Many chronic pain conditions are caused by inflammation, dysfunctional nerves, disease, or fractures. Common complaints of chronic pain can be the result of injury or failed recovery and overtime the condition often becomes worse without an immediate plan of care. If you are suffering from chronic pain, you need to be well informed about your condition in order to understand proper recovery and to experience optimal relief.

SCIATICA
Sciatica refers to pain that is felt along the course of the sciatic nerve. It can vary from a mild ache to a sharp burning pain that is felt in the lower back (lumbar area) and buttocks, down the back of the leg, as well as the foot, usually affecting one side of the body. Some people may also experience tingling numbness and muscle weakness.

Sciatica is most often due to a herniated disc or degenerated inter vertebral disc, growth of a bone spur on the spine or lumbar spinal stenosis (narrowing of the spinal canal) causing nerve compression. People who are elderly, obese or diabetic have an increased risk of sciatic pain. A sedentary lifestyle, an occupation that involves prolonged sitting or one that involves lifting heavy loads are also more prone to experiencing sciatica. While mild sciatic pain may resolve over time, it can potentially cause nerve damage which then leads to weakness and loss of sensations in the affected leg in addition to loss of bowel and bladder control, in severe cases.

Interventions usually involve controlling the pain, physiotherapy, exercising regularly and maintaining good posture, while severe cases may require surgery.

SPINAL STENOSIS
Spinal stenosis refers to the narrowing of the spinal canal due to bone spurs, herniated discs, thickened ligaments, tumors or injury; causing swelling and inflammation in the tissues surrounding spinal canal.

Degenerative changes usually occur in elderly patients, while younger patients may have spinal stenosis due to trauma or spinal deformities like scoliosis (which affects bone and muscle development in the body).

The symptoms of spinal stenosis vary based on the area of the spine affected. The most common presentations are:

  1. Cervical Stenosis: narrowing of the spinal canal in the neck area, causing neck pain.
  2. Lumbar stenosis: narrowing of the spinal canal in the lower back, causing back pain along with leg cramps that get better after resting or bending forwards.

Patients may also experience tingling numbness and weakness in the upper or lower limbs, difficulty in walking or maintaining balance. In severe cases, loss of bowel or bladder control occurs. Spinal stenosis can be seen in an MRI or CT scan and is treated by managing the pain, physical therapy, surgery or a combination of these.

HERNIATED DISCS
A herniated disc is formed when the tough, fibrous outer covering of an intervertebral disc becomes weak and tears, causing the soft tissue in the center, to be pushed outwards through the tear, due to pressure from the vertebrae above and below the disc, resulting in a slipped or ruptured disc. The disc protrusion presses on the surrounding nerves and soft tissue causing pain. Herniated discs occur due to aging and wear and tear of the tissues. Obesity or a sudden strain on the spinal column due to lifting heavy objects with incorrect posture or an unexpected, violent twisting motion, have also led to slipped discs.

Although the condition occurs most often in the lumbar spine (lower back), they may also affect the thoracic spine (chest) or the cervical spine (neck) leading to tingling numbness, muscle weakness or spasms as well as,

  1. back pain and sciatica or pain that radiated to the buttocks, legs and feet
  2. neck pain, especially on the back and sides of the neck, which increases with movement

Herniated discs are visualized on x-rays, MRIs or CT scans, and evaluated for pain and muscle weakness on clinical examination of the patient. Pain management, bed rest, physical therapy, spinal injections or nerve blocks and even surgery in severe cases or large herniations are used for treatment of the condition.

CERVICAL RADICULOPATHY
Cervical Radiculopathy is often called “pinched nerve” due to the compression of nerve roots near the cervical vertebrae (forming the cervical spine, from the base of the skull and extending down to the neck). Damage to the nerve roots cause pain and loss of sensation along the nerve’s pathway, that extends from the neck to the arm or the hand, depending on where the damaged roots are located.

Common causes of cervical radiculopathy are degenerative changes in the intervertebral discs that can cause herniation and compression of the nerve roots, cervical foramen stenosis or narrowing of the openings in the cervical vertebrae through which the nerves travel, in addition to injury due to sudden lifting, twisting or pulling motions.
Repetitive motions like diving, playing golf or driving vibrating vehicles as well as infections or tumors in the spine have also led to injury of the nerve roots.

Patients present with both sensory and motor nerve issues. They experience tingling numbness in fingers or hands along with muscle weakness, loss of reflexes or lack of co-ordination. Cervical Radiculopathy can be diagnosed with physical examinations, X rays MRI and CT scans to identify the cause and is treated by managing the pain, physical therapy or surgery to relieve the pressure on the nerve root in very severe cases.

FACET JOINT PAIN
The facet joints are hinge like joints that link vertebrae together to form the spine, providing stability, support as well as mobility to the spine, allowing bending, extension and twisting motions. These joints have cartilage tissue that act as buffers between two bony surfaces. Injury to the facet joints causes facet joint pain, which leads to muscle weakness, tingling numbness, muscle pain and spasms, radiating pain and joint stiffness in the neck or back, depending on the location of the injury along the spine.

The causes of facet joint pain could be osteoarthritis (inflammation or infections of the joint), shrinking or degeneration of the intervertebral discs causing additional wear and tear, excessive body weight and increasing age. These conditions are diagnosed by physical examination of muscle strength, reflexes and range of motion, along with X rays, CT scans or MRIs. The treatment includes pain relief, physical therapy and in severe cases nerve blocks or nerve ablations.

MYOFASCIAL PAIN
Myofascial pain (chronic muscle pain) refers to the pain or inflammation affecting the fascia or connective tissue that covers either single muscles or muscle groups in the body. This pain may be due to injury caused by increased strain on a muscle, ligament or tendon which leads to damage of the muscle fibers. The actual site of the injury prompts a trigger point of pain that is felt in other areas, known as referred pain. There are active and latent trigger points. Active points are tender and painful areas located within the muscle, while a latent rigger point is a dormant or inactive area that causes muscle weakness or restricted movements.

Myofascial pain is treated with pain relievers, physical therapy and more specifically, myofascial release therapy or massage therapy. For severe cases, trigger point injections containing local anesthetic drugs or steroids are injected in trigger points to inactivate them.

SACROILIITIS
Sacroiliitis is the inflammation of one or both of the sacroiliac joints, which are located where the sacrum or tailbone, in the last section of the spinal column, meets the ileum, which is a part of the bony pelvis. This inflammation causes lower back pain that may extend to the buttocks and the thighs. The pain gets worse after prolonged periods of sitting or standing and ranges from a sharp and stabbing pain to a dull ache over the affected area.

It occurs due to trauma, osteoarthritis (wear and tear of the joints and ligaments), psoriatic arthritis (condition that causes joint pain as well as psoriasis or scaly patches on the surface of the skin) and pyogenic sacroiliitis (due to bacterial infections). Hormones released during pregnancy relaxes the ligaments and muscles supporting the joint, causing them to rotate. Excessive weight gain during pregnancy also adds to wear and tear of the joint.

The condition is diagnosed by physical examination to detect the location and extent of the pain, in addition to the range of movement possible for the joint. Imaging tests like X rays, CT scans and MRIs help to diagnose the source of the pain. Patients are treated with pain relievers, physical therapy, steroid injections or never blocks by ablating (or destroying) the nerve in severe cases. Left untreated, sacroiliitis may lead to difficulty in moving the joints, sleep deprivation or depression.

SHINGLES
Shingles is caused by the varicella-zoster virus, which also causes chickenpox. In a person who has been exposed to chickenpox or its vaccine, the virus can lie dormant in the nerves for many years. However, in those with weakened immune systems (due to old age or disease) the virus can get reactivated decades after they have had chickenpox.

It presents as a band- like rash on one side of the body, along with flu like symptoms. The rash develops as itchy lesions with tingling to extreme pain in the area and extreme sensitivity to touch or temperature changes. This happens because of the damage that occurs to the nerve fibers during an outbreak of shingles. Damaged fibers cause the exaggerated sensation of pain on the skin, which has been described as an intense burning, stabbing pain, shooting along the course of the affected nerve. This is known as post-herpetic neuralgia or nerve pain. Chronic, excruciating pain may lead to depression and difficulty in sleeping or concentrating.

Adults over the age of 50 may be given a vaccine for shingles as a preventive measure. Patients are treated with pain relievers and antiviral medications, along with nerve stimulation during physical therapy.

PHANTOM LIMB PAIN
Phantom limb pain (PLP) refers to ongoing painful sensations that seem to be coming from a part of a limb that has been amputated. While the limb, or part of the limb is gone, the pain in that region, is real. The pain occurs soon after the amputation surgery and may be constant or intermittent. It may start as pins and needles and increase in severity to become a shooting, stabbing, cramping, crushing, burning or throbbing pain. It is believed that PLP develops as a response to mixed signals from the brain and spinal cord. After amputation of a body part, the brain and the spinal cord lose sensory input from the missing limb and adjust to this change by triggering pain. Damaged nerve endings or scar tissue at the amputation site also contribute to phantom pain.

For most patients the sensation of pain fades on its own, but for others it may last weeks to months after the surgery. Patients are treated with pain relievers, acupuncture, spinal cord nerve stimulation. In severe cases, surgical options include deep brain stimulation.

VERTEBRAL FRACTURE
Fractures in the vertebral bones of the spinal column, usually occur because of trauma or injury. Other causes could be pathological fractures that occur due to weakening of the bones in conditions like osteoporosis or cancer. Depending on the location of the fracture, affecting the cervical (neck), thoracic (chest) or lumbar (lower back) vertebrae, patients may exhibit different symptoms, ranging from pain due to compression or damage of the nerves, to paralysis or the inability to move arms or legs, tingling numbness, muscle spasms and loss of bowel or bladder control. The characteristic feature of a vertebral fracture is mild to moderate pain that increases with any type of movement and decreases with rest. Fractures may be diagnoses on X-rays, CT- scans or MRIs. Vertebral fractures may be:

  1. Compression Fractures: These occur due to weakened bones in osteoporosis or tumors, where the front of the vertebrae is fractured but the back part remains intact forming a wedge-shaped vertebral bone.
  2. Axial Burst fractures: These occur due to fall from a height where the person lands heavily on their feet, the force of which fractures the vertebral bone both on the front and back side, with fragments of bone that separate causing damage to surrounding nerves and soft tissues.
  3. Chance fractures or seat belt injuries: These occur in car accidents, when the pelvic bone is stabilized with a seat belt while the upper body is pulled forward or flexed violently.
  4. Minor fractures that can heal by themselves are usually stabilized by bracing and patients are given pain relievers to control symptoms. Fractures compressing nerves require traction or spine surgery. Physical therapy is recommended after the fracture has healed to improve range of movements and strengthen muscles.

FIBROMYALGIA
Fibromyalgia is a common condition that causes soft tissue or myofascial pain. While the symptoms may resemble those of arthritis (inflammation of the joints) the condition is limited to soft tissues. Fibromyalgia may be caused by traumatic injury, rheumatoid arthritis, genetic factors or autoimmune conditions like Lupus.

In addition to muscle pain, that is accompanied by muscle twitching or tightness, patients may also have tender points all over the body. They experience fatigue and insomnia and find it difficult to concentrate, in a condition called “fibro fog.”
Patients are treated with pain relievers. Regular, moderate, low impact exercise or physical therapy, that build endurance, while stretching and strengthening muscles, have also improved painful fibromyalgia. Endorphins released during exercise help to combat pain, stress, insomnia and depression. Complementary therapies include massages, and acupuncture.

ARTHRITIS : OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS
Arthritis is the swelling and tenderness of one or more joints due to inflammation or infection in the joint lining or cavity. Swelling occurs because of the increased secretion of synovial fluid, i.e. fluid that lubricates the joints, to facilitate smooth movement of the bones in the joint.

Types of arthritis:

Osteoarthritis causes cartilage to break down due to excessive wear and tear. Cartilage is the hard, slippery tissue that covers the ends of the bones, where they meet to form a joint, in order to protect the bone surfaces from scraping over each other as they move. As the cartilage decreases, bones grind directly on bone, creating friction and pain.

Rheumatoid arthritis is a disease in which the body’s own immune system attacks the lining of the joint or the joint capsule. The lining or synovial membrane is inflamed and swollen.
Other inflammatory conditions are:

  1. Symptoms include joint pain (arthralgia) and stiffness, which typically worsen with age. The joint may be red and swollen, allowing restricted, painful motions, making it difficult to perform routine activities, and walk or sit comfortably. In severe cases, joints may get deformed. Elderly or obese patients or those with previous joint injury have a tendency to develop arthritis.

    In addition to laboratory tests to analyze blood and urine, a sample of synovial or joint fluid may be aspirated from the joint, using a needle, in order to determine the cause of the arthritis. Ultrasound, x rays, CT scans and MRIs are done to visualize the joint cavities. Treatments include pain relievers and physical therapy, as well as specific measures to deal with the causative agent of joint pain. In severe cases, surgery may be required for joint repair or replacement.

MIGRAINE
A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It is often accompanied by nausea, vomiting, as well as extreme sensitivity to light and sound. Migraine attacks can last for hours to days, with severe headaches that interfere with daily activities. The condition develops in 4 phases:

Prodrome, which occurs 1-2 days before an attack, warns the patient of an upcoming migraine with mood swings and neck stiffness. This is followed by Aura which includes visual disturbances, such as flashes of light or blind spots, tingling in the face, arm or leg and difficulty speaking. The actual migraine attack can last from 4-72 hours and is followed by the Post-drome phase, where the patient is fatigued.

There are several triggers that lead to migraines; like hormonal changes in women during monthly periods, pregnancy or menopause, increased stress, consumption of alcohol or caffeine, overloaded sensory stimuli like bright lights or sunlight, sleep, climate or food changes. CT scans and MRIs may be taken to rule out any other physical causes of the recurrent headaches. Treatment includes pain relievers and anti-nausea medication.

PINCHED NERVE
A pinched nerve occurs when pressure is applied to a nerve by surrounding tissues, such as bones, cartilage, muscles or tendons, causing tingling numbness, pins and needles (paranesthesia), a sharp, aching or burning pain, muscle weakness with radiating pain. There is usually no permanent damage, if the nerve is compressed for a short duration. Chronic pain with permanent nerve damage can occur if the nerve compression continues.

The symptoms felt by the patient depend on the location of the nerve. A herniated disk in the lower spine exerts pressure on a nerve root that leads to radiating pain in the lower limb. Or, a pinched nerve in the wrist can lead to pain and numbness in the hand and fingers which is commonly known as “carpal tunnel syndrome”

Compression or pinching of the nerve can occur due to:

  • Injury
  • Formation of bone spurs
  • Stress from repetitive actions in sports activities
  • Obesity, diabetes or thyroid disease
  • Pregnancy or prolonged bed rest
  • Autoimmune disease like Rheumatoid arthritis

The condition is diagnosed using nerve conduction studies or electromyography. MRIs or ultrasonography can be used to determine the cause of compression. Splints and braces are required to immobilize and rest the area, followed by physical therapy to relieve the pressure on the nerve. Pain relievers or corticosteroid injections at the site are used to decrease symptoms. Chronic compression may require surgery.

TRIGGER POINTS
Trigger points, more commonly known as knots, are sensitive and hyperirritable areas in the muscle or connective tissue (fascia) that are painful when compressed and may also cause referred pain in another part of the body. Patients may experience persistent pain and have limited movements. It may also manifest as tension headaches, lower back or neck pain and tinnitus. Myofascial pain syndrome (MPS) is a chronic disorder identified by multiple trigger points, causing generalised body pain as it radiates from the trigger point throughout the muscle and fascia.

Patients can be treated with Trigger point myotherapy /neuromuscular therapy / massage therapy which applies concentrated pressure on the muscle in spasm. This relaxes the muscle and encourages blood and oxygen circulation to the affected area. Myofascial release is a manipulative treatment that releases tension and reduces chronic pain in muscle fascia. Trigger point injections also relieve symptoms.