Article by Dr Manasa S, B.A.M.S

What is Chronic Pain Syndrome? – Introduction

Pain, a fundamental sensation in the human experience, serves as a vital signal from the body, indicating injury or illness. Typically, this discomfort subsides as the body heals, allowing individuals to resume their daily activities without persistent hindrance.

However, for a significant portion of the population, pain persists long after its initial cause has been addressed, evolving into what is known as Chronic Pain Syndrome (CPS). Defined as enduring discomfort lasting beyond 3 to 6 months, chronic pain not only imposes physical distress but also takes a profound toll on emotional well-being.

Chronic pain syndrome encompasses more than just the sensation of pain itself. It extends its reach to encompass a spectrum of symptoms that extend beyond physical discomfort, such as depression and anxiety. These additional burdens can significantly disrupt daily life.

Statistics show that approximately 25% of individuals grappling with chronic pain will develop CPS, amplifying the challenges they face. While the complexities of CPS can present formidable obstacles, it is not an insurmountable condition.

Through a multifaceted approach that incorporates counselling, physical therapy, and relaxation techniques, individuals can find relief not only from the pain but also from the accompanying emotional distress. This introduction delves into the nuances of chronic pain syndrome, shedding light on its impact and the array of treatments available to alleviate its burdens.

Causes of Chronic pain syndrome

– Arthritis and other joint problems
– Back pain
– Headaches
– Muscle strains and sprains
– Repetitive stress injuries (doing the same movement over and over)
– Fibromyalgia (muscle pain throughout the body)|
– Nerve damage
– Lyme disease
– Broken bones
– Cancer
– Acid reflux or ulcers
– Inflammatory bowel disease (IBD)
– Irritable bowel syndrome (IBS)
– Endometriosis (when tissue grows outside the uterus)

Roots of CPS

– Physical and mental factors contribute to CPS.
– Some experts believe CPS results from issues with the body’s nerve and gland system, which handles stress.
– Others suggest CPS is a learned response, where behaviours persist even after the pain diminishes.

Demographics and Risk Factors

– CPS can affect people of all ages and both sexes.
– It’s more common in women.
– Individuals with major depression and other mental health conditions are more prone to developing CPS.

Types of Chronic pain

Many patients experiencing chronic pain report multiple types of pain ailments. For instance, a patient enduring chronic back pain may also suffer fibromyalgia. A considerable portion of these patients also contend with major depressive and generalized anxiety disorders. Statistics reveal that over 67% of chronic pain patients face concurrent psychiatric conditions.

Pain manifests in various categories and types, encompassing neuropathic, nociceptive, musculoskeletal, inflammatory, psychogenic, and mechanical pain.

Sl No	Type of Chronic Pain	Example
1	Neuropathic Pain	Peripheral neuropathic pain, such as post-herpetic neuralgia or diabetic neuropathy.Central neuropathic pain, exemplified by sequelae of cerebral vascular accidents.
2	Nociceptive Pain	Arises from actual tissue injuries like burns, bruises, or sprains.
3	Musculoskeletal Pain	Includes back pain and myofascial pain.
4	Inflammatory Pain	Linked to autoimmune disorders like rheumatoid arthritis or infections.
5	Psychogenic Pain	Results from psychological factors, leading to conditions like headaches or abdominal pain stemming from emotional, psychological, or behavioural influences.
6	Mechanical Pain	Associated with expanding malignancies.

Signs and symptoms of CPS

Chronic Pain Syndrome (CPS) impacts various aspects of your well-being, including physical health, emotions, and social interactions. Manifestations of CPS may include:

– Anxiety
– Depression
– Disrupted sleep patterns
– Persistent fatigue
– Irritability
– Feelings of guilt
– Diminished sexual interest
– Substance abuse tendencies
– Challenges in relationships, including marriage and family dynamics
– Occupational instability
– Suicidal ideation
– Individuals suffering from CPS may develop a tolerance to pain medications, leading to dependence on these drugs.

Associated conditions

a. Central pain syndrome (CPS)

– Arises following spinal injury and damage to the central nervous system
– Symptoms include pain, itching, numbness, and loss of sensation
– Individuals may become extremely sensitive to pain

b. Complex regional pain syndrome (CRPS)

– Excess and chronic pain and inflammation following a limb injury
– Typically improves over time but can persist in severe cases

 c. Trigeminal neuralgia

– Also known as “tic douloureux”
– Causes excruciating pain in the lower face and jaw
– Symptoms include intense, electric shock-like pain due to trigeminal nerve irritation

d. Phantom limb pain

– Occurs after limb amputation
– Ongoing pain sensation in the absent limb
– Pain may feel like burning, itching, or pressure

e. Postherpetic neuralgia (PHN)

– Complication of shingles
– Causes severe and debilitating pain for months or years after rash subsides
– Up to 18% of individuals with shingles experience PHN

Risk factors of chronic pain

– People with chronic and painful conditions like arthritis: They experience ongoing pain in their bodies.
– Individuals who are depressed: Depression might change how the brain understands pain signals.
– Those who smoke: Smoking can worsen pain in arthritis, fibromyalgia, and other chronic pain disorders. About half of people seeking pain relief are smokers.
– People who are obese: Half of those seeking treatment for obesity also report experiencing pain. It’s unclear if the pain is due to the stress of extra weight or how obesity affects hormones and metabolism.
– Women: Females often feel pain more intensely than males. This might be linked to hormones or differences in nerve fibres.
– Those older than 65: Aging increases the likelihood of various conditions leading to chronic pain.

Diagnosing ‘Chronic Pain’

Blood tests: To detect underlying conditions or markers of inflammation.

Electromyography (EMG): Assesses muscle activity and detects abnormalities.

Imaging tests: Such as X-rays and MRI scans, to visualize structures and detect abnormalities in bones, joints, or soft tissues.

Nerve conduction studies: Evaluate the function of peripheral nerves.

– Reflex and balance tests: Assess neurological function and identify abnormalities.
– Spinal fluid tests: Used in specific cases to diagnose conditions affecting the spinal cord or brain.
– Urine tests: May be conducted to rule out certain conditions or assess kidney function if relevant to the pain presentation.

These diagnostic procedures are used in combination to identify potential causes or contributing factors to chronic pain.

What is the need of prompt treatment for chronic pain?

The chronic pain needs prompt treatment as it involves complications like:

– Decreased quality of life
– Depression
– Anxiety
– Substance abuse disorders
– Worsening of existing chronic disease
– An increased risk of suicidal ideation and/or suicide

Given the seriousness of these complications, seeking medical care is essential if experiencing chronic pain. Numerous options exist for pain treatment and management. Although finding the right combination of therapies may require time and effort, the endeavour is worthwhile.

Treatment Options for Chronic Pain Syndrome

– Anticonvulsants: Medications that prevent seizures, often used for nerve pain.
– Antidepressants: Tricyclic antidepressants are commonly prescribed.
– Corticosteroid: Used to reduce inflammation and alleviate pain.
– Muscle relaxers: Help alleviate muscle spasms contributing to pain.
– Nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen: Common over-the-counter options for pain relief.
– Topical products: Applied directly to the skin for localized relief, can include pain relievers or ingredients for soothing heat or cold sensation.
– Opioids: Reserved for severe pain due to their addictive nature and potential for tolerance buildup. Usually considered after trying other treatment options.
– Sedatives: Prescribed to manage anxiety or insomnia associated with chronic pain.
– Medical marijuana: Considered in some cases for pain management.

Other Medical Treatments

– Transcutaneous Electrical Nerve Stimulation (TENS): Delivers small shocks through skin patches to relieve pain.
– Nerve Blocks: Injection of anaesthetic near the site of pain to reduce sensation, also used for diagnostic purposes.
– Epidural Steroid Injections: Injection of anti-inflammatory medicine into the epidural space around spinal nerves to treat pain caused by inflammation.

Complications of prolonged medication

Acute liver failure from acetaminophen

Opioid addiction/overdose

Mood changes, Confusion, Respiratory issues from nerve pain medications.

Spinal cord damage or infection from spinal cord stimulators.

Lifestyle Changes for Pain Management

Four pillars of chronic pain management:

– Stress Management: Techniques include meditation, mindfulness, and deep breathing.
– Exercise: Low-intensity activities like walking or swimming can help reduce pain and manage stress.
– Diet: Following an anti-inflammatory diet by avoiding foods that cause inflammation, such as red meat and refined carbohydrates.
– Sleep: Adequate, quality sleep is crucial for overall health and pain management.

Discuss these lifestyle changes with your healthcare provider to tailor a plan to your specific needs and condition.

Few therapies for chronic pain

Therapies for managing chronic pain:

– Cognitive-Behavioural Therapy (CBT): Counselling method to reframe thoughts about pain and develop coping strategies.
– Counselling: Talk therapy aimed at managing chronic pain, particularly psychogenic pain.
– Occupational therapy: Teaches adaptive techniques for daily tasks to minimize pain and prevent injury.
– Physical therapy: Involves exercises targeting flexibility and strength to alleviate pain and enhance overall function.

Alternative treatment approach

– Acupuncture: Utilizes small needles placed in specific points on the body.
– Aromatherapy: Involves the use of aromatic plants and essential oils.
– Biofeedback: Teaches techniques to regulate physiological functions like heart rate, breathing, and muscle tension.
– Hypnotherapy: Utilizes hypnosis to induce a relaxed state and alleviate pain.
– Mindfulness training: Teaches techniques to cultivate present-moment awareness and reduce stress.
– Music, art, or pet therapy: Utilizes creative or animal-assisted interventions to promote relaxation and well-being.
– Reiki or Healing Touch: Involves therapists using touch to manipulate energy fields within the body.
– Relaxation techniques: Includes massage, meditation, and guided imagery to induce relaxation and reduce pain perception.

Additional Lifestyle changes

– Smoking Cessation: Refrain from smoking to promote overall health and well-being.
– Effective Time Management: Develop a structured daily schedule with a focus on prioritized tasks and adequate intervals for rest and self-care.
– Nutritious Eating: Maintain a balanced and healthy diet to support optimal physical function and pain management.
– Regular Exercise: Engage in consistent physical activity to enhance mobility, reduce stiffness, and alleviate chronic pain.

 Adequate Rest: Ensure sufficient sleep duration to facilitate recovery and promote overall wellness.

– Stress Management: Employ strategies to effectively cope with stressors, such as relaxation techniques and mindfulness practices.
– Participation in Support Groups:  Join support groups tailored to individuals with chronic pain conditions for mutual learning and encouragement.
– Moderate Alcohol Consumption: Limit alcohol intake as excessive consumption may exacerbate sleep disturbances and pain symptoms.
– Positive Thinking: Cultivate a positive mindset to foster resilience and enhance overall psychological well-being.

Exercise for chronic pain

Exercise plays an important role in managing the signs and symptoms of chronic pain.

 Benefits of Exercise:

– Decreases inflammation.
– Increases mobility.
– Reduces pain levels.

Types of Exercises

Cardio Exercises:

– Walking: Increases strength and heart health.
– Swimming: Low-impact and therapeutic.

Relaxation Exercise

– Deep breathing and visualization: Helps relax and ease pain.

Stretching Exercises

– Low back and glute stretch: Relieves tension.
– Levator scapula and neck stretch: Reduces stiffness.

Strengthening Exercise

– Dead bug: Strengthens core muscles.
– Bird dog: Improves core stability.

Warnings

– Consult a doctor before starting an exercise routine.
– Get personalized advice from a physical therapist.
– Start slowly and monitor symptoms, especially for conditions like fibromyalgia.

Prognosis

Chronic pain is often persistent, but it can be managed through a variety of strategies tailored to the individual. Current treatments have shown the potential to reduce pain scores by approximately 30%. Ongoing research in neuroscience and enhanced understanding of the human body hold promise for more effective treatments in the future. Additionally, addressing mental health conditions like depression and anxiety is crucial, as untreated mental health issues can exacerbate pain and diminish quality of life. Seeking treatment for both physical and mental health aspects is essential for holistic pain management.

Chronic Pain Syndrome: Ayurveda Understanding

Chronic pain is associated with body and mind. As discussed, it presents in different ways.

In Ayurveda, vyadhi is a word used to describe ‘a disease’. There are many definitions of vyadhi, most of which define it as ‘pain or discomfort caused at the physical or mental plane or both’. Vyadhi is caused due to the dosha dushya sammurchana – the damage caused to the tissues of the body by the morbid doshas and it does not happen overnight. It is a process and takes a long time to form. It requires six stages of pathogenesis for the disease to gradually develop and graduate to the stage of manifestation (in fifth stage) and stage of complications (in the sixth stage). The stage of complications itself indicates that the disease has had a chronic run and hence the sixth stage i.e. bheda avastha describes chronic pain syndrome. We can also see that many complications of an existing disease have been considered in the description of chronic pain syndrome.

Similarly, the synonyms of vyadhi like ruk, ruja, roga, gada, atanka etc explain the association of longstanding pain in the process, as a complication and as a sequel of a disease. So, the upadravas i.e. complications and udarka i.e. sequel of disease is also a description of chronic pain syndrome.

Chronic pain syndrome can be just physical, just mental or present at both levels. Both physical and mental symptoms are described among the symptoms of chronic pain syndrome. Ayurveda has considered body and mind as two sides of the same coin. Sharirika roga i.e. physical disease will manifest first at the physical level and in later stages the mind is involved. Reverse is the case of Manasika roga i.e. mental disease. These diseases will first manifest at the mental plane and will later encroach to involve the body. They can also coexist. So, the involvement of mind in physical diseases and body in mental diseases takes a long time to show up and hence describe ‘chronic pain syndrome’.

The nature and characteristic features of krichra sadhya i.e. difficult to cure diseases, yapya – manageable but not curable types of diseases and asadhya, pratyakhyeya or anupakrama vyadhis i.e. incurable diseases are depiction of ‘chronic pain syndrome’.

Related Reading – ‘Chronic Pain Syndrome – Ayurveda Understanding’