Sean White - London Pain Service

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What is pain and how would you describe it in layman’s terms?

The International Association for the Study of Pain define pain as……. ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.’

This means that pain is the mixture of nerve signals to the brain indicating that something is damaged, broken or inflamed. The messages change our behaviour, such as removing the splinter from our finger. There is an emotional response that is part of the NORMAL response to pain; anger, frustration, sadness or depression. This is part of a learning experience and also modifies our future behaviour and sends messages to other people around us.

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Are there different types of pain? If yes, how can we differentiate?

The experience of pain outlined in the definition is the same regardless of the cause. However, there are broad categories of pain defined by the cause and duration of the process stimulating the nerve. There are nerves in the layers under the skin with specialised nerve endings, to tell us about the environment, stimulated by heat, cold, pressure etc. Some of these nerve endings are called ‘nociceptors’ and fire messages off to the spinal cord and brain when an unpleasant sensation is applied to the skin. This may be a sudden impact to the body, no matter how small, that damages cells, releasing chemicals that then stimulate the nociceptor. This may be very transient. However, if the stimulus is repeated or the damage/trauma caused is great, then the pain will persist and evolve.

Inflammation / trauma. White blood cells migrate to the area of tissue damage and release chemicals that have a number of functions, one of which is to make nociceptors even more sensitive.

Chronic Regional Pain Syndrome Type I (CRPS) also called Reflex sympathetic dystrophy. Poorly understood and no obvious or apparent nerve damage with what would appear to be disproportionately severe pain.

CRPS Type II also known as Causalgia. This involves obvious nerve damage. Examples would be severing a nerve in an accident. Damaging the small nerves in the skin of the hands and feet such as by poor circulation or diabetes

What does ‘good’ pain management look like?

Good pain management. The same rules apply to all pain. First, try and identify the cause:

  1. Take the history of the problem. What were the events and factors that resulted in the pain? What provokes the pain now? What limitations, e.g. sleep deprivation, does the pain bring?

  2. Examine the patient for signs of trauma, limitation of movement etc.;

  3. Organise investigations, such as X-rays, MRI scans etc.;

Then deal with what I call the ‘building blocks’:

  1. Explain the problem, reassure the patient and give advice;

  2. If there is an obvious avoidable cause for the pain, then avoid it, at least temporarily;

  3. If overweight then modify the diet;

  4. If not moving/exercising, then start, ideally with supervision;

  5. If stressed/distressed, whether emotional, financial, or psychological address it;

This in itself may solve the pain problem. If exercise /movement cannot commence or advance because of the pain then to control the pain there are, in order:

  1. Therapy strategies; physio, osteopathy, massage etc.;

  2. Medications;

  3. Injections;

  4. Operations;

  5. Disease-modifying interventions: Humira for Rheumatoid arthritis etc.;

Have you noticed a change in the number of chronic pain patients you see?

(transition from acute to chronic. brain fog, headaches for 5 years, scans clear, however, I still have pain. Gut issues and gut pain).

I have seen an increase in the number of chronic patients year on year since I started working in Pan medicine over 25 years ago. I feel that this is a reflection of the increased longevity of the population and the ever increasing expectations regarding quality of life. As people age, the potential for mechanical degeneration and other painful medical conditions to develop becomes all the greater. Often there is no ‘cure’ for these conditions, and so chronicity ensues.

‘Brain fog’ and all that goes with it; a headache, fatigue, de-motivation seem to be on the increase. I have more patients complaining of a non-specific headache-related symptoms and expressing concerns that they may have a sinister pathology. They all want an MRI scan of their brains to find out what is the cause and reassurance. The scan is reassuring in terms of excluding major illness but is always incapable of explaining the multitude of symptoms.

Often the symptoms seem likely to be driven by stress. We live increasingly stressful lives again with high expectations, often unrealistic, of what our lives should be like. Striving to achieve our goals and failing, brings another layer of stress.

Functional gut pain is an area of great concern to me. Often young women presenting with non-specific abdominal pain. Before an adequate diagnosis is made, the patient is given weak opioid pain-killers like Codeine, and before long this has escalated to Morphine strength drugs. These medications have very negative effects on gut function and can turn a drama into a crisis. A gut that is already not functioning well can stop working altogether in these circumstances, sometimes permanently. Other more holistic approaches to abdominal pain must be used, whilst investigations are performed, a diagnosis made and specific treatment administered. If no diagnosis is made, then coping strategies are the best option.

The London Pain Service

116 Harley Street, London  W1G 7JL