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Chronic Shoulder Pain

Abdul Lalkhen

You may have been told by your doctor that you have chronic or persistent pain.  
These words or terms mean that you have pain which has lasted for more than 6 months and in some cases it can last for most of a lifetime.  
It is a surprisingly common problem and some studies suggest that as many as one in ten people in the United Kingdom are living with some form of chronic pain condition. 
Chronic pain can be a confusing and frustrating condition to live with, particularly as it is something that cannot be seen from the outside by those around us.  Most of us grow up understanding that pain will go away.  So how can we make sense of pain that doesn’t go away – pain that becomes persistent?

Why do we feel pain?  What is its job or function?

Normally the job of pain is to tell the body about damage which can be from an injury or a disease and to help make decisions about what to do.
However, in chronic pain, our most up-to-date research tells us that something different is going on:  the pain is no longer serving a useful function. It is a real sensation, but not a useful one.  There is a lot of research to show that in chronic pain there are changes in the way that the whole pain system is working. 
These changes affect:
  • How the pain messages are carried around the body 
  • How the brain makes sense of the messages

What happens in the pain messaging system?

Messages from the body about damage, light touch, hot, cold and pressure are sent to the brain using small nerves. These nerves are like small A and B roads which become bigger nerves (dual carriageways) and then the spinal cord (motorway) to eventually reach the brain. Pain messages, like cars, go in both directions to and from the brain.

If you were to cut your foot, nerves send the message to the spinal cord where it makes a connection – the information is passed to other nerves before it goes to the brain. Some of these messages in the spinal cord can be blocked by other messages that compete for ‘the right of way’. When you rub an injured part of your body the rubbing messages block some of the damage messages. The ‘damage’ traffic slows to going in just one lane as another lane is opened for the ‘rubbing’ traffic.

When the “damage” message reaches the brain it goes to different departments which process the information in slightly different ways. So there are separate departments that:

  • Work to focus our attention on the area that is painful;
  • Identify the location of pain and what it feels like (e.g. hot);
  • Influences our movement;
  • Guides decision-making and planning about how we manage it
  • Creates an emotional response (e.g. anxiety, anger, depression).
All these areas working together make up what we experience as pain. They happen without the person being aware of the process. All we know is that we have pain in one or more areas.

In acute pain (new injury), pain is very important.  It makes us rest and protect the injured area so that no more damage happens and things have a chance to heal.  However, even then, it is possible to have an increase in pain – without further injury: think of a new, purple, swollen bruise.  What does it feel like if someone gently prods it?  Gentle pressure on the bruise does not cause further damage – but it will certainly cause pain!  

In chronic pain it is as if the useful changes that happen to the messaging system after an injury don’t ‘switch off’ - even though any healing has finished. The messages continue to be sent even though there is no more damage.  It is a bit like having a fire alarm system that has gone off and keeps ringing even when the fire has been put out.  Medical science has not yet discovered why the pain messages system stays “switched on” for some people after injuries or operations have healed.    

In chronic pain (no new or further damage), these initially useful sensations don’t switch off, even though information has stopped and healing is complete.

  1. Pain “gates” (in the spinal cord) open and let through messages, which would not normally be painful (e.g. stretch and touch).
  2. Chemicals circulating in the body as a result of stress, fear or anxiety can make these gates easier to open.
  3. Each message can set off many other nerves effectively turning up the ‘volume’ of pain.
  4. Messages and nerves can fire off randomly with no stimulation at all.
  5. Normally ‘inactive’ nerves in the area ‘wake up’ and become sensitive.
  6. There are areas in your brain which have “memory maps” for pain.  They can continue to signal pain even when there is no message coming from the original area of injury.  This is similar to what happens in other pain conditions e.g. phantom limb pain where part of the body has been amputated but the experience of pain from that area continues ‘as if’ the limb was still present and had recently been damaged.  The brain, then, can become ‘tuned’ to expect pain.  Being on ‘high alert’ makes it more likely that non-painful sensations get changed into pain sensations.
  7. Thoughts, emotions and concentration can effect how we experience pain.  Pain intensity can be reduced at times of excitement and increased at times of stress.

Why does the amount of pain alter?

Different factors can affect the messages going through  ‘pain gates’ in the spine so that they can become “louder” (i.e. amplified) or “fainter” (i.e. dampened or muffled). 

Pain gates can then remain on “high alert” (a bit like after a bruise). If you get an injury, this can be started, for example, by chemicals traveling up the nerve from an injured area, causing the relay stations to pass more messages on. This increased sensitivity in settings can persist long after the injury has been repaired by the body’s normal healing processes. As a result of this, even gentle normal movement stretching or even temperature changes can produce severe pain that feels exactly like some sort of injury or damage. In other words, the message is changed and one that starts out as a message about touch or stretch is translated into one about pain.  Many painkillers work on these gates / relay stations in the spinal cord and brain.  They also work on the nerves themselves and at the site of any tissue damage.

In Summary:

  • Receptor cells (touch, pressure, temperature) can act differently and start sending pain messages.
  • Pain messages can be made ‘bigger’ as they travel through the nerve pathways to the brain.
  • The brain can develop ‘memory maps’ of pain which can be set off without further injury happening.
So, the amount of pain we experience is not related directly to damage and there are many things which can increase or decrease pain messages.

Which factors, that we can alter, increase pain messages?

  • Lack of sleep
  • Imbalance between rest and exercise
  • Low mood
  • Anxiety regarding the nature of the pain

Which factors, that we can use, reduce pain messages?

  • Massage, rubbing
  • Good balance between rest and exercise - pacing
  • Heat or cold packs 
  • Stretching
  • Relaxation
  • Distraction
  • Being reassured that pain is real and what it is all about 
  • Feeling more confident, having fun and socialising
You may be able to identify with some of the factors above and already recognise the effect of these on your pain levels.  

CHANGES IN YOUR LEVEL AND TYPE OF ACTIVITIES

Many people with chronic pain respond either by reducing their activity or by trying to ‘push through’ their pain:

Have you ever reduced your activity levels when in pain?

  • This is a common sense response to pain.  Many people try their best to rest or avoid activities which ‘wind up’ their pain which can, in itself, cause problems.  

What effect does this have over a long period of time?
  • We sit, stand or walk differently which can affect other joints and muscles.
  • Muscles get weaker and tighter and unable to provide optimum support
  • Muscles may get tired and ache more easily – so that even a small amount of exercise can be enough to increase the sensation of pain.
  • Muscles may go into spasm: the body is trying to stop you from moving because it wants to try and protect you from further problems.
  • We put on weight and become less ‘fit’.
  • When joints don’t get moved regularly they become stiff as ligaments and muscles tighten up.  This will cause movement to be painful.
  • There can be changes in balance and co-ordination skills

Have you ever tried to push through your pain?
  • Some people feel frustrated by the pain and try to ‘push through’ it but this can also cause problems.

What effect does this have?
  • Pushing through the pain is a bit like prodding a bruise – as mentioned earlier.  Gently prodding it will not cause any further damage – but will feed into the pain system that is already ‘on high alert’ and make it more likely to become more sensitive and more irritable. 
  • Continuing to wind up the pain by ‘pushing through’ may add to your source of frustration – and this will not be helpful in you managing your pain in the long-run.  
  • The more often you are “punished” by the increased pain of over activity, the more wary of activity you may become.
  • It also means that the ‘movement’ parts of the brain links this type of activity with pain – even though there is no further injury or damage happening.
Your pain will be a combination of all of these factors and just because pain cannot be seen from the outside doesn’t mean that it is either ‘all in the mind’ or that ‘it is not real’.  Your pain is real.

Just because we may not able to give you a specific ‘diagnosis’ or tell you exactly which structure is causing the pain, it does not mean that your pain is not real.  It simply means that from your symptoms, from examining you and from the tests you have had we can say there is no further medical or surgical treatment needed to help with your pain. Unfortunately we do not have a cure for your pain.

Helping to manage chronic pain focuses on tackling the knock-on effects of chronic pain.  It involves teaching you coping strategies that help you to get on with your life, despite the pain.  Part of the treatment consists of exercise and movement methods.   Another element is using the skills of a psychologist to examine the beliefs and thoughts about pain, which can cause worry, frustration and feeling depressed.  We are also able to teach practical problem solving skills which help you to restart valued and necessary activities, finding confidence and pleasure in performing them. 



For more information about the treatment of chronic pain please contact:
Manchester and Salford Pain Centre
Salford Royal NHS Foundation Trust
Stott Lane
Salford
M6 8HD
Telephone: 0161 206 4136
www.srft.nhs.uk/about-us/depts/neuro-pain/

For more information you may want to look at the following resources:
Books (these may be available from your local library)
Explain Pain - Lorimer Moseley and David Butler.
Coping successfully with Pain - Neville Shone.
http://www.britishpainsociety.org/patient_home.html
http://www.ppaonline.co.uk/pain_information.html




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