Chronic Pain Med & Treatment Guide

ACPA Quality of Life Scale 1
ACPA Quality of Life Scale 2

ACPA Arthritis Ability Chart
ACPA Migraine Conversion Chart

Guidelines for Low Back Pain

Art of Pain Management: Art & Music

The famous physician, Dr. Albert Schweitzer proclaimed in 1931 that:
“Pain is a more terrible lord of mankind than even death itself.”

Chronic Pain is pain lasting 12 weeks or longer after an injury has healed.

• Pain is a serious medical condition that can impact anyone at any time.
• Pain that lasts only for a short period of time is called Acute Pain; it’s a normal feeling that typically alerts us to a possible injury.
• Chronic Pain is very different. Chronic pain is defined as any pain that lasts for 12 weeks or longer. According to the Institute of Medicine, chronic pain is estimated to affect approximately 116 million American adults.
• Chronic Pain may be caused by an initial injury or there may be an ongoing cause, like a medical illness.  But for some people, there may also be no clear cause.  Other health problems, such as fatigue, sleep disturbance, decreased appetite, and mood changes, often accompany chronic pain.
• Chronic Pain often affect people’s ability to participate in daily tasks.  When people have chronic pain, the parts of the brain associated with mood and attention are constantly active:
  1. The brain ends up being occupied with pain signals.
  2. This helps explain why people with chronic pain suffer from:
     • Depression, Anxiety, Difficulty Focusing, Lack of Sleep

• 116 Million American Adults struggle with Chronic Pain in 2016
• Chronic Pain affects more Americans than Diabetes, Heart Disease and Cancer combined
• Chronic Pain is the Top Cause of Disability in the U.S.
• Chronic Pain disturbs all aspects of life: Mood • Activity • Energy • Sleep

Chronic Pain costs the U.S. over $560 billion annually

• Pain is a significant public health problem that costs society at least $560-$635 billion annually in 2010 dollars (an amount equal to about $2,000 for everyone living in the U.S.).
• $560-$635 billion annually combines the medical costs of pain care and the economic costs related to disability days and lost wages and productivity.
• Pain is cited as the most common reason Americans access the health care system. It is a leading cause of disability and it is a major contributor to health care costs.
• According to the National Center for Health Statistics, 76.2 million, one in every four Americans, have suffered from pain that lasts longer than 24 hours and millions more suffer from acute pain.
• Chronic pain is the most common cause of long-term disability.
• The diversity of pain conditions requires a diversity of research and treatment approaches.
• Pain can be a chronic disease, a barrier to cancer treatment, and can occur alongside other diseases and conditions (e.g. depression, post-traumatic stress disorder, traumatic brain injury).
• For infants and children, pain requires special attention, particularly because they are not always able to describe the type, degree, or location of pain they are experiencing.

Source   NIH.gov

WASHINGTON, D.C. 2011 — More than one-third of Americans in their mid-50s and older have chronic pain in their neck or back, and a similar percentage report chronic knee or leg pain. Further, more than one in five adults in their late 40s through late 80s has some other type of recurring pain. Chronic pain conditions increase rapidly from about ages 25 to 60, after which reports of chronic pain increase only slightly or decrease.

These findings are based on 2011 Gallup-Healthways Well-Being Index daily tracking data, encompassing surveys with more than 353,000 U.S. adults, aged 18 and older. The resulting sample sizes for every five-year age group — ranging from roughly 2,800 to 47,000 cases — allow for a granular look at how chronic pain progresses as Americans age.

The Gallup-Healthways Well-Being Index measures the prevalence of chronic pain by asking respondents if they have a neck or back condition, a knee or leg condition, or another condition that caused recurring pain in the last 12 months.

Overall in 2011, an average of 31% of Americans reported having a neck or back condition, 26% had a knee or leg condition, and 18% had another condition causing recurring pain. Gallup finds similar rates each year since tracking began in 2008. In all, 47% of Americans reported having at least one of the three types of chronic pain measured in the survey, including 7% who reported all three types.

Americans’ reports of chronic pain conditions increase most sharply from their mid-20s to late 50s. This is likely related to the repeated use of muscles, joints, and ligaments over time, as well as this age group’s increased likelihood of being overweight or obese. A key finding, however, is that beginning at about age 60, rates of self-reported chronic pain level off and do not increase further, even as Americans move into their 70s, 80s, and 90s.

The percentage of Americans reporting they have a neck or back condition climbs steadily between the ages of 18 and 59, rising from 16% among 18- to 23-year-olds to 37% among 54- to 59-year-olds and then plateaus at about 36% among people ages 60 and older.

The pattern for knee and leg conditions is similar. Thirteen percent of 18- to 23-year-olds report this type of pain. It rises rapidly to 21% among those aged 36 to 41 years, then to 34% among those aged 54 to 59, and slightly increases to 38% among 84- to 89-year-olds.

The pattern is somewhat different for the percentage of Americans who report “other chronic pain conditions.” The 9% of 18- to 23-year-olds who have other chronic pain conditions steadily increases to 24% among those in their late 50s, but then slowly declines to 18% among those ages 90 and older.

The rates would likely continue to compound into old age, except for the mortality rates associated with chronic pain conditions. According to the U.S. Centers for Disease Control and Prevention, 47% of people with arthritis have one comorbid condition such as heart disease, chronic respiratory conditions, diabetes, or stroke. It is possible that those who survive into their 70s and 80s are typically less likely to have such chronic pain conditions.

Source Gallup.com   2011 survey of 353,000 U.S. Adults

• Abdominal Pain
• Back Pain
• Cancer Pain
• Cervical Neck Pain
• Disc Pain
• Failed Back Surgery Syndrome
• Fibromyalgia
• Joint Pain
• Tension Headache
• Chronic Migraine
• Myofascial Pain
• Neuralgias
• Pelvic Pain
• Peripheral Neuralgia
• Postherpetic Neuralgia (PHN)
• Reflex Sympathetic Dystrophy
• Shoulder Impingement
• Trigeminal Neuralgia

The goal of pain management is to improve function, enabling individuals to work, attend school, and participate in day-to-day activities. People with pain and their physicians have a number of options for treatment; some are more effective than others. Sometimes, relaxation and the use of imagery as a distraction provide relief. These methods may be powerful and effective, according to those who advocate their use. Whatever the treatment regime, it is important to remember that, while not all pain is curable, all pain is treatable.

Advanced Pain Consultants perform the following pain treatments:

• Cryoablation
• Disograms with Provocative Discography
• Epidural Steroid Injections
• Facet Blocks
• IDET
• Joint Injections
• Narcotic Maintenance
• Nerve Blocks
• Nucleoplasty
• Occipital Nerve Blocks
• Pain Medicine Management
• Percutaneous Disectomy
• Physical Therapy
• Radiofrequency Ablation
• Sacroiliac Joint Injection
• Spinal Cord Stimulators
• Steroid Injections
• Sympathetic Block
• Transforaminal Nerve Blocks
• Trigger Point Injections

Treatment varies depending on the duration and type of pain.  For the most part, the medications listed below have been shown in clinical trials to relieve or prevent pain associated with a specific condition(s), but none have been proven fully effective in relieving all types of pain. A health care professional should be consulted to determine which medication is effective for a given pain condition and what to expect for pain relief and side effects.

Many patients do not ask for or get help because they have common misperceptions regarding pain control. Here are 10 reasons they do not seek pain relief:

1. I will become addicted. Fear of addiction is very common for people who take opioid analgesics (narcotics) for pain relief. Drug addiction is defined as dependence on the regular use of opioid analgesics to satisfy physical, emotional, and psychological needs rather than for medical reasons. Pain relief is a medical reason for taking opioids. Therefore, if you take opioid analgesics to relieve pain, you are not an “addict,” no matter how much or how often medicines are taken. Drug addiction in patients following physician’s orders is rare, and almost never occurs in people who do not have a history of drug abuse prior to illness.
2. I won’t be able to handle the side effects of pain medication. Some people think pain relief medication will make them feel drowsy, dizzy, or not “themselves.” Not everyone has side effects from analgesics. However, some of the more common ones are drowsiness, constipation, and nausea and vomiting. If you experience side effects from opioid pain relievers, they can usually be treated successfully. Often side effects get better in several days.
3. Pain is an inevitable consequence of many diseases. There are many patients who never experience pain. Most pain can be relieved safely and effectively.
4. I should be able to tolerate the pain. People’s religious, moral, cultural, or family backgrounds can lead them to think that needing pain medication makes them weak. It is actually pain that can make a patient weak. Not only can pain weaken the body, it can also weaken the spirit.
5. My doctor won’t understand my pain. Some people are afraid health care professionals will think they are exaggerating the level of pain or are being too cowardly. It is a patient’s right to receive assistance in pain management. In fact, if your doctor or nurse does not understand and control your pain, you may need to seek further assistance.
6. If I complain, I am not being a good patient. Some people are afraid of being a burden or nuisance if they talk about their pain. Understanding how bad pain is helps the health care professional decide how to treat it. You are the best judge of your pain, and the better you can describe it, the more helpful it will be. It may help to keep a record with ratings of pain and what is tried for pain relief. The record helps you and those who are caring for you understand more about the pain, the effects it has, and what works best to ease it.
7. Pain means my disease is getting worse. Some people think pain is a sign of deteriorating health. However, pain may occur at any time during the course of an illness, for any number of reasons. Pain may even occur for people whose condition is stable and whose life expectancy is long.
8. If my doctor focuses on pain control, it will distract him/her from why I am here. Working on managing the pain will actually help improve your quality of life. In fact, chronic unrelieved pain can cause patients to have other medical problems.
9. I will not be able to afford pain medication. Most health plans cover partial costs for prescription medications that are medically necessary. Use of a generic medication is an option in some situations for lowering costs. Many pharmaceutical companies have patient drug assistance programs to help with the costs associated with pain medication.
10. I have too many pills to take as it is. Some people find it hard to remember to take all of their medications. Return of the pain is not the best reminder to take pain medication. It is important to try to prevent the pain before it starts or gets worse by using a pain-relief method on a regular schedule. If pain begins, do not wait for it to get worse before doing something about it.

Pain in its most benign form warns us that something isn’t quite right, that we should take medicine or see a doctor. At its worst, however, pain robs us of our productivity, our well-being, and, for many of us suffering from extended illness, our very lives. Pain is a complex perception that differs enormously among individual patients, even those who appear to have identical injuries or illnesses.

The burden of pain in the United States is astounding.  More than 100 million Americans have pain that persists for weeks to years.  The financial toll of this epidemic cost $560 billion to $635 billion per year according to Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research^[1], a recent report from an Institute of Medicine (IOM).  Pain is ultimately a challenge for family, friends, and health care providers who must give support to the individual suffering from the physical as well as the emotional consequences of pain.

What is pain? The International Association for the Study of Pain (IASP) defines it as: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. The IASP definition means that pain is a subjective experience; one that cannot be objectively measured and depends on the person’s self-report. As will be discussed later, there can be a wide variability in how a person experiences pain to a given stimulus or injury.

Pain can be classified as acute or chronic, and the two kinds differ greatly.

• Acute pain, for the most part, results from disease, inflammation, or injury to tissues. This type of pain generally comes on suddenly, for example, after trauma or surgery, and may be accompanied by anxiety or emotional distress. The cause of acute pain can usually be diagnosed and treated.  The pain is self-limiting, which means it is confined to a given period of time and severity.  It can become chronic.
• Chronic pain is now believed to be a chronic disease condition in the same manner as diabetes and asthma. Chronic pain can be made worse by environmental and psychological factors. By its nature, chronic pain persists over a long period of time and is resistant to many medical treatments. It can—and often does—cause severe problems.   People with chronic pain often suffer from more than one painful condition.  It is thought that there are common mechanisms that put some people at higher risk to develop multiple pain disorders.  It is not known whether these disorders share a common cause.

We may experience pain as a prick, tingle, sting, burn, or ache. Normally, acute pain is a protective response to tissue damage resulting from injury, disease, overuse, or environmental stressors.  To sense pain, specialized receptors (called nociceptors) which are found throughout the body, trigger a series of events in response to a noxious (painful) stimulus.  The events begin with conversion of the stimulus to an electrical impulse that travels through nerves from the site of injury or disease process to the spinal cord. These signals are transmitted to a specialized part of the spinal cord called the dorsal horn (see section on Spine Basics in the Appendix), where they can be dampened or amplified before being relayed to the brain.

Pain signals from the head and face directly enter the brain stem where they join the pain pathways that travel from the spinal cord to the brain.  One central place these signals travel to is the thalamus. The thalamus is a relay station that distributes sensory signals to many other brain regions—including the anterior cingulate cortex, somatosensory cortex, insular cortex, and prefrontal cortex.  These cortical brain regions process the nociceptive (pain causing or reacting to pain) information from the body and generate the complex experience of pain.  This pain experience has multiple components that include the: 1) sensory-discriminative aspect which helps us localize where on our body the injury occurs, 2) affective-motivational aspect which conveys just how unpleasant the experience is and the 3) cognitive-evaluative which involves thoughtful planning on what to do to get away from the pain. Many of these characteristics of pain have been associated with specific brain systems, although much remains to be learned. Additionally, researchers have found that many of the brain systems involved with the experience of pain overlap with the experience of basic emotions.  Consequently, when people experience negative emotions (e.g. fear, anxiety, anger), the same brain systems responsible for these emotions also amplify the experience of pain.

Fortunately, there are systems in the brain that help to dampen or decrease pain. Descending signals from the brain are sent back to the spinal cord and can inhibit the intensity of incoming nociceptive signals, thereby reducing the pain experience.

Differences in our genes highlight how different we are in respect to pain.  Scientists believe that genetic variations can determine our risk for developing chronic pain, how sensitive we are to painful stimuli, whether or not certain therapies will ease our pain, and how we respond to acute or chronic pain.  Many genes contribute to pain perception, and mutations in one or more pain-related genes account for some of the variability of each individual’s pain experiences. Some people born genetically insensate to pain—meaning they cannot feel pain—have a mutation in part of a gene that plays a role in electrical activity of nerve cells. A different mutation in that same gene can cause a severe and disabling pain condition. Scientists have identified many genes involved in pain by screening large numbers of people with pain conditions for shared gene mutations.  While genes play a role in determining our sensitivity to pain, they only account for a portion of this variability.  Ultimately, our individual sensitivity to pain is governed by a complex interaction of genes, cognitions, mood, our environment and early life experiences.

The link between the nervous and immune systems also is important. Cytokines, a group of proteins found in the nervous system, are also part of the immune system—the body’s shield for fighting off disease and responding to tissue injury. Cytokines can trigger pain by promoting inflammation, even in the absence of injury or damage. After trauma, cytokine levels rise in the brain and spinal cord and at the site where the injury occurred. Improvements in our understanding of the precise role of cytokines in producing pain may lead to new classes of drugs that can block the action of these substances to produce analgesia.

Neural Circuits and Chronic Pain

The pain that we perceive when we have an injury or infection alerts us to the potential for tissue damage.  Sometimes this protective pain persists after the healing occurs or may even appear when there was no apparent cause. This persistent pain is linked to changes in our nervous system, which responds to internal and external change by reorganizing and adapting throughout life. This phenomenon is known as neuronal plasticity, a process that allows us to learn, remember, and recover from brain injury. Following an injury or disease process, sometimes the nervous system undergoes a structural and functional reorganization that is not a healthy form of plasticity. Long-term, maladaptive changes in both the peripheral and central nervous system can make us hypersensitive to pain and can make pain persist after injuries have healed.  For example, sensory neurons in the peripheral nervous system, which normally detect noxious/painful stimuli, may alter the electrical or molecular signals that they send to the spinal cord.  This in turn triggers genes to alter production of receptors and chemical transmitters in spinal cord neurons setting up a chronic pain state.  Scientists have methods to identify which genes’ activities change with injury and chronic pain.  Knowledge of the proteins that ultimately are synthesized by these genes are providing new targets for therapy development. Increased physiological excitation of neurons in the spinal cord, in turn enhance pain signaling pathways to the brain stem and in the brain.  This hypersensitivity of the central nervous system is called central sensitization. It is difficult to reverse and makes pain persist beyond its protective role.

There is no way to tell accurately how much pain a person has.  Tools to measure pain intensity, to show pain through imaging technology, to locate pain precisely, and to assess the effect of pain on someone’s life, offer some insight into how much pain a person has.  They do not, however, provide objective measures of pain.  Sometimes, as in the case of headaches, physicians find that the best aid to diagnosis is the person’s own description of the type, duration, and location of pain. Defining pain as sharp or dull, constant or intermittent, burning or aching may give the best clues to the cause of pain. These descriptions are part of what is called the pain history, taken by the physician during the preliminary examination of a person with pain.  Developing a test for assessing pain would be a very useful tool in diagnosing and treating pain.

Physicians, however, do have a number of approaches and technologies they use to find the cause of pain. Primarily these include:

• A musculoskeletal and neurological examination in which the physician tests movement, reflexes, sensation, balance, and coordination.
• Laboratory tests (e.g. blood, urine, cerebrospinal fluid) can help the physician diagnose infection, cancer, nutritional problems, endocrine abnormalities and other conditions that may cause pain.
• Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, evoked potential (EP) studies, and quantitative sensory testing.  These procedures measure the electrical activity of muscles and nerves.  They help physicians evaluate muscle symptoms that may result from a disease or an injury to the body’s nerves or muscles.  EMG tests muscle activity.  It can help physicians tell which muscles or nerves are affected by weakness or pain.  Nerve conduction studies are usually performed along with EMG.  These studies record how nerves are functioning.  EP studies measure electrical activity in the brain in response to sight, sound, or touch stimulation. Quantitative sensory testing can establish thresholds for sensory perception in individuals which can then be compared to normal values.  These tests are used to detect abnormalities in sensory function and nerve disorders.
• Imaging, especially magnetic resonance imaging or MRI, provides physicians with pictures of the body’s structures and tissues, such as the brain and spinal cord. MRI uses magnetic fields and radio waves to differentiate between healthy and diseased tissue.
• X-rays produce pictures of the body’s structures, such as bones and joints.

It is widely believed that pain affects men and women differently.  In fact, according to the Institute of Medicine’s 2011 report:  Relieving Pain in America, women often report a higher prevalence of chronic pain than men and are at a greater risk for many pain conditions.  Women are likely to have more pain from certain diseases, such as cancer.  Also, a number of chronic pain disorders occur only in women and others occur predominantly in women.  These include chronic fatigue syndrome, endometriosis, fibromyalgia, interstitial cystitis, vulvodynia, and tempromandibular disorders. 

The IOM report mentions at least three theories that may explain the differences in pain experience by gender:

• A gender-role theory that assumes it is more socially acceptable for women to report pain;
• An exposure theory that suggests women are exposed to more pain risk factors; and
• A vulnerability theory proposing that women are more vulnerable to developing certain types of pain, such as musculoskeletal pain.

Of these, the vulnerability theory is best supported by scientific evidence.

A greater understanding of gender differences in pain may lead to better avenues of pain management.

Hundreds of pain syndromes or disorders make up the spectrum of pain. There are the most benign, fleeting sensations of pain, such as a pin prick. There is the pain of childbirth, the pain of a heart attack, and the pain that sometimes follows amputation of a limb. There is also pain accompanying cancer and the pain that follows severe trauma, such as that associated with head and spinal cord injuries. A sampling of common pain syndromes follows, listed alphabetically.

Arachnoiditis is a condition in which one of the three membranes covering the brain and spinal cord, called the arachnoid membrane, becomes inflamed. A number of causes, including infection, chemical irritation, or trauma, can result in inflammation of this membrane. Arachnoiditis can produce disabling, progressive, and even permanent pain.

Arthritis. Millions of Americans suffer from arthritic conditions such as osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and gout. These disorders are characterized by joint pain in the extremities. Many other inflammatory diseases affect the body’s soft tissues, including tendonitis and bursitis.

Back pain has become the high price paid by our modern lifestyle and is a startlingly common cause of disability for many Americans, including both active and inactive people. Back pain that spreads to the leg is called sciatica and is a very common condition (see below). Another common type of back pain is associated with the discs of the spine, the soft, spongy padding between the vertebrae (bones) that form the spine. Discs protect the spine by absorbing shock, but they tend to degenerate over time and may sometimes rupture. Of note, as people age, discs tend to normally lose elasticity and degenerate.  This process, by itself, is not necessarily associated with pain. Spondylolisthesis occurs when one vertebra extends over another and may result in pressure on nerve roots and therefore pain. It also may cause damage to nerve roots (see Spine Basics in the Appendix) so called radiculopathy, which can be extremely painful and can be associated with weakness or numbness due to nerve compression. Treatment for a damaged disc includes drugs such as painkillers, muscle relaxants, and steroids (administered orally or via epidural); exercise or rest, depending on the patient’s condition; adequate support, such as a brace or better mattress; and physical therapy. In some cases, surgery may be required to remove the damaged portion of the disc, especially when it is pressing a nerve root.  However, surgery cannot return the disc to its original condition, it can only relieve the pressure on the nerve root.  Surgical procedures include discectomy, laminectomy, or spinal fusion (see section on surgery in How is Pain Treated? for more information on these treatments).

Burn pain (pain that is caused by burns) can be profound and poses an extreme challenge to the medical community. Depending on the injury, pain accompanying burns can be excruciating, and even after the wound has healed people may have chronic pain at the burn site.

Cancer pain can accompany the growth of a tumor, the treatment of cancer, or chronic problems related to cancer’s permanent effects on the body. Fortunately, most cancer pain can be treated to help reduce discomfort and stress.

Central pain syndrome:  Some individuals who have had an injury to the spinal cord experience intense pain ranging from tingling to burning and, commonly, both. Such persons are sensitive to hot and cold temperatures and touch. For these individuals, a touch can be perceived as intense burning, indicating abnormal signals relayed to and from the brain. This condition is called central pain syndrome or, if the damage is in the thalamus (the brain’s center for processing bodily sensations), thalamic pain syndrome. Central pain syndromes affect as many as 100,000 Americans with disorders such as multiple sclerosis, Parkinson’s disease, amputated limbs, spinal cord injuries, and stroke. Their pain may be severe and is extremely difficult to treat effectively. A variety of medications, including analgesics, antidepressants, anticonvulsants, and electrical stimulation, are options available to people with central pain.

Complex regional pain syndrome (CRPS) is accompanied by burning pain and hypersensitivity to temperature. Often triggered by trauma or nerve damage, CRPS causes the skin of the affected area to become characteristically shiny and the limb swollen. In the past, CRPS was often called reflex sympathetic dystrophy syndrome or causalgia.

Fibromyalgia affects millions of Americans, more often women than men.  It is a disorder characterized by fatigue, sleep disturbances, stiffness, tender points, joint tenderness, and widespread muscle pain.

Headaches affect millions of Americans. The three most common types of chronic headache are migraines, cluster headaches, and tension headaches. Each comes with its own telltale brand of pain.

• Migraines are characterized by throbbing head pain, sensitivity to light and sound, and sometimes by other symptoms, such as nausea, dizziness, and visual disturbances that begine before the headache. Migraines are more frequent in women than men. Stress can trigger a migraine headache, and migraines only very rarely put the sufferer at risk for stroke.
• Cluster headaches are characterized by excruciating, piercing pain on one side of the head and eye; they occur more frequently in men than women.
• Tension headaches are often described as a tight band around the head.

Head and facial pain can be agonizing, whether it results from dental problems or from disorders such as cranial neuralgia, in which one of the nerves in the face, head, or neck is inflamed. Another condition, trigeminal neuralgia (also called tic douloureux), affects the largest of the cranial nerves (see The Nervous Systems in the Appendix) and is characterized by a stabbing, shooting pain.

Muscle pain can range from an aching muscle, spasm, or strain, to the severe spasticity that accompanies paralysis. Polymyositis, dermatomyositis, and inclusion body myositis are painful disorders characterized by muscle inflammation. They may be caused by infection or autoimmune dysfunction and are sometimes associated with connective tissue disorders, such as lupus and rheumatoid arthritis.

Myofascial pain syndromes affect sensitive areas known as trigger points, located within the body’s muscles.

Neuropathic pain is a type of pain that can result from injury to nerves, either in the peripheral or central nervous system (see The Nervous Systems in the Appendix). Neuropathic pain can occur in any part of the body and is frequently described as a hot, burning sensation, which can be devastating to the affected individual. It can result from diseases that affect nerves (such as diabetes) or from trauma, or, because chemotherapy drugs can affect nerves, it can be a consequence of cancer treatment. Among the many neuropathic pain conditions are diabetic neuropathy (which results from nerve damage secondary to vascular problems that occur with diabetes); complex regional pain syndrome, which can follow injury; phantom limb and post-amputation pain (see Phantom Pain in the Appendix), which can result from the surgical removal of a limb; postherpetic neuralgia, which can occur after an outbreak of shingles; andcentral pain syndrome, which can result from trauma, stroke or injury to the brain or spinal cord.

Repetitive stress injuries are muscular conditions that result from repeated motions performed in the course of normal work or other daily activities. They include:

• writer’s cramp, which affects musicians and writers and others,
• compression or entrapment neuropathies, including carpal tunnel syndrome, and
• tendonitis or tenosynovitis, affecting one or more tendons.

Sciatica is a generic term representing pain in the buttocks that continues down into the thighs, legs, ankles, and feet . Sciatica can be caused by a number of factors including an injury or irritation to the nerve roots exiting the spinal cord that make up the sciatic nerve (e.g. herniated disc), or to the sciatic nerve directly.

Shingles and other painful disorders affect the skin and nerves. Pain is a common symptom of many skin disorders, even the most common rashes. One of the most distressing neurological disorders is shingles or herpes zoster, an infection that often causes agonizing pain resistant to treatment. Prompt treatment with antiviral agents is important to stop the infection and prevent an associated condition known as postherpetic neuralgia. Since postherpetic neuralgia is more common in the elderly, a vaccine is often recommended for persons over age 60 as part of one’s proactive health care. Other painful disorders affecting the skin include:

• vasculitis, or inflammation of blood vessels;
• other infections, including herpes simplex;
• skin tumors and cysts, and
• tumors associated with neurofibromatosis, a neurogenetic disorder.

Sports injuries are common. Sprains, strains, bruises, dislocations, and fractures are all well-known words in the language of sports. Pain is another. In extreme cases, sports injuries can take the form of costly and painful spinal cord and head injuries, which cause severe suffering and disability.

Spinal stenosis refers to a narrowing of the canal surrounding the spinal cord. The condition occurs naturally with aging. Spinal stenosis causes weakness in the legs and leg pain usually felt while the person is standing up and often relieved by sitting down.

Surgical pain may require regional or general anesthesia during the procedure and medications to control discomfort following the operation. Control of pain associated with surgery includes presurgical preparation and careful monitoring during and after the procedure.

Temporomandibular disorders are conditions in which the temporomandibular joint (the jaw) is damaged and/or the muscles used for chewing and talking become stressed, causing pain. The condition may result from a number of factors, such as an injury to the jaw or joint misalignment.  It may give rise to a variety of symptoms, most commonly pain in the jaw, face, and/or neck muscles. Physicians reach a diagnosis by listening to the individual’s description of the symptoms and by performing a simple examination of the facial muscles and the temporomandibular joint.

Trauma can occur after injuries in the home, at the workplace, during sports activities, or on the road. Any of these injuries can result in severe disability and pain.

Vascular disease or injury—such as vasculitis or inflammation of blood vessels, coronary artery disease, and circulatory problems—all have the potential to cause pain. Vascular pain affects millions of Americans and occurs when communication between blood vessels and nerves is interrupted. Ruptures, spasms, constriction, or obstruction of blood vessels, as well as a condition called ischemia in which blood supply to organs, tissues, or limbs is cut off, can also result in pain.

Stacked on top of one another in the spine are more than 30 bones, the vertebrae, which together form the spine. They are divided into four regions:

• the seven cervical or neck vertebrae (labeled C1-C7),
• the 12 thoracic or upper back vertebrae (labeled T1-T12),
• the five lumbar vertebrae (labeled L1-L5), which we know as the lower back, and
• the sacrum and coccyx, a group of bones fused together at the base of the spine.

The vertebrae are linked by ligaments, tendons, and muscles. Back pain can occur when, for example, someone lifts something too heavy, causing a sprain, pull, strain, or spasm in one of these muscles or ligaments in the back.

Between the vertebrae are round, spongy pads of cartilage called discs that act much like shock absorbers. In many cases, degeneration or pressure from overexertion can cause a disc to shift or protrude and bulge, causing pressure on a nerve and resultant pain. When this happens, the condition is called a slipped, bulging, herniated, or ruptured disc, and it sometimes results in permanent nerve damage.

The column-like spinal cord is divided into segments similar to the corresponding vertebrae: cervical, thoracic, lumbar, sacral, and coccygeal. The cord also has nerve roots and rootlets which form branch-like appendages leading from its ventral side (that is, the front of the body) and from its dorsal side (that is, the back of the body). Along the dorsal root are the cells of the dorsal root ganglia, which are critical in the transmission of “pain” messages from the cord to the brain. It is here where injury, damage, and trauma become pain.

The central nervous system (CNS) refers to the brain and spinal cord together. The peripheral nervous system refers to the cervical, thoracic, lumbar, and sacral nerve trunks leading away from the spine to the limbs. Messages related to function (such as movement) or dysfunction (such as pain) travel from the brain to the spinal cord and from there to other regions in the body and back to the brain again. The autonomic nervous system controls involuntary functions in the body, like perspiration, blood pressure, heart rate, or heart beat. It is divided into the sympathetic and parasympathetic nervous systems. The sympathetic and parasympathetic nervous systems have links to important organs and systems in the body; for example, the sympathetic nervous system controls the heart, blood vessels, and respiratory system, while the parasympathetic nervous system controls our ability to sleep, eat, and digest food.

The peripheral nervous system also includes 12 pairs of cranial nerves located on the underside of the brain. Most relay messages of a sensory nature. They include the olfactory (I), optic (II), oculomotor (III), trochlear (IV), trigeminal (V), abducens (VI), facial (VII), vestibulocochlear (VIII), glossopharyngeal (IX), vagus (X), accessory (XI), and hypoglossal (XII) nerves. Neuralgia, as in trigeminal neuralgia, is a term that refers to pain that arises from abnormal activity of a nerve trunk or its branches. The type and severity of pain associated with neuralgia vary widely.

• Prepared by:
    • Office of Communications and Public Liaison
    • National Institute of Neurological Disorders and Stroke
    • National Institutes of Health
    • Bethesda, MD 20892

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• Last Modified March 9, 2016