Chronic pain, also called persistent pain, is pain that continues beyond the time expected for a painful condition or injury to heal, usually about 3 months.

Chronic pain occurs because the nerves and spinal cord become over-sensitive and magnify messages when there is no active damaging stimulus. When the nerve messages reach the brain, the brain thinks there is harm and reacts by feeling pain – even when there is no injury.

When chronic pain continues for some time, the brain may start to react to messages from other parts of the body near the site of the now-healed damage and you feel pain in those areas too, making the situation worse.

Neuropathic pain is a type of chronic pain that occurs following damage to the nervous system itself. It is also called nerve pain or nerve-damage pain. The sensations associated with this type of pain are described as burning or shooting pains. The skin can be numb, tingling or extremely sensitive.

Here are some of the most common causes affecting adults today:

Chronic Back Pain

Often occurring in the lower back, the pain may be caused by an injury or develop progressively due to arthritis, osteoporosis, or normal wear-and-tear.

Back pain has become an epidemic in the world and is today a leading cause of disability and lost productivity in the workplace.

Common causes of chronic back pain include:

• Slipped or bulging discs, typically caused by twisting or lifting injuries
• Spinal stenosis involving the narrowing of the spinal canal and compression of nerves
• Compression fractures commonly associated with osteoporosis
• Soft tissue damage caused by strain or trauma to back muscles, ligaments, or tendons
• Spinal fractures
• Structural deformities such as scoliosis (the abnormal sideways curvature of the spine) or lordosis (the excessive inward curvature of the lower back)

Chronic Headaches

A chronic headache is one which occurs for at least 15 days per month for no less than three consecutive months. The most common types of chronic headaches are:

• Tension headaches caused by stress, fatigue, or sleeping wrong
• Eye strain headaches caused when the ocular muscles become strained
• Migraines caused by nervous system triggers or hormonal irregularities
• Cluster headaches caused by the enlargement of blood vessels in the head

Chronic Joint Pain

• Osteoarthritis, common in the elderly and usually affecting the larger joints
• Rheumatoid arthritis, an autoimmune disorder which causes swelling od the joint spaces
• Repetitive motion injury, common in athletes and people who do repetitive physical activities
• Bursitis caused by swelling of the fluid-filled sacs that cushion the joints
• Tendinitis caused by the inflammation of joint tendons

Chronic Nerve Pain

Chronic nerve (neuropathic) pain commonly occurs when the nerves are either compressed, damaged, or exposed to drugs which strip their protective exterior coating (called the myelin sheath).

Some of the more common examples of chronic neuropathic pain are:

• Sciatica, typically caused by nerve compression which triggers a shooting pain down the leg
• Diabetic neuropathy, often occurring in the hands or feet.
• Carpal tunnel syndrome, commonly associated with repetitive motion
• Postherpetic neuralgia, a type of chronic pain which persists after a shingles outbreak
• Trigeminal neuralgia, caused by injury to the trigeminal nerve of the face, typically caused by twisting or lifting injuries.

The challenge of managing and living with persistent (chronic) pain benefits from the understanding of the mechanism of pain. 

Biopsychosocial model

This sounds very complex, but basically means that 3 aspects of the client should be considered:

a) Bio – biological: the physical body should be assessed for changes or injury,

b) Psycho – psychological: the aspects of anxiety and stress should be addressed,

c) Social – aspects of the social situation and home/ work environment should be considered.

Essentially, the BPS model is a way of looking at the wider causes of disease. Until relatively recently, it had been common to view disease as largely the result of biological factors only and to treat it accordingly; a purely biomedical approach. However, chronic medical conditions invariably have multiple, interlinked causes which continually affect one another, perpetuating and exacerbating a person’s overall condition.

To achieve the very best outcome for the patient, the BPS model highlights the importance of treating or addressing all causes of the condition, not just one or two in isolation.

Perhaps the best way to visualise the the model is to think of it as a Venn diagram of three overlapping circles, labelled respectively Biological, Psychological and Social. Biology can affect psychology, which can affect social well-being, which can further affect biology and psychology, and so on.

Let’s take an example

Katy develops Complex Regional Pain Syndrome (CRPS) in her dominant right arm, severely restricting her function. The biological component of the model takes into consideration (non-exhaustively) factors such as:

• genetic and other pre-dispositions;
• the autoimmune system;
• brain chemistry;
• the effect of medication;
• the fight-flight response;
• her psychological response.

That of course leads us neatly to the psychological component. The biological factors may influence how Katy feels about herself:

• her thoughts;
• her emotions;
• her behaviour.

She may develop low self-esteem, fear for the future, and a fear of the judgement of others, all ultimately leading to anxiety and depression. As a result of these factors, Katy may begin avoiding certain situations, avoiding people, staying at home or leaving her job. As her world and her outlook is compressed, her anxiety and depression worsen.

The social component of the model examines the related social factors influencing Katy’s health; her interaction with other people, her worsening financial situation, her declining overall physical fitness and mental well-being.

Perhaps Katy has a young child and her pain means that basic mother/child physical contact is necessarily limited. It means that she struggles to bathe and dress her child or prepare its food. Her partner steps up to the mark and her mother also offers to help out but maybe Katy perceives underlying resentments. These further stressors may lead to the exacerbation of Katy’s biological and psychological problems which then further exacerbate the social problems, and so on, perpetuating a downward spiral.

The focus of treatment needs to be on managing your pain and improving your day-to-day function, rather than completely stopping the pain.

Chronic pain is best managed through a multidisciplinary pain management plan with your healthcare professional, covering aspects such as:

• physical fitness and activities
• medication
• mood
• sleep
• relaxation and overall health.

Learning self-management skills is key.

Starting to exercise and learning coping skills are important ways to help improve your ability to function and reduce the impact of your pain. Don’t wait for your pain to be completely gone before starting normal activities, including work.

People who are actively engaged in self-management techniques report lower levels of pain-related disability, improvements in mood, better general health and reduced use of medicines.

Psychological treatments including cognitive therapies, behavioural treatments and acceptance and commitment therapy (ACT) may be effective for improving quality of life in those with chronic pain.

Cognitive Therapy

Cognitive therapies to pain management are concerned with the way the pain sufferer thinks about their pain. These thoughts involve beliefs about the causes of the pain, the threat of illness and incapacity, and the effects of treatment. Although there may still be hope for a cure, with most chronic pain conditions, the goal is to minimise any disability and facilitate adjustment to a new lifestyle with its permanent handicaps.

Different techniques are used in cognitive therapy to pain management. Among those, the most important ones are:

1. explaining and understanding the patient’s pain,
2. eliminating or reducing negative thinking (e.g., blaming, shoulds, unrealistic control, led by emotions, dark glasses),
3. changing beliefs by listening (e.g., being non-judgmental),
4. teaching intrusive thought stopping techniques,
5. utilising the ABCD Model of cognitive therapy to identify the activating events, beliefs and consequences in order to dispute them,
6. teaching effective cognitive coping strategies,
7. increasing pain tolerance,
8. promoting an active role in self-management (empowerment),
9. mood management,
10. teaching positive thinking, positive imagery as well as other distraction techniques.

Behavioural Treatment

Behavioural treatments are concerned with changing the behaviour of the patient. Numerous behavioural techniques applicable to the management of chronic pain exist. The four that are the most frequently used are:

1. the operant conditioning protocol,
2. the psychophysiological protocol,
3. the conditioned fear response protocol, and
4. the muscle reeducation protocol.

Acceptance and commitment therapy 

ACT is an acceptance and mindfulness-based approach that can be applied to many problems and disorders, including chronic pain. ACT emphasizes observing
thoughts and feelings as they are, without trying to change them, and behaving in ways
consistent with valued goals and life directions. The basic premise of ACT as applied to chronic pain is that while pain hurts, it is the struggle with pain that causes suffering. The pain sensation itself is an unconditioned reflex serving the function of alerting us to danger or tissue damage. The noxious sensation of pain is critical for our survival. 

The aim of ACT in the treatment of chronic pain is to help the client to develop
greater psychological flexibility in the presence of thoughts, feelings, and behaviors
associated with pain.

Team Approach

Working with your doctor, psychologist and/or other healthcare providers to develop a strategy that works best for you will improve your experience of living with chronic pain.

The more you tell your healthcare providers about your pain, your personal situation and what strategies you have tried to manage your pain, the better. This will help them tailor a pain management plan to suit your individual needs.

Consider your answers to some questions your health professional may ask to help understand and manage your pain:

• What is your pain like?
• What brings it on?
• What other symptoms do you get when you have pain?
• What medications and treatments have you tried?
• How does your pain affect your activities of daily living?
• How does your pain affect your relationships and role in your family?
• How does your pain make you feel?
• How well do you sleep?
• What would you like to be able to do?
• Develop a personal pain management plan

Your plan could include setting achievable goals to give you something to aim for. Topics that could be covered in the plan include:

• activity management (eg, pacing of tasks)
• behavioural management (eg, relaxation)
• cognitive therapy to help you think more positively about your ability to manage your pain
• exercise
• medicines management, as needed.

Take a copy of your plan with you each time you visit your health professional. Be proactive and highlight the goals you have reached or any problems you have faced

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