Should we worry about “how much it hurts” in Chronic Pain?

Should we worry about “how much it hurts” in Chronic Pain?

History of pain management suggests strong value of focusing on pain intensity as the goal of treatment. This is true for cancer pain towards the end of life and probably for acute pain with injury or pathology. However, for pain without obvious pathology or trauma, addressing elimination of pain may not be right goal of management. Chronic pain is any pain lasting for longer than three months when the normal tissue healing is over. This says that the local tissue is no longer at fault, but the problem lies somewhere else other than the tissues.
In a recent article titled “Must we reduce pain intensity to treat chronic pain?” by Sullivan and Ballantyne (published ahead of print) in Pain, they give reference to a very interesting case of Mr. Harris. Read the case at the end of the article.


So should we target pain intensity for the management of chronic pain?
Assessment of pain and management has been considered important. Pain is also often considered the 5th vital sign. It is recommended to use a Numerical Pain Rating Scale (NPRS) and any pain that scores more than 4/10 warrants pain management. Recent recommendation for the low back pain research is to assess at least pain intensity, pain interference and physical function. Other aspects that can be assessed are depression, sleep quality, catastrophization, fear avoidance, work disability etc. These factors are more related with suffering and or disability due to chronic pain than pain intensity.

Pain severity can have different meanings and implication. I always remember a patient who had lower extremity trauma during Nepal Earthquake in April 2015, who was highly catastrophic of pain and did not want to move out of the bed after surgery. In another big tremor, the patient ran out of the hospital building without feeling any pain on the injured leg. Women take extremes of pain during labour as this is a reward, however, they find difficult to take a pain that she gets in her lower back when she washes her mother in law’s clothes. I am sure the pain is not as much as the labour pain. So, pain intensity is something not the sole thing that has to be targeted, when managing chronic pain that is so complex and is multifaceted.

In the course of pain – cognitive factors take over nociception. This means pain perception is more linked with central experiences such as emotions, stress, catastrophizing, fear avoidance than actual pain in the tissue (nociception). Tissue generally heals by three months before the pain becomes chronic. Many of these central factors contribute to ongoing pain though the tissue is healed locally. It is also believed that anxiety increases pain rather than pain increasing anxiety.

pain is part of life

So what should we target while managing chronic pain?
Interventions to target the function rather than pain could be of more value. If the person is doing his or her work/ task/ function well, they feel better, they have less avoidance of activity due to fear, they do not heighten their pain experience, become more active and functional and thus decrease pain. Active life style is recommended for chronic pain. But, when we target pain intensity in these patients, we are concerned about pain, we ask patient to be more cautious and probably also ask to avoid painful activities (which is not required most of the times), they become scared to move the body, when they have to move- they know that will harm them. When they believe movement will cause harm, it will for sure hurt/ cause pain. They again become more scared of this activity and rest. Rest is not good for chronic pain.

Thus, acceptance of pain as a normal phenomenon is useful pain management strategy. We can help the patients by talking to them about pain with examples and metaphors, convincing them to accept their painful state, explaining them that stressful situations may lead to some pain, which will subside when the stress is removed. Low back or the neck hurt just like headache during stress, or appearances of cold sore or pimples in stressful situations. Just as getting more stressed about a pimple over the face causes to occur, stress about low back pain and neck pain increases the pain more. Most of the times, they do not even require treatment. Thus, we should address the false understanding about the patients regarding chronic pain more effectively rather than using analgesics, TENS, or other passive techniques to manage chronic pain.

Implication for patient: Do not worry about how much it hurts, that will increase the pain more, accept the pain as normal part of life, stay active which is the best way to cope with chronic pain.

Implication for clinicians: Do not worry much about getting rid of all the pain, but try to maximize their potential to be functional. Explain them why it hurts and counsel them to accept the pain in the best way possible.

Case example in the article by Sullivan and Ballantyne in Pain:
(Mr. Harris is a 41 y/o male who has had axial low back pain for 1 year. He has just moved into town and comes for his first appointment with you, his new primary care physician. A previous lumbar MRI showed a disc bulge at L5-S1 and some degenerative changes at other levels, but there is no evidence on physical exam of nerve root irritation. He rates his average pain intensity as 10/10. He takes oxycodone SR 20mg BID which used to provide him significant relief, but does no longer. He wants his opioids increased until they relieve his pain. He explains that this was the treatment goal that he agreed on with his previous physician who had called it the “titrate to effect principle.” When you express doubt as to whether an opioid dose increase is the right treatment, he responds, “Don’t you believe I am in pain? Don’t you believe that I deserve relief? Do you just want me to suffer?” You are confused. You do believe Mr. Harris is in pain and deserves relief, but you doubt that escalating his opioid dose will provide him lasting and overall benefit.)

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16 Comments on “Should we worry about “how much it hurts” in Chronic Pain?

  1. enjoyed reading and benefited by this as i went through this i remember all my patients with chronic pain…. changed my mind set… its always intresting to read ur articles. Thanks

  2. Thank you sir for such a great article. I loved it.
    And sir,if the pain is chronic, is it always that there is no fault at tissue level?

    1. HI Sewika,
      Thanks for writing.

      Regarding the question you have asked- which is really very interesting. I would like to say a few things,

      1. If there is no acute injury superimposed over chronic painful sites (some people call this, acute on chronic), then probably there isn’t any tissue damage.

      2. In people with chronic pain, when biopsies are taken from the painful site(s), there are evidences of pain causing substances present at local level. This also in a way means, pain is locally present, however, that does not mean that the tissue is damaged.

      I would love to hear replies to this from other pain experts about how they would answer to this question.


      1. Thank u so much sir.
        And again,What about degenerative conditions,which are both Chronic and painful and its damaging everyday.How come there wont be tissue damage locally then.

        1. Hi Sewika. It is proven that degeneration doesn’t quite correlate with the amount of pain the person has. For example, those with severe degeneration may have no pain, and those with no or minimal degeneration may have severe pain. That is why radiodiagnosis has little to no value in management of arthritis. There are other factors that modulate pain in osteoarthritis. This year, Jyoti will probably look at this as her internship project. It will be nice if you can chat with her. 🙂

  3. I learnt more about pain from this writing. Examples mentioned in it helped me understand the topic more easily and in a interesting way. I’d love to read more.

      1. Even reading all the comments is so knowledgable. Chronic pain from different perpectives (accdn to different conditons) which i have never thought of; i have come to know from the comments.

  4. Well to be honest at times I feel patient with chronic pain is my archellis heel. I have many patients with chronic pain (I don’t catagorize people having pain from 1 year as chronic pain), I have one patient she is 27 year old and living with chronic back pain (VAS 9 when worse on first interview) from around 8 years before which is after having her first baby. When i examined her obliques strength were 0 and her forward flexion was completly uncontrollable, and as she had whole body pain she was protecting her hip so all the movement was coming purely from lumber (which I think is a serious problem). I normally give pain toolkit to patients who have been living with that pain from ages. I did send my patient back to her doctor to get proper pain medication and discuss about emotional difficulty she is having (she was very distressed when I first saw her). I do not suggest about doing exercise when on pain as evidences show that pain acts as a vicious cycle and as a physio normally we try to provide with isolated muscle exercise and when we are in chronic pain, instead of targeted muscles their synergist come in play. Like you have said I do advise them to accept their pain but I also encourage to take pain meds (after consulting with their doctors) if they need. I never challenge patients re:pain meds as that is not my profession and I just explain same to them. The patient I talked earlier that girl is now in anti-depressant, taking proper counselling and able to walk 10 mins (initially walking 5 mins was a challenge for her) and do loads of functional exercise provided by us. Well above is just my experience and the route that I take to treat chronic pain as I think it is multidisciplinary approach as their whole life is upside down.
    Will be waiting for more articles from you.

    1. Chronic pain is a big problem. It is also a pain of the clinicians not just patients, because of the complexities associated with it. More than the local changes in the tissues, changes occur in the brain that pain overwhelms the patients. They develop impaired bodily image, inability to differentiate between the right and left side (laterality), even thought of moving a body part becomes painful (but body isn’t yet moving), they develop fear of the movement, they catastrophize the pain including magnification, rumination and helplessness. Slowly with the time, there are bodily changes to name a few – stiff joints, weak muscles, impaired sensations and proprioception etc. You mentioned about the extremely weak oblique muscles here.

      The recent body of knowledge recommend active lifestyle, coping strategies, pacing, cognitive behavioral therapy, cognitive functional therapy, graded motor imagery etc for management of chronic pain.

      For the patient to start moving the body part, patient should believe that movement is not harmful. So, first they should be educated with knowledge of pain (why and how it occurs) with examples. The various factors that aggravate or alleviate their pain should be identified and be linked with how they alter pain. These factors mostly include social support, emotional triggers, stress etc. So patients should first learn that: not just biological, but also psychosocial factors modulate pain.

      Then interventions could be directed to improve the bodily image, laterality etc addressing the brain again. Motor imagery could also be may reduce the fear of movement, and thought of movement that is painful. Mirror therapy can train the brain to perceive the movement as painless. After addressing these central issues, activity pacing, coping strategies, and low grade aerobic exercise can be used which can be slowly progressed.

      As in most chronic pain without local tissue pathology, respecting pain too much isn’t very important. However, precipitating (severe) pain should be avoided. That’s why education and pacing is important.

      In 2015, Daenen and colleagues published a paper with a very interesting title, “Exercise, Not to Exercise, or How to Exercise in Patients With Chronic Pain? Applying Science to Practice” in clinical journal of pain. It is a good read I think. May be I write a next blog/ article on “how to exercise in chronic pain?”.

      I am very very pleased to see your comment here, and would like to discuss about “pain” again and again. Damn!!!! it is so interesting. And to hear different approaches to management is also interesting. There isn’t consensus among the all the researchers too. So, its lovely to hear different opinions and views. Also, not all patients with chronic pain improve with same approach. The treatment should be individualized.

  5. My mother is having chronic pain since a decade and i will implement your given knowledge starting from my own family. thank you sir.

    1. Hi Srijana, it is I think a good idea. Please do share the outcome with us. We are posting another blog today for exercises for chronic pain, so please read that too. That can be of some help.

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