Chronic pain: What is it and what are the treatment options?

Chronic pain is defined as pain that lasts beyond 12 weeks. Photo / File

“Was I the victim of the pain mistake?” So wondered Paul Biegler, five months after a seemingly innocuous knee injury continued to plague his days. He had developed patellofemoral pain syndrome (PFPS) – a common condition that usually dissipates of its own accord – after overloading the panniers of his bicycle. The pain would not let up with rest, nor gentle exercise like swimming, Biegler, now 59, recalls.

With all of the sports he enjoyed stripped from his life, the science journalist and former doctor sought help – and was told that, as the pain had persisted for so long, the original injury had probably healed. It was not the PFPS causing his discomfort, then, but central sensitisation – where symptoms get “stuck” in the nervous system, causing neurons to become over-sensitive, and then overreact to the stimuli they encounter.

Biegler’s nervous system, he says, was not just amplifying pain signals from his knee. It also seemed to be picking out “non-painful signals from the knee, like movement, pressure, and even a breeze blowing on my knee, and turning those non-painful stimuli into pain”. His “brain was making pain”, he recalls. And that pain – though from the mind instead of the body – “was real, it was 100 per cent real”.

Biegler’s persistent discomfort is something many in the UK have experienced. Chronic pain – defined as pain that lasts beyond 12 weeks – affects an estimated 28 million Britons, with back pain alone accounting for more than 12 million work days lost every year, according to the public service union, Unison. The problem has become so widespread that chronic pain is increasingly considered a condition in its own right, with a growing amount of funding going towards research projects that seek to understand why some people experience pain long after it should have vanished.

Treatment for chronic pain ranges from surgery to hypnosis. Photo /123RF

For now, though, central sensitisation – that hyper-awareness around a particular part of the body – remains poorly understood. There is no definitive reason why it strikes, aside from a vague theory that it is linked to predisposing factors, such as pain thresholds and stress. And without that understanding, people like Biegler – formerly active and well – find their lives coming unstuck, with their health nosediving and livelihoods destroyed.

It took a long time for him to learn that you can have pain, but that it’s not indicative of ongoing damage to the tissue. “And that is a very vital piece of knowledge,” he says. “It can actually [give you] confidence to start moving again.”

Varying approaches

Biegler discusses his route through this fog in Why Does It Still Hurt?, a book that also describes the latest research into chronic pain and the experiences of a host of other sufferers. There’s the policewoman and ultramarathon runner whose pain, initially brought on by a cycling accident, took her to the brink of suicide; the boat-builder whose spinal injury forced him out of work; and the teacher who was left barely able to stand following a series of knee operations.

Their stories highlight how little is known about chronic pain and how widely treatment varies, with prescriptions ranging from surgery to hypnosis. Biegler was advised to seek out surgery, despite the chances of the operation solving his problem being relatively low. Such a lack of options means many sufferers are left in agony, and without answers.

Rich Harrison, co-head of the Centre for Integrative Neuroscience and Neurodynamics at the University of Reading, is part of Pain Research Reading – a consortium of chemists, pharmacologists, psychologists, neuroscientists and philosophers trying to ascertain where pain comes from, and how best to treat it. Their working hypothesis is that patients divide into two groups – those that feel their pain is rooted in their brain and those that feel it is rooted in their body – and that interventions such as mindfulness or cognitive behavioural therapy only benefit the former and are unlikely to benefit the latter.

Direct action

Consequently, a patient at the mind-centric end of the spectrum can see dramatic improvements in their condition, while those that are body-centric can find a course of psychotherapy disheartening.

“Patients with chronic pain already have a horrible journey to navigate their way through a system to be able to find the right treatments for them,” says Harrison. “We’re very much of the belief that if we could cut down the time it takes for that patient to find the right thing to help them manage their condition, then that would be one step in the right direction.”

Other research is focused on more direct action. Findings from a recent, small study at Duke University, in North Carolina, showed that wearing green-tinted glasses for four hours a day over a fortnight significantly reduced anxiety among sufferers of fibromyalgia, a chronic pain condition thought to affect one in 20 people in the UK.

“Those who wore the green eyeglasses showed higher odds of a 10 per cent decline in opioid use, demonstrating that their pain was adequately controlled,” explained Padma Gulur, who led the study. One theory for the findings is that green light, which falls in the middle of the light colour spectrum, triggers the release of natural painkiller-like chemicals in the body called enkephalins, and may also change the way the brain processes pain.

Researchers are planning to further interrogate how the cones and rods in the eyes (which sense light) send pain messages to the brain. It could eventually have an impact on the consumption of opioids in the UK – which is the highest per capita in the world.

Other studies have found that hypnotherapy can be effective in reducing chronic pain. Caroline Atkins, 53, was born with Ehlers-Danlos Syndrome – a genetic disorder that causes the regular dislocation of joints and leads to osteoarthritis – and has been managing pain all her life.

“I take a lot of very strong painkillers as part of my pain management but often they are not enough on their own,” she explains. In 2016, she tried hypnotherapy for the first time.

“Frankly, hypnotherapy always seemed a bit ‘woo-ey’ and I was slightly scared of being out of control,” she says. But, with her life becoming ever more limited by her pain, despite numerous operations, and with no other treatments on offer, she decided to give it a go.

In her first session she was induced into a trance-like state. She then went on to lose all feeling in her hands and feet – the latter being an endless source of pain – which was “wonderful”, she says.

“To have half an hour of complete relief from pain in the hands and feet was miraculous.”

Atkins no longer has the sessions, but employs the tools she was taught in them, which have continued to help; she believes they would be of benefit to anyone with the kind of chronic, intractable pain that does not respond to standard treatment. “It was not a complete solution and I still need the medication,” she says. “But it has been invaluable in helping me cope with life and allow me to do more with it.”

A combination of treatments better tailored for patients is the only thing that will move the needle on the UK’s chronic pain problem, says Harrison. Yet, in the short term, he thinks things are likely to get worse.

“[Chronic pain] is very susceptible to stress, depression, anxiety, [poor] diet and [a lack of] sleep,” he says. “Life is really, really hard for lots of people at the moment. Unfortunately, that means that chronic pain is likely to become more of an issue.”