Associate Professor Yoong Chee Seng, Senior Consultant Anaesthetist & Director of Chronic Pain Service, Changi General Hospital, explains the types of chronic pain and how the condition is treated.
You know what regular pain feels like – the sharp jolt from a cut, the throbbing of a headache, or the dull ache of a bruise. These examples of pain are usually short-lived. Some acute pain, specifically those arising from major surgery or trauma, can be severe though they usually ease with time and healing.
Pain that persists beyond the period of normal tissue healing, or longer than three months, is defined as chronic pain. Common examples include chronic low back pain, osteoarthritis, cancer pain, and various types of neuropathic pain.
For those living with chronic pain, everyday activities are a struggle. In a study about chronic pain, the findings reveal that about two-thirds of sufferers have trouble sleeping, while almost half report having difficulty in doing household chores. Nearly one-fifth of sufferers also say that pain affects their relationships with family and friends.
The initial reaction to chronic pain is usually fear. For some, persistent pain that fails to respond to treatment leads to anxiety, depression, anger and irritability.
Nerve pain (neuropathic pain)
An example of chronic pain, neuropathic pain (commonly known as nerve pain) is caused by damage to a nerve or a dysfunction within the nervous system. When nerves are damaged, a person may feel abnormal sensations (tingling), painful sensations (burning or stabbing), or no feeling at all (numbness).
Nerve pain can also be described as electric shock-like, shooting or stabbing, depending on the circumstances and particular type of condition. It can be a symptom of many different conditions, including diabetes, shingles, cancer, HIV, traumatic nerve injuries and stroke.
Regardless of the cause, neuropathic pain is difficult to treat as pain is an invisible, subjective symptom. There are no objective tests to detect pain or measure its intensity. Often, the doctor has to depend on the patient’s description.
The psychological and social consequences of neuropathic pain can be enormous. Living with chronic nerve pain may lead patients to feel that they have lost control of their life. It can also rob a person’s ability to enjoy life, maintain relationships, fulfil spousal and parental responsibilities, or perform well at work.
Diabetic nerve pain
Also known as diabetic neuropathic pain, diabetic nerve pain is one of the most common causes of chronic pain. It results from nerve damage due to high blood-sugar levels that have persisted for a long period of time.
Patients with painful diabetic nerve pain often experience peripheral nerve pain (which affects body parts such as hands and feet), including burning pain, pins and needles, or shooting pain. This can lead to muscle weakness and loss of reflexes, thereby leading to problems with balance and walking.
Almost one in five patients with diabetes suffers from nerve pain, and its prevalence has grown as the number of adults living with diabetes has increased.
David (name changed to protect privacy), a 46-year-old logistics manager, was first diagnosed with Type 2 diabetes about 12 years ago. But it was only recently that he was referred to the neurology clinic by his primary care doctor for pain in his feet.
He experienced stabbing pains in his toes followed by numbness in his feet with some gait imbalance when he walked on uneven surfaces. Since then, the numbing sensation has slowly progressed to the middle of his shins. The pain reached an unbearable level that when he walked, it felt like walking barefoot on broken glass. At night, he feels a burning sensation in his feet when he lies down, and the stabbing pain continues in his toes and shins. He rates his pain as an eight out of 10.
David mentioned all these symptoms to his primary care doctor only recently because he thought he could just live with them. Despite his limited mobility, he seems like any other healthy man. It is hard to tell that he, or any other person plagued with chronic pain, could be suffering so much.
Causes of nerve pain
Nerve pain may result from damage to the nerves that normally sense pain and transmit pain signals, or from damage to parts of the nervous system that transmit pain signals and interpret them (e.g. spinal cord and the brain, or the central nervous system).
Examples of conditions that can cause nerve damage include:
- Slipped disc
- Malignant tumours
- Excessive, repetitive use of joints
How nerve pain is treated
Treating nerve pain starts with reaching out and asking for help. If you think you might have nerve pain, make an appointment to see your doctor. Clearly describe the pain you feel and which parts of your body it affects. Patients can also keep a diary and record the timing and duration of the pain.
If you have diabetes, have your foot examined every year to check for peripheral nerve disease. A comprehensive foot exam includes checking the skin, muscles, bones, circulation, and sensations in the feet. It is important to check sensations in the feet because losing sensitivity increases the risk for developing foot sores and other problems.
Nerve pain is not ordinary pain, conventional painkillers often don’t work well for treating it. If your current prescribed medicine isn’t helping, talk to your doctor about other options, including adjusting the dose of your medication and other ways of fine-tuning your pain management plan. It is important for patients to know that with proper treatment, the pain can be alleviated and they can enjoy a better quality of life.
Doctors use a wide range of treatments to help alleviate nerve pain including:
- Topical treatments (creams, gels or patches) containing capsaicin, a local anaesthetic
- Medications such as antidepressants, anticonvulsants, opioids (which are reserved for a very small group of patients because of potentially serious side effects)
- Physical therapy to improve muscle strength, flexibility, balance or general physical health
- Psychological therapy to improve selfmanagement of pain and pain-related disability, and reduction of emotional distress
- Injections and surgery
- Acupuncture, meditation, and other traditional treatments
FAQs about nerve pain
1. How is chronic pain evaluated?
Your doctor will try to identify the cause of pain by asking you to describe your symptoms in detail. He or she will perform a physical examination and may recommend diagnostic testing, such as blood tests, nerve conduction studies, and imaging studies (X-ray, CT-scan or magnetic resonance imaging (MRI)), or even tissue biopsies.
There are no diagnostic tests to prove that pain exists, although the results of such tests may suggest a cause. Unfortunately, unlike acute pain, the exact cause of chronic pain is sometimes difficult to identify. In this situation, your doctor will ensure that the chronic pain is not due to a life-threatening illness, or an illness that requires urgent surgery or treatment.
Patients often have problems describing their pain in words, and differences in genetics, physiology, life experiences, and other socioeconomic factors affect the way each individual perceives pain. Therefore, no single event will cause the exact same pain experience in two people. A number of instruments are available to help measure chronic pain, ranging from simple pain-rating scales to detailed “multidimensional” pain survey instruments that are especially helpful for research studies.
Trying to sort out whether pain is “real” is not particularly helpful. Unless a person is consciously fabricating symptoms to his or her healthcare provider, all pain is real.
2. How can a patient describe his/her pain symptoms to help the doctor make the correct diagnosis and prescribe the best treatment?
As only you know how your pain feels, it's important for you to pay attention and try to describe it as accurately as you can. Use any adjective that can paint an accurate picture of your pain to your doctor, or use pain descriptors such as:
3. What other tools can a patient use to describe his/her pain?
A pain diary is a record of the occasions when you feel pain. It will help your doctor determine what kind of pain you have, and it will help you and your doctor find out what worsens your pain or eases it. Take note of:
- When you felt pain
- How bad it is, using the pain scale of 0–10
- How your pain feels (see pain descriptors on the left)
- What lessened the pain
- What made the pain worse
- Has your pain interfered with your sleep
4. How can family members help to take care and support pain sufferers?
Taking care of a loved one with chronic pain is difficult, and seeing him/her suffer is heartbreaking. The most important thing to do is to give comfort when the pain is particularly severe, and provide support and encouragement in finding the best treatment.