Chronic Pain and Well Being

Over the course of human evolution, a system has developed that allowed the human animal to understand and recognize when something was not right with the organism itself both physically and psychologically. That something was pain. According to Marcia Meldrum (2003) pain is universal to all of mankind and is one of the oldest medical issues. The fact that the physiology of pain has been understudied for centuries has made pain a complex quandary for researchers and laypeople (2003). Centuries of thought and ingenuity has given rise to many remedies to pain. For example, in Europe the early 1600's saw the wide spread use of opium to relieve pain (Meldrum, 2003). Chloroform and ether became popular in the relief of pain during childbirth and dental work during the 1800's (2003). Still pain remains with us and through a better understanding of what pain is it can be dealt with effectively.

The American Psychological Association has defined the term pain to mean "the body's response to noxious stimuli that are intense enough to cause, or threaten to cause, tissue damage" (Gerrig & Zimbardo, 2002, Glossary, Section P). In addition, chronic pain has been defined as any pain lasting for a period of six months or more and causing disruptions to the daily life of the individual experiencing that pain (Molitor, Keck, & Nordal, 2004). Over the course of human evolution, a variety of structures, biochemicals, neural pathways, and systems have developed to convey the pain signal to the brain for interpretation. Pain also has the ability to create a plethora of physical and psychological issues for any given individual. This paper investigated the biological structures and functioning of pain in the human organism as well as physical and psychological issues brought about by pain, and finally some of the more current treatments to managing pain.

Pain is experienced by individuals in a variety of fashions such as auditory, olfactory, through taste, visually, and finally tactile or touch. Central to the pain debate is the apparatus that is involved within the human body that acknowledges pain and subsequently responds to that pain. The somatosensory system is in charge of regulating, interpreting, and dealing with the various pain sensations (Pinel, 2009). The somatosensory system is broken down into three subsystems which are: 1) the extroperceptive system, which is concerned with sensory sensations to the skin, 2) the proprioceptive system, which is concerned with body position and sensory information from joints, muscles and balance control organs, and 3) the interovceptive system, which is concerned with general conditions within the body (2009). The following section describes many of the structures and pathways contained within the brain and nervous systems that are responsible for sending, receiving, and interpreting those pain experiences that many individuals encounter daily.

The portion of the brain that is primarily concerned with the body's sensations is the forebrain which contains the primary somatosensory cortex or SI (Pinel, 2009). It has been discovered that the SI is somatotopic (2009). Somatotopic has been defined as being "organized according to a map of the body surface" (Pinel, 2009, p. 174). The SI has been shown to be contained in the postcentral gyrus (2009). A secondary somatosensory cortex has been defined as well and it lies ventrally to the postcentral gryus and within the lateral fissure (2009). Another one of the brain structures which is concerned with the sensation of fear is the amygdale (Kulkami, Bentley, Elliot, Youell, Watson, Derbyshire, et al., 2005). In addition to the physical structures of the brain, neurochemicals also play a key role in the pain experience. Specifically the catechol O-methyltransferase (COMT) enzyme has been singled out (Vastag, 2003). Research has demonstrated that with a slight manipulation of COMT at the genetic level, a reduction of the enzyme's efficiency, resulted ultimately in the under activation of pain relieving µ-opioid receptors (2003). The study stated that approximately 16% of the population contains the genetic-variant of COMT (2003). In a different study, it was demonstrated that the C-fiber neurons were involved in pain and subsequent blocking of those neurons reduced chronic pain (Hampton, 2004). Certainly the listed brain structures are not the only structures and chemicals responsible for the pain experience in humans as new research is constantly refining and adding to this list and our understanding of how the body generates the pain experience.

Pain has been thought to be an evolutionary response to changing environments internally and externally of the human species and as a result an adaptive process (Cortelli and Pierangeli, 2003). Two of the primary somatosensory pathways include the dorsal-column medial-lemniscus systems and the anterolateral system (Pinel, 2009). With respect to the dorsal-column media-lemniscus, a pain sensation enters the system through a skin receptor, then travels into the dorsal root, to the dorsal column, into the trigeminal nucleus, onto the medial lemniscus, into the ventral posterior nucleus, and finally into the somatosensory cortex for final processing (2009). The anterolateral system is comprised of three tracts which include the spinothalamic tract, the spinoreticular tract, and the intralaminar tract (2009). Each of these systems provide the brain with the specific types of sensory information needed to adjust to present pain. Another one of the human pain pathways includes the lateral pain systems (Kulkami, Bentley, Elliot, Youell, Watson, Derbyshire, et al., 2005). The lateral pain system includes the primary and secondary somatosensory cortices and the lateral thalamic nuclei (2005). Another system would be the medial pain system. This system includes the medial thalamic nuclei, the anterior cingulated, and the prefrontal cortices (2005). The purpose of this section was to give a brief outline of many of the neural pathways involved in how we experience pain. Research has been constantly refining the functioning of these pathways. As a result it is impossible, for this type of paper, to list and describe all of the neural pathways, their components, and how they operate.

Traditionally pain has been separated into three primary categories; those categories being nociceptive, neuropathic, and psychogenic. The purpose of the following section was to briefly introduce each of those categories.

Nocieptive pain, as defined by the American Psychological Association, is "pain induced by a noxious external stimulus; specialized nerve endings in the skin send this pain message from the skin, through the spinal cord, into the brain" (APA, 2008, p. N). Examples of this type of pain would be pain felt in or from the skin and muscles (Farkas, 2005) such as burning your finger or pulling a muscle.

Neuropathic pain is "pain caused by abnormal functioning or overactivity of nerves; it results from injury or disease of nerves" (APA, 2008, p. N). Neuropathic pain has also been defined as a "severe chronic pain in the absence of a recognizable pain stimulus" (Pinel, 2009). Typically, this type of pain occurs after an injury has healed (2009) resulting in the patient experiencing pain when no cause can be determined. Understandably, this type of pain is extremely frustrating for both the sufferer and the treating physician (2009).

Psychogenic pain has been defined as pain that is more associated with psychological factors rather than physical factors (Brenman, 2007). Common types of psychogenic pain include but are not limited to headaches, muscle pains, back aches, and stomach aches (2007).

All three types of pain played an important role in how sufferers dealt with the pain and how it affected their daily routine. Also understanding the nature of pain, which type of pain for example, is crucial to developing proper treatment options for the sufferer so that they may relieve and properly manage their pain.

With a basic understanding of what chronic pain was, the types of pain, and which brain and body systems are involved in the pain experience; it was time to turn the focus on to the prevalence of different types of pain.

Low back pain has been one of the most commonly reported types of chronic pain with 70 to 85% of individuals experiencing back pain some time during their lifetime (UAB, 2008). Additionally, in individuals 45 and younger, back pain is the number one factor in limited activity levels (2008). With over 1 million new cases of cancer been diagnosed yearly and half a million deaths as a result of cancer, the vast majority of patients report suffering from moderate to severe pain (2008). Forty five million headache pain sufferers report chronic severe disabling headaches each year (2008). A staggering 157 million lost workdays were reported due to migraines (2008). It was very evident that with the large numbers of individuals experiencing and dealing with pain on a constant basis, proper diagnosis of that pain was critical. The next section details many of the common practices to diagnosis pain.

There are many evaluation tools available to health practitioners to diagnose pain and/or chronic pain. However, the diagnosis of pain has proven to be a difficult task for many in the medical profession (Zeller, Burke, & Glass, 2008). The primary instrument used to diagnosis pain is the doctor interview (2008). This is the process through which a doctor or other health practitioner simple asks the patient questions relating to their illness history, injuries, or surgeries (2008). In some instances a questionnaire may be asked to be filled out by a patient (2008). In addition to these types of consultation, other tests may be required such as blood tests, imaging studies, diskograms or myleograms, or electromyographies (2008). A large part of diagnosing pain was correctly identifying the symptoms of pain and understanding which of the three types of pain classifications it fell. The following section describes some major symptoms of pain both physically and psychologically including some diseases and conditions.

A variety of physical symptoms and effects can accompany chronic pain. The following section describes some of the more common physical ailments associated with chronic pain. A pain ladder has been developed to help sufferers express the level of discomfort to their health practitioner. The pain ladder includes three levels: mild, moderate, and severe (Farkas, 2005). Symptoms can include sharp, shooting, or burning pain in muscles and joints (Erstad, 2007). Other symptoms can also include soreness, tightness, stiffness, fatigue, and/or sleeplessness (2007). Along with the physical symptoms of chronic pain, psychological symptoms may also be present and are reviewed in the following section.

The physical body is not the only part of the human anatomy susceptible to the effects of chronic pain. Chronic pain also affects the mental well-being of individuals. Some of the more common psychological effects are described in the following section.

One study that investigated 15 medical centers in the Americas, Asia, Africa, and Europe concluded that nearly 15% of chronic pain patients experienced depression as opposed to their non-chronic pain counterparts (Gureje, Von Korff, Simon, & Gater, 1998). Another study determined that depression was a risk factor of poor health outcomes in arthritic patients (Lin, Katon, Von Korff, Tang, Williams, et al., 2003).

Fibromyalgia or FM has been defined as "a chronic pain condition characterized by diffuse muscle pains, increased negative mood and sleep disturbance" (Hamilton, Affleck, Tennen, Karlson, Luxton, Preacher, & Templin, 2008, p.490). The chronic pain of FM has been shown to cause serious sleep disturbances which then cause the individual suffering from FM to miss out on the important recuperative sleep (2008). Recuperative sleep, as research has revealed, is critical to maintaining an allostatic load within the individual (2008). In conjunction with sleep disturbances, FM may also cause severe disruptions in the sufferer's cognitive, metabolic, and affective resources as well as their ability to reply and recuperate from stress (2008).

One study conducted on the American workforce concluded that approximately 2.0% of lost work resulted from arthritis related pain (Stewart, Ricci, Chee, Moganstein, & Lipton, 2003). The most common reason for missing work or reduced productivity at work was headache at 5.4% concluded one study conducted on the American workforce (Stewart, Ricci, Chee, Morganstein, & Lipton, 2003). Nicholson and Martelli (2004) reported that after individuals sustained head trauma, pain, specifically posttraumatic headaches, was the most commonly reported issue. The researchers reported rates as high as 90% of headache reported pain after head trauma injuries (2004). With such a widespread and varied exposure to pain, it was important for health practitioners to develop effective methods to treat chronic pain. The next section investigate the more popular physical an psychological methods in combating chronic pain.

The treatment of chronic pain is an ongoing battle with both the pain sufferer and their health practitioner working together. A variety of factors, such as mood disorders, employment difficulties, subpar coping skills, and even abuse, have been identified by chronic pain sufferers (Tunks, Weir, & Crook, 2008). Subsequently the treatment of chronic pain has been dealt with by using a variety of modalities such as psychopharmacological treatments, support groups, medical treatments, and psychological treatments (2008). The following sections reviewed two of the primary treatments used to combat chronic pain: physical and psychological treatments.

A large portion of pain treatment and management throughout history has been centered on the administration of drugs. During the 17^th century the use of opium became widespread due to its pain numbing properties (Meldrum, 2003). However, during the previous 30 years, research has worked diligently to replaced the use of opiates or at the very least develop other medications to be taken in conjunction with opiates (2003). Another fast up and coming popular treatment for chronic pain is acupuncture.

The acupuncture process involves the insertion of stainless steel needles into a patient's skin at defined points (Berman, 2007). A survey conducted in 2002 reported that nearly 8 million Americans tried acupuncture as a means to combat chronic pain (2007).

Other treatments include surgery, physical therapies, and exercise as methods for dealing with pain. Exercise, most arguably, is the easiest, most readily available, and cost effective of all the physical treatments and it's success rate has been very high. Participation in some type of exercise program has been shown to alleviate and/or manage chronic pain and improve a person's well-being (Martin Ginis, Latimer, McKechine, Ditor, McCartney, Hicks, et al., 2003). Also, a study conducted with sufferers of low back pain concluded that regular exercise was an excellent method to relieving that pain (Pengel, Refshauge, Maher, Nicholas, Herbert, & McNair, 2007). Another important aspect to consider when attempting managing pain is the psychological effects of pain. Psychological treatment approaches are described in the following section.

In addition to the physical treatments of pain management, psychological treatments and advancements have bee studied and developed as well. A variety of cognitive-behavioral theories that instruct individuals on the use of coping skills (Meldrum, 2003) have been developed and revised over that time frame. Cognitive-behavioral theory suggests that through a give and take relationship between sensation, cognition, emotion, and behavior, the individual can learn to deal with chronic pain effectively (2003). One studied tested the effectiveness of cognitive behavior treatments with a group of rheumatoid arthritis sufferers and found that cognitive behavior therapy to be very effective in managing pain through self-reporting (Zautra, Davis, Reich, Nicassio, Tennen, Finan, & et al., 2008). The study also concluded that coping skills were improved through the use of cognitive behavioral therapy (2008). The gate-control theory has been one such theory that has taken center stage when applied to the relief of chronic pain.

The gate-control theory simply states that pain can be blocked by cognitive and emotional factors (Melzack & Wall, 1965; as cited by Pinel, 2009). It has been postulated that an individual has the ability to trigger specific circuits within the spinal cord to prevent the inward bound pain signals (Melzack & Wall, 1965; as cited by Pinel, 2009). Through the use of neural mechanisms, numerous gate-control practitioners use counterstimulations, such as touch or electricity, to control or alleviate a multitude of chronic pain problems (Meldrum, 2003).

Another psychological treatment is the use of mindfulness mediation and other types of positive social support. While conducting a study with rheumatoid arthritis patients, it was concluded that the use of mindfulness mediation was effective in improving coping efficacy and those study participants with recurrent depression improved their affect greatly (Zautra, Davis, Reich, Nicassio, Tennen, Finan, & et al., 2008). A key to remember is that any pain management pain should include and incorporate both physical and psychological components.

This paper has arrived at the conclusion that chronic pain is a widespread and debilitating condition. Turk, Swanson, and Tunks (2008) stated in their study that not only was chronic pain a costly problem; it also affected all aspects of daily life for individuals whom suffer from it. In addition to that conclusion, Marcia Meldrum (2003) declared that pain was universal to all of mankind. It would appear that chronic pain or pain of any type is a common denominator in binding people from all walks of life and from all corners of the globe. It was determined that the investigation into both the psychological and physical causes and ramifications of pain was of the utmost importance.

The Turk, Swanson, and Tunks study (2008) concluded that both behavioral and psychosocial dynamics played a central role in the "experience, maintenance, and exacerbation of pain" (p. 213). In another study it was determined that depression was a risk factor of poor health outcomes in arthritic patients (Lin, Katon, Von Korff, Tang, Williams, et al., 2003). With respect to the physical issues resulting from chronic pain, the most common reason for work absences or lowered productivity was headache concluded a study carried out on the American workforce (Stewart, Ricci, Chee, Morganstein, & Lipton, 2003). Naturally, these widespread ailments lead to developments in treatments.

Treatment modalities for chronic pain were forged on both the physical and psychological fronts. One of the major driving forces behind these movements was the gate-control theory. The gate-control theory simply stated that pain can be blocked by a combination of cognitive and emotional factors (Melzack & Wall, 1965; as cited by Pinel, 2009). This line of reasoning allowed for the development of a variety of different treatment options for the chronic pain sufferer. For example, surgery, medications, holistic approaches as well as cognitive-behavioral therapies and mindfulness mediation have all been used to combat chronic pain.

Future considerations should continued to be made in furthering the knowledge of how pain works, ie. the physical pathways and neurochemical elements, the ways pain manifests itself in people, and further revisions and development of new treatment options.

Chronic pain impacts every individual to some extent daily. It is an issue that even early humans had to take note of and acknowledge. Currently hundreds of hours of work and millions of dollars are lost due to chronic pain. Both physical and psychological treatments due provide relief from chronic pain but it is this researchers opinion that pain will always be simply a part of life.

American Psychological Association (2008a). Nociceptive. Retrieved from the APA online website http://www.psychologymatters.org/glossary.html#n.

Berman, B. (2007). A 60-year-old-woman considering acupuncture for knee pain. JAMA, 297(15), 1697-1707. Retrieved on October 3, 2008 from JAMA Online.

Brenman, E.K. (2007). Pain management: Psychogenic pain. WebMD. Retrieved on October 19, 2008 from http://www.webmd.com/pain-management/guide/pain-management-psychogenic-pain.

Cortelli, P. and Pierangeli, G. (2003). Chronic pain-autonomic interactions. Neurol Sci, 24, S68-S70. Retrieved on November 2, 2008 JAMA online.

Erstad, S. (2007). Chronic pain symptoms. PainManagementHealthCenter. Retrieved on November 4, 2008 from http://www.webmd.com/pain-management/tc/chronic-pain-symptoms.

Farkas, H. (2005). Chronic Pain. WebMD. Retrieved on November 10, 2008 from http://www.emedicinehealth.com/chronic_pain/article_em.htm.

Gerrig, R.J. and Zimbardo, P.G. (2002). Glossary (16^th ed.). Allyn and Bacon, Boston. Retrieved on October 18, 2008 from http://www.psychologymatters.org/glossary.html#p.

Gureje, O., Von Korff, M., Simon, G.E., Gater, R. (1998). Persistent pain and well-being: A World Health Organization study in primary care. JAMA, 280(2), 147-151. Retrieved on October 3, 2008 from JAMA Online.

Hampton, T. (2004, November). Chronic Pain. JAMA, 291(24), 2933. Retrieved on October 3, 2008 from JAMA Online.

Hamilton, N.A., Affleck, G., Tennen, H., Karlson, C., Luxton, D., Preacjer, K.J., & Templin, J.L. (2008). Fibomyalgia,: The role of sleep in affect and in negative event reactivity and recovery. Health Psychology, 27(4), 490-494. Retrieved on October 28, 2008 from PsyARTICLES database.

Lin, .H.B., Katon, W., Von Korff, M., Tang, L., Williams, J.W. Jr., et al. (2003, November). Effect of improving depression care on pain and functional outcomes among older adults with arthritis: A randomized controlled trial. JAMA, 290(18), 2428-2434. Retrieved on October 3, 2008 from JAMA Online.

Martin Ginis, K.A., Latimer, A.E., McKechnie, K., Ditor, D.S., McCartney, N., Hicks, et al. (2003). Using ecercise to enhance subjective well-being among people with spinal cord injury: The mediating influences of stress and pain. Rehabilitation Psychology, 48(3), 157-164. Retrieved on November 1, 2008 from Academic Search Premier database.

Meldrum, M.L. (2003). A capsule history of pain management. JAMA, 290(18), 2470-2475. Retrieved on October 3, 2008 from JAMA Online.

Molitor, N., Keck, A., & Nordal, K. (2004). Coping with chronic pain. American Psychological Association. Retrieved on October 18, 2008 from http://apahelpcenter.org/articles/article.php?id=180.

Nicholson, K. and Martelli, M.F. (2004). The problem of pain. J Head Trauma Rehabil, 19(1), 2-9. Retrieved on November 3, 2008 from JAMA online.

Pengel, L.H.M., Refshauge, K.M., Maher, C.G., Nicholas, M.K., Herbert, R., & McNair, P. (2007). Physiotherapist-directed exercise, advice, or both for subacute low back pain. Annals of Internal Medicine, 146(11), 787-798. Retrieved on November 3, 2008 from Academic Search Premier database.

Pinel, J.P.J. (2009). Biopsychology (7^th ed.). Pearson Education Inc. Boston, Mass. United States of America.

Stewart, W. F., Ricci, J. A., Chee, E., Morganstein, D., & Lipton, R. (2003). Lost productive time and cost due to common pain conditions in the US workforce. JAMA, 290(18), 2443-2454. Retrieved on October 3, 2008 from JAMA Online.

Tunks, E.R., Weir, R., & Crook, J. (2008, April). Epidemiologic perspective on chronic pain treatment. The Candian Journal of Psychiatry, 53(4), 235-242. Retrieved on October, 28, 2008 from PsycINFO database.

Turk, D.C., Swanson, K.S., & Tunks, E.R. (2008). Psychological approaches in the treatment of chronic pain patients-When pills, scalpels, and needles are not enough. Canadian Journal of Psychiatry, 53(4), 213-223. Retrieved October, 18, 2008 from the PsycINFO database.

UAB Health Systems (2008). Chronic Pain. Retrieved on November 3, 2008 from http://www.health.uab.edu/15044/.

Vastag, B. (2003, March). Pain in the brain. JAMA, 289(11), 1368. Retrieved on October 3, 2008 from JAMA Online.

Zautra, A.J., Davis, M.C., Reich, J.W., Nicassio, P., Tennen, H., Finan, P., & et al. (2008). Comparison of cognitive behavioral and mindfulness meditation inteventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. Journal of Consulting and Clinical Psychology, 76(3), 408-421. Retrieved on October 15, 2008 for PsyARTICLES database.

Zeller, J.L., Burke, A.E., & Glass, R.M. (2008). Acute pain treatment. JAMA, 299(1), 128. Retrieved on November 5, 2008 from JAMA online.