Say Goodbye to Back Pain with These Proven Techniques

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Chronic pain is pain that persists or recurs for longer than 3 months.^[7][8][9] It is also known as gradual burning pain, electrical pain, throbbing pain, and nauseating pain. This type of pain is in contrast to acute pain, which is pain associated with a cause that can be relieved by treating the cause, and decreases or stops when the cause improves.^[10] Chronic pain can last for years.^[11] Persistent pain often serves no apparent useful purpose.^[12]

The most common types of chronic pain are back pain, severe headache, migraine, and facial pain.

Chronic pain can cause very severe psychological and physical effects that sometimes continue until the end of life. Analysis of the grey matter (damage to brain neurons), insomnia and sleep deprivation, metabolic problems, chronic stress, obesity, and heart attack are examples of physical disorders; and depression, and neurocognitive disorders are examples of mental disorders.

A wide range of treatments are performed for this disease; drug therapy including opioid and non-opioid drugs, cognitive behavioral therapy and physical therapy are the most significant of them. Medications such as aspirin and ibuprofen are used for milder pain and morphine and codeine for severe pain. Other treatment methods, such as behavioral therapy and physiotherapy, are often used as a supplement along with drugs due to their low effectiveness. There is currently no definitive cure for chronic pain, and research continues into a wide variety of new management and therapeutic interventions, such as nerve block and radiation therapy.

An average of 8% to 11.2% of people in different countries have severe chronic pain, with higher incidence in industrialized countries. Epidemiological studies show prevalence in countries varying from 8% to 55.2% (for example 30-40% in the US and 10-20% in Iran and Canada). Chronic pain is a disease that affects more people than diabetes, cancer, and heart disease.

According to the estimates of the American Medical Association, the costs related to chronic pain in the US are about US$560-635b.

In ICD-11 chronic pain is classified under MG30. It is described as pain that persists or recurs for longer than 3 months. Contributing factors can be multiple, and can include biological, psychological and social factors.^[7]

Subcategories of MG30 are;

• • primary (MG 30.0)
  • cancer related
  • postsurgical or post traumatic
  • secondary musculoskeletal
  • secondary visceral
  • neuropathic
  • secondary headache or orofacial
  • Other specified
  • Unspecified^[7]

Primary chronic pain (MG30.0) has subcategories;

• • widespread (diffuse pain in at least 4 of 5 body regions, and is associated with emotional distress or functional disability. This subcategory is an inclusion for fibromyalgia.^[13])
  • primary musculoskeletal
  • primary headache or orofacial
  • Complex regional pain syndrome
  • Painful bruising syndrome
  • Other specified
  • Unspecified^[7]

Specific pain syndromes can be placed in these categories.

According to the DSM-5 index, a complication is chronic when the resulting complication (pain, disorder, and illness) lasts for a period of more than six months (this type of classification does not have any prerequisites such as physical or mental injury).^[14]

The International Association for the Study of Pain (IASP) describes pain as chronic if it persists for months or even years, beyond the usual recovery time from an injury or illness.^[15] The IASP uses the terms nociceptive, neuropathic and nociplastic (see below).^[16]

In many cases pain fits into 3 categories;^[17]

• "nociceptive"; pain caused by inflamed or damaged tissue that activates special pain sensors called nociceptors.^[18] Nociceptive pain can be divided into "superficial," "deep physical" and "deep visceral" pain.^[19]

• "neuropathic"; pain caused by damage or malfunction of parts of parts of the nervous system. This can be the peripheral nervous system, the central nervous system or the somatosensory nervous system.^{[20][18][21][22]} Peripheral neuropathic pain is often described as "burning", "tingling", "electrical", "stabbing", or "pins and needles".^[23]

• "nociplastic"; pain that arises despite no clear evidence of tissue or somatosensory system damage causing the pain.^[24]

Chronic pain can be classified by origin area as neuropathic, musculoskeletal, visceral, inflammatory or central sensitisation.^[11]

Chronic pain syndromes can be divided between primary and secondary. Secondary pain results from another disease.

Chronic pain has many pathophysiological and environmental causes and can occur in cases such as neuropathy of the central nervous system, after cerebral hemorrhage, tissue damage such as extensive burns, inflammation, autoimmune disorders such as rheumatoid arthritis, psychological stress such as headache, migraine or abdominal pain (caused by emotional, psychological or behavioral) and mechanical pain caused by tissue wear and tear such as arthritis.^[2] In some cases, chronic pain can be caused by genetic factors which interfere with neuronal differentiation, leading to a permanently lowered threshold for pain.^[25]

The pathophysiological etiology of chronic pain remains unclear. Many theories of chronic pain^[26][27] fail to clearly explain why the same pathological conditions do not invariably result in chronic pain. Patients' anatomical predisposition to proximal neural compression (in particular of peripheral nerves) may be the answer to this conundrum. Proximal neural lesion at the level of the dorsal root ganglion (DRG) may drive a vicious cycle of chronic pain by causing postural protection of the painful site and consequent neural compression in the same spinal region. Difficulties in diagnosing proximal neural lesion^[28] may account for the theoretical perplexity of chronic pain.

The mechanism of continuous activation and transmission of pain messages, leads the body to an activity to relieve pain (a mechanism to prevent damage in the body), this action causes the release of prostaglandin and increase the sensitivity of that part to stimulation; Prostaglandin secretion causes unbearable and chronic pain.^[29] Under persistent activation, the transmission of pain signals to the dorsal horn may produce a pain wind-up phenomenon. This triggers changes that lower the threshold for pain signals to be transmitted. In addition, it may cause non-nociceptive nerve fibers to respond to, generate, and transmit pain signals.^[30][31] Researchers believe that the nerve fibers that cause this type of pain are group C nerve fibers; these fibers are not myelinated (have low transmission speed) and cause long-term pain.^[31][32]

These changes in neural structure can be explained by neuroplasticity.^[32] When there is chronic pain, the somatotopic arrangement of the body (the distribution view of nerve cells) is abnormally changed due to continuous stimulation and can cause allodynia or hyperalgesia.^[a] In chronic pain, this process is difficult to reverse or stop once established.^[34] EEG of people with chronic pain showed that brain activity and synaptic plasticity change as a result of pain, and specifically, the relative activity of beta wave increases and alpha and theta waves decrease.^[33]

Inefficient management of dopamine secretion in the brain can act as a common mechanism between chronic pain, insomnia and major depressive disorder and cause its unpleasant side effects.^[35] Astrocytes, microglia and satellite glial cells also lose their effective function in chronic pain. Increasing the activity of microglia, changing microglia networks, and increasing the production of chemokines and cytokines by microglia may exacerbate chronic pain.^[29][36] It has also been observed that astrocytes lose their ability to regulate the excitability of neurons and increase the spontaneous activity of neurons in pain circuits.^[36]

Some diseases such as diabetes, shingles, phantom limb pain, hypertension, and stroke play a role in the formation of chronic pain.

Chronic pain is associated with fibromyalgia.

Complete, longterm remission of many types of chronic pain is rare.^[37] Chronic pain is often difficult to treat.^[38]

Chronic pain can significantly reduce individuals' quality of life, productivity, and wages, worsen existing health issues, and provoke the onset of new conditions like major depression, anxiety disorders, and substance use disorders.^[2]

Many of the often-used medications for chronic pain carry risks for side effects and complications. For example, chronic use of opioids is associated with decreased life expectancy and increased mortality of patients relative to non-users.^[39][40] Acetaminophen, a frequently used drug in chronic pain management, can cause hepatotoxicity when taken in excess of four grams per day,^[41][42] and even therapeutic doses administered to pain patients with chronic liver disease may cause hepatotoxicity. ^[43] Long-term risks and side effects of opioids, another class of analgesic, include constipation, drug tolerance and dependence, nausea, indigestion, arrhythmia (e.g., QT prolongation during methadone treatment), endocrine gland disruptions promoting amenorrhea, erectile dysfunction, and gynecomastia, and fatigue. A major public health and clinical concern in and since the 2010s has been opioid overdose, especially in the context of an opioid epidemic in the United States.^[2][44]

As of 2011, drug treatments for chronic non-cancer pain reduced pain by 30%, although effectiveness varied widely by modality, diagnosis, and population studied.^[45] This reduction in pain can significantly improve patients' performance and quality of life. However, the general and long-term prognosis of chronic pain shows decreased function and quality of life.^[46] Also, this disease causes many complications and increases the possibility of death of patients and suffering from other chronic diseases and obesity.^[2] Similarly, patients with chronic pain who require opioids often develop drug tolerance over time, and this increase in the amount of the dose taken to be effective increases the risk of side effects and death.^[2]

Mental disorders can amplify pain signals and make symptoms more severe.^[47] In addition, comorbid psychiatric disorders, such as major depressive disorder, can significantly delay the diagnosis of pain disorders.^[48] Major depressive disorder and generalized anxiety disorder are the most common comorbidities associated with chronic pain. Patients with underlying pain and comorbid mental disorders receive twice as much medication from doctors annually as compared to patients who do not have such co-morbidities.^[49] Studies have shown that when coexisting diseases exist along with chronic pain, the treatment and improvement of one of these disorders can be effective in the improvement of the other.^[50][51]

Patients with chronic pain are at higher risk for suicide and suicidal thoughts. Research has shown approximately 20% of people with suicidal thoughts, and between 5 and 14% of patients with chronic pain commit suicide.^[50] Of patients who attempted suicide, 53.6% died of gunshot wounds, and 16.2% died of opioid overdose.^[51]

Sleep disturbance, and insomnia due to medication and illness symptoms are often experienced by those with chronic pain.^[52] These conditions can be difficult to treat due to the high potential of medication interactions, especially when the conditions are treated by different doctors.^[53]

Severe chronic pain is associated with increased risk of death over a ten-year period, particularly from heart disease and respiratory disease.^[54] Several mechanisms have been proposed for this increase, such as an abnormal stress response in the body's endocrine system.^[55] Additionally, chronic stress seems to affect risks to heart and lung (cardiovascular) health by increasing how quickly plaque can build up on artery walls (arteriosclerosis). However, further research is needed to clarify the relationship between severe chronic pain, stress and cardiovascular health.^[54]

People with chronic pain tend to have higher rates of depression^[56] and although the exact connection between the comorbidities is unclear, a 2017 study on neuroplasticity found that "injury sensory pathways of body pains have been shown to share the same brain regions involved in mood management."^[57] Chronic pain can contribute to decreased physical activity due to fear of making the pain worse. Pain intensity, pain control, and resilience to pain can be influenced by different levels and types of social support that a person with chronic pain receives, and are also influenced by the person's socioeconomic status.^[58]

In a study, Mendelian randomization was used to identify causal relationships between chronic pain and certain psychiatric, cardiovascular, and inflammatory conditions that were initially thought to be unrelated to pain. It was found that exposure to depression increases the likelihood of reporting pain, but not the other way around. Exposure to coronary diseases increases the risk of developing chronic pain, and vice versa. An increase in body mass index modestly raises the likelihood of experiencing pain, while high blood HDL levels reduce the probability of suffering from chronic pain. Regarding inflammatory traits, exposure to asthma increases the likelihood of experiencing pain, and vice versa.^[59]

Chronic pain of different causes has been characterized as a disease that affects brain structure and function. MRI studies have shown abnormal anatomical^[60] and functional connectivity, even during rest^[61][62] involving areas related to the processing of pain. Also, persistent pain has been shown to cause grey matter loss, which is reversible once the pain has resolved.^[63][64]

One approach to predicting a person's experience of chronic pain is the biopsychosocial model, according to which an individual's experience of chronic pain may be affected by a complex mixture of their biology, psychology, and their social environment.^[65]

Chronic pain may be an important contributor to suicide.^[66]

Spinal stenosis
Spinal stenosis
Specialty	Orthopedics, neurosurgery
Symptoms	Pain, numbness, or weakness in the arms or legs[1]
Complications	Loss of bladder control, loss of bowel control, sexual dysfunction[1]
Usual onset	Gradual[1]
Types	Cervical, thoracic, lumbar[2]
Causes	Osteoarthritis, rheumatoid arthritis, spinal tumors, trauma, Paget's disease of the bone, scoliosis, spondylolisthesis, achondroplasia[3]
Diagnostic method	Based on symptoms and medical imaging[4]
Differential diagnosis	Cauda equina syndrome, osteomylitis, peripheral vascular disease, fibromyalgia[5]
Treatment	Medications, exercises, bracing, surgery.[6]
Medication	NSAIDs, acetaminophen, steroid injections[7]
Frequency	Up to 8% of people[4]

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots.^[6] Symptoms may include pain, numbness, or weakness in the arms or legs.^[1] Symptoms are typically gradual in onset and improve with leaning forward.^[1] Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.^[1]

Causes may include osteoarthritis, rheumatoid arthritis, spinal tumors, trauma, Paget's disease of the bone, scoliosis, spondylolisthesis, and the genetic condition achondroplasia.^[3] It can be classified by the part of the spine affected into cervical, thoracic, and lumbar stenosis.^[2] Lumbar stenosis is the most common, followed by cervical stenosis.^[2] Diagnosis is generally based on symptoms and medical imaging.^[4]

Treatment may involve medications, bracing, or surgery.^[6] Medications may include NSAIDs, acetaminophen, anticonvulsants (gabapentinoids) or steroid injections.^[8][7] Stretching and strengthening exercises may also be useful.^[1] Limiting certain activities may be recommended.^[6] Surgery is typically only done if other treatments are not effective, with the usual procedure being a decompressive laminectomy.^[7]

Spinal stenosis occurs in as many as 8% of people.^[4] It occurs most commonly in people over the age of 50.^[9] Males and females are affected equally often.^[10] The first modern description of the condition is from 1803 by Antoine Portal, and there is evidence of the condition dating back to Ancient Egypt.^[11]

The most common forms are lumbar spinal stenosis, at the level of the lower back, and cervical spinal stenosis, which are at the level of the neck.^[12] Thoracic spinal stenosis, at the level of the mid-back, is much less common.^[13]

In lumbar stenosis, the spinal nerve roots in the lower back are compressed which can lead to symptoms of sciatica (tingling, weakness, or numbness that radiates from the low back and into the buttocks and legs).^{[citation needed]}

Cervical spinal stenosis can be far more dangerous by compressing the spinal cord. Cervical canal stenosis may lead to myelopathy, a serious condition causing symptoms including major body weakness and paralysis.^[14] Such severe spinal stenosis symptoms are virtually absent in lumbar stenosis, however, as the spinal cord terminates at the top end of the adult lumbar spine, with only nerve roots (cauda equina) continuing further down.^[15] Cervical spinal stenosis is a condition involving narrowing of the spinal canal at the level of the neck. It is frequently due to chronic degeneration,^[16] but may also be congenital or traumatic. Treatment frequently is surgical.^[16]

• Standing discomfort (94%)
• Discomfort/pain, in shoulder, arm, and hand (78%)
• Bilateral symptoms (68%)
• Numbness at or below the level of involvement (63%)
• Weakness at or below the level of involvement (43%)
• Pain or weakness in buttock / thigh only (8%)
• Pain or weakness below the knee (3%)^[17]

• Cervical (spondylotic) myelopathy,^[18] a syndrome caused by compression of the cervical spinal cord which is associated with "numb and clumsy hands", imbalance, loss of bladder and bowel control, and weakness that can progress to paralysis.
• Pinched nerve,^[19] causing numbness.
• Intermittent neurogenic claudication^[17][20][21] characterized by lower limb numbness, weakness, diffuse or radicular leg pain associated with paresthesia (bilaterally),^[20] weakness and/or heaviness in buttocks radiating into lower extremities with walking or prolonged standing.^[17] Symptoms occur with extension of spine and are relieved with spine flexion. Minimal to zero symptoms when seated or supine.^[17]

• Radiculopathy (with or without radicular pain),^[20] a neurologic condition in which nerve root dysfunction causes objective signs such as weakness, loss of sensation, and loss of reflex.
• Cauda equina syndrome:^[22] lower extremity pain, weakness, numbness that may involve perineum and buttocks, associated with bladder and bowel dysfunction.
• Lower back pain^[17][21] due to degenerative disc or joint changes.^[23]

• Spinal canal is too small at birth
• Structural deformities of the vertebrae may cause narrowing of the spinal canal.

Any of the factors below may cause the spaces in the spine to narrow.

• Spinal ligaments can thicken (ligamenta flava)^[24][25]
• Bone spurs develop on the bone and into the spinal canal or foraminal openings
• Intervertebral discs may bulge or herniate into the canal or foraminal openings^[26]
• Degenerative disc disease causes narrowing of the spaces.^[27]
• Facet joints break down
• Facet joints may hypertrophy^[28]
• Compression fractures of the spine, which are common in osteoporosis^[29]
• Synovial cysts form on the facet joints causing compression of the spinal sac of nerves (thecal sac)

• Osteoarthritis^[30]
• Rheumatoid arthritis—much less common cause of spinal problems^[31]

• A vertebra slips forward on another (spondylolisthesis)

• Accidents and injuries may dislocate the spine and the spinal canal or cause burst fractures that yield fragments of bone that go through the canal.^[32]
• Patients with cervical myelopathy caused by narrowing of the spinal canal are at higher risk of acute spinal cord injury if involved in accidents.^[33]

• Irregular growths of soft tissue will cause inflammation.
• Growth of tissue into the canal pressing on nerves, the sac of nerves, or the spinal cord.

The diagnosis of spinal stenosis involves a complete evaluation of the spine. The process usually begins with a medical history and physical examination. X-ray and MRI scans are typically used to determine the extent and location of the nerve compression.^{[citation needed]}

The medical history is the most important aspect of the examination as it will tell the physician about subjective symptoms, possible causes of spinal stenosis, and other possible causes of back pain.^[34]

The physical examination of a patient with spinal stenosis will give the physician information about exactly where nerve compression is occurring. Some important factors that should be investigated are any areas of sensory abnormalities, numbness, irregular reflexes, and any muscular weakness.^[34]

MRI has become the most frequently used study to diagnose spinal stenosis. The MRI uses electromagnetic signals to produce images of the spine. MRIs are helpful because they show more structures, including nerves, muscles, and ligaments than seen on X-rays or CT scans. MRIs are helpful in showing exactly what is causing spinal nerve compression.^{[citation needed]}

In CT myelography, spinal tap is performed in the low back with dye injected into the spinal fluid. X-rays are performed followed by a CT scan of the spine to help see narrowing of the spinal canal. This is a very effective study in cases of lateral recess stenosis. It is also necessary for patients in which MRI is contraindicated, such as those with implanted pacemakers.^{[citation needed]}

• Fever
• Nocturnal pain
• Gait disturbance
• Structural deformity
• Unexplained weight loss
• Previous carcinoma
• Severe pain upon lying down
• Recent trauma with suspicious fracture
• Presence of severe or progressive neurologic deficit^[22]

Treatment options are either surgical or non-surgical. The overall evidence is inconclusive whether non-surgical or surgical treatment is better for lumbar spinal stenosis.^[35]

The effectiveness of non-surgical treatments is unclear as they have not been well studied.^[36]

• Education about the course of the condition and how to relieve symptoms
• Medicines to relieve pain and inflammation, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs)
• Exercise, to maintain or achieve overall good health, aerobic exercise, such as riding a stationary bicycle, which allows for a forward lean, walking, or swimming can relieve symptoms
• Weight loss, to relieve symptoms and slow the progression of the stenosis
• Physical therapy to support self-care.^[37] Also may give instructions on stretching and strength exercises that may lead to a decrease in pain and other symptoms.
• Lumbar epidural steroid or anesthetic injections have low quality evidence to support their use.^[36][38]

Lumbar decompressive laminectomy: This involves removing the roof of bone overlying the spinal canal and thickened ligaments in order to decompress the nerves and sacs of nerves. 70–90% of people have good results.^[39]

• Interlaminar implant: This is a non-fusion U-shaped device that is placed between two bones in the lower back that maintains motion in the spine and keeps the spine stable after a lumbar decompressive surgery. The U-shaped device maintains height between the bones in the spine so nerves can exit freely and extend to lower extremities.^[40]
• Surgery for cervical myelopathy is either conducted from the front or from the back, depending on several factors such as where the compression occurs and how the cervical spine is aligned.
  • Anterior cervical discectomy and fusion: A surgical treatment of nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine with a discectomy in order to stabilize the corresponding vertebrae.
  • Posterior approaches seek to generate space around the spinal cord by removing parts of the posterior elements of the spine. Techniques include laminectomy, laminectomy and fusion, and laminoplasty.

Decompression plus fusion appears no better than decompression alone, while spinal spacers appear better than decompression plus fusion but not better than decompression alone.^[41][42] No differences were found in the type of decompression.^[42]

• The NAMCS data shows the incidence in the U.S. population to be 3.9% of 29,964,894 visits for mechanical back problems.^[43]
• It occurs more frequently in women.^[8]

In a study of 146 patients with lumbar spinal stenosis (mean age, 68 years, 42% women) who did not undergo surgery, followed up for 3 years, the study reported that approximately one-third of participants indicated improvement; approximately 50% reported no change in symptoms; and approximately 10% to 20% of patients condition worsened.^[41]

A RCT is being conducted in Sweden, to compare surgery versus non-surgical treatment for lumbar spinal stenosis.^[44]

• Spinal cord compression

• "Spinal Stenosis". PubMed Health. National Center for Biotechnology Information, U.S. National Library of Medicine. 25 May 2010. Archived from the original on 8 February 2011.
• "Questions and Answers About Spinal Stenosis". US National Institute of Arthritis and Musculoskeletal and Skin Diseases. 11 April 2017.
• "Most Common Back Surgery Types". Royal Spine Surgery. 13 September 2019.