“You’ve seen four doctors, why aren’t you better?” or “My treatment always works, so this must be in your head.” Many of the patients I see with pain have never had a thorough evaluation. It’s critical to take the time to find out what’s really going on.

Chronic pain is any painful condition that lasts longer than six months. I’ve treated those with pain for many years. The longer I work with patients with this problem, the more convinced I am that the key to a successful outcome is a comprehensive history and physical exam. More often than not, once we’re done, my diagnosis of the problem is different from what the patient believed they had. If we understand the nature of the problem, effective treatment is a lot easier to arrange.

This is an enormous topic, and I can’t do it justice in the few pages available here. But I hope it will be helpful as a guide, provided you’re under the care of a good physician. (I won’t talk here about pain due to cancer, because it behaves very differently.)

Here are eight articles describing the nature of chronic pain and the approach I think works best in the majority of patients. Topics are summarized below with links to more detailed discussions:

Cause of pain. With many patients who have chronic pain, either there is no single clear cause of their pain — or the cause is obvious, but they’re not better. Moreover, many patients with pain improve over time. If you’re still hurting, then often the most helpful question is, “Why aren’t you better?” The usual problem is that an entire system of factors keeps the pain going, including one that isn’t polite to talk about. It’s also important to learn the central role of the nervous system in keeping pain going.

Types of pain. The majority of patients with pain have the myofascial syndrome: achy, sore muscles. But it’s important to know a little about the three major categories of pain, and the different approaches each requires. Many people have been told they have fibromyalgia but aren’t sure just what this is.

Treatment. The majority of patients with pain spend too much of their time resting, because it hurts to exercise. This is a trap: for many people, the more you rest, the more you hurt. But overdoing it also makes you worse. The answer is called functional restoration: slowly and gradually improving your physical condition so that you become fit, flexible, and strong.

Also, it’s critical to address depression if present. Even if you’re not depressed, antidepressant medications are often tremendously effective. Acupuncture and deep tissue massage are often helpful. If pain tends to make you tense and frustrated, biofeedback and meditation/relaxation training are critical to recovery.

New article for medical professionals. Dr. Sonnee Weedn is a psychologist who lives and practices in Marin County, north of San Francisco. Last year, at a professional’s weekend at the Canyon, we met and decided to collaborate on an article that appeared in the Fall 2010 issue of Marin Medicine, the peer-reviewed journal of the Marin Medical Society. Its title is “Addressing the Complexities of Chronic Pain.” The editor at Marin Medicine graciously granted permission to reproduce the article here (in PDF format), for educational purposes only. As you might expect from our collaboration, the article emphasizes psychological causes of chronic pain.