Rheumatology Book


Chronic Pain

Aka: Chronic Pain, Chronic Nonmalignant Pain
  1. Definition
    1. Pain that persists beyond expectations and is independent of the original cause
  2. See Also
    1. Chronic Pain Resources
    2. Pain Physiology
  3. Approach: Counseling
    1. Explain to patient
      1. Both physical and psychological causes of pain (see Pain Physiology)
      2. Difficult to distinguish what causes what
      3. Chronic Pain differs from acute pain
        1. Chronic Pain has no physiologic purpose
        2. Chronic Pain does not improve with tissue recovery
    2. Use gate control theory to discuss Chronic Pain
      1. Discuss role of mood and emotion in pain blocking
      2. Discuss with family and patient
  4. Causes
    1. See Diffuse Musculoskeletal Pain Causes
    2. Musculoskeletal pain accounts for 80% of Chronic Pain
  5. Evaluation
    1. See Pain Evaluation
  6. Protocol: Understand why the patient presents at this time
    1. Increased concern about potential serious illness
    2. Increased environmental stressors
    3. Worsening functional capacity
      1. Decreased physical activities (walking or sleeping)
      2. Decreased psychological well-being (mood or energy)
      3. Decreased social activities (relationships)
      4. Roles (work)
    4. Worsening of psychiatric illness
    5. Termination of prior physician-patient contract
      1. History of "doctor shopping"
      2. Frustration and anger of previous "ineffective care"
      3. High expectations for help from the new provider
    6. Hidden agenda
      1. Narcotic seeking
      2. Disability
      3. Sick-role privilege
      4. Legitimize illness to family and coworkers
  7. Protocol: Explore concurrent psychosocial Factors
    1. History of loss (death or divorce)
    2. Prior Traumatic life events
    3. Physical or sexual abuse history
    4. Concurrent psychiatric illness
      1. Major Depression
      2. Anxiety Disorder
      3. Somatization Disorder
      4. Alcoholism or Drug Abuse
      5. Malingering
    5. Abnormal illness behaviors (see Somatization)
      1. Disability out of proportion to disease
      2. Persistent search for underlying organic disease
      3. Assign responsibility for illness to physician
      4. Sense of entitlement for care by others
      5. Behaviors to maintain the sick-role
  8. Protocol: Understand patient's concerns and expectations
    1. What does the patient think is causing the pain?
    2. What about the pain does the patient fear?
    3. What does the patient expect from the physician?
    4. What are patient's expectations in context of culture?
  9. Protocol: Understand patient's resources
    1. Social supports not centered around illness
      1. Family and Friends
      2. Work and community organizations (e.g. Churches)
    2. Coping strategies
  10. Management
    1. See Chronic Pain Management
  11. Prognosis
    1. Poor Prognostic Factors
      1. High frequency of physical complaints (Somatization)
      2. Long history of frequent healthcare visits
    2. Good Prognostic Factors suggestive of recovery
      1. Brief history of Chronic Pain (<2 years)
      2. No underlying psychiatric disorder
      3. Followed by primary care physicians
  12. References
    1. Ansari (2000) Harv Rev Psychiatry 7:257 [PubMed]
    2. Barkin (2000) Am J Ther 7:31 [PubMed]
    3. Bajwa (1999) Neurology 52:1917 [PubMed]
    4. Berland (2012) Am fam Physician 86(3): 252-8 [PubMed]
    5. Dellemijn (1999) Pain 80:453 [PubMed]
    6. Jackman (2008) Am Fam Physician 78(10): 1155-62 [PubMed]
    7. Kingery (1997) Pain 73:123 [PubMed]
    8. Laird (2000) Ann Pharmacother 34:802 [PubMed]
    9. McQuay (1995) BMJ 311:1047 [PubMed]
    10. Sindrup (1999) Pain 83:389 [PubMed]
    11. (2000) Med Lett Drugs Ther 42(1085):73-8 [PubMed]

Chronic pain (C0150055)

Definition (MSH) Aching sensation that persists for more than a few months. It may or may not be associated with trauma or disease, and may persist after the initial injury has healed. Its localization, character, and timing are more vague than with acute pain.
Definition (CCC) Pain that persists over time
Definition (MEDLINEPLUS)

Pain is a feeling set off in the nervous system. Acute pain lets you know that you may be injured or have a problem you need to take care of. Chronic pain is different. The pain signals go on for weeks, months, or even years. The original cause may have been an injury or infection. There may be an ongoing cause of pain, such as arthritis or cancer. But in some cases there is no clear cause.

Problems that cause chronic pain include

Chronic pain usually cannot be cured. But treatments can help. They include medicines, acupuncture, electrical stimulation and surgery. Other treatments include psychotherapy, relaxation and meditation therapy, biofeedback, and behavior modification.

NIH: National Institute of Neurological Disorders and Stroke

Definition (NCI) A longstanding unpleasant sensation associated with real or perceived physical or mental trauma.
Definition (NCI_NCI-GLOSS) Pain that can range from mild to severe, and persists or progresses over a long period of time.
Definition (NAN) Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a duration of greater than 6 months
Definition (CSP) pain which has persisted over a long period of time; also use NTs for specific types of pain if appropriate.
Concepts Disease or Syndrome (T047)
MSH D059350
ICD9 338.2
SnomedCT 82423001
LNC MTHU013382
Dutch chronische pijn, chronisch; pijn, pijn; chronisch
German chronischer Schmerz, Schmerz, chronischer, Chronischer Schmerz
Portuguese Dor crónica, Dor Crônica
Spanish Dolor crónico, Dolor Crónico, dolor crónico (hallazgo), dolor crónico
Japanese 慢性疼痛, マンセイトウツウ
English chronic pain (diagnosis), chronic pain, Chronic pain, rndx chronic pain (diagnosis), rndx chronic pain, Pain;chronic, Chronic Pains, Pains, Chronic, Chronic Pain, Pain, Chronic, Chronic Pain [Disease/Finding], Chronic pain (finding), CHRONIC PAIN, chronic; pain, pain; chronic
Czech Chronická bolest, bolest chronická, chronická bolest
Hungarian Krónikus fájdalom
French Douleur chronique
Polish Chroniczny ból, Przewlekły ból, Ból przewlekły
Italian Dolore cronico
Norwegian Smerter, kroniske, Kroniske smerter
Derived from the NIH UMLS (Unified Medical Language System)

Chronic nonmalignant pain (C3662064)

Concepts Disease or Syndrome (T047)
SnomedCT 3061000119102
English Chronic nonmalignant pain, Chronic nonmalignant pain (finding)
Spanish dolor crónico de etiología no maligna (hallazgo), dolor crónico de etiología no maligna
Derived from the NIH UMLS (Unified Medical Language System)

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