Chronic Pain and Self-Care

Chronic pain has been defined by the International Association for the Study of Pain as "pain that persists beyond normal tissue healing time, which is assumed to be three months."¹ When chronic pain is not associated with cancer or end-of-life care, it is often referred to as chronic non-cancer pain (CNCP); over the past 20 years, the use and misuse of opioids for CNCP has increased significantly. This is because "guidelines are not universally accepted by those involved in pain management and pain treatment seems to be driven mainly by tradition and personal experience."²

Many physicians and most patients hold unrealistic expectations with regard to the potential effectiveness of treatment with opioids and should be informed that total pain relief is exceedingly rare. In fact, clinical trials have demonstrated that pain scores improve less than two to three points on a 10-point scale, and often even less.³

Chronic Pain: The Consequences

A Finnish study of 5,646 patient visits identified pain as the reason for visits to a doctor 40 percent of the time. The low back, abdomen and head accounted for the most common locations, and 50 percent of confirmed diagnoses were musculoskeletal. Twenty percent of the patients had experienced pain for over six months and demonstrated considerable limitation in various activities of daily living.⁴

Another large sample, this one consisting of 28,902 working adults in the United States, found that 52.7 percent of workers reported having headache, back pain, arthritis or other musculoskeletal pain over a two-week period, 12.7 percent of whom lost 3.5 to 5.5 hours per week of productive work. Attributed losses in productive time at work were highest for headache (5.4 percent), back pain (3.2 percent), arthritis pain (2.0 percent) and other musculoskeletal pain (2.0 percent). There appeared to be no difference in the proportion of workers who lost productive time at work in terms of sex, age, residence, occupation, length of time on the job, or health insurance status. Workers with less education, high-demand / high control jobs, as well as those with four or more co-existing pain conditions, lost the most time.⁵

Pain occurs in a variety of forms, including monophasic events (e.g., due to injury), chronic episodic conditions (e.g., migraine headache) and chronic problems (e.g., persistent pain from arthritis). Sixty-nine percent of people over the age of 65 have two or more chronic illnesses. Moreover, it has been estimated that more than 40 percent of people with chronic illnesses have at least one co-morbidity that can often lead to increased disability and diminished physical well-being, reduced quality of life, increased use of health services and increased mortality.⁶

Pain Management Strategies

Effective management of chronic pain and chronic illness is complex and requires significant participation in self-care by patients and their families. However, patients who attempt to manage their multiple health conditions are faced with conflicting demands and competing priorities. The daily routines required by patients to manage their pain can be burdensome, but should include:

• Engaging in activities that promote physical and psychological health;
• Interacting with health care providers and adhering to treatment recommendations;
• Monitoring personal health status and making the necessary care decisions;
• Managing the impact of illness and pain on physical, psychological and social functioning.

"Dual task theory" proposes that patients will most often perform those tasks first in which they have the greatest emotional investment, such as acute symptoms and serious illness, at the expense of the more chronic conditions. Similarly, there is currently an increased focus by many health care providers on "acute care," effectively delaying or "triaging" treatment for the diverse and complex needs of patients with chronic pain and chronic health conditions.⁷

There are many barriers to self-care. Some of the most common include physical limitations, lack of knowledge, financial constraints, logistics of travel, social and emotional support, aggravation of one condition by symptoms of/or treatment of another condition and problems with multiple medications.

The Latest Guidelines

According to Passik and Kirsh, "Good pain management should lead to some decreases in pain perception combined with a corresponding increase in ability to function."⁸ The American Society of Anesthesiologists Task Force on Chronic Pain Management has released its 2010 practice guidelines, which propose to:

• Optimize pain control, recognizing that a pain-free state may not be attainable;
• Enhance functional abilities, physical and psychological well-being;
• Enhance the quality of life of patients;
• Minimize adverse outcomes.

The list of single-modality interventions mentioned in the guidelines is extensive; here are the top 12, in no particular order:

• Ablative techniques including chemical denervation, cryoneurolysis or cryoablation, thermal intradiscal procedures and radiofrequency ablation
• Traditional acupuncture and electroacupuncture
• Joint and nerve or nerve-root blocks
• Botulinum toxin injections
• Transcutaneous electrical nerve stimulation, subcutaneous peripheral nerve stimulation and spinal-cord stimulation
• Epidural steroids with or without local anesthetics
• Intrathecal drug therapies
• Minimally invasive spinal procedures including vertebroplasty, kyphoplasty, and percutaneous disc decompression with nucleoplasty or coblation
• Pharmacologic management includes anticonvulsants, antidepressants, benzodiazepines, N-methyl-D-aspartate receptor antagonists, opioids, skeletal muscle relaxants, and topical agents such as lidocaine, capsaicin or ketamine
• Physical or restorative therapy, including specific exercises
• Psychological treatment
• Trigger-point injections

The task force describes the difference between multimodal and multidisciplinary interventions as follows: "Multimodal interventions constitute the use of more than one type of therapy for the care of patients with chronic pain. Multidisciplinary interventions represent multimodality approaches in the context of a treatment program that includes more than one discipline. The literature indicates that the use of multidisciplinary treatment programs compared with conventional treatment programs is effective in reducing the intensity of pain reported by patients for periods of time ranging from four months to one year."⁹

Chiropractic has achieved increased credibility and amassed an important body of evidence in support of the non-surgical, non-pharmaceutical treatment of acute and chronic musculoskeletal pain conditions. We have also demonstrated a willingness to follow clinical practice guidelines and collaborate in multidisciplinary care pathways.^10-13

References

1. International Association for the Study of Pain. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Pain, 1986;3(Suppl):S1-S226.
2. Varrassi G, Muller-Schwefe G, Pergolizzi J, Oronska A, et al.Pharmacological treatment of chronic pain - the need for CHANGE.Curr Med Res Opin, 2010 May;26(5):1231-45.
3. Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ, 2006 May 23;174(11):1589-94.
4. Mantyselka P, Kumpusalo E, Ahoen R, Kumpusalo A, et al. Pain as a reason to visit the doctor: a study in Finnish primary health care. Pain, 2001 Jan;89(2-3):175-80.
5. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. JAMA, 2003;290:2443-54.
6. Bayliss EA, Steiner JF, Fernald DH, Crane LA Main DS. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Ann Fam Med, 2003;1:15-21.
7. Wagner Eh, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Millbank Q, 1996;74:511-44.
8. Passik SD, Kirsh KL. The interface between pain and drug abuse and the evolution of strategies to optimize pain management while minimizing drug abuse. Exp Clin Psychopharmacol, 2008 Oct;16(5):40-4.
9. The American Society of Anesthesiologists Task Force on Chronic Pain Management. Practice Guidelines for Chronic Pain Management.Anesthesiology, 2010;112:810-33.
10. Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J, 2008 Jan-Feb;8(1):213-25.
11. Bishop PB, Quon JA, Fisher CG, Dvorak MF. The Chiropractic Hospital-Based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical lower back pain. Spine J, 2010; in press.
12. Shaw L, Descarreaux M, Bryans R, Duranleau M, et al. A systematic review of chiropractic management of adults with whiplash-associated disorders: recommendations for advancing evidence-based practice and research. Work, 2010;35(3):369-94.
13. Mior S, Barnsley J, Boon H, Ashbury FD, Haig R. Designing a framework for the delivery of collaborative musculoskeletal care involving chiropractors and physicians in community-based primary care. J Interprof Care, 2010 May 4. ( Epub ahead of print)