Mature patients often hear how, in medical consultations, their pain and discomfort are attributed to “things of age,” a reflection that carries a certain hopelessness, as if the discomfort were inexorably attributable to the years, a factor against which we cannot fight. Does this statement make sense? Does everything hurt because of age, or is the discomfort due to pathologies that can be treated in many cases? What chronic pain is more common as we age and how can it be addressed?
A few weeks ago the Pain Forum was held in Barcelona. In this meeting, topics such as the most frequent pains and their impact on the patient's functionality have been addressed. Dr. Marta Ferrándiz, president of the Catalan Pain Society, receives us in her office at the Sant Pau Hospital, in Barcelona, where she is assistant to the Anesthesiology Service and Director of the Pain Unit.
26% of Spaniards have chronic pain… It is a very high figure. What is the way to address it effectively?
Pain is now considered a disease and not a symptom, and is very prevalent; and it is one of the biggest reasons for going to primary care. It is a health problem that represents a large consumption of resources. First of all, we must educate the patient about the fact that this pain is a disease in itself and perhaps he or she will have to take medication for a long time. Secondly, pain must be addressed in a multidisciplinary way, covering this problem from different spheres: biological, psychological, social (playing sports, good nutrition)... Chronic pain should be managed with psychologists and physiotherapists. .., and of course with doctors who specialize in different pain therapies.
In many cases this is not put into practice...
It's not easy, but a lot of progress is being made. Soon we will be able to see that any patient with chronic pain has some brain areas overrepresented. We are doing a lot of research and we need all professionals to join forces in this regard, looking for an answer and a solution to this sociocultural phenomenon.
A high proportion of patients with chronic pain are people over 55 or 60 years old, the so-called silvers...
Yes, the highest age prevalence is between 55 and 75: the cause is the degeneration of the joints, bone structure, muscle malfunction... Currently, we live longer, society moves very fast and is very consumerist, we want We do many things, we take better care of ourselves, we live longer than before, but the structure of the body is still older. Health institutions (hospitals or primary care) should implement the fact that the patient can improve their physical activity with a trainer, with a physiotherapist... This would solve problems that we cannot solve with pharmacotherapy.
What pains are the most prevalent in this age group that we are discussing?
Low back pain is the most prevalent pathology in chronic pain that makes patients seek primary care. After 70, knee osteoarthritis (operable or not) and multiple other ailments also begin.
What is behind low back pain, what can be its causes?
The most common are discopathies. Between vertebra and vertebra there is like a bearing, a disc, which dries out with age because it becomes dehydrated. If it wears out, it moves, it can unbalance the spine and cause the nerves and joints at each vertebral level to suffer; Low back pain may appear, dull lumbar pain that may be due to disc disease or arthritic degeneration of the vertebrae, radiculalgia due to nerve compression...
And what causes so much knee pain in patients of a certain age?
Osteoarthritis, basically, degeneration of the joints. We also have menisci, which dehydrate and wear out
“At your age it is normal to have pain,” some doctors say in consultation. This is very frustrating. Is age a cause of pain per se?
No. Today we operate on 95-year-old patients: we all live longer and with a better quality of life. Today we are treating patients aged 88, 92 and 94 years. Today we have, for example, a 94-year-old woman who has injections in her knees, and she goes shopping alone. She now goes unsteadily with her car because it hurts her; Well, we must do whatever it takes so that she has a better quality of life, less pain and more functionality. That is why there are more and more elderly and super-elderly patients, very active, and we have to treat their pain. Pain should not be attributed to age, years do not equate to a diagnosis of senile illness and this will occur less and less.
Carme Batet said that if “everything hurts” when I get up, it means there is inflammation. Do you agree?
Clear! Osteodegenerative pain appears with onset in the morning: at night patients do not feel pain, and when they wake up they hurt everything and cannot move. Well yes: you have to move, start walking and take the medication. There is inflammation if the tissues and joints are ankylosed, it is a pain when starting that movement. It is logical to have pain when getting up in these cases, but it does not have to be linked to the loss of functionality during the day. Sometimes this pain lasts about 10 minutes, and it can be common.
When is pain considered chronic?
When it lasts more than three or four months. Other pathophysiological mechanisms of pain are set in motion. Acute pain makes you protect yourself, if you have a herniated disc in the acute phase, you go to the doctor right away. When pain becomes chronic, specific brain areas become hyperactive, especially in the cerebral cortex. At that moment the pathophysiology changes, and pain treatment has to be approached in a different way.
An example?
A specific and usual prototype for the difference between acute and chronic pain is herpetic/postherpetic neuralgia. The first three months of herpes zoster are considered herpetic neuralgia and are treated in one way, and from the fourth month onwards, other pathophysiological mechanisms come into operation that will make the chronic pain chronic and we will treat it in another way.
How does pain reception work and what neurological tools do we have to address it?
We are going to put an example. I cut my finger, and there is a transmission of the painful stimulus to my spinal cord, and then up to the brain. Special connections are made along the way (such as “pit stops”). There are neuromodulators and neurotransmitters that act in the central nervous system, from the moment the painful stimulus arrives until it is interpreted, because until the pain reaches the cerebral cortex, you are not aware that you have cut yourself. At a peripheral level we can act on these neuromodulators with agents that reduce inflammation, that reduce the release of histamine, prostaglandins... We can act at the level of the receptor, in the spinal cord and also in the cortex. How do we act in the cortex? We have endogenous opioid receptors that are activated. Then through antidepressants and antiepileptics, which we use to modulate pain. At low doses, antidepressants can improve a patient's anxiety and pain.
Can psychological therapy help mitigate pain and cope with it?
Yes, psychological therapy helps a lot. Characterizing the patient individually at a psychosocial level can help him or her have the tools to fight the pain, and reactivate it. He may be in pain, but he lives better. There are patients who say: “I have pain, but I'm going to have tea with my friends”, thanks to neuromodulation from the outside and from the inside. We must reduce the intensity of pain and above all improve the patient's functionality.
These chronic pains in people over 55 years old, what treatments do they have?
It depends on each pathology, but we try to go from less aggressive to more aggressive therapies. We try to get them to improve their habits, both dietary and physical, to exercise... Now many more older patients do physical exercise, walk, go to the pool... For pain, aquatic activities are very important, and even if it hurts, you have to get going, Like we have already said
Any new techniques being applied to control chronic pain?
Today, we have neuromodulation, which is modulating the pain from where it is generated and transmitted: we enter the spinal cord, place cables, electrodes or catheters with devices that administer drugs. But they are very expensive and are only used for certain specific pathologies, not for the pain we mentioned, common in people of a certain age, of osteodegenerative origin.
What advice would you give to patients with chronic pain, to address a crisis, at home?
Local heat. Almost all of us have an electric mat, and this is a treatment: if there is pain, you can put it on for 30 minutes every eight hours. It should not be used to warm up when we go to sleep. Local heat is a treatment and is very effective for osteodegenerative pain. For acute pain like a herniated disc, for example, it is not effective; for herpes either (it even makes it worse). But for older people I would advise: walking, good dietary habits, not becoming overweight, local heat and some painkiller if necessary, although the latter must be controlled under a doctor's prescription.
Is there still a big gender bias in pain treatment, a big difference in how men and women are cared for?
Men and women are treated the same, but they should not be treated the same. The woman has more pain than the man, but she arrives later to the appointments. Until now, men spent more time working actively, now we see women who have worked their entire lives. Women suffer more and have sociocultural burdens that make them put the entire family ahead of them. There are more and more platforms that address sex and gender disparities in pain. More and more aspects are being discovered, and this is very much in vogue. Testosterone, the male-dominated hormone, is now seen to protect against pain. On the other hand, estrogen makes women more sensitive to pain.
What risk does this delay in going to the doctor's office for pain imply for the health of elderly women?
Waiting to go to the doctor is not good, you may find a totally deformed joint that we could have acted on previously, being more effective. And with advanced age this is even more risky.
