The complexity of chronic pain

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The definition of pain as chronic gives us a clue that it may not change much over time, indeed attempts to cure the problem are often disappointing. In addition, Chapman and Dunbar21 note that:

Pain is not an isolated symptom. Severe pain creates fatigue, impairs concentration, compromises mood, degrades sleep and diminishes overall activity level. The goal of intervention for chronic pain must include alleviating the functional impairment that pain produces as well as its discomfort. Evaluating treatment outcome requires:

1. quantification of both pain intensity and pain-related impairment; and

2. review of how the relationship between these variables changes as a function of treatment.

Simply tracking pain intensity level as an indicator of pain relief is insufficient and can lead to misinterpretation of the effects of an intervention.

Important material losses and perceptions of loss that shape patients' views can only be discovered and understood by detailed questioning and exploration of individual narratives.22 The losses are unlikely to be standardized between patients and therefore are difficult to group or categorize. We must nevertheless be careful to try to capture these important features rather than simply measure that which is easily measurable.

The biopsychosocial model of pain allows us to categorize outcomes into the following groups:

• Biomedical - e.g. pain, either spontaneous or evoked by touch or pressure (allodynia) or activity. This will almost always be included, but many patients find dysesthesia (e.g. numbness or tingling) to be as disruptive and in these, analgesic treatments will be ineffective. Physical functioning (e.g. time to walk

50 m), weight gain due to inactivity, medication use or dose reduction, and number of physician visits will also be of interest in some studies. McCracken and Eccleston23 have noted that acceptance of chronic pain predicts physical function and this is yet another dimension to be taken into account.

• Psychological - there are many measures of depression and cognitions, such as pain beliefs, negative thoughts, or catastrophization (see also Chapter 10, The psychological assessment of pain in patients with chronic pain and Chapter 13, Psychological effects of chronic pain: an overview, as well as Ref. 24). It is well established that depression affects the measurement of pain.25

• Social - e.g. effects on relationships, family, leisure, and working. The relationship between psychological and social factors is reviewed by Stroud et al.26

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