3. Cohen et al. 2021

Introduction

• Chronic pain: unpleasant sensory and emotional experience associated with actual or potential tissue damage
  • It is the main reason why people seek medical care
  • Higher prevalence rates for women, people from low socioeconomic background, military veterans, and people residing in rural areas
  • Racial + ethnic minorities: due to enhanced physiological pain sensitivity, cultural differences, and reduced access to care
• The economic costs of chronic pain are substantial

Chronic pain as a disease model

• Acute pain: in response to tissue trauma, has a survival value and plays a role in healing
• Pain becomes pathological when it persists beyond the expected healing period (3 months)
• Chronic pain = disease
  • Alterations in the PNS and CNS + quality of life decrements
• Factors promoting resiliency can promote healing and reduce pain chronification

Biopsychosocial model and consequences of chronic pain

• Biopsychosocial model: pain and disability are multi-dimensional. They are dynamic interactions among biological, psychological, and social factors that reciprocally influence each other
• Chronic pain effects
  • Interferes with someone’s ability to work and can lead to financial ramifications, including homelessness
  • Affects relationships and self-esteem
  • Reduces life expectancy
  • Deleterious pathophysiological and anatomical changes
  • Suppression of cell-mediated immunity and humoral immunity
  • Alterations in gene expression
  • Decreases in grey brain matter
• Pain might affect the survival rate of patients with cancer

Classification of pain and its importance

• Pain is always subjective
  • A patient’s report of pain should be accepted at face value in absence of evidence to the contrary
• 3 main categories of chronic pain:
  • Nociceptive
  • Results from activity in neural pathways
  • Most common
  • Neuropathic
  • Caused by damage or disease affecting the somatosensory nervous system
  • It is maladaptive
  • Associated with greater decrements in quality of life
  • Nociplastic
  • Arises from the abnormal processing of pain signals without any clear evidence of tissue damage of discrete pathology involving the somatosensory system
  • Augmented sensory processing + diminished inhibitory pathways

Mixed pain and pain classification as a continuum

• Many pain conditions have a mixed pain phenotype
• Types of pain occupy different points on a continuum
• There is no reason cancer and non-cancer patients should be treated differently
  • In patients who have recovered from cancer and have chronic pain, treatments should be similar to other patients, tailored to unique consideration

Pain management

Best practices

• Mechanism-based pain treatment = optimal but difficult
• Treatment is typically symptom-based or disease-based
• Goals of therapy: tailored towards an improved quality of life
• Interdisciplinary treatment: uses a personalized approach and a shared-decision model
• Multimodal approach: includes self-care, a healthy lifestyle, and ergonomic modifications

Exercise and psychotherapy

• Exercise: excellent self-management strategy
• CBT

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