Chronic pain is when a person suffers from pain in a particular area of the body (for example, in the back or the neck) for at least three months. Chronic pain can be caused by many things and lasts beyond the normal amount of time that an injury takes to heal. Some people get chronic pain such as arthritis or carpal tunnel syndrome from normal wear and tear of the body or from aging. Others have chronic pain from various types of medical illnesses such as cancer or diabetes. In some cases the chronic pain may be from an injury that happened during an accident or an assault. Some chronic pain has no physical explanation. Our bodies and minds work together. When we are stressed, we often feel muscle tension in our necks and backs, stomach problems and/or headaches. This pain is very real and, in addition to impairing sleep, leisure activities and potentially causing depression and/or anxiety, it can also cause people to carry themselves differently leading to real physical changes and ultimately physical pain. Approximately one in three Americans suffer from some kind of chronic pain in their life, and about 25% of them are not able to do day to day activities because of their chronic pain.



How is pain evaluated?

Providers generally assess pain during a physical exam, but how much pain someone is in is hard to determine. Every person is different and perceives and experiences pain in different ways. There is often very little consistency when different doctors try to measure a patient's pain. Many practitioners will evaluate the type of pain (i.e. sharp, dull, throbbing), the duration or the pain (constant, 2-3X/day etc), the intensity of the pain on a scale of 1 to 5 and what makes the pain better or worse. Sometimes the care provider may not believe the patient, or might minimize the amount of pain. It is important to remember that when you are depressed or have PTSD, your pain tolerance is often much lower; therefore, what would only mildly bother you at other times might cause significant distress when you have other mental health issues going on. This kind of experience often makes patients feel helplessness and hopeless, which in turn increases tension, depression and pain. If you do not feel like you are being taken seriously or if you do not feel empowered to control your trreatment, seek a second opinion.

Some people's chronic pain stems from a traumatic event. Under these circumstances the person may experience both chronic pain and PTSD. Approximately 15% to 35% of patients with chronic pain also have PTSD. One study found that 51% of patients with chronic low back pain had PTSD symptoms. For people with chronic pain, the pain may actually serve as a reminder of the traumatic event, which will tend to make the PTSD even worse. Survivors of physical, psychological, or sexual abuse have a greater risk for developing certain types of chronic pain later in their lives.

People with chronic pain are less able to function in daily life than those who do not suffer from chronic pain. They may have trouble with things such as walking, standing, sitting, lifting light objects, doing paperwork, standing in line at a grocery store, going shopping, or working. Many patients with chronic pain cannot work because of their pain or physical limitations. People who also have PTSD often have difficulty concentrating, problems sleeping, are hypervigilent (startle easily) and have to deal with things that trigger flashbacks. These things culminate to increase depression and anxiety which further limits their ability to lead a quality life. Because the pain and disability are always there and that may even become worse over time, many of people think suicide is the only way to end their pain and frustration. They think they have no control over their life. This frustration may also lead the person to use drugs or have unneeded surgery.

Depression is common for those with chronic pain. The reasons are as follows:

Pain causes sleep difficulties, leading to fatigue and irritability

Since chronic pain often causes problems with mobility, many people are home-bound. This leads to social isolation and a lack of enjoyable activities.

Due to the inability to work, there may also be financial difficulties

Stomach pain may also be present and caused by the stress of the chrinic pain and by the pain medications themselves.

The pain is distracting, leading to memory and concentration difficulties.

Sexual desire is reduced causing more stress in the patient's relationships.

Understandably, these symptoms may lead to feelings of despair, hopelessness and other symptoms of a major depression or clinical depression. People with chronic pain report a wide range of limitations on family and social roles leading to changes in the family, depression and anger among the patients and to stress, resentment and strain in family relationships.

So what can you do? When you realize the biopsychosocial nature of the problem, you can see that there are many things you can do to start feeling better. Talk with your doctor about getting a TENS (Transcutaneous Electronic Nerve Stimulation) unit. These units send tiny electrical impulses that feel like a tingling sensation and essentially block the nerve impulses to the area, thus relieving the pain. Look into massage or physical therapy. Many of the shiatasu back massagers available now help alot for people who "store" their stress in their upper to mid-back. While not a panacea, they are much cheaper than a massage therapist. Consider exercise. Many people actually begin experiencing fatigue, aches and pains when they are too sedentary. Talk with your doctor about swimming, walking, stationary biking or just stretching. Many malls open early so people can walk in the air conditioning. Work with your physician to address any side effects of the pain medication. Get out of bed and get dressed each day by 9am. Even if you cannot go far, try to at least get out on your porch so you can get some fresh air. Evaluate your diet. While chocolate and pizza may feel like comfort foods, they also will add to your depression (and weight). Join a support group. There are many online if you cannot get out to one. Finally, evaluate the ways your stress, depression, PTSD and pain might be causing a self-perpetuating cycle. The pain reminds you of the incident that caused the PTSD which causes more stress and increases the pain which continues to remind you of the PTSD. In these cases, a short-term course of antidepressant and/or anti-anxiety medication might be very helpful while you work through the trauma in therapy. Opiate-based pain medication can increase your depression so it is important to discuss treatment options with your doctor and maybe limit strong painkillers to one dose at night if possible

Ultimately, if you think of your problems as a woven blanket, if you start to pull one thread, the rest of the blanket starts to disintegrate. The same is true for your pain. If you start to do one positive thing, then it will have a positive impact on all other areas and exponentially reduce your pain. For example, just starting to do some simple doctor prescribed stretching or very mild exercise will help not only reduce weight, increase mood and self-esteem, improve sleep and reduce aches and pains. They key is to pick something you are willing to change and start there. Patients with PTSD will need at some point to engage in counseling to deal with the trauma. Many patients find that once they start physically feeling a bit better, they have the strength to face the trauma. During this period though, patients need to take extra good care of themselves. Recovery from PTSD is a full-time job. Most patients will find that they have a hard time working or even keeping up with household chores. Prepare for that ahead of time so it does not add to your stress. PTSD is real and as you start to face the trauma, you might experience crisis symptoms again such as confusion, difficulty making decisions and depression. These symptoms will subside, but you need to be prepared to encounter them and deal with them one more time. There is no easy answer for patients with chronic pain and PTSD. They are extremely interrelated and debilitating. Life will never be exactly the same. Nevertheless, with comprehensive treatment, many people can regain their prior quality of life.