When pain is unbearable

Liz Bestic looks at the physical, psychological and social impact of chronic pain which can devastate sufferers’ lives

Chronic pain is that which persists for more than three to six months after healing should have taken place.

Most people go to see their GP when chronic pain starts to interfere with their lives. In an ideal world, the GP then considers referral either to a specialist service for diagnosis or to a specialist pain management clinic, so that the pain can be properly managed.

“Sadly, however, there is still a huge lack of awareness among GPs about pain,” says Dr Beverly Collett, consultant in pain medicine at University Hospitals of Leicester. “Indeed even though chronic pain is the most common reason for patients to visit their GP, less than 1 per cent of GPs’ training is devoted to the subject.”

In the UK, the provision of pain management services is patchy, with the latest estimates showing only around one in six patients are referred on to a pain specialist. “People need to get referred earlier so they can be given the tools to help them manage their pain effectively,” says Dr Collett.

Pain is far more than a physical sensation. It is often described as a bio-psychosocial phenomenon and as such is influenced by external factors

Chronic pain often has a massive impact on people’s quality of life. Research shows that 25 per cent of people with chronic pain become depressed and 25 per cent lose their jobs. Of those who continue in employment, 50 per cent find they cannot concentrate as well as they did before and eventually give up work. This can place a huge strain on family resources.

Those most affected are working people aged between 40 and 50 with families to support. “Chronic pain is the second commonest reason for receiving incapacity benefit, so there are often huge financial consequences for the family in these cases,” explains Dr Collett.

Pain is far more than a physical sensation. It is often described as a bio-psychosocial phenomenon and as such is influenced by external factors. Up until the mid-1960s, pain was believed to be a one-way process where the site of pain sent signals via the nerves to the brain. Now we know that pain activates cells in the spinal cord and, once they are activated, cause other pain cells to fire and the pain signal can be amplified.

“This is called ‘central sensitisation’ and leads to increased activation of nerve cells in the spinal cord and the brain,” says Dr Collett, who is also chairwoman of the Chronic Pain Policy Coalition.

It is not only adults who are affected by chronic pain. According to the British Pain Society, studies have shown that the cost of adolescent pain is almost £4 billion a year, which works out at an average of £8,000 for every young person.

US research has shown that the desperate search for a cure and the strain of being unable to help their child who is in pain, places a huge burden on parents. It also shows that mothers of children with chronic pain have far higher rates of anxiety and depression.

Medication is still the most widely used treatment for chronic pain, but in one in three cases it is ineffective. In these instances, patients often turn to other chronic-pain management strategies. Many patients benefit from psychological treatments, including cognitive behavioural therapy, hypnosis and meditation.

Some of the most commonly used medications for chronic pain include painkillers for lower back pain, anti-inflammatory drugs to reduce painful swelling in arthritis or drugs to relieve nerve damage in fibromyalgia.

But with some drug treatments, pain relief may be short-lived. Turning off the nervous system’s barrage of pain signals or decreasing inflammation can have longer- lasting effects.

Latest technology may offer some solutions. Spinal cord stimulators work by applying an electrical current to the source of chronic pain. This creates a sensation which blocks the brain’s ability to sense pain.

Nerve blocks have been developed from the same drugs given in epidural injections, which can stop the pain signal travelling along the affected nerves and dampen down swelling in the painful area.

Transcutaneous electrical nerve stimulation (TENS) is used to treat a range of different pain conditions, including those affecting the bones and joints. It has become extremely popular with both patients and health professionals.

However, a review into the effectiveness of TENS, by researchers at the Cochrane Collaboration – a gold-standard medical research body – showed results to be inconclusive. Experts say more controlled trials of TENS are needed to be sure this is an option for people with chronic pain caused by bone and joint conditions.

So what’s on the horizon for pain relief? Genetics has thrown up some interesting research. We know, for example, that in some families genes dictate how pain develops.

But Dr Collette concludes: “It really is important that people with chronic pain see a specialist team of professionals, including doctors, physiotherapists, occupational therapists and psychologists, so they can learn to manage their condition.”

CASE STUDY

Aimee’s story of coping with arthritis

Juvenile arthritis, known as juvenile idiopathic arthritis or JIA, affects around 12,000 children and young people in the UK, and at least a third of cases continue into adulthood.

There are many different types of JIA. Polyticular juvenile arthritis affects the smaller joints, such as fingers and hands, and commonly occurs in children from the ages of seven to twelve, but it can affect adolescents as old as 15. It is more common in girls than boys.

Aimee Gallagher is just ten years old and lives in County Antrim, Northern Ireland. She was diagnosed with polyticular juvenile arthritis 18 months ago.

Her mum Maire says the family has found it very hard adjusting to Aimee’s illness. “There are so many issues,” she says. “Aimee found it very hard to take the medication. We tried everything – liquid, tablets, injections. We went to a psychologist to see if that might help. She has had such a lot to go through. She has had to grow up very quickly.”

Aimee takes up the story: “At first my knees swelled up, and felt really hot and painful. It was quite scary when they told me after the X-ray that I had arthritis because I thought it was what old people got. Then the medication made me feel so sick and I fought against taking it.

“It has been quite difficult at school because I have to stay in the classroom. I can’t go out and play in case I hurt myself. Some of the other kids don’t really understand. Some days I am in so much pain I can’t move much and other days I feel sort of OK.

“I have got used to the medication now. I take two tablets a day and once a week I have an injection of a steroid called methotrexate. My dad gives me the injection into my tummy and I hold my mum’s hand. The drug has really helped the pain and I am starting to get more confident about playing outside. I hope the JIA will go away when I am older but, if not, I think I will be used to it by then.

“I know it has been really hard for my brother and sister because I get a lot of attention with all the medications. But they have been really good. I’m lucky to have a nice family.”

ALTERNATIVE THERAPIES

Mindfulness meditation

An early US study in the 1980’s by Jon Kabat-Zinn, professor of medicine at the University of Massachusetts Medical School’s Stress Reduction Clinic, showed that 65 per cent of the patients who spent ten weeks on his mindfulness programme reported a 67 per cent reduction in their chronic pain.

Hypnosis

Dr Catherine Bushnell, of Montreal’s McGill University, has found in her studies of hypnosis that people can be taught to reinterpret painful sensations. “Relaxation techniques, including meditation and hypnosis, might allow people to tolerate pain they would ordinarily describe as unbearable,” she says.

Acupuncture

Recent research published in the Journal of Rheumatology shows that acupuncture was superior to placebo in improving pain and function in patients with chronic knee pain. However, the research calls for more research into long-term effects.

Massage 

Massage may stimulate endorphins and reduce muscle spasms. Recent research published in the Archives of Internal Medicine showed that therapeutic massage was more effective for lower back pain than Chinese medical acupuncture, providing long-lasting benefits.