Understanding Pain

From creakyjoints.org

Learn about pain, its various types, and how to communicate your pain effectively to your health care provider

Pain is your nervous system signalling to you that something may be wrong. It can be a warning that something is damaged or about to be damaged. It can be sharp, dull, tingling, burning, pricking, stinging, or aching. It can be localized to one spot or all over. Or, sometimes, it can just be hard to pinpoint.  

What’s more, people experience pain differently. What is excruciating for some may be mild for others. Beyond the physical burden, pain can impact your quality of life and make you avoid being with other people. It can keep you in your house — or in your bed. Pain can impact your emotional well-being. Pain can make it hard to live. 

A study based on a national survey found that the most common areas of pain for adults were the back, hip, knees, and feet. People surveyed reported limitations in daily functioning, including social activities and activities of daily living. They also reported significantly more workdays missed compared with those without chronic pain.  

A 2019 review said chronic pain is an epidemic for older adults, and has become a risk factor for premature death and accelerated cognitive decline. Pain does not only affect the old. A 2022 global study published in the journal Pain, found that one in every nine people between ages 15 and 34 years experience chronic pain. 

It’s important to talk to your doctor about your pain. It can be an important clue to something going wrong with your body that needs to be fixed. For 50 million U.S. adults, chronic pain is a daily occurrence, according to the National Institutes of Health.  

                                                                                                  Credit: Tatiana Ayazo

Types of Pain

Understanding pain requires knowing its source. “Everybody perceives pain as a warning sign,” says Dr. James Wyss, MD, PT, a physiatrist at the Hospital for Special Surgery in New York.  

For that reason, it’s important to get to the bottom of your pain. If you know the source of your pain, you will know if you need to heed it or push past it, says Dr. Wyss. “Is it your body’s way of telling you there is something more serious going on,” he says. 

Pain can be categorised by where it is located, and can be grouped as inflammatory versus mechanical or focal versus systemic. Pain can be experienced bilaterally (both sides). Pain can also be categorized by its severity or duration, such as acute versus chronic pain. Fibromyalgia carries with it its own unique form of pain. Neuropathic pain happens when your nervous system is damaged.  

Whatever type of pain you are suffering from, it’s important to know where it is coming from so you can get the right medical treatment.  

Inflammatory vs. Mechanical Pain

There are two kinds of inflammatory pain. It can be the increased sensitivity that occurs when there is an inflammatory response as a result of tissue damage. Another type of inflammatory pain is the result of disease, often, but not always, an autoimmune disease that causes the immune system to attack healthy tissue. Inflammatory pain can have the following attributes: 

• Lasts more than three months (chronic) 
• Causes heat, swelling, and loss of function 
• Causes joint pain and stiffness after long periods of rest 
• Appears in “flares” with intense symptoms alternating with periods of remission 
• Feels like a gnawing, throbbing deep pain

Conditions that can cause inflammatory pain include: 

• Ankylosing spondylitis 
• Gout 
• Inflammatory bowel disease 
• Lyme disease 
• Lupus 
• Polymyalgia rheumatica 
• Psoriatic arthritis 
• Rheumatoid arthritis 

Another feature of inflammatory pain is that it can intensify without reason, says Dr. Wyss. For example, in psoriatic arthritis, the pain you have been experiencing can ramp up without any connection to activity or lifestyle habits, he says. Another example is gout, where there can be a sudden spike in pain, swelling, redness, and warmth. 

Mechanical pain can be anywhere but is often associated with the back and is the result of stress on the discs, ligaments, muscles, or nerves. Some attributes of mechanical pain include: 

• Acute 
• Linked to an injury, body weight, or degenerative process like aging 
• Sudden onset 
• Does not improve with movement 

Types of mechanical pain can include: 

• Degenerative disc disease 
• Spinal stenosis 
• Herniated disc 
• Fracture 
• Severe scoliosis 
• Osteoarthritis 

It’s important to identify which kind of pain you have in order to get the most effective treatment.  

To help distinguish whether you have mechanical or inflammatory pain, your doctor may ask questions like: 

• How long have you been experiencing pain? 
• Does your family have a history of inflammatory arthritis? 
• When did the pain start? 
• Is the pain worse in the morning? 

Mechanical pain can be treated with rest, nonsteroidal anti-inflammatory drugs (NSAIDS), ice and heat applications, and physical therapy. Dr. Wyss says the rest needed for mechanical pain is a relative rest, not an absolute rest. “You still need movement, but modified or you will have the risk of the joints becoming stiff or muscle atrophying, which will make it more difficult to recover.”

If your pain is due to an inflammatory response, there are medications to treat the underlying condition. However, a 2022 study in the journal Neuron has found that chronic pain can remain, even after the inflammation is treated. Over the counter NSAIDS can be used for daily pain management. Corticosteroids, disease modifying anti-rheumatic drugs (DMARDs), biologics, and Janus kinase (JAK) inhibitors are some of the many options to treat the inflammation and disease. 

Focal vs. Systemic Pain 

Focal pain is pain that is localized in one area, usually caused by trauma or injury. You should be able to put your finger on it, says Dr. Wyss. Systemic muscle pain is widespread body pain that is caused by illness, infection or a reaction to a medication. All the inflammatory diseases would fall under systemic pain plus bacterial or viral infections such as Lyme disease, COVID-19, and hepatitis, to name a few. 

“An example of systemic pain would be waking up in the morning and your whole body is stiff and it takes two or three hours to get moving,” Dr. Wyss says. “As opposed to waking up in the morning and feeling some stiffness in your knee.”  

Bilateral Pain

Bilateral pain is pain that affects both sides of the body. Because you feel it on both your right and left sides, the pain can be more intense and affect mobility. Swelling and stiffness can be additional symptoms. Bilateral pain is often associated with inflammatory illness, as opposed to mechanical pain that targets one area.  

With the exception of osteoarthritis, the inflammatory conditions that cause bilateral pain are autoimmune diseases, which means the immune system malfunctions and begins attacking itself, causing inflammation. 

Certain conditions are associated with bilateral pain, but they can sometimes present as unilateral pain as well. The bilateral pain can affect different areas of the body.   

These conditions include:  

• Fibromyalgia affects tender points throughout the body. 
• Osteoarthritis is less commonly bilateral and affects knees, hips, hands, and feet. 
• Polymyalgia rheumatica affects shoulders, upper arms, neck, and pelvis. 
• Psoriatic arthritis affects knees, ankles, hands, and feet. 
• Rheumatoid arthritis affects hands, wrists, knees, or hips. 

It’s important to identify the cause of your bilateral pain because, if left untreated, some of these conditions — namely, psoriatic arthritis, osteoarthritis, and rheumatoid arthritis — can lead to permanent joint damage.  

Fibromyalgia Pain

Fibromyalgia is a chronic condition that causes pain and tenderness throughout the body. People with fibromyalgia have a heightened sensitivity to pain. There is no cure for fibromyalgia, but there are medications that can treat the symptoms. Anyone can get fibromyalgia, although it tends to affect more women and people over 40. Fibromyalgia is associated with other diseases, including rheumatoid arthritis, lupus, osteoarthritis and ankylosing spondylitis. 

According to the National Institutes of Health, the symptoms of fibromyalgia are chronic widespread pain throughout the body, often in the arms, legs, head, chest, abdomen, back, and buttocks. It is described as aching, burning, throbbing or stabbing.  

Other symptoms may include: 

• Fatigue 
• Trouble sleeping 
• Muscle and joint stiffness 
• Tenderness to the touch 
• Numbness or tingling in the arms and legs 
• Problems concentrating 
• Sensitivity to light, noise, odours and temperature 
• Bloating or constipation 

The central feature of fibromyalgia pain is that it occurs in multiple sites. It is also known for causing tender points that make people with fibromyalgia more sensitive to touch than people without it. The penny-sized tender points are specific areas of pain — often located symmetrically — that are not the joints and that can hurt with even the touch of a finger.  

There are 18 tender points in all and they include: 

• Lower neck in front 
• Edge of upper breast 
• Arm near the elbow 
• Knee 
• Base of the skull in the back of the head 
• Hip bone 
• Upper outer buttock 
• Back of the neck 
• Back of the shoulders 

If left untreated, the symptoms of fibromyalgia can become increasingly worse and the pain can become excruciating, impacting your emotional well-being. If you are experiencing tender points throughout your body, discuss your symptoms with your doctor to get a diagnosis and devise a treatment plan. 

Acute vs. Chronic Pain 

An acute pain can come on suddenly and may last a few days or a few weeks, but will generally resolve itself  in less than three months. It can feel sharp, throbbing, tingling, burning, or numb. It is most often intense and is caused by something specific, such as illness, injury, or surgery. Acute pain is protective because it is your body telling you something is wrong and the painful area needs attention.   

Examples of acute pain are: 

• Bone break or bone fracture 
• Muscle sprain or tear 
• Surgery 
• Burns and cuts

Chronic pain develops slowly and may get worse over a longer period of time — months or years. It varies in intensity and can be intermittent, depending on the reason for the pain. It can be an aching, burning, or shooting pain. Chronic pain impacts every aspect of daily life and is linked to higher rates of anxiety and depression.  

Here are several conditions linked to chronic pain and what the pain may feel like. However, keep in mind that people can experience pain differently.  

• Ankylosing spondylitis: ongoing, deep, dull back pain 
• Fibromyalgia: aching all over, muscle discomfort, twitching sensations 
• Inflammatory bowel disease: cramping, burning, stabbing, aching in abdominal area 
• Lower back pain: tingling, burning, dull, achy, sharp, radiating 
• Osteoarthritis: joint swelling, tenderness, stiffness, “crunching” feeling 
• Psoriatic arthritis: worse in the morning, tender, throbbing joints 
• Rheumatoid arthritis: numbness and tingling in hands and feet, stiffness, and swelling in joints

The importance of reporting any pain that lasts longer than three months is critical for getting treatment if you have a chronic disease. If left untreated, some diseases can cause permanent damage to joints. 

Neuropathic Pain

Neuropathic pain is caused by damage or disease in the somatic nervous system. People with neuropathic pain make up 25 percent of people with chronic pain, according to a 2019 study. The somatic nervous system is made up of the network of neurons that help you feel objects and textures and give you sensory motor feedback.  

With neuropathic pain, messages of pain, pressure, movement, or temperature from the nerves to the brain become altered. Neuropathic pain is less sharp, often described as burning, tingling, or electric. 

The most common causes of neuropathic pain come from: 

• Diabetes — high blood sugar injures nerves and causes tingling or burning that starts in the feet and can travel up the leg causing eventual loss of sensation 
• Chemotherapy treatment — some cancer treatments can cause a tingling sensitivity or numbness and weakness in the extremities, typically the hands and feet, that sometimes goes away when the treatment is finished 
• Human immuno-deficiency virus (HIV) — burning, stiffness, tingling, or prickling in the toes or soles of the feet in people with advanced HIV 
• Multiple sclerosis — ranges from minor irritations to intensely sharp, burning 

In the case of diabetes and HIV, there is no cure for neuropathic pain, but treating the respective diseases it is associated with can slow down its progression.  

Questions to Ask Your Doctor About Pain

The way you articulate your pain to your health care provider can significantly influence their understanding of the type of pain you’re experiencing and guide them in recommending the right treatment. 

Dr. Wyss emphasizes the importance of being proactive in your health care by asking questions. He suggests that patients should feel empowered to ask their doctor how they determine the nature of their pain. “For example, If I’m being told I have joint, muscle or nerve pain, I would ask how they know,” he says. 

Some other questions you can ask your doctor about different types of pain to help pinpoint the problem can be: 

• If my pain is a shooting or burning sensation is it because of nerve pain? 
• When I feel a stiffness or tenderness in my joints is it linked to a type of arthritis? 
• What does a deep, throbbing pain mean? 
• Why has my pain lasted more than three months? 
• Why do I feel more pain in the morning? 
• What does it mean if my pain spreads from my back to my thighs and buttocks? 

Communicating your experience of pain can be a clue in identifying the reason for your pain and seeking out the right treatment. 

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