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7/14/2021 Noura Hotait
The 5 W’s of Chronic Pain Syndrome
Chronic Pain Syndrome is the severe development of chronic pain where it affects emotional and mental well-beings. It is a constellation of syndromes that responds well to a multidisciplinary approach.
In Greek mythology, Poena (Poini) is the spirit of retribution, vengeance and punishment for the crime of murder and manslaughter. She was also the attendant of Nemesis, the goddess of divine retribution. In fact, the word “pain” is derived from the Latin word “poena” which means penalty. In Ancient Greece, Plato and Aristotle thought of pain as an emotional experience rather than a sensory one. It was also described as an external invader that tests the person’s faith or punishes him. Moving on to the Renaissance period, Descartes refuted the idea of an external invader, and argued that pain is an internal mechanical process. Given that the body is a machine, according to Descartes, pain is a disturbance that occurs within the “machine”, and passes through the nerves to the brain. However, in modern history, pain is defined as “an aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury” by the International Association for the Study of Pain (IASP). In simpler terms, pain is a subjective experience that can arise due to external factors, such as a sport injury, and internal factors, such as an underlying medical or psychological condition, where its concepts can be learned. Classifying the types of pain takes on different forms such as its intensity, location, duration, etc. An example of a pain type is chronic pain which is synonymous with Chronic Pain Syndrome (CPS).
Pain is the body’s alarm that is set off after an injury or illness, and is expected to subside during the healing process. However, for some, the pain persists even after the cause has healed. Consequently, when the pain lasts for at least 3 months, the patient is diagnosed with chronic pain. In some cases, chronic pain develops severely beyond pain symptoms where it encompasses emotional and mental well-beings such as anxiety or depression. This is classified as Chronic Pain Syndrome. Chronic pain syndrome presents a major challenge to doctors because of its complex natural history, vague causes and ineffective response to therapy.
Chronic pain syndrome’s pathophysiology is multifactorial, complex and still inadequately understood. Some have suggested that CPS might be a learned behavioral syndrome that begins with a noxious stimulus that causes pain. This pain behavior is then rewarded externally or internally. Thus, this pain behavior is reinforced, and reoccurs without any noxious stimulus.
The below figure illustrates an example to chronic pain syndrome mechanism; specifically, Complex Regional Pain Syndrome:
1- Conditions that cause widespread and/or continuous pain (i.e. chronic pain) such as:
It is a type of arthritis that occurs when the protective cartilage between the bones breaks down.
• Rheumatoid Arthritis
It is an autoimmune disease that cause painful inflammation in the joints due to bone erosion and breakage of the cartilage.
It is a neurological condition that causes pain and tenderness in various parts of the body called trigger points.
• Inflammatory Bowel Disease
It causes chronic inflammation of the digestive tract, and can also yield intestinal pain and cramping.
• Lyme Disease
It is caused by a bacterial infection when bitten by a tick that carries the bacteria Borrelia burgdorferi. Cognitive and psychological symptoms are being recognized among the symptoms of untreated or chronic lime disease. Case studies have found an association between Lyme disease and common symptoms of schizophrenia and bipolar disorder.
• Advanced Cancer
Patients in advanced stages can suffer from chronic pain due to nerve changes. Changes in the nerves can result from the cancer treatment, tumor pressing on the nerves or chemicals produced by the tumor. Other factors come in play such as fear, anxiety and lack of sleep.
2- Injuries and diseases that leave the body more sensitive to pain.
3- Psychogenic pain or Psychosomatic pain
Psychological factors such as stress, anxiety and depression can contribute to chronic pain syndrome. Many scientists believe that this link comes from low levels of endorphins, natural chemicals that trigger positive emotions, in the blood. In addition to that, some also believe that there is a problem between the nervous system and the adrenal glands used by the body to handle stress. Others believe that chronic pain syndrome is a learned response. In other terms, it is when one mimics certain behaviors after healing or when the pain subsides. For instance, if a person has suffered from a leg limp due to an injury, he might continue limping even after the pain is gone. Think of Dr. Watson’s limp from the series Sherlock.
Regardless of the cause, chronic pain syndrome affects all aspects of one’s life i.e. physically, mentally and socially. Some of its symptoms include:
Studies have found that some people are more prone to developing chronic pain syndromes more than others such as:
It goes without saying that the doctor will ask routine questions, conduct a physical exam and assess the patient’s medical history. Further tests might be requested to determine whether it is caused by a medical condition. For instance, an X-ray can determine if the patient is suffering from osteoarthritis while a blood test can determine rheumatoid arthritis. Other tests are conducted by electromyography which tests the muscle activity, nerve conduction studies to examine the reaction of the nerves, reflex and balance tests, spinal fluid tests, urine tests and so one. However, things might get tricky when there is not a direct cause.
After reaching a diagnosis, the doctor will tailor a suitable treatment plan for the patient’s case. However, given the mental and emotional implications, an effective treatment plan is a versatile one that places an equal emphasis on psychological components and physical symptoms.
1- Psychological Support
On a physiological level, the pathways of pain and emotions are interconnected in the brain and spinal cord. Studies observed changes in chronic pain patients at the cellular level in the neurons and neurotransmitters. Consequently, patients can become extremely sensitive to the point where emotions like anger can cause flare-ups at the neurological level due to increased stress, anxiety or depression.
With that being said, treating the emotional side of chronic pain is a big piece of managing chronic pain and chronic pain syndrome. Some options include:
• Cognitive Behavior Therapy:
It is a form of psychological treatment, and a common type of talk therapy. It helps identify and change negative or unhelpful thoughts and behavior patterns that affect one’s actions. Once identified, one can learn how to reframe them in a positive light. It’s like looking at the glass half full rather than half empty. For instance, it works on helping the patient cope with pain, and recognize that it doesn’t interfere that much with his/her daily life routine. Cognitive behavior therapy encourages a problem-solving attitude, journaling, fostering life skills, among others.
• Biofeedback Therapy:
It is a type of therapy that helps the patient harness the power of his mind to control his health. Biofeedback therapy may help relieve the discomfort of different conditions such as lower back pain, abdominal pain, fibromyalgia, etc. For instance, it helps identify tight muscles in the lower back, and then learn to relax them.
• One-on-One therapy or a support group
2- Medical Treatment
3- Alternative Treatments
It is part of the traditional ancient Chinese medicine practice. According to traditional Chinese medicine practitioners, the human body has more than 2,000 acupuncture points connected by pathways (meridians). These meridians create an energy flow throughout the body, and is responsible for one’s overall health. However, the disruption of the energy flow can lead to diseases. So, by applying acupuncture to certain points, it is thought to improve the energy flow. Thus, improving health.
This alternative treatment involves the usage of thin, solid, metallic needles which penetrate the skin, and are then activated by an electrical stimulation or through gentle and specific hand movements.
Hypnosis utilizes a set of techniques that enhances concentration, reduces distractions and increases responsiveness to options aimed at altering one’s feelings, behavior or physiological state. In fact, research found that 71% of the subjects suffering from irritable bowel syndrome reported a significant improvement in symptoms after one session of hypnosis.
Yoga can be traced back to India over 4,000 years ago. It is a practice that connects the mind and body, and constitutes three elements: physical postures, breathing exercises and meditation. Given the nature of chronic pain syndrome, yoga helps with pain perception by improving the coping mechanism on a mental level, reduces inflammation and improves flexibility.
Chronic pain syndrome can be defined as the persistence of pain for at least 3 months, after the healing process, and can affect one’s mental health as much as his physiological health. At times, more attention and priority are given to traditional medical treatment plans tailored for physical symptoms in comparison to addressing cognitive, mental and emotional needs. Consequently, effective treatment for reducing and relieving chronic pain syndrome is a three dimensional approach that entails mechanics (injections and surgeries), medications and psychological support.