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Chronic pain has several different meanings in medicine. Traditionally, the distinction between acute and chronic pain has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the initiation of pain,[1] though some theorists and researchers have placed the transition from acute to chronic pain at 12 months.[2] Others apply acute to pain that lasts less than 30 days, chronic to pain of more than six months duration, and subacute to pain that lasts from one to six months.[3] A popular alternative definition of chronic pain, involving no arbitrarily fixed durations is "pain that extends beyond the expected period of healing."[1]

Chronic pain
ICD-10 R52.1-R52.2
ICD-9 338.2

Contents

Definition

Pain may arise from injury or disease to visceral, somatic and neural structures in the body. More broadly pain is described as malignant or non-malignant in origin.[4]

Pathophysiology

Under persistent activation nociceptive transmission to the dorsal horn may induce a wind up phenomenon. This induces pathological changes that lower the threshold for pain signals to be transmitted. In addition it may generate nonnociceptive nerve fibers to respond to pain signals. Nonnociceptive nerve fibers may also be able to generate and transmit pain signals. In chronic pain this process is difficult to reverse or eradicate once established.[5]

Nociception

Nociceptors convey information regarding damage or trauma from the body to the central nervous system, a process called nociception, where it is interpreted by the brain as pain. Nociception occurs in any tissue or organ in which pain signals arise secondary to a disease process or trauma. If the pain occurs due to dysfunction or damage to nerves themselves, it is called neuropathic pain.[6]

Diagnostic approach

Pain may be a response to injury or any number of disease states that provoke nociception. Advances in imaging studies and electrophysiological studies allow us to gain a deeper insight into the characteristics and properties associated with the phenomenon of chronic pain.[7][8][9]

Some chronic pain may be psychosomatic. Indicators include diffuse, difficult to describe symptoms, especially if they moved around the body and have no obvious verifiable physical cause.[10] Having unexplained pain in three or more body parts is especially indicative.[11]

Management

Complete and sustained remission of many neuropathies and most idiopathic chronic pain (pain that extends beyond the expected period of healing, or chronic pain that has no known underlying pathology) is rarely achieved, but much can be done to reduce suffering and improve quality of life.

Pain management (also called pain medicine) is that branch of medicine employing an interdisciplinary approach to the relief of pain and improvement in the quality of life of those living with pain.[12] The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists, and nurse practitioners.[13] Acute pain usually resolves with the efforts of one practitioner; however, the management of chronic pain frequently requires the coordinated efforts of the treatment team.[14][15][16]

While narcotics are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose.[17]

Prognosis

Chronic pain may cause other symptoms or conditions, including depression and anxiety. It may also contribute to decreased physical activity given the apprehension of exacerbating pain.[18] Very little work has been done on the cognitive effects of chronic pain, with most of the publications focussing on the effects of cognition on pain but only 5% examining the effects of pain on cognition.[19]

Attention

Chronic pain impairs the ability to direct attention, in particular when compared to controls with low intensity or no chronic pain, people with high-intensity chronic pain have significantly reduced ability to perform attention-demanding tasks.[20] The pain sensations appear to strongly capture the attention of people with chronic pain; tests assessing the ability to attend show poorer performance than peers who do not experience chronic pain on all tests demanding attention.[21] The exception is found with tasks that are highly demanding of attention, where performance between the two groups is equivalent.[21] In experimental testing, two-thirds of individuals with chronic pain demonstrate clinically significant impairment of attention, independent of age, education, medication and sleep disruption. Individuals with the highest levels of pain showed greatest disruption of memory traces, suggesting that pain diminishes working memory.[22]

See also

Conditions related to pain
Drugs
Other approaches in Physical medicine and rehabilitation (Physiatry)
Alternative therapies
Surgery

References

  1. ^ a b Turk, D.C.; Okifuji, A. (2001). "Pain terms and taxonomies". in Loeser, D.; Butler, S. H.; Chapman, J.J. et al.. Bonica's management of pain (3 ed.). Lippincott Williams & Wilkins. pp. 18–25. ISBN 0683304623. http://books.google.com.au/books?id=TyNEicOiJqQC&pg=RA1-PA18&dq=Pain+terms+and+taxonomies&cd=1#v=onepage&q=Pain%20terms%20and%20taxonomies&f=false. 
  2. ^ Main, C.J.; Spanswick, C.C. (2001). Pain management: an interdisciplinary approach. Elsevier. p. 93. ISBN 0-443-05683-8. http://books.google.com.au/books?id=wcEQPzTOEAoC&pg=PA93&dq=chronic+acute+subacute+pain&lr=&client=firefox-a&cd=48#v=onepage&q=chronic%20acute%20subacute%20pain&f=true. 
  3. ^ Thienhaus, O.; Cole, B.E. (2002). "Classification of pain". in Weiner, R.S.. Pain management: A practical guide for clinicians (6 ed.). American Academy of Pain Management. ISBN 0-8493-0926-3. http://books.google.com.au/books?id=lg7sIgP9D3kC&pg=PA28&dq=chronic+acute+subacute+pain+idiopathic&lr=&client=firefox-a&cd=1#v=onepage&q=chronic%20acute%20subacute%20pain%20idiopathic&f=true. 
  4. ^ Vanderah TW (2007). "Pathophysiology of pain". Med. Clin. North Am. 91 (1): 1–12. doi:10.1016/j.mcna.2006.10.006. PMID 17164100. 
  5. ^ Vadivelu N, Sinatra R (2005). "Recent advances in elucidating pain mechanisms". Current opinion in anaesthesiology 18 (5): 540–7. doi:10.1097/01.aco.0000183109.27297.75. PMID 16534290. 
  6. ^ Merskey H (1994). "Logic, truth and language in concepts of pain". Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation 3 Suppl 1: S69–76. PMID 7866375. 
  7. ^ Dunckley P, Wise RG, Fairhurst M, Hobden P, Aziz Q, Chang L, Tracey I (2005). "A comparison of visceral and somatic pain processing in the human brainstem using functional magnetic resonance imaging". J. Neurosci. 25 (32): 7333–41. doi:10.1523/JNEUROSCI.1100-05.2005. PMID 16093383. http://www.jneurosci.org/cgi/content/full/25/32/7333. 
  8. ^ Geha PY, Apkarian AV (2005). "Brain imaging findings in neuropathic pain". Current pain and headache reports 9 (3): 184–8. doi:10.1007/s11916-005-0060-1. PMID 15907256. 
  9. ^ Turton AJ, McCabe CS, Harris N, Filipovic SR (2007). "Sensorimotor integration in Complex Regional Pain Syndrome: a transcranial magnetic stimulation study". Pain 127 (3): 270–5. doi:10.1016/j.pain.2006.08.021. PMID 17011705. 
  10. ^ From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era
  11. ^ Wall and Melzack's Textbook of Pain
  12. ^ Hardy, Paul A. J. (1997). Chronic pain management: the essentials. U.K.: Greenwich Medical Media. ISBN 1 900 151 855. http://books.google.com.au/books?id=EtZ-4eb_aDUC&pg=PA10&lpg=PA10&dq=%22the+reduction+of+suffering+and+enhanced+quality+of+life+%22&source=bl&ots=b0X4N7en9K&sig=hBo5LAE4n7l2SOlqgDp-qoYgswk&hl=en&ei=1kMBS_qYLIfa6gP-9ZTmCg&sa=X&oi=book_result&ct=result&resnum=1&ved=0CAgQ6AEwAA#v=onepage&q=%22the%20reduction%20of%20suffering%20and%20enhanced%20quality%20of%20life%20%22&f=false. 
  13. ^ Main, Chris J.; Spanswick, Chris C. (2000). Pain management: an interdisciplinary approach. Churchill Livingstone. ISBN 0 443 05683 8. 
  14. ^ Thienhaus, Ole; Cole, B. Eliot (2002). "The classification of pain". in Weiner, Richard S,. Pain management: A practical guide for clinicians. CRC Press. p. 29. ISBN 0 8493 0926 3. http://books.google.com.au/books?id=L2CSdeiMZi4C&pg=PA27&dq=%22the+classification+of+pain%22+thienhaus&client=firefox-a#v=onepage&q=%22chronic%20pain%20frequently%20requires%20the%20coordinated%20efforts%20of%20a%20broadly%20based%20treatment%20team%22&f=false. 
  15. ^ Henningsen P, Zipfel S, Herzog W (2007). "Management of functional somatic syndromes". Lancet 369 (9565): 946–55. doi:10.1016/S0140-6736(07)60159-7. PMID 17368156. 
  16. ^ Stanos S, Houle TT (2006). "Multidisciplinary and interdisciplinary management of chronic pain". Physical medicine and rehabilitation clinics of North America 17 (2): 435–50, vii. doi:10.1016/j.pmr.2005.12.004. PMID 16616276. 
  17. ^ Dunn KM, Saunders KW, Rutter CM, et al. (January 2010). "Opioid prescriptions for chronic pain and overdose: a cohort study". Ann. Intern. Med. 152 (2): 85–92. doi:10.1059/0003-4819-152-2-201001190-00006. PMID 20083827. 
  18. ^ Pruimboom L, van Dam AC (2007). "Chronic pain: a non-use disease". Med. Hypotheses 68 (3): 506–11. doi:10.1016/j.mehy.2006.08.036. PMID 17071012. 
  19. ^ Kreitler S; Niv D (2007). "Cognitive impairment in chronic pain" (pdf). Pain: Clinical Updates (International Association for the Study of Pain) XV (4): 1–4. http://www.iasp-pain.org/AM/TemplateRedirect.cfm?template=/CM/ContentDisplay.cfm&ContentID=4132. Retrieved 2008-04-15. 
  20. ^ Eccleston C (1995). "Chronic pain and distraction: an experimental investigation into the role of sustained and shifting attention in the processing of chronic persistent pain". Behav Res Ther 33 (4): 391–405. doi:10.1016/0005-7967(94)00057-Q. PMID 7538753. http://linkinghub.elsevier.com/retrieve/pii/0005-7967(94)00057-Q. 
  21. ^ a b Von Bueren Jarchow A; Radanov BP; Jäncke, L (2005). "Pain influences several levels of attention". Zeitschrift für Neuropsychologie 16 (4): 235–242. doi:10.1024/1016-264X.16.4.235. http://www.psyjournals.com/content/63h8323036164896/?p=718a7c59614c48e89417bafe1e23681b&pi=4. Retrieved 2008-04-15. 
  22. ^ Dick BD, Rashiq S (2007). "Disruption of attention and working memory traces in individuals with chronic pain". Anesth. Analg. 104 (5): 1223–9, tables of contents. doi:10.1213/01.ane.0000263280.49786.f5. PMID 17456678. http://www.anesthesia-analgesia.org/cgi/pmidlookup?view=long&pmid=17456678. 

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