain. This can be very helpful in establishing whether there is any particular pattern to the pain, or any triggers that could be avoided.
Your GP may also conduct a physical examination (which will vary depending on site and type of pain) to look for possible causes of pain and to rule out certain conditions. Once your GP has assessed your pain they may conduct further tests to try and determine the underlying cause of pain.
By describing your symptoms clearly and fully and the impact these have on your life your GP will be better positioned to make the correct diagnosis, begin treatment and / or refer you to specialist services.
Referral to a Pain Specialist
Chronic pain can be difficult to diagnose and treat and if your GP thinks that you may have chronic pain then he/she should refer you to see a pain specialist. If your GP is unwilling to do so, ask him / her to arrange for a second opinion. Please note that patients cannot make an appointment for themselves, the referral must come via a GP or other medical professional.
Be prepared for your appointment and again if you are anxious that you might forget something write it down or bring someone along with you. Keep a pain diary (either on paper or by using an app e.g. paintracker.ie). A Pain Diary involves recording your level of pain several times a day over a period of time. You note activities or other things that seem to increase pain, and note when taking any medication the effect it has on your pain. This can be very helpful in establishing whether there is any particular pattern to the pain, or any triggers that could be avoided.
Pain Management Programme
A Pain Management Program (PMP) is a psychologically-based rehabilitative treatment for people with persistent pain. It is delivered in a group setting by an interdisciplinary team of experienced health care professionals working closely with patients. Some Pain Centres may run Pain Management Programs that aim to teach a group of patients with similar problems about pain, how best to cope with it and how to live a more active life.
For the majority of people, attending a Pain Management Program reduces the disability and distress caused by persistent pain by teaching physical, psychological and practical techniques to improve quality of life. It differs from other treatments provided in Pain Clinics in that pain relief is not the primary goal, although improvements in pain following participation in a Pain Management Program have been demonstrated.
Referral to a Pain Management Programme is usually through your general practitioner to your local pain clinic.
There are public pain management programmes in:
- St Vincent’s University Hospital, Dublin
- Tallaght University Hospital, Dublin
- Mater Misericordiae University Hospital
- Mercy University Hospital, Cork
In addition, St James Hospital, Dublin offer mindfulness meditation while in Galway, the Galway University Hospital is also developing an online program to allow access by patients in all regions of the country.
A video link is attached here which demonstrates what you can expect from a pain management programme.
Self-Management
Self-Management fits well with clinical approaches and the sooner you start the better. It’s not easy but it is possible. A lot of people make huge improvements in the quality of their life when they thought all was lost. While there is no immediate cure for Chronic Pain implementing strategies/techniques through self-management can help reduce your pain, improve the quality of your life and puts you, not the pain, in control.
Self Management is an approach to improving health and well-being by addressing the impact chronic pain has on life i.e. stress, anxiety, poor sleep and over-doing things. It is important to take control wherever possible through improving understanding and building skills in relaxation, stress management, pacing and challenging negative thinking. Details of our self-management meetings can be found here
