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7/14/2021 Noura Hotait


Understanding Chronic Pain Syndrome


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.


Introduction

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).



Understanding Chronic Pain Syndrome

Defining Chronic Pain and Chronic Pain Syndrome

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.



Pathophysiology

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:


Causes of CPS

1- Conditions that cause widespread and/or continuous pain (i.e. chronic pain) such as:


• Osteoarthritis

It is a type of arthritis that occurs when the protective cartilage between the bones breaks down.


Understanding Chronic Pain Syndrome

• Rheumatoid Arthritis

It is an autoimmune disease that cause painful inflammation in the joints due to bone erosion and breakage of the cartilage.


Understanding Chronic Pain Syndrome

• Fibromyalgia

It is a neurological condition that causes pain and tenderness in various parts of the body called trigger points.


Understanding Chronic Pain Syndrome

• Inflammatory Bowel Disease

It causes chronic inflammation of the digestive tract, and can also yield intestinal pain and cramping.


Understanding Chronic Pain Syndrome

• 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.


Understanding Chronic Pain Syndrome

• 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.


Symptoms of Chronic Pain Syndrome

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:

  •   Pain in the joint(s)
  •   Muscle aches
  •   Burning pain
  •   Fatigue
  •   Sleep problems (Insomnia)
  •   Loss of stamina and flexibility due to decreased activity
  •   Mood swings and problems such as depression, anxiety and irritability
  •   Family and/or work problems

Risk Factors

Studies have found that some people are more prone to developing chronic pain syndromes more than others such as:

  •   Patients suffering from chronic diseases
  •   People suffering from depression. Scientists assume that depression changes the way the brain receives and interprets messages from the nervous system.
  •   Smokers. Scientists are exploring the reason(s) behind the worsening pain in patients suffering from chronic pain disorders.
  •   People suffering from obesity. This might be due to the stress exerted by extra weight, conditions linked to obesity, or the interplay between obesity and hormones and metabolism.
  •   Women are more sensitive to pain that men. It might be due to hormones or differences in the density of nerve fibers between men and women.
  •   Elderlies above 65 since they’re more prone to suffering from conditions that cause chronic pain.

Diagnosing Chronic Pain Syndrome

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.


Treating Chronic Pain Syndrome

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


Understanding Chronic Pain Syndrome

2- Medical Treatment

  •   Medications such as anti-inflammatory, steroids, muscle relaxers and anti-depressants can help relieve pain.
  •   Physical therapy and exercise help increase flexibility and range of motion.
  •   Nerve block injections can interrupt pain signals by blocking the plexus or ganglion in a specific area.
  •   Resorting to transcutaneous electrical nerve stimulation (TENS) which involves the usage of low-voltage electric currents to treat pain. However, TENS isn’t suitable for pregnant women, cancer patients, epileptics, people with an implanted device, patients suffering from cardiovascular disease and patients suffering from deep vein thrombosis or a bleeding disorder.
  •   Surgery to treat the medical condition causing the pain.

3- Alternative Treatments

Understanding Chronic Pain Syndrome

• Acupuncture:

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:

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:

Understanding Chronic Pain Syndrome

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.


Takeaway

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.

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