Conditions Chronic pain

Pain is one of the most common reasons why people seek medical advice. Chronic pain usually refers to pain that:

• lasts longer than 3 months or
• persists following an injury or other form of tissue damage, despite the cause itself being healed

Chronic pain may be persistent or recurring. The perception of pain differs significantly between individuals and may be influenced by social and psychological factors.

Chronic pain affects all areas of a person’s life and impacts their daily routine. Individuals with chronic pain are more likely to develop anxiety, depression or sleep disorders. This can have a negative impact on their perception of pain and their body’s processing of the pain, so that their symptoms worsen.

Therefore, chronic pain is most effectively treated not only by various types of medication but also by taking account of the person’s psychological and social circumstances.

Pain can be felt in many different ways. Pain in internal organs may be dull, deep-seated or spasmodic (cramping). People are often unable to pinpoint the precise origin of the pain. Pain in the musculoskeletal system is often described as a stabbing, dragging or burning pain and is easier to pinpoint. Pain resulting from nerve damage may be experienced as sudden attacks of shooting pain and may be associated with tingling sensations, numbness or oversensitivity.

Older people in particular can sometimes find it difficult to describe their pain. They frequently talk about “unpleasant” feelings or symptoms. People with diseases such as dementia are often completely unable to express their pain in words. Signs of pain then include:

• a facial expression that is contorted in pain
• making moaning and groaning sounds
• holding the painful area protectively
• labored breathing
• confusion

Possible causes of chronic pain include a nervous system disturbance, impaired pain processing or chronic inflammation.

Examples of conditions frequently associated with chronic pain:

• osteoarthritis
• back problems
• rheumatoid arthritis
• fibromyalgia
• diabetes mellitus

Different causes generally produce different types of pain:

• Pain caused by the stimulation of pain receptors: Pain signals are sent by nerve endings, which serve to perceive pain. These pain receptors are activated, for example, by injuries, burns, kidney stones or a heart attack.
• Inflammatory pain: This occurs as a result of inflammation in the tissues, as inflammatory messengers also stimulate pain receptors. This type of pain can be triggered by infections or autoimmune disorders, in which the body’s own cells cause an inflammation.
• Neuropathic pain: This results from direct damage to the nerves. It may be triggered by nerve injuries, damage to nerve roots, metabolic disorders like diabetes, cytoxins (cell-killing toxins) like alcohol, or viral infections such as shingles.
• Central pain: This is caused by a change in the way that pain is processed in the brain or spinal cord. The brain generates pain signals in response to a cause of pain in the body. However, with central pain, pain signals are generated without any physical cause. Central pain occurs, for example, in fibromyalgia, irritable bowel syndrome or chronic pelvic pain.

Pain signals can take on a life of their own. In other words, pain may persist even after the trigger is removed. Persistent pain can also make nerves more sensitive, so that pain signals are transmitted sooner and faster. New neural connections in the spinal cord and brain may then produce a “pain memory”. Furthermore, persistent stress can cause a person to perceive pain sooner or more strongly than before.

Several factors increase the risk of developing chronic pain. These include:

• genetic predisposition
• prior treatment for acute pain that was not sufficiently effective
• mental illness, such as depression or post-traumatic stress disorder
• living in socially disadvantaged circumstances
• older age
• long-term use of painkillers, in particular opioids
• alcohol or drug abuse

Around 2 in every 10 people in developed countries report moderate to severe pain lasting longer than 3 months to their doctor.

Three quarters of patients with chronic pain are over the age of 50. The back, knees or head are most commonly affected. Osteoarthritis and a slipped disc are among the most common causes of chronic pain. 

Around 5 in every 100 children have chronic pain.

Chronic pain is only completely resolved with treatment in a small number of cases. The main aim of treatment is to improve quality of life for people with chronic pain. 

OTC pain medication

The limited effectiveness of over-the-counter pain medication can lead people with chronic pain to continually increase their dose or to take different types of painkillers together. This increases the risk of side effects. For example, paracetamol can cause severe liver damage. If taken over an extended period, paracetamol can also cause kidney damage. 

Prescription pain medication

Taking strong painkillers like opioids on a regular basis can lead to drug dependency. An overdose of opioids can cause respiratory failure. Taking opioids can also sometimes cause patients to become oversensitive to pain.

The most effective way to prevent chronic pain is to ensure that acute pain is treated effectively. It is important to be able to talk about pain in an open, honest manner.

An important first step is to pinpoint the precise cause of the pain. Imaging techniques, such as x-ray, computed tomography (CT) or magnetic resonance imaging (MRI) can be used for this purpose. Certain blood values can also provide an indication of the cause.

Nerve blocks or measurements of nerve conduction velocity are sometimes used for diagnosis.

However, it is not always possible to locate the trigger, even if the pain is severe.

For treatment purposes, it is essential to pinpoint the origin of the pain and assess it. Doctors will therefore ask the patient specific questions, such as:

• When and where did the pain first occur?
• What does the pain feel like?
• How bad is the pain on a scale of 1 to 10?
• How does the pain affect daily activities?

A physical examination allows doctors to determine whether any physical functions are restricted due to the pain. They also ask the patient about their mood, the quality of their sleep, and any family-related or work-related stress in order to find out whether aspects of their lives could be affecting their perception of pain or are being impacted by pain.

Where possible, chronic pain should be treated using multi-modal therapy, which combines medical treatment with psychotherapy, physiotherapy and occupational therapy. Treatment is ideally administered by experts in pain therapy. People with chronic pain also benefit from advice from experts in the area of social medicine.

Non-pharmaceutical interventions

• physical activity and movement exercises
• physiotherapy, physical therapy, occupational therapy
• behavioral therapy, stress management training
• supportive measures, such as acupuncture, manual therapy or peripheral nerve stimulation
• nutritional counseling and weight loss if the pain is caused or increased by obesity
• medical aids, such as walking aids, splints or orthopedic shoes in the case of serious orthopedic issues

Regardless of which therapeutic measures are prescribed, complementary relaxation techniques, such as progressive muscle relaxation or the application of heat and cold, can be practiced independently at home.

Drug therapy

• Ointments and gels containing anti-inflammatory pain medication can be applied to help with localized pain.
• For joint pain or a slipped disc, pain medication or anti-inflammatory cortisone an also be administered locally using an injection.
• Antidepressant medication can influence the perception of pain, even if the patient is not depressed. It may take several weeks for some drugs to produce a pain-relieving effect.
• Drugs used to treat epilepsy (anti-epileptics) are used to treat nerve pain that occurs with nerve damage.
• Muscle-relaxing medication is used to treat pain associated with muscle cramps.
• Anti-inflammatory painkillers classified as non-steroidal anti-inflammatory drugs (NSAIDs) – for example, ibuprofen or paracetamol – should only be taken to treat acute flare-ups of pain symptoms. It can be useful to try out different types of painkillers, as their level of effectiveness varies from person to person.
• In most cases, strong painkillers like opioids should be taken on a temporary basis only.

It is always best to decide on treatment measures in collaboration with your doctor. A trust-based doctor-patient relationship is essential to ensuring satisfactory treatment of chronic pain.

Chronic pain requires long-term treatment. The condition often improves temporarily and repeatedly flares up from time to time. People often feel frustrated if a specific cause of their pain cannot be identified. It may be helpful to gain a better understanding of what happens in the body when chronic pain occurs. Colleagues and loved ones may also find it easier to be understanding if they are well informed about the mechanisms of chronic pain.

For people with chronic pain, it is important to learn how they themselves can influence their pain. It may also be helpful to find ways to improve quality of life despite the pain. Support is available from doctors and therapists, as well as information and advice centers and self-help groups.

You will find a database of suitable self-help groups on the website of the National Contact and Information Point For Encouraging and Supporting Self-Help Groups (Nationale Kontakt- und Informationsstelle für Selbsthilfe, NAKOS).

More information about chronic pain is provided on the website of the German Society for Psychological Pain Therapy and Research (Deutsche Gesellschaft für psychologische Schmerztherapie und -forschung e. V.) and the German Pain Association (Deutsche Schmerzgesellschaft e. V.).

Summarized information about various pain disorders and answers to frequently asked questions are provided on the website of the German Brain Foundation (Deutsche Hirnstiftung e. V.).