12 Things to Know About Chronic Pain

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. Check out the session here.

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.

Image courtesy of Stefan Friedrichsdorf MD

Activity expectations: the goal after a surgical procedure or other acute pain situation is to return to baseline functioning and activities in an age-appropriate manner. This includes the following:

- Activities of daily living (ADLs) - personal hygiene, brushing teeth, hair, showering /

bathing

- Normal sleep and wake times and minimizing naps / sedentary time

- Mobility expectations such as being up and out of bed to a chair a number of times

throughout the day, increasing the number of steps taken each day, participating in

physical therapy (minimizes deconditioning that can occur during medical illness)

- Participating in fun activities, engaging with peers, family

Taking this biopsychosocial approach to acute pain prompts us to think about functioning and how to do so despite the presence of some pain. It is important then while treating pain that we pay attention to assuring that children maintain as 'normal a lifestyle as possible'.

What can parents do if they suspect their child has chronic pain?

It is imperative to assure that a thorough medical work-up is conducted to assure that no underlying condition is present which is driving pain. However, one must be careful not to prolong the medical workup which could increase fear and reinforce the sick role in a detrimental manner. Having one primary provider who helps to direct care and is the liaison between medical providers and the patient can be very beneficial to assure the assessment and treatment is made in a cohesive manner.

While medical evaluation is being sought, children and adolescents must be encouraged to participate in activities of daily living, educational activities, physical activity and socialization with friends and family. These should be encouraged on a regular basis rather than overdoing on days when one feels well and withdrawing from activities for days when not feeling well (the 'crash and burn' cycle).

One of the invaluable aspects of treatment includes psychology support for those with chronic pain. Pain is often associated with anxiety, mood disorders, a general sadness, grief, and it is important to explore these and find the treatments and activities that will address them.

What are some of the effective strategies for managing chronic pain?

There are some basic concepts that are paramount to understand about chronic pain and functioning. Here I will list some that are most meaningful to me and helpful to patients with chronic pain.

- Set consistent wake and bed times; minimize or eliminate naps as this disrupts the sleep cycle

- Eat consistent meals which means at least three meals per day and snacks; do not base your food consumption on your symptoms (unless this is specifically recommended by your physician)

- Plan to get to school (or work) everyday. Deciding in the morning prior to school whether you will attend or not based on your symptoms is associated with poorer functioning, lower mood, more anxiety, isolation. Unless you have an additional medical condition, these are some reasons you may decide to NOT attend school.

- Fever of greater than 102

- Broken bones

- Suicidal ideation (you need to seek medical attention immediately for this)

My point about this is that there should only be very well-defined reasons to not attend school. Be cautious if your provider suggests that you or your child seek on-line schooling without a specific plan to return to school.

- Stay well-hydrated. Carry a water bottle with you and sip throughout the day. Your urine should be light yellow or clear in color to indicate you are hydrating well.

- Get some exercise daily in a gradual way specific to you. Moving your body helps to release endorphins and enkephalins, your body's own pain-fighting chemicals. Don't overdo it. You want to be ready to come back tomorrow and exercise again.

- Make plans for a difficult day. Agree to call a friend, watch a fun movie, listen to music, journal, meditate, do some art. Rewarding yourself for the difficult work you are doing to stay functioning is imperative to your mental and physical health.

- Seek out the expertise of a professional counselor who can help you understand the thoughts you have about pain and the work you are doing. I believe we all need someone to fill this role for us. It is a sign of strength to reach out for assistance and to help you maintain mental health.

- Give yourself some space to make some mistakes. Creating new habits can be difficult (which is why you need a counselor to help keep you accountable). If you slip up on some of your goals, get right back to them later in the day or tomorrow. The point is that you ARE making goals for yourself. You'll get the hang of it and pretty soon all of these suggestions above can become part of your normal life.

Does chronic pain get better?

Yes! The question often is ' Does chronic pain get better or Am I just coping better with the pain?' The truth is that both can be true at the same time. Chronic pain can improve but know that improved coping sets you up for an improved pain experience.

Paying attention to the specific recommendations above you can help get your body ready for the pain to improve. As mentioned, it is important to get back to the things you wish to do and that are required of you (school, work, household and family responsibilities) and sometimes that must be done in a gradual fashion. While you are doing those things, you can feel joy, feel empowered, feel that you accomplish things. These activities are associated with release of neurotransmitters such as endorphins, enkephalins, and dopamine to name a few.

Are medications appropriate for treating chronic pain?

Medications can be part of the puzzle for improving the chronic pain experience. For example, neuropathic pain can be treated with medications of the anticonvulsant or antidepressant class. However, any medication that is initiated for chronic pain should be done so with specific expectations and on a trial basis. Certain medications such as opioids, benzodiazepines, muscle relaxants have not been proven to be beneficial in the long-term. And specifically, the long-term use of these medications are not always associated with improved functioning; in reality the reverse may be true.

Here are some questions you should ask your healthcare provider about regarding medications for pain.

- what is the expected effect of the medication? How will I know it is working?

- what are the side effects? Will I need to stop the medication if I experience these?

- what is the expected duration of the medication trial? Will I be on this long term?

- how will I taper off this medication if it is not helpful?

- are there any interactions with the medications I am taking currently?

Asking these questions makes you a good medical consumer. Your physician should not feel threatened by these questions. Your doctor wants to help you and sometimes medications can be part of that treatment but you have the right to know these answers. You also have the right to say you would like to avoid medications. Medications can be helpful in the short term but it is often behavior and habit changes that are most often associated with improved functioning and decreasing pain.

You should have a list of all of your current medications in the Notes portion of your phone or some other safe place. Make sure your doctors know all of the medications you are taking and that you review on a regular basis whether you need to continue on your medications. Always seek the advice of your medical provider before making decisions to discontinue a medication.

What is functional restoration?

Basically this is representative of a gradual returning to a more typical level of functioning that is age-appropriate. This may include attending school in a regular school building, socializing with friends, participating in physical activity, having fun. These are important activities that help to foster appropriate independence and psychological development. Even individuals who have missed a lot of school as adolescents can get back on track to graduate from high school and attend college or go into the workforce, dependent upon the specific goals. Chronic pain as an adolescent does not necessarily have to lead to chronic pain that persists into adulthood.

Which individuals have the best chance of improvement in their chronic pain and functioning?

All of the work towards normal functioning takes dedication and desire to live your best life despite the presence of pain. This is a concept called 'acceptance'.

This can be explained as choosing to be in control of your life rather than your pain in control of your life.

It is expected that one has had an appropriate medical workup to assure concerning health conditions have been addressed and treated. Keeping an open mind about what you can change (and are willing to change) in your life for an improved experience is directly correlated to improved quality of life. The secret is that you must become more functional before the pain will improve rather than waiting for the pain to get better before you become more functional.

You can check out the Facebook live interview here.

Which of these recommendations resonated with you or made the most sense to you? Whether you are a healthcare professional or an individual with pain, I'd love to hear your thoughts and take your questions about these concepts. Please share your thoughts and some of your own recommendations for the management of pain.