When the pain just won’t go away

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Professor Jenny Firman
Chief Health Officer
Department of Veterans’ Affairs
 

Do you have chronic or persistent pain? If so, you are not alone – almost 1 in 5 Australians aged 45 or over experience chronic pain.

If you do suffer from persistent pain, DVA can help you manage it so that you can get back to enjoying the good things in life.

What is pain? Pain occurs when a harmful stimulus is felt (e.g. boiling hot water on your hand) which is then transmitted as a signal through the spinal cord to the brain where it is perceived as pain. Your brain then tells you to pull your hand away. This is a protective response and very normal. 

Acute pain occurs with tissue damage of any sort – e.g. a sprained ankle, a broken bone or a surgical incision – and usually tends to resolve over 6 weeks or so. The pain prevents you from doing further harm – it is a protective response.

Chronic or persistent pain is pain that persists after the damaged tissues have healed and is present daily for more than 3–6 months after the initial injury.

Persistent pain is thought to be a result of the normal protective response pathways becoming increasingly sensitised such that activities that previously caused no problem can suddenly trigger the pain response. The brain becomes sensitised in the absence of any ongoing tissue damage. The tissues have healed, but the pain continues and can result in an escalating cycle where you avoid further activity and experience increasing pain, which has a negative effect on your mood and sense of wellbeing. 

In other words, the normal protective response does not settle down once the initial injury has resolved but continues to ramp up. The longer our pain system is heightened, the more protective it becomes.

Why this happens is not known but is thought to be a mix of physical, psychological, social and environmental factors. Persistent pain can be exhausting for both the patient and their family as it becomes all consuming, and the patient loses motivation and can become irritable and frustrated. 

Treatment however is available and is focused on retraining the brain and the body to desensitise the abnormal nerve pathways, which results in less pain. 

Many patients with persistent pain also have a mental health condition such as depression or anxiety, but the relationship is not straightforward. Unexplained pain is a common feature of a depressive illness and already having had depression or anxiety increases your risk of developing persistent pain. Any co-existing mental health disorder will also need treatment.

A multidisciplinary approach is considered the most effective way of managing persistent pain. This can be managed by your GP or, if more severe, there are specialised pain clinics that can help.

Your treatment plan will include learning about your pain, setting goals to improve your day-to-day function and increasing your activity levels. Your GP or pain clinic will take a full history to rule out any treatable cause of the pain. They will then develop a plan with you to address improving your function, manage any psychological or social factors, and minimise the use of medications, with the aim of having you resume meaningful and enjoyable activities.

Being active is important as inactivity leads to loss of conditioning and muscle mass, which leads to further stiffness and guarded movements. Physical activity improves strength and flexibility. A physiotherapist or exercise physiologist can develop an individual exercise plan to help you re-learn how to move and how often. This could be based on goals such as being able to walk the dog or walk around the park. The program should be self-paced, with gradual increases in activity over an agreed time frame.

An occupational therapist can help you to identify activities or movements that decrease your pain. They can help you to develop confidence in undertaking activities and can teach you safe ways of doing things in real life situations.

A psychologist can teach you relaxation techniques or challenge you to think about your pain in a different way. They can help you build new coping skills and address any co-existing mental health conditions.

Social workers may be able to assist with increasing your engagement with the local community.

Pain-relieving medications are useful in the short term, but their role in persistent pain should be reviewed by your treating doctor. Strong pain killers such as opioids can actually cause more harm by making the brain more sensitive to pain and can cause drowsiness. Newer treatments such as medicinal cannabis have only low to moderate quality evidence to support their use in persistent pain. Tapering (gradually reducing) your medication may paradoxically make you feel more alert and reduce your pain.

Loved ones and carers may become overly protective of their family member with persistent pain and want to take over all household duties,  encouraging the person to rest and discouraging activity with the aim of preventing their pain from getting worse.  We know activity, movement and a focus on functional activities are vital. Encouragement and support to keep going is preferred rather than encouraging rest and a reduction in activity.

Other keys to recovery include having adequate sleep (again, the psychologist may be able to help), a good diet, and reducing alcohol and smoking.

DVA will fund persistent pain treatment for all Gold Card holders and White Card holders with an accepted condition relating to the persistent pain. This includes specialist pain clinics, allied health providers and your GP. You may also be eligible for the DVA Veterans’ Home Care Program, which can provide assistance with household services if you are limited by pain.

There are strategies for re-training you brain to enable you to manage your pain. Talking to your GP is a great place to start.