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 three 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 older patients can result in depression, poor quality of life, and loss of independence.
Some treatments, such as stretching exercises, relaxation techniques, antidepressants, and anticonvulsant drugs, are beneficial for a wide variety of chronically painful conditions.
Opioids should not be used as first-line or routine therapy for chronic pain; evidence for effectiveness is limited, and they are associated with risk of adverse events such as overdose, misuse, fractures from falls, hormonal changes, and increased sensitivity to pain.
Acute pain is a common consequence of injury or illness, generally decreasing 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 periods 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.
History and exam
Key diagnostic factors
- 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
- medication use
- muscle spasm
- associated somatic symptoms
- muscle tenderness to palpation
- trigger-point tenderness
- taut bands
- twitch response
- joint swelling and tenderness
- tender points
Other diagnostic factors
- precipitating factors for chronic headache
- duration of headache pain
- 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
- 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
- age over 45 years
- female sex
- history of trauma or chronic pain
- family history of chronic pain syndromes
- acute back pain with neurological signs
- high-risk occupation
- comorbid personality disorder/psychological distress
- pain-related disability
- cigarette smoking
Investigations to consider
- plain x-rays of spine, bones, and/or joints
- MRI of spine
- electromyogram and nerve conduction studies
Gaurav Chhabra, MBBS, FRCA, FFPMRCA
Consultant, Pain Medicine and Anaesthesia
North Bristol NHS Trust
GC declares that they have no competing interests.
Dr Gaurav Chhabra would like to gratefully acknowledge Dr Sarah Love-Jones and Dr Dawn A. Marcus, previous contributors to this topic.
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 topic.
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 principal investigator and has participated in advisory boards for Grunenthal Ltd., and has given lectures for Pfizer Ltd. JH 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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