Rheumatology Book

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Chronic Pain

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  1. See Also
    1. Chronic Pain Resources
  2. Pathophysiology
    1. Pain Perception Factors
      1. Response to chronic pain may be learned
      2. Reaction to pain may be reinforced (patient, family)
      3. Behavior may persist after pain resolves
    2. Modulation of sensation
      1. First dorsal horn synapse enhances or inhibits pain
      2. Modulation occurs in various locations
        1. Spinothalamic tract
        2. Frontal cortex
        3. Descending inhibitory neuro-systems
    3. Pain Mechanisms
      1. Neuropathic pain
        1. Characteristics: Burning, stabbing or shooting pain
        2. Examples: Stroke, Radiculopathy
      2. Musculoskeletal pain or Mechanical compression pain
        1. Characteristics: Aching, soreness, stiffness
        2. Examples: Myofascial Pain Syndrome, Fibromyalgia, Low Back Pain
      3. Inflammatory pain
        1. Characteristics: Aching, swelling, hot, red
        2. Examples: Rheumatoid Arthritis, Postoperative pain, Septic Joint
  3. Pathophysiology: Gate Control Theory
    1. Specific pain fibers from injured tissues via
      1. Alpha fibers myelinated
      2. Delta and C-fibers unmyelinated
      3. Modulated at spinal cord gate
        1. Substantia gelatinosa
        2. Control transmission cells
      4. Spinothalamic tract cephalad
    2. Descending signals (regulate gate at spinal cord)
      1. Pain transmission can be blocked by emotion or mood
      2. Sensory discriminative system
        1. Determines differences in sensory threshold
      3. Motivational Affective System
        1. Reciprocal relationship between mood and pain
      4. Central control processes
        1. Include unknown processes of pain
  4. Approach to counseling
    1. Explain to patient
      1. Both physical and psychological causes of pain
      2. Difficult to distinguish what causes what
    2. Use gate control theory to discuss chronic pain
      1. Discuss role of mood and emotion in pain blocking
      2. Discuss with family and patient
  5. Causes of Chronic Pain
    1. See Diffuse Musculoskeletal Pain Causes
  6. Evaluation
    1. See Pain Evaluation
  7. Protocol: Understand why the patient presents at this time
    1. Increased concern about potential serious illness
    2. Increased environmental stressors
    3. Worsening functional capacity
      1. Decreased physical activities (walking or sleeping)
      2. Decreased psychological well-being (mood or energy)
      3. Decreased social activities (relationships)
      4. Roles (work)
    4. Worsening of psychiatric illness
    5. Termination of prior physician-patient contract
      1. History of "doctor shopping"
      2. Frustration and anger of previous "ineffective care"
      3. High expectations for help from the new provider
    6. Hidden agenda
      1. Narcotic seeking
      2. Disability
      3. Sick-role privilege
      4. Legitimize illness to family and coworkers
  8. Protocol: Explore concurrent psychosocial Factors
    1. History of loss (death or divorce)
    2. Prior traumatic life events
    3. Physical or sexual abuse history
    4. Concurrent psychiatric illness
      1. Major Depression
      2. Anxiety Disorder
      3. Somatization Disorder
      4. Alcoholism or Drug Abuse
      5. Malingering
    5. Abnormal illness behaviors (see Somatization)
      1. Disability out of proportion to disease
      2. Persistent search for underlying organic disease
      3. Assign responsibility for illness to physician
      4. Sense of entitlement for care by others
      5. Behaviors to maintain the sick-role
  9. Protocol: Understand patient's concerns and expectations
    1. What does the patient think is causing the pain?
    2. What about the pain does the patient fear?
    3. What does the patient expect from the physician?
    4. What are patient's expectations in context of culture?
  10. Protocol: Understand patient's resources
    1. Social supports not centered around illness
      1. Family and Friends
      2. Work and community organizations (e.g. Churches)
    2. Coping strategies
  11. Management
    1. See Chronic Pain Management
  12. Prognosis
    1. Poor Prognostic Factors
      1. High frequency of physical complaints (Somatization)
      2. Long history of frequent healthcare visits
    2. Good Prognostic Factors suggestive of recovery
      1. Brief history of chronic pain (<2 years)
      2. No underlying psychiatric disorder
      3. Followed by primary care physicians
  13. References
    1. Ansari (2000) Harv Rev Psychiatry 7:257
    2. Barkin (2000) Am J Ther 7:31
    3. Bajwa (1999) Neurology 52:1917
    4. Dellemijn (1999) Pain 80:453
    5. Jackman (2008) Am Fam Physician 78(10):1155
    6. Kingery (1997) Pain 73:123
    7. Laird (2000) Ann Pharmacother 34:802
    8. McQuay (1995) BMJ 311:1047
    9. Sindrup (1999) Pain 83:389
    10. (2000) Med Lett Drugs Ther 42(1085):73

Chronic pain (C0150055)

Definition (NCI)Pain that can range from mild to severe, and persists or progresses over a long period of time.
Definition (CSP)pain which has persisted over a long period of time; also use NTs for specific types of pain if appropriate.
ConceptsDisease or Syndrome (T047)
ICD9338.2
EnglishChronic pain
Spanishdolor cronico
Parent ConceptsPain (C0030193), Pain, not elsewhere classified (C0995154), Finding of pattern of pain (C0578060)
SourcesCSP, ICD9CM, LNC, NCI, PNDS, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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