Why is pain so difficult to diagnose and treat?

Kevin Walker, MD

Pain Medicine

Pain is not always easy to define, but everyone knows what it feels like. It’s that unpleasant sensation when you stub your toe against the coffee table, the physical and emotional experience that comes with broken bones, cuts or scrapes, severe injury or disease and more. Pain is, inherently, very different in how it is felt by different people. Those dealing with chronic pain may wonder why it seems so difficult to diagnose and treat the pain they experience.

Why is pain so difficult to diagnose and treat? Pain medicine specialist Kevin Walker, MD, discussed the unique problems that come with handling pain.

Why is it so hard to treat pain?

“The truth is that our understanding of how pain is transmitted along our nerve pathways, and how our brain interprets those signals, is still incomplete,” said Dr. Walker. “Acute pain generally works like a fire alarm, a hard to ignore sign warning us of immediate damage or danger, but this model of understanding doesn’t work that well for chronic pain.”

How each person perceives and feels pain is unique to them, influenced by a combination of social, biological and psychological factors. Everything from your personal history to your living environment can shape how you experience pain.

For some, it can be difficult to even begin to define their pain clearly, making it more complex to treat.

“In a few cases, there isn’t any physical cause for the pain that we can identify,” said Dr. Walker. “These cases can sometimes be rooted in trauma, and involve emotional pain and distress being felt as very real physical symptoms.”

What are the different types of pain?

There are a few kinds of pain, with different categories breaking them down by timing and how they are felt.

Types of pain, broken down by timing, include:

• Acute pain: Pain that is felt for anything between a few minutes to a few weeks, often associated with physical injury or damage
• Subacute pain: Pain that lasts between one to three months
• Chronic pain: Pain that continues for more than three months and can last for years or longer

Pain is also broken down into categories based on how it is experienced, including:

• Nociceptive: Pain related to trauma and inflammation
• Neuropathic: Pain related to trauma, injury or damage to the nervous system
• Visceral: Pain related to trauma, injury or damage to an organ
• Mixed: A combination of the above
• Psychosomatic: Sometimes called conversion disorder or reaction, this involves pain with no organic physical cause, usually related to psychological trauma

“There is sometimes a persistent myth that doctors don’t believe psychosomatic pain is ‘real,’” said Dr. Walker. “But psychological trauma experienced as physical pain is very, very real and well-documented.”

What information does your doctor need when treating pain?

To effectively treat pain, your doctor needs to perform a thorough assessment, including asking questions designed to help put together the most accurate picture they can of your experience with pain.

Questions your doctor might ask include:

• When did the pain begin?
• Was your pain triggered by an injury, illness or specific event?
• How would you describe your pain? Does it feel sharp, dull or burning?
• Where is the pain located within your body?
• Do you feel that your pain radiates from an initial spot to other areas?
• What factors or actions make your pain feel better or worse?
• Do you have other symptoms, like numbness, weakness or problems with bowel or bladder function?

“Doctors may also ask you to rate your pain on a scale, usually from 0 to 10, as a way to gauge its intensity,” said Dr. Walker. “However, the usefulness of the pain scale is debated. While it attempts to help your doctor understand a deeply personal and subjective experience, everyone’s life experiences mean they experience pain itself differently, so it doesn’t really work when comparing to others. One person may describe the same level of pain as a 4 on the scale that another person would consider a 7.”

Despite these limitations, the scale can be helpful in tracking changes over time and evaluating the effectiveness of treatment for an individual patient. Since cultural and psychological factors can influence how pain is reported, some people may unintentionally or intentionally exaggerate or understate their pain to try and influence the outcome of their treatment appointments.

When is it helpful to see a pain medicine specialist?

“Getting a “second set of eyes” can often provide valuable insight, especially when standard treatment approaches haven’t led to significant improvement,” said Dr. Walker. “If your pain persists despite initial treatments, or if the underlying cause of the pain is unclear, it may be time to consult a specialist.”

Pain itself is a symptom, not a diagnosis. A pain medicine specialist can help identify the root cause of the pain, explore advanced treatment options and offer a more comprehensive approach to management.

What advice do you have for patients coming to their first appointment?

“My first and most important piece of advice is to come prepared,” said Dr. Walker. “Write down any questions you may have ahead of time, so you don’t forget them during the visit. It may also be helpful to take some time to write down your experience of pain, with every detail you can think of. This can help you during the appointment to make sure you’re not leaving out any useful details.”

If you’ve had imaging studies or treatments done by outside offices, bring those records with you, as they can provide valuable background.

Most importantly, keep an open mind.

Pain management isn’t one-size-fits-all, and what worked for a friend or family member may not work for you.

How can patients make the most of their appointment?

“Be patient with the process,” said Dr. Walker. “Treatment may not begin right away. Often, additional diagnostic testing is needed to understand the root cause of your pain and to develop the best plan moving forward.”

Dr. Walker also noted that you should not expect that previously used treatments will automatically continue. As our understanding of pain evolves, so do our treatment approaches. Be open to conversation and collaboration, as your input is vital in shaping your care.

What are some helpful questions to ask if you’re prescribed opioids?

“First off, ask what the common side effects are for the specific medication you are being prescribed,” said Dr. Walker. “Really, this is important to ask about when it comes to any medication, not just opioids. Make sure you read the listed side effects on the medication itself as well.”

Other useful questions to ask if you’re prescribed opioids include:

• Are there alternative treatment options available? In many cases, there could be a non-opioid treatment or therapy that could be just as effective, with fewer risks.
• What can I do to support my own recovery? Managing pain often requires actively participating in your treatment. It can help to understand the role you play in your own care, including physical activity, lifestyle changes and more.
• Can you explain why this treatment is recommended? Never hesitate to ask for more details. Knowing the reasoning behind your treatment can help you understand your condition and how to manage it.

“It’s never wrong or bad to ask questions,” said Dr. Walker. “But it’s important to also be open to the answers, even if they’re not what you expected to hear. Managing pain is often about setting realistic expectations and working with your doctor together to achieve the best possible outcome.”