Pain, be it acute or chronic, is distressing, unpleasant and completely different from person to person.
Chronic pain does differ from acute pain. Acute pain will occur following injury, trauma or surgery, and tends to ease off over a relatively short period of time. It is manageable with pain relief, and if it limits a personas life (e.g. post-surgery), it is only for a short period of time.
Chronic pain, on the other hand, persists for longer (usually more than 12 weeks) and could have a variety of causes. Sometimes, it occurs post-trauma or alongside a long-term health condition. It can even be hard for doctors to pinpoint exactly what is causing it. It is tricky to manage, and sometimes reaches a point where no pain relief or other medication has any effect, severely limiting a persons life.
But how does chronic pain develop? Well, there are several theories. Two that I come across often in my job are those associated with the way we think about pain, and how are nerves react to it.
Let’s say you’ve injured your leg doing something relatively normal, and for a temporary period of time you are out of action, and it hurts to move and socialise, so until it eases you don’t do those things or you do those things in small amounts. For people with a “healthy relationship” with pain, once the pain becomes easier, they will start to partake and move around more, and get back to normal activities after the pain has gone. Whereas those of us with “unhealthy relationships” with pain will find it a lot harder to get back to normal. Why? Well research suggests that the negative emotions and thoughts that those with “unhealthy relationships” around pain have can make pain more intense;
You’ve injured your leg –> it hurts to move –> you believe pain on movement equals damage –> activity levels/socialising decreases –>body becomes deconditioned –>less social interactions –> begin to feel isolated –> pain levels increase.
Can you see in that example how the thought of “pain equals damage” can make pain worse? Can you see how actually being less active and weaker may mean your leg injury doesn’t heal as quickly, leading to more pain? Can you see how feeling down and lonely can make your pain more intense?
The negative emotions, thoughts or behaviours around pain make pain signals more intense.
Now, this theory does in now way mean that any pain a person experiences is not real – it simply means that if you change the way you think or act regarding your pain, you may be able to make it a bit better.
The second theory that I mentioned, focuses on how our nerves respond. For example, after an operation, your free nerve endings (those in skin and surrounding soft tissue) became super irritated and damaged, because it is unavoidable that they are not only cut, but subject to a large degree of swelling. These nerve endings then send out pain signals in high intensity, and in the majority of patients will settle down, but for some the pain lasts a long time and remains quite high intensity. This is thought to be because as the free nerve endings have already been stimulated or fired up through making an incision/injury/trauma, they are much more sensitive and fire up a lot easier than those nerves that haven’t. A good example of this would actually be with an Endometriosis patient – because of the surgery they may have had an the inflammation they experience on a daily basis, things such as small minor cysts growing may be felt a lot more than in a patient with no concerning gynaecology history. This is because the nerves inside the pelvis are already on high alert because of the Endometriosis disease, they detect a cyst much easier. This theory sort of explains why some patients with long-standing health conditions may find things such as touch painful – there nerve fibres are on such high alert that they signal pain to things that shouldn’t be painful.
But what about in our patient population? Well, for someone like myself who’s vast majority of pain comes from the Endometriosis and Adenomyosis I have, it is fairly clear why my pain has become constant and long-standing;
- I have had the disease for a long-time, meaning my poor pelvis has been subject to all sorts of implants, growths and adhesion growing all over the place. There has been a constant cycle of pain nerve stimulation, meaning my brain is bombarded with pain signals all the time. To cope with this, because my brain and nerves recognise this pain as an ongoing problem (rather than an acute injury), it switches which nerve fibres it uses to tell my brain what’s going on. The fibres it switches too are slower ones and ones that are harder to get on top of
- My pelvic nerves are shot. The amount of surgery, cysts popping and pain I have experienced for a long-time mean the nerve endings in my pelvis are super sensitive and ready to go at any moment. This means that these nerve endings will often signal pain to my brain when they don’t really need to. Again the good example is cysts – most people have no symptoms with simple ovarian cysts, whereas someone like myself will be able to feel them like a ball in my abdomen.
- The degree of inflammation I have experienced is quite high. Endometriosis is an inflammatory disease – at least every month I will experience inflammation and it does a few things to our body. The first is, if you have an inflamed area, it will often increase in size and put a lot of pressure on surrounding structures, including nerves. The second is that the inflamed red and sore reaction brings a lot of healing to that area, so it may feel sore because it is trying to heal itself. And the third is the swelling, which technically consists of a chemical irritant fluid. This fluid irritates nerve endings and again signals pain.
- These conditions are tricky to manage. When pain is not managed well (and this could be because you are simply not taking your medication, or because a disease like Endometriosis is not as simple as popping some paracetamol), it escalates in intensity, and often lasts longer than it should.
The other thing to remember with chronic pain, is that pain predominantly is a protective mechanism for the body – it alerts us to injury and prevents further re-injury (think about if you broke your arm playing football – it starts to really hurt to let you know something serious has happened, but then it will continue to hurt if you try and move it). In chronic pain, some people view it as this protective system gone wrong – it is alerting us to pain that is not harmful (go back to the Endometriosis example).
Just a reminder – this article is NOT telling you that your pain is not real or not as bad as you say it is. It is simply advising on the medical view to pain and why it occurs. Sometimes education is a good thing, and in my job we often find that patients pain levels and/or their ability to manage their pain improves following education.
Managing pain can be a long and hard road, and it completely varies from person to person. Better pain management will not only improve pain levels, but it will help you get back to any activities you are currently unable to do.
Pain Relief – pain relief is quite an obvious one. It works buy blocking nerve signals and preventing cells from releasing chemicals or hormones associated with pain. There are a variety, from simple paracetamol and anti-inflammatories, to stronger ones from codeine and morphine derivatives. There are also neurogenic drugs that specifically target nerve-based pain. Each one works slightly different, but when used in an appropriate combination and correct manner, they can reduce pain well. Other forms of pain relief that are not medication based, include the use of heat, ice, massage, acupuncture and TENs. You can see my article on that here.
Physiotherapy – This might not be the first thing you think about wanting to do when you are in pain, but the idea is that restoring joint flexibility and strength will enable it to be used more efficiently, thus decrease pain. Think about a shoulder injury – its stiff, hurts to move and hurts to lift even light objects. Physiotherapy to improve strength and movement will mean that it becomes less painful to move and your ability to life objects increases. Sometimes, physiotherapy can incorporate massage and acupuncture, dependent on the clinician.
Cognitive Behavioural Therapy (CBT) and Counselling – CBT focusses on looking at that present and improving a persons thoughts, behaviours and emotions associated with something (e.g. pain). It is particularly useful in patients who develop mental health problems, such as depression, alongside their pain symptoms. Counselling is similar, but tends to look at the past or a specific event. This is more useful in patients who pain stems from a traumatic event.
Pain Clinic Referral – Most hospitals should have a facility for chronic pain management, or at least be able to refer you to one. When your pain is not being managed in the community (e.g. by your GP) or alternative methods, a referral to a pain specialist can be really useful. Pain specialists, as the name suggests, have a lot more specialist knowledge into pain and often have other tools they can offer to patients. I have my first appointment next week, and plan on writing a piece on how that went.
The bottom line is, pain is real and different for everybody, and these are just a few tips and advice to help you understand and perhaps give you new tools to manage your pain.
Got any other tips? Let me know!