Chronic pain is one of the most common reasons for seeing a primary care physician.
Classification of chronic pain may be based on major pain features or by body region: myofascial, musculoskeletal (mechanical), neuropathic, fibromyalgia, and chronic headache syndromes.
One in 3 patients over the age of 65 years is affected by chronic pain, often due to arthritis, osteoporosis with fractures and/or lumbar spinal stenosis. These conditions are treatable and should not be considered part of the normal ageing process. Untreated chronic pain in geriatric patients can result in depression, poor quality of life, and loss of independence.
Some treatments, such as stretching exercises, relaxation techniques, antidepressants, and antiepileptic drugs, are beneficial for a wide variety of chronically painful conditions.
About 25% to 30% of chronic pain patients treated with opioids will demonstrate medicine abuse behaviour.
Acute pain is a common consequence of injury or illness, generally lessening shortly after onset and resolving once healing is complete. Since healing occurs over a maximum of 3 months, pain persisting longer than 3 months is deemed chronic pain or persistent pain. Chronic pain may also occur in patients with ongoing degenerative illnesses, such as rheumatoid arthritis, or other chronic conditions, like migraine or neuropathic pain. Neuropathic pain is characterised by allodynia and hyperalgesia. Allodynia is the perception of non-noxious stimuli as painful. In hyperalgesia, noxious stimuli produce exaggerated or prolonged pain. Pain severity may fluctuate in patients with chronic pain, with times of increased pain or pain flares occurring either in relation to increased activity or stress, or insidiously. Chronic pain occurs due to persistent activation of neural pain pathways and muscle spasm. Chronic pain is discussed here as a syndrome and includes non-malignant conditions without localised or regional causes (such as abdominal pain or pelvic pain).
History and exam
- presence of risk factors
- duration of pain more than 3 months
- physical comorbidity
- psychological comorbidity
- previous history of acute pain episodes
- pain causing difficulty in performing routine activities of daily living
- precipitating factors for myofascial pain
- precipitating factors for musculoskeletal pain
- herpes zoster infection
- history of trauma or limb immobilisation
- analgesic use
- muscle spasm
- associated somatic symptoms
- muscle tenderness to palpation
- trigger-point tenderness
- taut bands
- twitch response
- joint swelling and tenderness
- tender points
- precipitating factors for chronic headache
- headache pain lasting less than or more than 2 hours
- radiating pain
- morning stiffness in joints
- pain with prolonged walking, relieved with stooping or sitting
- joint pain
- burning quality of pain
- chronic headache associated with nausea, vomiting, and sensitivity to light and noise
- intermittent pattern of chronic headache pain
- bilateral chronic headache pain
- unilateral chronic headache pain
- limited range of motion (ROM)
- painful or limited straight leg raising
- shoulder girdle and pelvic girdle pain distribution
- symmetrical body pain distribution
- worsening headache symptoms despite treatment
- headache with posterior head or neck pain
- excessive guarding of the painful extremity
- diminution or loss of reflexes
- tenderness over temporal artery distribution
Gaurav Chhabra, MBBS, FRCA, FFPMRCA
Consultant, Pain Medicine and Anaesthesia
North Bristol NHS Trust
GC has been sponsored by Boston Scientific, St Jude Medical, and Nevro to attend cadaveric workshops relevant to neuromodulation.
Dr Gaurav Chhabra would like to gratefully acknowledge Dr Sarah Love-Jones and Dr Dawn A. Marcus, previous contributors to this monograph. SLJ has received consultancy fees for Boston Scientific and Nevro Corporation (regarding spinal cord stimulation) and is an Elected Council member of the British Pain Society. DAM is an author of a reference cited in this monograph.
J. David Sinclair, MD
Department of Anesthesiology
University of Washington School of Medicine
JDS declares that he has no competing interests.
Joan Hester, MBBS, FRCA, LRCP, MRCS
Consultant in Pain Management
King's College Hospital
JH has chaired advisory boards for Napp Pharmaceuticals Ltd., chaired a symposium, is a principle investigator and has participated in advisory boards for Grunenthal Ltd., and has given lectures for Pfizer Ltd. JH has also attended the American Pain Society meeting in 2009 sponsored by Grunenthal.
Beverly J. Collett, MB BS, FRCA, FFPMRCA
Consultant in Pain Medicine
Pain Management Service
University Hospitals of Leicester
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