Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage.” This definition emphasizes that the pain experience is multidimensional and may include sensory, cognitive, and emotional components. Additionally, the latter part of the definition allows for the possibility, as in chronic pain states, that the overt tissue damage may no longer be present. Pain persisting longer than 3-6 months is defined as chronic pain. Pain persisting for 3 months, however, is unlikely to resolve spontaneously and may continue to be reported by patients after 12 months. In addition, many of the secondary problems associated with chronic pain, such as deconditioning, depression, sleep disturbance, and disability, begin within the first few months of the onset of symptoms of pain. Studies indicate that early patient identification and treatment are essential to reduce pain chronicity and prevent further disability.

Chronic pain is one of the most common complaints seen in primary care. A survey of 89 general practices in Italy showed pain as a complaint for 3 of every 10 patients seen. Among these patients, pain was chronic for over half (53%). Women were more likely than men to report both acute (1.2:1) and chronic pain (1.8:1). The most common type of pain was musculoskeletal (63%). Similarly, a survey of over 10,000 women attending general practices identified a chronic pain complaint in 38% of women, with over 80% consulting their physician for their chronic pain complaint. The most common site for chronic pain was the back (54%).

Costs related to chronic pain are high. A survey of an employer claims’ database showed annual direct plus indirect costs for employees with painful conditions were 1.5-3.5 times greater than those for the average employee ($7088-16,874 vs $4849; P <0.01). Of the costs, about 60% were attributed to direct health care expenses. Among patients with low back pain, there is an estimated direct cost for medical expenses of $357 per month.

Acute pain occurs following some form of tissue injury (eg, ankle sprain) and is treated with RICE (rest, immobilization, compression, and elevation) and pain-soothing treatments, such as heat, ice, and massage. During the acute period of tissue injury and healing, patients appropriately limit activity to reduce risks of further injury (eg, development of a Charcot joint in a patient with neuropathy who risks aggravation of the injury because of impaired sensation). Studies show that patients improve best after acute injury when they reduce activities to what can be tolerated and allow healing to occur, in contrast to patients treated with either bed rest or acute physical therapy.

Chronic pain occurs after the acute healing period has been completed or in the context of chronic conditions (eg, neuropathy or arthritis). Restriction of activity in patients with chronic pain leads to deconditioning, with muscle and bone loss that increases pain and the risk for reinjury, and also promotes psychological sluggishness, if not depression. Consequently, the RICE approach will actually aggravate the symptoms of chronic pain. The natural response of restricting activities when experiencing pain is appropriate for acute injury pain but aggravates chronic pain. Patients with chronic pain require an active, progressive exercise program. They must learn appropriate strategies for treating pain, must avoid a tendency to restrict activity excessively, and must resume more normal activity levels through a stepwise, progressive activity program.

The most common chronic pain conditions in young and middle adulthood are low back pain, neck pain, and headaches. Musculoskeletal diseases rank fifth in generating hospital expenses and first in generating expenses related to work absenteeism and disability. The most common cause of chronic pain in older adults is degenerative joint and disc diseases, with arthritis causing chronic pain in over 80% of elderly patients with pain. Other causes of chronic pain that occur more frequently with increasing age are pain related to cancer, vascular disease, and neuropathy (eg, postherpetic neuralgia). Throughout the life cycle, pain can be associated with a variety of general medical conditions, such as Crohn’s disease or sickle cell anemia.

The overall pain experience includes primary pain– generating signals, along with common secondary problems that develop regardless of pain etiology and that complicate pain management (Figure 50-1). Both physical (eg, joint restrictions and deconditioning) and psychological (eg, depression and anxiety) changes frequently accompany chronic pain. Psychological distress is common. In a survey of 500 patients with chronic low back, hip, or knee pain, depression or anxiety accompanied pain complaints for 46% of patients. Both depression and anxiety were identified in 23%, with depression alone in 20% and anxiety alone in 3%. Patients with pain plus the combination of depression and anxiety experienced significantly greater pain severity and disability (P <0.0001 for each). Psychosocial stress may result from difficulties related to school or work, family relationships, social isolation, and legal and financial areas. Although the possibility of secondary gain (eg, litigation) may increase pain complaints, true malingering and factitious disorders are uncommon, occurring in only 1%-10% of patients. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), appropriately recognizes the ability of psychological variables to influence complaints of pain and offers the designation of a pain disorder, reflecting the coexistence of both physical dysfunction and psychological factors, both of which affect patients’ overall presentation and function. The family physician is in a unique position to identify and treat the physical and psychosocial factors influencing complaints of pain.

Chronic pain management focuses on reduction in symptoms and improvement of function rather than on disease cure. Both medication and nonmedication treatment modalities effectively decrease primary and secondary symptoms of chronic pain, with a range of treatments often being provided through a treatment team (Table 50-1). However, physicians and patients must accept that complete resolution of complaints of pain may not be possible. Thus they need to work toward rehabilitative goals of reducing symptoms and minimizing disability. Although modern medicine and rehabilitation techniques can be beneficial, the patient’s mindset must shift from searching for a medical cure to engaging in collaborative rehabilitation, geared toward decreasing pain and optimizing function. Goals of chronic pain rehabilitation are improvement in both pain and secondary symptoms, including deconditioning, depression, and disability (Table 50-2). Early identification and treatment should reduce the severity of secondary symptoms.

Psychological Approaches

Cognitive-behavioral therapy (CBT) is an effective psychological treatment technique that challenges dysfunctional precepts or perception of pain (“My pain must be cured. I can’t do anything if I have pain.”) and replaces it with one that is more conducive to change (“Pain limits me from lifting 25 pounds, but I can still carry a bag of groceries.”). CBT helps change patients’ perceptions or locus of control from external control (believing pain is not controllable by the patient) to internal control (believing the patient can positively influence symptoms). When patients endorse an external locus of control, they see themselves as victims of the pain and as powerless to improve their situation. This results in the expectation that only fate or the physician can help when pain becomes severe. When expectations are not met, these patients seek alternative evaluations and treatments (eg, another physician, a different diagnostic test, or surgical procedures) that may not be in their best interest. The clinician must help patients to move into a pain self-management, internal locus of control belief system, in which patients see themselves as the agent for change. Greater perceived self-control of pain decreases both pain and secondary symptoms. Although CBT is typically the purview of psychologists, the family physician can reinforce these concepts through interactions with the patient. Mind-body approaches can be very helpful and are often integrated with CBT in a self-management program (see section “Complementary and Alternative Therapies“).

Additionally, counseling should be directed toward issues concerning mood, sleep, and other psychosocial factors. Severe symptoms of depression or anxiety or significant psychosocial stressors may necessitate a psychiatric referral.

Physical and Occupational Therapy