It's chronic & it's painful...

Despite a close association of pain with mankind, it took centuries of observations, experimentations and research for man to become more cognisant of this phenomenon. The history of pain is rather interesting as it has travelled from religious and moral realms, to be understood as a biological event and to the current biopsychosocial one.

Pain has been broadly categorised as acute and chronic pain. Acute pain is seen as a result of injury, surgery, illness, trauma or painful medical procedures. It lasts for a short duration only and usually responds to treatment. Chronic pain, however, is much more complicated, complex and harder to treat. By definition, chronic pain is that which has lasted for over three months and has persisted longer than the expected time for healing. Apart from being a distressing physical experience, chronic pain affects the day-to-day functionality of a person and affects the very quality of life.

When the set patterns of our lives get affected, it brings serious psychological, social and even spiritual repercussions. While dealing with chronic pain, the sufferer may experience chronic low mood, depression, anxiety, stress, ideas of self-harm, suicidal ideation to complete suicide, difficulty in occupational performance, relationship disturbances with spouse and family members and other social relationships as well. Even simple biological functions like sleep, appetite and bowel functions get affected.

This interplay of biological, psychological and social factors makes chronic pain a biopsychosocial phenomenon.

The concept of ‘Total Pain’ was first described by Dame Cicely Saunders, the pioneer of palliative care in 1960. According to this concept, pain is not just experienced in the physical realm but also in the psychological, social and spiritual realms. Since pain is multi-faceted, its treatment also needs to be tailored in a holistic way to address all the aspects of pain. Very often clinicians are focusing their treatment strategies only on the physical pain and are not addressing other psychosocial issues that act as deterrents to pain relief.

It was earlier thought that a single area in the brain, the somatosensory cortex, was responsible for the perception of pain. However, with advances in pain medicine and imaging modalities, it was observed that multiple areas in the brain are involved in processing the pain impulse. Thus, besides the somatosensory cortex (physical pain), limbic system (motivation and affective or emotions), prefrontal area (evaluative functions like thoughts and actions) and hypothalamus (autonomic responses) get activated.

In addition, the pineal gland responsible for sleep also gets affected by the pain impulse.

This multiple-area stimulation following a pain stimulus has been termed the pain matrix. According to International Human Rights Law, countries have to provide pain relief to sufferers as part of their core obligations under the right to health.

The incidence of chronic pain is 20% worldwide and it has serious ramifications in terms of mental health, occupational efficiency, and quality of life and also puts a heavy burden on the medical budget of any country.

Since chronic pain is multifaceted, a single modality for pain management may not be as efficacious as a multi-pronged, multimodal and multidisciplinary management would be. It would be a more logical and rational way to manage chronic pain.

Pain specialists and pain clinics are specially geared to address chronic pain. Starting with various medications they are also trained in performing multiple pain interventions like dry needling, trigger point injections, nerve blocks, epidural steroid injections and even advanced procedures like radiofrequency ablation and other neuromodulation procedures.

These methods are useful in conditions like myofascial pain, neuropathic pains, musculoskeletal pains, headaches, abdominal and pelvic pains and even cancer pain. These treatment modalities, often when combined with physiotherapy, substantially relieve the physical aspects of chronic pain.

The psychological aspects can be addressed by psychotherapy and counselling by clinical psychologists. These include in its ambit firstly, acceptance of the problem and willingness to deal with both the physical and emotional impact of chronic pain.

Some therapeutic methods used are behavioural, cognitive, stress inoculation, acceptance and commitment therapy, problem-solving strategies and supportive psychotherapies.

Amongst these, Cognitive Behaviour Therapy and Acceptance and Commitment Therapy are the most efficacious ones. In addition, simple daily routines like yoga, meditation, and supportive therapy incorporating dance, art, and music therapies can also be done. For emotional release, strategies like ventilation, externalisation of interests, tension release through emotional diary writing and maintaining pain diaries are helpful. 

Besides, they are encouraged to pursue their cherished goals and work on them to the best of their capacities despite the presence of pain.

Socially, the family and workplace too may need to be addressed. When a person is afflicted with chronic pain, the family and workplace dynamics are affected. The healthier partner quite often has to don the mantle of responsibilities for the family.

A cohesive family that is better able to deal with changed circumstances would have a positive effect on the pain sufferer. When family relationships seem affected, appropriate marital therapy and family therapies are used as part of the treatment programme.

Also, lifestyle modifications like performing daily physical activity and exercises, good and healthy nutrition, controlling body weight, good work ergonomics, adequate sleep, controlling stress levels and maintaining a good work-life balance are useful in pain alleviation.

In our country with its population of 1.4 billion, there is still a lack of pain specialists, dedicated clinical psychologists, pain clinics and palliative care organisations. Also, the awareness among the public of these facilities is woefully lacking especially in the rural areas where the majority of our population lives.

As a result, ignorance of the concept of pain, the available facilities, the appropriate doctors, and whom to approach are some of the pressing issues. 

(The authors recently published Managing Chronic Pain with Harper Collins India.)