Chronic Pain

Cause

The cause of chronic pain is not clear.

When you have an injury or illness, certain nerves send pain signals to your brain. With chronic pain, these pain signals keep going for weeks, months, or even years after you recover.

Chronic pain can develop after a major injury or illness, such as a back injury or shingles, or it can happen without a known cause. It is also possible that certain brain chemicals that usually suppress pain stop working the way they're supposed to.

Pain can affect:

• Muscles, bones, and joints. This pain can happen from injuries or muscle strain. Health problems like osteoarthritis, rheumatoid arthritis, and fibromyalgia also can cause it.
• Nerves and the nervous system. This type of pain happens because of pressure on nerves or damage to them from an injury or a health problem. Sometimes pain occurs when something goes wrong with the central nervous system. This can happen with diabetes, shingles, and sciatica, for example.
• Organs. Pain in your organs occurs because of injuries, infections, or health problems such as inflammatory bowel disease, irritable bowel syndrome, pelvic pain, and stomach ulcers.

You can have more than one kind of pain at the same time. For example, fibromyalgia can cause pain in muscles and nerves.

Symptoms

The symptoms of chronic pain include:

• Pain that does not go away as expected after an illness or injury.
• Pain that may be described as shooting, burning, aching, or electrical.
• Discomfort, soreness, tightness, or stiffness.

Pain can lead to other problems, such as:

• Fatigue, which can cause impatience and a loss of motivation.
• Sleeplessness, often because the pain keeps you awake during the night.
• Withdrawal from activity and an increased need to rest.
• A weakened immune system, leading to frequent infections or illness.
• Depression, which is common and can make your pain worse.
• Other mood changes, such as hopelessness, fear, irritability, anxiety, and stress.
• Disability, which may include not being able to go to work or school or perform other daily activities.

What Happens

Whether your chronic pain develops after an injury or illness or on its own, the result is often the same: a cycle of sleeplessness, inactivity, irritability, depression, and more pain.

Chronic pain may be mild to severe. It may come back from time to time over several weeks, months, or years. Exercise, regular massages, and pain-relieving medicines—such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or aspirin—may be enough to manage your symptoms.

On the other hand, you may have constant chronic pain that is severe and needs more than home treatment. Without treatment, chronic pain syndrome (changes in the body caused by long-term pain) can become disabling.

The lives of your family members, friends, or caregivers can also be affected. The people you count on to help you may also need some support. Family therapy or involvement in a caregiver support program may help.

What Increases Your Risk

Risk factors are things that increase your chances of getting sick or having a problem. Risk factors for chronic pain include:

• Aging. Older adults are more likely to have certain health problems that can lead to chronic pain, such as arthritis, diabetes, and shingles.
• Certain health problems. These include:
  • Existing health conditions, such as fibromyalgia, shingles, arthritis, depression or anxiety disorders, or phantom limb pain.
  • Past health problems, such as joint injuries or past surgeries.
  • Overall general health. You may have a weakened immune system, which can lead to frequent infections or illness.
• Lifestyle, such as not eating healthy foods, not exercising regularly, smoking, or having a drug or alcohol problem.

Other risk factors include stress, relationship problems, or a history of physical, sexual, or emotional abuse.

When To Call

Call a doctor about chronic pain if:

• Your pain has lasted more than 3 months without a clear reason.
• You are feeling down or blue or are not enjoying the activities or hobbies that you have enjoyed in the past. You may have depression, which is common with chronic pain.
• You can't sleep because of the pain.
• You had an illness or injury that healed, but you still have pain.

Watchful waiting

Watchful waiting is a period of time during which you and your doctor watch your symptoms without using medical treatment.

During this period of watchful waiting, your doctor may have you try to get more sleep, work on reducing stress, and get more exercise. If you are able to control pain with exercise, massage, and pain relievers, you may not need further treatment.

But watchful waiting is not appropriate if your pain is severe or if it interferes with your life. If you delay treatment, the pain may get worse.

Who to see

If you have mild to moderate pain that keeps coming back and that you can't manage at home on your own, you may need to see one of the following health professionals:

• Family doctor
• Internist, a doctor who specializes in the care of adults
• Nurse practitioner, a nurse who has advanced training
• Physician assistant, a health professional who practices medicine under a doctor's supervision
• Osteopathic physician, a doctor who uses medicine, surgery, and other kinds of treatment but may also use manipulation or manual treatment

If your chronic pain is moderate to severe and is constant, or if treatment does not control the pain, you may need to see a specialist, such as one or more of the following:

• Pain management specialist, a doctor who specializes in treating chronic pain
• Physiatrist, a doctor who specializes in physical medicine and rehabilitation
• Physical therapist, someone who evaluates physical problems and injuries and then provides education and treatment
• Neurologist, a doctor who specializes in treating the brain, spinal cord, and nervous system
• Anesthesiologist, a doctor who specializes in using pain-blocking techniques and medicines
• Psychiatrist, psychologist, or licensed mental health counselor, all of whom specialize in treating mental health and behavior issues
• Orthopedic surgeon, a doctor who specializes in bone, muscle, and joint surgery
• Rheumatologist, a doctor who specializes in treating autoimmune diseases and problems in the joints
• Chiropractor, someone who specializes in treating problems that affect the alignment of muscles and bones

Often more than one specialist will treat your chronic pain. For example, a primary physician may manage your medicines, and a physical therapist may help you restore function through exercise or other treatments. A professional counselor may help you with coping and depression. Someone else may help you with acupuncture or yoga.

Exams and Tests

Your doctor will take a detailed medical history, asking you questions about your overall health; past illnesses, surgeries, or injuries; and your pain. He or she may ask you to start keeping a pain diary .

Physical exam

In your physical exam, your doctor will look for areas that are tender, weak, or numb. The doctor will also check for health problems that contribute to chronic pain, such as:

• Nervous system problems. You may be asked to do a few physical tasks, such as walking up and down a hall or getting up from a chair. By checking your reflexes and your ability to feel light touch, your doctor can look for a nerve problem. The doctor may also ask you to repeat a series of numbers or to answer simple questions about dates, places, and current events.
• Mental health problems. A mental health assessment involves asking you questions to help your doctor find out whether such conditions as depression, insomnia, or stress are contributing to or happening as a result of your chronic pain. These conditions often occur with chronic pain. You may also be asked about your use of alcohol and drugs. Answering these questions fully and honestly may help your doctor and you identify the sources of your chronic pain.

Tests

One or more of these tests may help your doctor rule out health problems that can cause chronic pain.

• Blood tests or other lab tests: A small sample of your blood is taken and then checked to see if you have an infection or other condition that could be causing your pain.
• X-rays or other imaging tests (such as CT scans, MRIs, or ultrasounds): These tests take pictures of the inside structures of your body to look for disease and injury.
• Electromyogram (EMG) and nerve conduction studies or other nerve tests: These tests measure muscle and nerve function to find out whether your chronic pain is related to muscle or nerve problems.
• Angiogram or other studies of your blood vessels: This test injects a dye and inserts a small tube into your arteries to trace the movement of blood within your body.
• Diagnostic nerve blocks: One example is an injection of a local anesthetic into or around a nerve to identify whether that nerve is causing the pain.

Treatment Overview

Treating chronic pain can be challenging. And it may take several types or combinations of treatments before you find relief.

Be sure to seek treatment if your pain lasts longer than 2 to 3 months. Early treatment may prevent the pain from getting worse.

The goals of treatment are to reduce your pain and increase your ability to function. This includes improving your sleep and your coping skills and reducing stress so you can return to your regular activities.

It's important to build a clear treatment plan with your doctor. Part of this plan includes identifying ways for you to manage your pain. Only you know the severity of your pain and how it affects your life. Be sure to ask your doctor if you are not clear about what steps you can take when pain occurs or gets worse.

Chronic pain treatments

You may be able to control your pain at home by using pain relievers and practicing healthy habits. For more information, see Home Treatment.

When home treatment isn't enough, other treatments may include:

• Pain medicines or medicines to treat problems that are linked to chronic pain. For more information, see Medications.
• Treatments such as counseling, physical therapy, and complementary therapies. For more information, see Other Treatment.
• Surgery, such as intrathecal drug delivery and spinal cord stimulation. For more information, see Surgery.

If your chronic pain is not relieved after you have tried numerous treatments, you may want to think about going to a pain management clinic. Treatment is provided by a team of doctors who work together to address all the things that may cause your chronic pain.

Prevention

Chronic pain can't always be prevented. But staying in good physical and mental health may be the best way to prevent it or help you cope with it.

• Treat your health problems early.
• Get enough sleep every night. Learn to alternate activity with rest throughout each day.
• Exercise.
• Eat a balanced diet.
• Try to reduce stress in your life.

Self-Care

Get enough sleep

If you are tired during the day and have trouble sleeping, try to:

• Set a bedtime and a wake-up time—and stay with these times, even on weekends. This helps your body get used to a regular sleep time.
• Get some exercise during the day.
• Avoid taking naps, especially in the evening.
• Avoid drinking or eating caffeine after 3 p.m. This includes coffee, tea, cola drinks, and chocolate.

Deal with problems right away

Treat medical conditions and mental health concerns early, before they get worse and become harder to treat.

Untreated health conditions (such as shingles) or mental health problems (such as depression or anxiety) can make chronic pain harder to treat.

Stay active

Get regular aerobic exercise—such as swimming, stationary cycling, and walking—to build your strength and health.

Water exercise may be especially helpful in reducing pain that gets worse during weight-bearing activities, such as walking.

Talk to your doctor before you begin an exercise program. Start slowly and increase your efforts bit by bit. If your joints are stiff, try taking a warm bath or shower first to loosen up. Also, do some stretching exercises each day.

Schedule your day so that you are most active when you have the most energy. Learn to move in ways that are less likely to make your pain worse.

Practice healthy habits

• Eat a balanced diet. Good nutrition will help you stay healthy and strong. For more information on good nutrition, see the topic Healthy Eating.
• Stop smoking. Smoking may affect your level of pain and may reduce how well your chronic pain treatment works. For more information, see the topic Quitting Smoking.
• Reduce stress. Try a relaxation therapy such as breathing exercises or meditation. For more information, see the topic Stress Management.

Think about tools that may help

Assistive devices, such as walking canes or doorknob extenders, may help you do your daily activities. These devices can help you to be more mobile and independent.

Try self-massage

With self-massage you can help relax your own back muscles using a tennis ball.

Caregivers need care too

If you are a caregiver for a person who has chronic pain, your own stress and worry can also cause you to have symptoms of depression, vague body pains, digestive disorders, or headaches.

Experts say that it is important to take care of yourself, too, and not to feel guilty about it. For more information, see the topic Caregiver Tips.

Medicines

Medicines can often help control chronic pain. In some cases, it may take several weeks for the medicine to work.

Medicine may work best when it's used along with other types of treatment, such as physical therapy and counseling, to address the different causes of chronic pain.

Sometimes a medicine loses some or all of its ability to work when it is used daily over a long period of time. This is because your body develops a tolerance to it. If this happens, you may need to take more of the medicine, change medicines, or add another medicine. Your doctor can work with you to do this.

Pills for pain

You will likely start with medicines that cause the fewest side effects (such as acetaminophen). The dose will be increased or the medicines will be changed as needed. Be safe with medicines. Read and follow all instructions on the label.

• Acetaminophen , such as Tylenol.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) , such as aspirin, ibuprofen (Advil, for example), and naproxen (Aleve, for example).
• Antidepressants , such as amitriptyline or duloxetine (Cymbalta).
• Corticosteroids , such as prednisone.
• Anticonvulsants, such as gabapentin (Neurontin) and pregabalin (Lyrica).
• Opioid pain relievers , such as hydrocodone (for example, Norco). These may be used when other medicines do not help.

Medicines you put on your skin

A variety of creams, gels, sprays, and patches may be used to relieve chronic pain, including:

• Topical analgesics. These are pain relievers that are applied directly to the skin, such as EMLA cream or a lidocaine patch (Lidoderm). Some creams or gels can be made at the pharmacy according to your doctor's directions. Some may contain capsaicin, a naturally occurring substance found in chili peppers.
• Cooling spray. This involves using a cooling spray (such as Biofreeze) directly on the skin. This may be repeated several times.

Injections

Injected medicines—shots—may be used to treat chronic pain, including:

• Epidural steroid injections (injecting steroids around the spine). Although these injections have been used for many years and may provide relief for low back or neck pain caused by disc disease or pinched nerves, they may not work for everyone.
• Joint block injections. A corticosteroid is injected into the painful joint or joints.
• Nerve block injections. An anesthetic is injected into the affected nerve to relieve pain. The anesthetic may relieve pain for several days, but the pain often returns. Although nerve blocks do not normally cure chronic pain, they may allow you to begin physical therapy and improve your range of motion.
• Trigger point injections. These may relieve pain by injecting a local anesthetic into trigger points (or specific tender areas) linked to chronic myofascial pain or fibromyalgia. These injections do not relieve chronic pain in everyone.

Surgery

Surgery for chronic pain isn't common. It's usually considered only after other treatments have failed or if it is considered medically necessary.

Surgery may provide pain relief, but it also may permanently damage your ability to perceive other sensations, such as light touch and temperature changes. It can also cause a different pain to occur.

Implanted pain control systems

Implanted pain control systems involve inserting devices under your skin or elsewhere in your body. The devices use medicine, electric current, heat, or chemicals to numb or block pain.

• Intrathecal drug delivery sends medicine to the area of your pain.
• Electrical nerve stimulation uses electric current to interrupt pain signals.
• Nerve ablation destroys or removes the nerves that are sending pain signals.
• Chemical sympathectomy uses chemicals to destroy nerves. This treatment may be used for a type of chronic pain called complex regional pain syndrome, which affects the nervous system.

Decompression

Decompression is a type of surgery used for nerve pain, such as from trigeminal neuralgia. The doctor cuts open your skin and then tries to move away blood vessels or other body structures that are pressing on nerves and causing pain.

Other Treatment

Manual therapy

For back pain, physical therapy, osteopathic care, or chiropractic care usually includes spinal manipulation, which is a kind of manual therapy. It involves working on the head, shoulders, neck, back, or hips. It can range from massage and slow pressing to a quick thrust. Your care provider may also use hot and cold therapy to relieve pain.

You may also learn stretching and range-of-motion exercises to maintain strength, flexibility, and mobility.

TENS

Transcutaneous electrical nerve stimulation (TENS) applies brief pulses of electricity to nerve endings in the skin to relieve chronic pain.

Counseling

It's common to respond to chronic pain with feelings of frustration, depression, anxiety, fear, and even anger. These feelings can make it harder to manage chronic pain, especially if you use alcohol or drugs to deal with your symptoms.

A counselor may use treatments such as cognitive-behavioral therapy to help you cope with your pain.

• Chronic Pain: Using Healthy Thinking

Support groups

A support group is made up of people with similar experiences who can understand your feelings and provide comfort. They can keep you from feeling isolated and alone.

Being around others who share your problem can help you and your family learn how to accept and manage chronic pain.

To find a group near you, contact the American Chronic Pain Association at 1-800-533-3231 or online at www.theacpa.org.

Complementary therapies

Complementary therapies may help you feel better by reducing your pain or stress. These therapies include:

• Acupuncture
• Biofeedback
• Guided imagery
• Healing touch
• Massage
• Meditation
• Yoga

If you decide to try one or more of these complementary therapies to treat your chronic pain, find a health professional who has special training and, whenever possible, certification in the particular therapy.

You may get a referral from someone you trust such as your doctor, family, or friends. Make sure all of your health professionals know every type of treatment you are using to reduce chronic pain.