No pain, no gain. A motto for students, trainees, recruits and trainers. Poets of various languages have described the ‘sweet ache’ of love and the ‘heartache’ of separation from the beloved. In many cultures, pain is the result of a curse, evil spirits or an imbalance in the body’s energies. Many different kinds of treatment for pain have been available in various parts of the world.

Pain is that unpleasant feeling one gets when a part of the body is hurt. It is a perception of the brain. If the hurt/ injury is fresh, the pain is called acute pain. Old injuries or certain diseased organs also send out pain stimuli to the brain through the nerves to say that something is wrong and needs to be fixed. There are many more reasons for pain. The pain may be felt as a prick, sting, burn, tingling, heaviness, crushing, stabbing or throbbing. It can happen in any part of the body. The pain might subside to reappear sooner or later (episodic pain). It may even be continuous.

What does modern medicine say? Physical pain is an important signal from our body that there is something wrong in the body,  and it needs immediate attention. A kind of survival mechanism. Pain alerts us to burning a finger if it touches a hot object or a fracture after a fall. Pain tries to keep us safe. Pain is an important message from our body in certain cancers. Sadly, in many other cancers, there is no pain, and hence these are detected quite late, when treatment is difficult.

Pain as Per Medical Science

Different medical agencies define pain in different ways. For easy understanding, it is explained below –

• An unpleasant sensation and emotional experience.
• Pain is a highly personal experience.
• The same medical cause may result in severe pain in some people and mild pain in others.
• Pain can be mild, moderate or severe. Some doctors ask patients to rate it on a scale of 0 to 5, while others may ask for a rating on a scale of 0 to 10.
• Pain can be described as pricking, tingling, burning, shooting, dull aching or pressing.
• Pain can be throbbing, coming in episodes or just continuous.
• Pain can be related to starting before or after a meal or after a moderate or severe exercise. Pain may also be related to a particular posture of the body or limb.

Types of Pain

• Acute pain. This pain usually starts suddenly and ends or decreases considerably when the cause is treated. Acute pain is commonly due to strained muscles, broken/ dislocated bones, diseased tooth/ teeth, childbirth, infections and burns.
• Episodic Pains. These happen from time to time. This pain may or may not be related to a ‘triggering event’. A classical example is migraine. Sickle cell disease and menstrual period pains are other examples.
• Chronic Pain. Pain which lasts longer than 3 months is called Chronic Pain. This will be discussed separately.

Perception of Pain

Pain perception is processed by our nervous system. We have special pain receptors, called nociceptors, which detect pain from all over our body (skin, muscles, as well as internal organs). These receptors are the ends of nerves which convert different types of pain into electric signals. These nerves then lead to the spinal cord. From the spinal cord, the pain signals (electric impulses) are carried to the brain. However, some nerves carry signals from the skin/organs to the brain directly. In the brain, the signals are interpreted as a sharp prick/ cut, a burn, a crush or any other. The pain reception areas of the brain are in interact with other areas of the brain, like emotion and memory, for better understanding.

The brain may immediately convey back message for the withdrawal of the body part to reduce the painful stimulus. Like preventing further burns from a hot stove, the hand is withdrawn. Or, like asking a runner to stop immediately in case their ankle is twisted..

Factors Related to Pain Causation and Pain Perception

Pain due to the same cause is perceived differently by different people. Even though initially acute pain is felt in the same manner, differences may occur later due to certain factors, which are noted below:

• Biological factors. These include the person’s nervous system, genes and our habits and behaviour, which may modify our genes. A simple example is of a person who has been exercising regularly may disregard muscle strains and consider them less painful than a sofa-bound person who does very few physical activities and gets a muscle strain. The person’s immune status, as well as their hormone, are directly involved in fighting inflammation and limiting pain due to infections.
• Psychological factors. A person’s high mental stress adds to physical pain. Pain continuation and its recurrence also depend on the emotional state, moods and mental health in general of a person. A mentally resilient person may have fewer chances of prolonged or chronic pain. Beliefs built up in childhood and thoughts also play a role in pain perception.
• Social factors. Social support from immediate family or close friends influences the outcome of chronic diseases and chronic pain. The social environment in which a person has grown up, religious rites, learning, playing and working, all factors decide which pain to bear and which to ignore. Volunteers in a boot camp for physical activities may feel very little pain even if a bone is fractured.  But if a person was forced by his parents to attend the camp may create mayhem due to pain in similar circumstances. Sad to quote, but in many societies, married women may continue to bear physical violence without complaining, as they may not have a social support group in their husband’s locality.

Connection with Gut Microbiome

The gut-brain axis is well known as the microbes of our intestines are in constant communication with the brain. The microbial family/ microbiome in the gut affect humans’ perception of pain in different ways. An imbalance in the gut microbiome called dysbiosis results in inflammation, and this can impact the signalling of pain. Dysbiosis can also depress a person’s immunity. Chronic Pain, recurrent headaches and migraines are especially affected.

Pains that Cannot be Ignored

Even though pain is a personal experience, certain pains should never be ignored by a person. Nor by the treating doctor!

• Sudden unexplained pain that doesn’t go away. It is better to err than to be sorry. Severe and sudden headache, with or without fever.
• Chest pain. A chest pain should always be investigated, and self-treatment for ‘gas’ avoided.
• Tearing upper back pain. This could be due to a serious tear in a large artery, not necessarily due to a faulty posture.
• Calf pain, especially if the calf muscle of one side is red/ swollen. This may occur after an episode of sitting too long, as in a flight or a drinking binge.
• Abdominal pains. These are extremely common and difficult to diagnose, especially in females. However, severe pain in the lower flanks in either sex is a cause of worry. Severe pain in the middle of the upper abdomen is also a cause of concern, especially in alcoholics.

Self Medication

Long-term use of Pain medicines without a prescription can cause other serious health problems. Many drugs for pain relief are available without a prescription in India. Self-medication for acute pains like toothache, headache, backache, muscle strains and period pain has become a common practice. In a recent study, it was found that a very high dose of cetaminophen (paracetamol/ crocin/ dolo) was frequently taken without a doctor’s prescription in India. One Indian gastroenterologist went on to write on X that “Indians take Dolo 650 like Cadbury gems”. Doctors and scientists worldwide have expressed deep concern about this habit of taking such high doses of this drug routinely.

Pitfalls of Self-medication

• Masking a serious condition. Taking drugs without having a confirmed diagnosis would reduce pain and hide the true illness. The result of such misadventures may delay diagnoses, resulting in the disease turning serious in the meantime.
• Incorrect dose. Patients often pick up ‘strong’ or higher-dose pain relievers from a chemist. This usually results in side effects complicating the primary cause of pain.
• Drug interactions. Many middle-aged/ senior citizens are already taking 2-5 drugs for lifestyle diseases like obesity, hypertension or diabetes. Adding a single or combination of drugs for pain relief may increase the chances of drug interactions in the body. Even alcohol or supplements can cause serious interactions.
• Drug Dependence and Tolerance. Frequently taking the same drugs for pain can cause dependency. Higher doses of the same drug required for pain relief because of tolerance may, in turn, cause side effects not seen earlier.

Chronic pain

A pain which lasts over three months is termed Chronic Pain. If left untreated, it interferes with routine tasks. A vicious cycle is formed with sleep, which becomes disturbed. Inadequate sleep may, in turn, increase the pain. Chronic Pain may lead to depression, anxiety, fatigue, mood swings and insomnia. Frequent job absenteeism and behavioural changes in society may also occur. Chronic Pain in a person puts an additional load on the family. This load is financial, causes work-absentism and is emotional.

Is Chronic Pain Common?

It is estimated that one person out of ten (10%) is in pain at any time in the world. However, in a large study in Indian adults over 45 years of age, the incidence of Chronic Pain was around 20%. The incidence is over 40% in senior citizens, those above 60 years of age. Women suffer more than men. The rural population and those of lower socio-economic class have less access to medical facilities, hence their percentage of pain sufferers is higher than others. The incidence is also higher in those who are obese and those who stay single in their old age.

How do We Feel Pain?

When we touch a sharp object, a special receptor (pain receptor) is activated and it sends an electrical message (of pain) through nerves, first to our spinal cord, which may cause a reflex action of pulling back our hand. Through the spinal cord, it goes to the brain, where the message is read and perceived as pain. Pain is also perceived when it is due to burns, inflammation or excessive use of muscles/ tears of ligaments or stretching, which causes lowered blood supply to internal organs. Some people may feel more pain from the same stimulus/ tissue damage than others. The suffering of pain is a highly complex behaviour of individuals. It is linked to psychosocial behaviour and also to emotional status. This factor is not being discussed any further in this blog.

Causes of Chronic Pain

Chronic pain is usually due to a cause as discussed above. It is scientifically divided into two:

1. Primary Chronic Pain. In some cases, the actual cause cannot be found despite detailed examination and investigations. Such long-term pain is called Primary Chronic Pain. Examples are some types of headaches, generalised bodily pains in which no cause is found – Primary Fibromyalgia. This, however, does not mean that the person’s pain is unreal. It does require treatment as well as a better understanding by the caregiver.

2. Secondary Chronic Pain: It is due to many causes, described below-

• Arthritis or Joint pain. Rheumatoid Arthritis, as well as Osteoarthritis of old age, gives lifelong pain in joints.
• Backache and Cervical/ neck pains are due to a host of causes.
• Muscular, ligament or other tissue pain after an injury/ trauma may last weeks or even months.
• Headaches due to identifiable causes and migraine.
• Post-herpetic neuralgia is the pain which continues long after the patient has recovered from herpes zoster.
• Secondary Fibromyalgia is diagnosed when a cause is found for muscular pain.
• Neurogenic pain due to nerve damage.
• Post-surgical/ operation pain in the operated area.
• Pain at scar sites of deep burns.
• Pain in the testes as well as the uterus (fibroids) can be long-lasting if not treated.
• Cancers and non-cancerous tumours.
• Pain due to long-term inflammation in internal organs. Most common are our teeth, ears, throat, etc, if infections are left untreated.

Management of Chronic Pain

Pain management can include Pain Medicines, antidepressants, alternative therapy and other specialised strategies. Chronic pain often does not respond to medication alone. There are specialised pain clinics in large hospitals in the metros. However, for most of our populace, the basic medical officer is the first to treat.

1. Pain relief drugs, creams, ointments, oils and special bandages (where required) are widely prescribed in the initial stages. Some respond better to injectable rather than oral pills.
2. Detailed medical investigations should also be done simultaneously to find the cause. If a specific cause is found, it needs to be treated accordingly.
3. Anti-depressant medication may be required for long-term patients in whom no cause is found and who find no relief with routine medicines. This should be under the care of specialists and should be done with psychotherapy.
4. Nerve stimulation or nerve blocks are required in some cases.
5. For others, Acupuncture or other Alternative therapy is best suited. Massage and physiotherapy do wonders for many.
6. Lifestyle changes: These are extremely beneficial and need to be supervised:
   • Stress management. Relaxation techniques and yoga do wonders and should be taught at appropriate centres.
   • Physical activity as per age and medical condition.
   • Diet, balanced, with supplements for seniors.
   • Adequate sleep. This is needed to break the sleep-pain cycle.
   • Others. Music, dance, and gardening are some of the mind-engrossing activities. A person loses pain in such activities.
   • Family support is of utmost importance. Yes, the healthy members of the family have to do additional chores, and it is not an easy task if the pain extends from months to years. But without their support, it is unlikely that the patient will improve.
   • Laughter group. Laughing loudly releases natural painkillers in the body. In a group, it helps bonding and connectivity with others, relieving anxiety, which accompanies Chronic Pain.
7. Online Help Groups: These are of three different categories. First, for Chronic Pain in general. These are online groups, but some also offer telephonic services. Second. These are for specific primary conditions like Migraine, Arthritis and so on. Third, which provides online plus home service or indoor treatment.

The incidence of Chronic Pain will keep increasing in most countries as their population transitions to middle age. The population of senior citizens will also increase by leaps and bounds. The increasing expectancy of life expectancy is due to better economic conditions and medical facilities. However, this will result in a concomitant rise in persons with Chronic Pain.

Role of Government

The government needs to give thought to and plan many more ‘Pain clinics’ to reach the vulnerable population. That is, in the rural areas and the urban slums. More doctors from all streams of medicine (modern medicine, ayurveda, homoeopathy and Unani/ siddha) need to be trained in Pain relief, especially in the geriatric population. A pain-free population is more work-productive and an asset to the country. In the US alone, a $100 billion economic loss is reported due to absenteeism/ lost jobs because of this malady. The medical services can be improved at half their cost.

Conclusion

Pain is a real phenomenon, not ‘just in the head’ as believed by some. Hence, pain should not be ignored. Pain doesn’t go away with a good rest. Some pains may worsen due to prolonged inactivity. Finding the cause of acute pain is necessary. Pain relievers may give relief for some time, but unless the root cause is found and treated, the pain rebounds. So, the bottom line is that, in case of a new, acute pain, do consult a doctor. Please do not consult Dr Google or AI, as these digital entities cannot take responsibility in case of a misadventure. Indeed, many medicines are easily available in India without a prescription, but it’s better to remain safe and hence, take medicines with a prescription.

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Article Courtesy: https://genkris.wordpress.com/

Disclaimer: The views and opinions expressed by the author do not necessarily reflect the views of the Government of India and Defence Research and Studies