Preventing Pain: An Introduction

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Preventing Pain: An Introduction
Pain is defined by IASP as “An unpleasant sensory and emotional experience associated with actual orpotential tissue damage, or described in terms of such damage.” Chronic pain is typically defined as painthat continues to be present for greater than 3 months [15], or lasts longer that the expected normalduration of recovery. Monitoring an individual’s pain that does not improve within 3 months isimportant given that early treatment of pain is the best way to prevent long-term, persistent chronicpain [7].
An estimated 1 in 5 people in the world population experiences some form of chronic pain [8]. In theUnited States alone, 50 million people suffer from chronic daily pain with 19.6 million have high-impactchronic pain (i.e., chronic pain that frequently limits life or work activities) [2]. The most common typesof chronic pain include:
 musculoskeletal pain (e.g., chronic low back pain, neck pain, arthritis pain)
 neuropathic pain (e.g., peripheral neuropathy, trigeminal neuralgia)
 functional pain syndromes (e.g., fibromyalgia, chronic migraine, chronic pelvic pain)
 chronic pain after surgery complex regional pain syndrome
 cancer painImpact of Chronic PainChronic pain represents a great burden on the global society as well as the individual. The whole personand their environment are impacted by chronic pain – physically, psychologically, behaviorally, andsocially [6]. The personal impact of chronic pain on a person’s life depends on the severity and durationof pain and how well the individual is able to manage their pain. Chronic pain can lead to reducedactivity and social isolation [3]. While it may seem like avoiding activities such as exercise and socialevents would allow rest and healing, scientific data show that gentle to moderate activity and continuedengagement in a healthy range of daily activities is best for prevention and management of chronic pain[11].

How Pain Transitions from Acute to Chronic PainA variety of physical, genetic, environmental, psychological, and social factors interact with
pathophysiology to contribute to the transition from acute pain into chronic pain. It is unknown,however, what the specific contributors are for individual cases of acute pain although psychosocialfactors are significant. ©Copyright 2020 International Association for the Study of Pain. All rights reserved.IASP brings together scientists, clinicians, healthcare providers, and policymakers tostimulate and support the study of pain and translate that knowledge into improvedpain relief worldwide.Physical factors include: Inflammation, stress, muscle tension, injury, tissue deterioration, issues withposture, muscle imbalance (stronger muscles some areas and weaker muscles in other areas),allergies/sensitivities, ongoing disease process (e.g., autoimmune, cancer), congenital disease process(e.g., sickle cell anemia), nutrient deficiencies, impaired bodily functions, inadequate sleep, muscleoveruse, and many others [5].Psychological and environmental factors include: depression, anxiety, post-traumatic stress disorder,social isolation, negatively impacting stressors, physical or psychological abuse or trauma, sexual abuse,exposure to disease, and others [4].Any of these factors can

contribute to the initiation of acute pain and allow for transition into chronicpain. Many types of chronic pain begin as acute pain with changes in the affected pain area – thesecould involve inflammation, muscle fatigue/imbalance, injury or any other physical factors listed above[5].As these conditions persist, the pain and other symptoms may change or remain consistent, and it isthought that around three months of persistent pain in a local body region, changes in the centralnervous system (brain and spinal cord) begin to occur [16]. These changes involve rewiring of the neuralpathways to compensate for the ongoing pain, and many studies have shown evidence of brain changesin individuals with chronic pain compared to healthy pain-free individuals [12]. As this occurs, even if thelocal site of pain has healed or is treated, the rewired central nervous system could enable theexperience of pain to continue and become chronic.Once pain becomes chronic it is much more difficult to treat, and this may be because reversing therewiring of the central nervous system is more difficult than improving physiology at the site of pain [6].Pain that is found to be associated with an ongoing disease in the body is best addressed by specificallytreating the effects and associated symptoms of the disease to reduce the impact of pain and preventrewiring of the central nervous system neural pathways.©Copyright 2020 International Association for the Study of Pain. All rights reserved.IASP brings together scientists, clinicians, healthcare providers, and policymakers tostimulate and support the study of pain and translate that knowledge into

improvedpain relief worldwide.How to Reduce the Chance of Developing Chronic Pain – General Health GuidelinesMaintaining a healthful lifestyle is a strong intervention to prevent chronic pain [10]. Maintain a healthful diet and weight Exercise regularly Eliminate unhealthy practices such as excessive alcohol use and smoking Work and rest in a variety of healthy postures Manage stress with deep breaths using the diaphragm muscles [13], participating inenjoyable activities, reducing sources of unnecessary stress whenever possible Seek counsel or psychological/behavioral therapy whenever needed [14]How to Manage Acute Pain and Prevent Transition to Chronic Pain *Primary Prevention*Discuss the plan for pain management for the short-term pre-surgery or post-injury. Ensuring effectivepain control can result in quicker resolution. Regular review of pain management is important. Doctorsshould take an individualized patient-centered approach and focus on multimodal treatment to preventthe transition to chronic pain [7].As recommended by the recent Pain Management Best Practices Inter-agency Task Force Report [18] it isadvisable for patients to: Take anti-inflammatory medications (for example, ibuprofen) Apply cold and/or heat to the affected areas Participate in therapeutic (mild to moderate)
exercise Physical therapy (or physiotherapy), massage therapy Manage stress Obtain psychological supportAdditionally, it may be advisable to:

 Take a short, tapered dose of oral steroids to reduce inflammation [9]
 Eat a low-inflammatory diet rich in fruits, vegetables, nuts, lean protein sourcesHow to Manage and Prevent Worsening of Chronic Pain *Secondary Prevention & Maintenance*Understand that chronic pain is common and often difficult to completely cure – good self-managementof chronic pain is often the best form of treatment to get pain to a tolerable level for an individual.Positive, yet realistic, expectations for treatments or therapies can be more helpful than extreme ornegative expectations. Whenever possible find a doctor and supportive individuals that you trust andfeel comfortable with sharing your experiences. Multimodal and interdisciplinary treatments that use avariety of pharmacologic, physical, lifestyle, psychological, and alternative and complementary therapiesare thought of as the gold standard and most effective way to manage and reduce chronic pain and itsimpact [1].
 Seek medical advice from a pain specialist / pain clinic if one is available in your area©Copyright 2020 International Association for the Study of Pain. All rights reserved.IASP brings together scientists, clinicians, healthcare providers, and policymakers tostimulate and support the study of pain and translate that knowledge into improvedpain relief worldwide.
 Take nonsteroidal anti-inflammatory drugs (NSAID) (for example, ibuprofen) to reduceinflammation
 Apply cold and/or heat to the affected areas Ask about medical treatments that include nerve blocks into joints or tissues. These areinjections of pain-relieving medications and/or steroids to reduce inflammation
 Consider other medications for pain [21]: Gabapentin/pregabalin, tricyclic antidepressants,serotonin/norepinephrine reuptake inhibitors, topical agents (lidocaine, capsaicin)
 Continue regular mild to moderate exercise - keep moving your body and, when possible, thepainful area Begin physiotherapy, ideally from a pain specialist
 Receive psychological support, ideally from a specialty trained pain psychologist
 Try complementary non-drug therapies for additional benefit: meditation, yoga, acupuncture,biofeedback, massage therapy, water/swim therapy If opioids are indicated for pain after a risk assessment is performed, have a plan with yourdoctor, review risks and benefits and ensure that you are taking the medication only asprescribed with specific goals as determined by you and your doctor [17, 18].
REFERENCES
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[8] Goldberg DS, McGee SJ. Pain as a global public health priority. BMC Public Health 2011;11:770.[9] Goldberg H, Firtch W, Tyburski M, Pressman A, Ackerson L, Hamilton L, Smith W, Carver R, Maratukulam A, Won LA,Carragee E, Avins AL. Oral Steroids for Acute Radiculopathy Due to a Herniated Lumbar Disk. JAMA 2015;313:1915.doi:10.1001/jama.2015.4468.
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[12] Martucci KT, Mackey SC. Neuroimaging of Pain: Human Evidence and Clinical Relevance of Central Nervous SystemProcesses and Modulation. Anesthesiology 2018;128:1241–1254.[13] Ma X, Yue Z-Q, Gong Z-Q, Zhang H, Duan N-Y, Shi Y-T, Wei G-X, Li Y-F. The Effect of Diaphragmatic Breathing on Attention,Negative Affect and Stress in Healthy Adults. Front Psychol 2017;8:874
.[14] Pegram SE, Lumley MA, Jasinski MJ, Burns JW. Psychological Trauma Exposure and Pain-Related Outcomes Among Peoplewith Chronic Low Back Pain: Moderated Mediation by Thought Suppression and Social Constraints. Annals of BehavioralMedicine 2017;51:316–320. doi:10.1007/s12160-016-9838-0
.[15] Treede R-D, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA,Kaasa S, Korwisi B, Kosek E, Lavandʼhomme P, Nicholas M, Perrot S, Scholz J, Schug S, Smith BH, Svensson P, Vlaeyen JWS, WangS-J. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification ofDiseases (ICD-11). Pain 2019;160:19–27
.[16] Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain 2011;152:S2–15.©Copyright 2020 International Association for the Study of Pain. All rights reserved.IASP brings together scientists, clinicians, healthcare providers, and policymakers tostimulate and support the study of pain and translate that knowledge into improvedpain relief worldwide.
[17] https://www.iprcc.nih.gov/sites/ ... treatments_508C.pdf
[18] HHS Best Practices Inter-agency Pain Management Task Force CARA Act https://www.hhs.gov/sites/defaul ... .pdfAUTHORKatherine T. Martucci, PhDAssistant ProfessorCenter for Translational Pain MedicineDepartment of AnesthesiologyDuke University School of MedicineDUMC 3094, Durham, NC 27710REVIEWERSVanila M. Singh, MDClinical Associate Professor, Anesthesiology, Perioperative and Pain MedicineStanford UniversityJianren Mao, MD, PhDChief, Division of Pain MedicineVice Chair for ResearchDirector, Mass General Hospital Center for Translational Pain ResearchHarvard University