12 Things to Know About Chronic Pain

Updated: Jun 4

I recently had the privilege of being invited to speak on 'Ask the Mayo Mom', a Facebook Live event with Dr. Angela Mattke, a pediatrician at Mayo Clinic. She asked me and a colleague to discuss chronic pain so that healthcare professionals and parents alike can better understand the condition of chronic pain. This is a fairly prevalent condition and increasing our awareness about this sometimes 'invisible' condition can be beneficial for all of us and allowing improved understanding.



What is the difference between acute and chronic pain?


Acute pain is a signal imperative for our survival. It warns us of impending tissue damage from a condition or an activity and prompts action to get us away from the threat. This may result in avoiding the activities that cause pain, allowing the body to heal and recover. In this situation, pain is helpful and changes our behavior to keep ourselves more safe.


Chronic pain on the other hand is not a helpful signal. It is actually a distorted signal that might have persisted three to six months after an injury. In that instance, healing has occurred but the nerves associated with that area continue to transmit a signal distortion.


The official definition of pain developed by the International Association for the Study of Pain (IASP) is 'an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage'.


The problem arises when we treat chronic pain by restricting activities as we might for acute pain. This contributes to a cycle of worsening pain, worsening mood, sadness for certain aspects in life that are not experienced fully.


One important point to make here:

All pain is REAL. Despite the fact that it might be very difficult if not impossible to measure pain in an objective manner, the pain is what the patient states it is. Since we are humans, we have a brain capable of emotions and higher thinking. That very fact means that our emotions will play a role in every single activity we participate in. Thus, rather than pain being described as a biomedical phenomenon, we know know it is a biopsychosocial phenomenon.


How does acute pain become chronic pain?


When acute pain is not properly managed and its presence is allowed to negatively impact functioning, acute pain can transition into chronic pain. If, as pain persists, you are removing yourself from expected tasks and social interactions, it becomes more and more difficult for you to return to normal functioning even if one day your pain is mysteriously taken away.


As the old adage goes 'If you don't use it, you'll lose it'.


Pain medicine specialists make sure that everything is done to prevent acute pain from transitioning to chronic pain. Every healthcare professional can understand this concept and apply it to every patient you encounter, child, adolescent, or adult for that matter. Acute pain should be appropriately managed with a biopsychosocial approach, which includes the following aspects:

- addressing nociception, or the raw pain signal transmitted through nerves

- addressing the emotional components of pain: worry, fear, anxiety, sadness

- addressing the manner in which we associate with others (friends and family)

and how the pain impacts those relationships and our responsibilities


Nociception - approach acute pain in a systematic manner based on the expected intensity of pain. Use both medicine and non-medicine strategies for pain to alter the strength by which the pain signal is transmitted.


Emotional - provide reassurance to the individual with pain that some pain is normal after a surgical procedure, physical trauma, or medical condition. It is a normal part of life. This helps to minimize the patient's fear or worry. Ask what other aspects are difficult for the individual to manage. Even emotions seemingly unrelated to pain can in reality have some impact on how pain is felt.


Relationships or status as a person in family / society - empower individuals to function despite their pain by setting expectations. Here are some examples:

- taking care of personal hygiene (brushing teeth, combing hair, taking a

shower)

- gradually returning to physical activity (increasing steps walked each day,

meeting physical therapy or exercise goals), maintaining school or educational

activities or employment responsibilities as age-appropriate.

- taking care of chores around the house such as making your bed, feeding a pet,

doing laundry, washing dishes. While these seem simple and unrelated to pain,

being a functioning member of the family helps improve self-esteem and self-

efficacy, two constructs important in the pain experience.

Most importantly, chronic pain is addressed in this manner rather than the pure biomedical approach of the past. And when you introduce these concepts to your patient and their parents in the acute setting, it is not such a 'stretch' for them to understand these concepts if pain does end up persisting to a chronic state.


How many children and adolescents have chronic pain?

It is estimated that between 20 to 35% of children / adolescents in the United States have chronic pain. Approximately 10% have characteristics of severe chronic pain. It is likely that this percentage has increased during the Covid-19 pandemic.


How does chronic pain affect children and adolescents?

Chronic pain can be associated with comorbid conditions such as anxiety, mood disorders, sleep disturbance, subjective cognitive dysfunction (brain fog), autonomic dysfunction (deconditioning), nutritional deficiencies. Some of these may have been pre-existing, or developed after the chronic pain. Individuals with chronic pain often find it difficult and overwhelming to attend school, participate in physical activity and social interactions with peers. These creates more isolation, negatively affects self-esteem, and interferes with attaining developmental milestones.


How does it affect families?

The effects of chronic pain in one member of the family can impact everyone in that family. When a child has chronic pain, it may be difficult for the family to participate in activities they enjoy together. When one member cannot reliably participate, it becomes difficult to make plans or take vacations. Often, children with chronic pain may find it difficult to perform chores and this may result in disparity with sibling responsibilities. Since chronic pain can be associated with fear of a serious medical condition, more attention may be directed toward the child with chronic pain, thus disturbing the balance of attention with other siblings.



What can medical providers and parents do when the child has acute pain to prevent if from becoming chronic pain?

When faced with an acute pain situation from a surgical procedure, physical injury, or medical condition, pain should be addressed with a systematic approach with attention paid to three components: medical evaluation and treatments, emotional support, and activity expectations.


These are the typical components of medical treatment:

- first-line agents such as acetaminophen and NSAIDs on a PRN or scheduled basis

- anticipation and treatment of symptoms such as nausea / vomiting / constipation

- use of regional anesthetics or local anesthetics during procedures

- consideration for role of opioids

Medical providers have the responsibility to do everything possible to minimize pain in a safe manner while understanding that complete elimination of pain is not possible nor a realistic expectation. Risk and benefit of any particular modality must always be weighed for each patient.


Emotional support: address the possibility for anxiety, mood difficulties, self-efficacy, negative self-talk with:

- reassurance to decrease fear

- thought-reframing

- cognitive behavioral therapy

- exploring what the pain means to you

And validate the patient's report of pain; pain is a subjective emotional experience and filtered through our unique characteristics. All pain is real but there can be different aspects of pain that require different treatments. Acknowledging the various types of pain is important for helping develop insight.