CHRONIC PAIN

            Chronic Pain Syndrome consists of both pain and suffering and, not surprisingly, many patients are of the belief that their pain and suffering are punishment for past transgressions. Some individuals are able to identify the event for which they are being punished, while others cannot, yet nonetheless maintain a strong believe that chronic pain and chronic illness only occur when people are deserving of them (69, 71, 87). 

            Chronic pain does not appear to serve any known scientific or medical purpose, in contrast to acute pain, which is integral to an early bodily defense system as an aid and survival mechanism.  Chronic pain is quite different, persisting long after its initial onset, such as in the case of a sprained back or serious infection, in which prolonged pain exists well after recovery (22, 23, 24, 21).  Yet, some individuals suffer chronic pain symptomatology in the absence of prior root cause that is self-perceived to be real, unremitting, and can be extremely demoralizing and incite mental depressive disorders.  In fact, chronic pain can be of such extreme magnitude as to overwhelm all other debilitating symptoms, leading to a dramatic triadic construct, involving suffering, sleeplessness, and extreme sadness.

            Approximately 50 to 80 percent of patients who present with depressive symptoms initially were determined to have physical symptomatology (20), and are less likely to receive an accurate psychiatric diagnosis than those who communicate feelings of depression to their physician.  The question can then logically be raised as to whether chronic pain causes depression or, conversely, does pain result from depression? Current evidence is highly supportive of a bi-directional relationship, in which one informs the other to form a combinatory result.  Research, from data from the World Health Organization (34), has demonstrated that patients presenting with chronic pain are four times as likely to develop depressive or anxiety disorders as those who are pain-free.

            In a review of the epidemiology of pain and depression as observed in primary care medical environments, Von Korff and Simon (195) concluded the following:

1.                  Pain is strongly associated with anxiety and depression.

2.                  The number of pain sites and the extent to which pain interferes in daily life are characteristics most strongly predictive of depression.

3.                  Psychological symptoms of depression, including low energy levels, sleep disturbances, and worry, are commonly experienced symptoms amongst patients, whereas guilt and loneliness are not.

4.                  Psychological distress often surfaces, then resolves early on in the course of a pain disorder that evolves into chronic conditions.

Based on these findings, it would appear that pain and psychological illness are inherently possessed of reciprocity, constructing a two-pronged cause-and-effect relationship.  The co-morbidity construct of pain-depression are supported by the following two theories:

1.                  Some individuals are susceptible genetically to both physical and psychological symptoms, as well as a state in which psychological distress works to amplify unpleasant physical discomfort and sensations.

2.                  The physical discomfort and stress related to pain can induce psychological distress, as the two work in cohesion to intensify the effects of each.

            Persistent pain is characterized by more intense sensitivity to pain, decreased threshold levels to painful stimuli, and episodic spontaneous occurrence of pain.  Individuals who present with persistent pain complaints also often display unresponsiveness to what is considered normal painful stimuli, as well as experiencing painful reactions to normally painless stimuli.  Many of these symptoms appear to result from alterations or anomalies in the central nervous system, resulting in sensitization and desensitization contingent upon the stimuli applied (38).

            Clinical trials have demonstrated that antidepressants can provide quite effective pain relief within the framework of a clinical setting.  Patients administered antidepressants are four times more likely to report overall improvement in symptoms than those receiving placebo.  The antidepressant group reports improvements in sleep patterns, fatigue levels, pain episodes, and general well-being. 

            Co-morbidity rates of pain and depression might be infinitely more difficult to treat than depression alone.  Pain can perpetuate the depression, whereas depression might well perpetuate the pain; again, evidence of a reciprocal, co-dependent pattern relationship.  This obstinate and difficult to manage syndrome might best be served through an integrated, interdisciplinary approach to treatment, including but not limited to use of medication, physical therapy, and behavioral and psychological-based therapies. 

            The posture of therapeutic activism that states, “don’t just stand there, do something!” finds its place among practices of medicine as well, yet does not acquit itself well in the management of chronic pain when in the absence of physically-based disease.  This medical conundrum might best profit from inverting that phrase to heed the injunction, “Don’t just do something, stand there” (Szasz, 1975), based on medical observation that, frequently, the more the use of diagnostic studies and treatment, the worse the condition of the patient.  In a majority of these cases, the patient might well be better managed and be more likely to achieve positive results if ministered to by pain management specialists than those in the clinical setting of Occupational medicine.

            Even when performing at its optimum level, the Workers’ Compensation system produces its share of injured workers who de-compensate, develop problems of dysfunction, and ultimately progress to become chronic pain patients.   In the event of a work-related injury, the worker might begin to experience a diminished sense of self, feeling demeaned and unwanted should the employer not request the individual’s return to work, or in cases in which co-workers become critical of his or her arrangement of modified duty.  The importance, therefore, of returning the injured worker to his or her former job as expeditiously as is possible cannot be overemphasized.  It is widely accepted knowledge that the probability of returning to work decreases proportionately to the longer the time away from the job.  These are factors that must, of necessity, be considered thoroughly prior to establishing diagnosis and setting up treatment protocols, and further demanding strict adherence to a predetermined schedule with mutually agreed-upon objectives between the treatment physician and worker.

THE SECONDARY INJURY

            Another frequently encountered issue consists of cases in which the worker communicates discomfort deriving from a secondary injury as an offshoot of the original, resulting from the accommodation or compensation for the prior-injured upper limb.  In compensating for or accommodating the one, originally-injured extremity, the patient will overutilize the other, causing fatigue to its structure through excessive, repetitive strain and/or overuse.  There does not appear to be medical basis for such conclusion considering that, if such were the case, amputees would be in a state of unrelenting suffering due to overuse syndrome.  It does appear, however, to be a product of patient imaginings and excessive suggestibility through peer pressure.  There is, of course, understandable muscle soreness from the increased use not normally experienced by the patient.  The resolution to such complaints and discomfort is concentration on appropriate repair of originally-induced problem, with return to normal use of the injured part as the primary objective.  The patient is optimally benefited by not being permitted to advance the cause of his or her complaints further with additional claims and treatment protocols.  The treatment provider thus must consider all aspects of a patient’s presenting complaints and discomforts, taking under advisement each phase of patient progress and evaluating, and if necessary reevaluating, the patient as a whole in a sometimes ever-changing dynamic.  If the injury is viewed with the perspective that not only is the physical being of the patient at risk, but the mental and emotional as well, the treatment options will broaden and become more fluid, allowing the physician to approach the patient in a more flexible manner.  Should secondary injuries emerge during the course of treatment, by rechanneling the focus to the original injury, in a sense diverting the patient’s attention away from the secondary disturbance, the opportunity for hastening the process of recovery will be all the greater, with the ultimate result that of a fully functional return-to-work status.

As so eloquently stated by Justice Louis Brandeis: