After seeing countless doctors and going through tons of diagnostic tests for my back pain over the past five years I have been sent to a psychiatrist. I am not crazy. I know that I am not making up my pain. Why does everyone think I need to see a psychiatrist?

It sounds like you have what the medical field calls chronic or persistent pain. This is a complicated diagnosis but one that can be managed with a team approach to care. In other words, at the very minimum, a doctor needs to be on board to manage your medication, a physical therapist to help your body heal and to realize that tissue is no longer being damaged, and a psychiatrist to help you deal with the emotional distress and or depression that comes from dealing with chronic pain. Important things to remember are that you are not crazy and that your pain is very real. A holistic approach has proved to be the most effective way to get your life back on track and a psychiatrist is a crucial part of that team.

I have chronic low back pain that does not seem to respond to opioids, despite me being on a heavy dose. I don’t like the way they make me feel or the dependence on the drugs itself. Is there a better option for managing my pain?

The recent consensus within the medical field is that a team approach is most important when managing chronic or persistent pain. Additional drug options for pain management that are recommended you first try are: Tramadol, Nortryptyline or an alternative TCA/SSRI, or lidocaine. You can ask your doctor about any of these. Non-pharmaceutical treatment is also important. This should include counseling or help from a psychiatrist to deal with any depression, anxiety, or past trauma as emotions are big controllers of pain as well as physical therapy to help to calm down your central nervous system and help it realize that movement is healthy and not damaging.

I’m concerned about my wife. She has chronic low back and leg pain that she takes several pain pills (narcotics) for. She’s also got high blood pressure and high cholesterol. So she takes pills for that, too. Then there’s a pill for her low thyroid and another that’s a blood thinner. How can she get any pain relief with all that crap in her system?

You raise a very good point and one for which there isn’t a clear or simple answer. But let’s talk about some of the factors involved. Physicians want their patients to experience good pain control with the fewest side effects possible.

We may all be the same species (i.e., humans), but every person is slightly different in how the body reacts to medications. We can’t predict how they will respond to individual drugs, drug combinations, and/or supplements such as vitamins, calcium, and antioxidants.

Sometimes the underlying disease or condition that is causing the pain affects medications at a biochemical level. Those reactions aren’t always predictable either. To take it even a little further, consider this: drugs are metabolized (broken down) by the liver and then sent through the blood stream throughout the body.

The drug doesn’t just affect one system. It impacts all the systems. Then the kidneys have to filter out all the chemicals and get rid of any by-products that aren’t used. Like your wife, many people who are taking opioids are also taking other medications and supplements at the same time.

Studies show that the average person taking opioids also swallows 10 or more other pills each day. All of these substances have to be broken down and processed within the body. The potential for adverse effects increases with each medication or supplement taken.

There are several strategies for people taking multiple medications (called polypharmacy). First, make sure you can use only one pharmacist for all prescriptions. The pharmacist is trained to evaluate our health and the pills we take. He or she will be quick to point out any potential problem areas.

Second, if you do happen to shop at different pharmacies, then make sure each pharmacist has all the information needed to advise you. This includes past medical history and current health problems along with and a list of all medications being taken.

Likewise, make sure your wife is followed by her primary care physician. He or she can oversee all medications and advice accordingly. Reporting any new symptoms that may develop when taking these medications can help prevent adverse effects. Even minor problems such as upset stomach, nausea, headaches, constipation, vomiting, and dizziness should be reported immediately to the primary care physician, prescribing physician, or dentist.

My sister was just hospitalized with something they are calling opioid toxicity. I always thought she was taking too many pain killers. What happens now?

All medications are processed, broken down or metabolized in the body in a variety of ways. The stomach releases acid to begin the process. The liver has several different pathways to complete the steps of drug metabolism. The kidneys filter out cellular waste and drug by-products when the body has done all it can.

The normal, healthy body can usually handle all that we ask it to — including absorbing and using multiple medications and supplements. But many people taking medications such as opioids (narcotics) have other health conditions that compromise their function.

Sometimes there are side effects from the medications. There can even be adverse events from drug-drug interactions. When the systems become overloaded, chemicals build up that can no longer be escorted out of the body. Toxicity can occur.

Opioid toxicity or overdose can put the body in crisis. There is often very low or high blood pressure, edema or swelling anywhere in the body but especially the legs, and excessive sleepiness. Breathing can be so slow it seems like the person isn’t breathing at all. Confusion, hallucinations, and delirium can develop.

The patient is usually hospitalized by this time where a diagnosis can be made and treatment begun. It can be a process of trial and error trying to find the best way to detox and stabilize the individual.

Alternate medications or combinations of medications may be tried until the optimal results can be obtained. Once your sister is released from the hospital, she should be followed carefully. Any signs of recurrence must be evaluated right away. Hopefully this episode will be the only one she has and it will bring her better overall management of her pain and health problems.

My 28-year-old daughter had her gallbladder removed three years ago. She’s had terrible pain in her side ever since. No one seems to know how to help her. What do you suggest?

The problem of chronic pain has not been solved yet. At this point, health care professionals recognize long-term pain as a disabling disease in itself. And it’s one that deserves a closer look.

In fact, the Institute of Medicine (IOM) is calling for a greater dedication to pain research and more money to fund it. There is a need to support researchers as they help find better ways to treat chronic pain,

Experts in pain management want to see new pain medications and therapies for the patients suffering this disease. They are advocating for training and education for physicians. And leaders of the Institute of Medicine (IOM) are asking for better reimbursement for health care professionals who spend the time to really understand and care for these patients.

That kind of time and dedication would help physicians find a management plan that could work for patients like your daughter. pain management needs a face lift. Physicians are often overly cautious when it comes to using narcotic (opioid) pain medications for fear their patients will become addicts. There are plenty of studies to show that opioids are safe and effective. They do require appropriate monitoring but they shouldn’t be withheld out of fear and ignorance.

Your daughter may need a a team approach to pain management using the skills and abilities of several health care professionals who are experts in the management of chronic pain. This could include a nutritionist, counselor or psychologist, physical therapist, and/or nurse. Alternative practitioners skilled in massage, Reiki, acupuncture, BodyTalk, or similar disciplines can also lend a hand.

The first place to start is often with the person’s primary care physician. He or she can effectively care for many of the chronic pain patients. Not everyone needs a full-blown, multidisciplinary team approach. But when patients don’t get the help they need and especially in very complex, complicated cases, then referral can be made to a pain specialist or team of professionals at a pain clinic.

Your daughter may be at that point in her life. She should sit down with her physician and review her history, her symptoms, her quality of life, and her goals. They can discuss what has been tried so far and what other options are yet to be considered.

Sometimes it takes a while to find the right treatment or combination of approaches that best support each patient during this recovery process. For many people, pain control becomes a matter of improving function without actually changing the frequency, intensity, or location of the painful symptoms.

Along with the Institute of Medicine, we hope that more funding will be devoted to the study of chronic pain. Researchers need to develop better drugs and better management techniques for chronic pain patients.

Finding factors that would predict who will respond to what medications and approaches is another area for scientific study. It’s time to lget to the bottom on effective treatment for chronic pain and deal with the complexities these patients often present. Such an approach will require the coordinated efforts of private, public, and governmental agencies.

I’m at a cross-roads when it comes to helping myself get out of a downward spiral of pain, pain, and more pain. My doctor considers me a chronic pain patient and probably a crock. But my pain is real. I’m not making this up. And I’m not trying to get out of anything. Unfortunately, I’ve exceeded what my insurance company will allow for treatment of this problem. Is there any hope that the system will change to help people like me?

There is always hope that change will come in various segments of the health care delivery system. Funding to support the help needed by patients with chronic pain is certainly an area that could use a shot in the arm so-to-speak.

Right now, there are 116 million adults in the United States alone looking for some help. And telling them “it’s all in your head” or “there’s nothing that can be done” just isn’t acceptable.

That’s the stance of the Institute of Medicine (IOM) and they are throwing their weight behind it. The IOM is calling for a greater dedication to pain research and more money to fund it. There is a need to support researchers as they help find better ways to treat chronic pain,

Experts in pain management want to see new pain medications and therapies for people like yourself who are suffering from this “disease”. They are advocating for training and education for physicians. And leaders of the Institute of Medicine (IOM) are asking for better reimbursement for health care professionals who spend the time to really understand and care for these patients.

The Institute of Medicine (IOM) has made several other recommendations of interest:

  • Add required courses to all medical school curriculums on pain and pain management.
  • Licensing and certification exams for physicians should include pain-related assessments
  • Expansion of pain-centered care under Medicare, Medicaid, Workers’ Compensation, and private insurance plans.
  • Remove barriers from physicians (and other health care professionals) billing and receiving reimbursement for the time it actually takes to find a workable solution for these patients.
  • Broaden the research scope to include genetic, psychologic, environment, social, and cultural aspects of chronic pain.

    These recommendations are supported by 35 other groups involved in pain management at some level (e.g., the American Academy of Neurology, the American Academy of Pain Management, the American Pain Foundation, American Pain Society). Any time you see efforts from this many health care groups, there’s hope that the message will move forward and yield fruit for everyone!

  • My brother was in a motorcycle accident that left him with severe damage to his left leg. It’s been two years now since it happened and he still seems to be emotional numb. Depression was a major problem before and has only gotten worse after the accident. Is there any way to shake him out of his misery?

    There’s an old saying, Pain is inevitable but misery is optional. That might be an easier idea to swallow when you aren’t in pain compared to when chronic, persistent pain colors every minute of every day. And usually, along with constant pain comes anxiety, depression, and decreased physical function.

    Negative mood or a pessimistic view of circumstances are well-known to contribute to someone’s physical pain. And physical pain does have a direct effect on level of function at home, at work, and even at play (recreational activities).

    Studies show that pain is the most significant factor during the first 12 months of recovery. After that, psychologic and emotional pain become much more obvious and impact the patient’s health more directly. As might be expected, the higher the psychologic distress, the lower the physical function. It appears that pain and negative mood affect level of function rather than the other way around (low function results in increased pain and negative mood).

    There is also a problem called fear-avoidance behaviors. Fear of pain causes patients to avoid any activities they think might cause pain or increase their pain. The less they do, the more likely they are to lose even more function. Fear leads to withdrawal from daily activities and an increased awareness of any physical symptoms. The resulting anxiety can be a key contributor to misery.

    There are ways to treat this problem. Medications for the mood disorder, exercise within the physical capacity of the patient, and behavioral counseling are all equally important. Even if your brother has already gone through a program of this type, it might be worth a second try. And if he has not been guided through a comprehensive rehab program, this would be a good time to suggest it.

    My father was involved in a major car wreck that has left him despondent and almost non-functioning. Even though it appears to us that he could do more, he doesn’t. How can we help him get back into the swing of things?

    It is well known that psychologic distress after severe injuries can have profound effects on recovery. When physical activities are restricted by injury, chronic disability can develop. Such conditions can have both personal as well as social implications. For example, only one out of every two patients goes back to work after severe leg injuries. Function limited by pain and psychologic distress are considered the main problem.

    This was demonstrated in a recent study of 327 adults with a severe leg injury. The group was studied to see the effects of pain, anxiety, and depression on physical function at home, at work, and at play. Measures for each effect were taken at regular intervals up to two years after the injury.

    Most of the patients were men between the ages of 26 and 45 who had either broken a leg and/or damaged the soft tissues in a motor vehicle accident. The goal of the study was to gain a better understanding of the psychological factors affecting function in complex injuries like your father’s.

    After analyzing all of the data collected on these patients, they found that pain and psychologic/emotional distress both decreased patients’ function. The effects are most noticeable during that first year after the injury.

    Once the physical body has recovered as much as it can, then the effects of psychologic and emotional distress take on a more significant (and obvious) role in long-term recovery. As might be expected, the higher the psychologic distress, the lower the physical function. It appears that pain and negative mood affect level of function rather than the other way around (low function results in increased pain and negative mood).

    What does all this mean for someone like your father? A comprehensive program to address all postinjury needs is required. Physical and emotional pain must both be treated in order to maximize function. Loss of control leads to anxiety and anxiety is linked with fear of pain. The end result is a self-imposed limitation on any movements or activities that might produce pain. This, in turn, reduces physical function and contributes to long-term chronic impairments or disability.

    If there is any way you can encourage him to get some counseling that might be the best first step. It may be that he would be willing to see a rehab counselor as a way to get back to a productive work status. Usually emotional and psychologic needs are addressed at the time of the return-to-work assessment. It’s worth at least asking a few questions and making the suggestion.

    I tried hypnosis for a few months to help with my terrible neck, shoulder, and back pain. Didn’t seem to do the trick. Someone else suggested mindfulness meditation. What the heck is that?

    Chronic pain is managed in many different ways by different patients under the care of a trained health care professionals. One of those approaches is called psychosocial treatment. Psychosocial treatment recognizes there are psychological, emotional, spiritual, and social factors that affect pain perception.

    Techniques such as hypnosis, relaxation, meditation, and behavioral therapy are just a few examples of psychosocial interventions for chronic pain. Hypnosis works on the basis of the power of suggestion. Suggestions are made to change your inner thoughts, emotions, the way you experience life, and your behaviors.

    If hypnosis isn’t successful, some people try relaxation therapy. Relaxation techniques usually involve contracting and relaxing muscles, biofeedback, or listening to instructions (suggestions) to train the body to relax. Research has shown that this approach works by changing patients’ beliefs about what they can do for themselves. Reducing the stress response and experience of pain results in less perception of pain.

    Mindfulness meditation helps people increase their awareness of the moment. The goal is to be “in the moment” — not living in the past with regrets or worrying about the future. Accepting each moment without judgment bring peace of mind. Meditation in every form slows down brain activity that puts you in a more relaxed mood.

    Relaxation training, hypnosis, and mindfulness meditation all share one thing in common: focused awareness. Accepting what is and letting go of the need to control all else (most of which isn’t under our personal power and control anyway) is the key to changing the pain experience with meditation.

    Since different people respond to pain management techniques with a wide range of results, it’s always a good idea to try something new. If one technique or approach doesn’t give you the pain relief, increase in function, or decrease in disability, then definitely give something else a try.

    I suffer from chronic low back pain. I notice that I’ve started saying things to myself like, “I can’t do that because my back won’t let me” instead of ignoring it like I used to. I think I’m losing ground and I don’t know why. How can I get back to a more positive frame-of-mind?

    Many people who suffer from chronic pain of any kind share your experience. Pain can be tiring. Over time, the effects of chronic pain can wear down even the most positive, optimistic folks. But the good news is there are ways around this and trained professionals to help you.

    Counselors, psychologists, and behavioral specialists have techniques they use and can teach patients to use to improve thoughts and coping strategies when dealing with chronic pain. For example, cognitive therapy teaches people to be aware of their inner thoughts and replace the negative ones with more positive, helpful thinking. The concept is that “thoughts are not necessarily the truth, they are just thoughts” that can be changed to affect how we live and function.

    Coping skills along with time and activity management (including scheduling pleasant activities) is another type of cognitive therapy. Accepting pain in a way that allows patients to live based on goals and values rather than on feelings, thoughts, and pain falls under the category of acceptance-based cognitive-behavior therapy.

    A slightly different approach using hypnosis involves suggestions for ways to think about and experience pain. Many people who try hypnosis report decreased pain intensity. Studies show that combining hypnosis with cognitive therapy yields even better results. Not too different from hypnosis are the self-relaxation procedures used by some patients.

    Relaxation techniques usually involve contracting and relaxing muscles, biofeedback, or listening to instructions (suggestions) to train the body to relax. Research has shown that this approach works by changing patients’ beliefs about what they can do for themselves. Reducing the stress response and experience of pain results in less perception of pain.

    You may find one technique works well for you while others do not. Some patients combine two or more approaches for the best results. It may take a bit of time but with trial and error, you should be able to find the method(s) that work best for you. Recognizing there’s a problem is the first step. You are already well on your way!

    My mother-in-law has had a couple of operations and always seems to struggle with intense nausea afterwards. Now she’s scheduled for a total knee replacement and scared silly about the nausea and throwing up afterwards. I saw a TV special that talked about using acupuncture to avoid these complications. Does this really work?

    Acupuncture as a healing tool has been around for many, many years. In fact, it is one of the oldest medical arts. The use of modern acupuncture is increasing in popularity for pain and other health conditions.

    Nausea after surgery is one of the areas that has been studied quite a bit. Results using before and after sessions of acupuncture to reduce pain, nausea, and vomiting have been very promising.

    How does it work? Well, that’s a good question and one that no one seems to have an exact answer to just yet. The basic idea behind acupuncture is that by placing a needle through the skin, blocked channels of energy called meridians can be reopened. The result is a balancing of the body’s energy flow (called Qi, pronounced “chee”). Meridians flow through every part of the body from head-to-toe.

    Some acupoints increase the flow of energy for a specific physiologic function such as gastric motility (good for constipation). Others calm it down (good for nausea and vomiting).

    Don’t hesitate to ask your mother-in-laws surgeon about this problem and possible solutions. More than ever before anesthesiologists and other physicians are receiving training in acupuncture to use along with more traditional medical approaches.

    It’s possible that someone in your mother-in-law’s community is available to provide such treatment. Not all insurance companies cover the cost yet so bear that in mind as well.

    I am new to the area of chronic pain but just got a job in a clinic where we help patients complete questionnaires about their pain. I’d like to learn a bit more about how these tests help and maybe how to view them a little bit more critically. We are using the painDETECT, ID-Pain, and Neuropathic Pain Scale.

    There are quite a few questionnaire-type screening tools being used to assess chronic pain and in particular, nerve or neuropathic pain. A recent review published on these questionnaires included the Leeds Assessment of Neuropathic Symptoms (LANSS), the Neuropathic Pain Questionnaire (NPQ), the Neuropathic Pain Scale (NPS), the Douleur Neuropathique en 4 Questions, DN4, ID-Pain, and painDETECT.

    Each one measures type of sensations experienced by patients (e.g., burning, electric shocks, itching, numbness, pins and needles). Most are self-administered (the patient fills out the form). A few are clinician-administered (the examiner asks the questions and completes the form).

    The questionnaires are not designed to measure frequency, intensity, or duration of the symptoms. Only the Neuropathic Pain Scale (NPS) attempts to measure quality of pain. The rest are just screening tools but represent a step in the right direction for at least recognizing what’s going on in the patient’s body. They provide a piece of the diagnostic puzzle but the information gained must be used in context of the whole patient.

    As useful as these screening tools are in clinical practice, there are some drawbacks. For one thing, they were designed to assess just one area of pain. Many patients come to the physician or pain clinic because of pain in several areas of the body. There are often cases of widespread pain (throughout the head, neck, body, and limbs).

    Sometimes the questionnaires fail to identify someone who (when tested by the physician) is found to have a true neuropathic problem. Neuropathic pain questionnaires don’t cover all possible pain types — just the most commonly reported descriptors. So some people will fall through the cracks if the survey doesn’t include questions about the specific type of pain experienced by that person.

    The questionnaires do not help point to the underlying cause or true etiology of the problem. That requires additional testing, lab work, and X-rays or other imaging studies. Electrophysiologic tests such as EMGs (electromyograpies of the muscles) or nerve conduction tests may also be needed.

    But from the studies done so far, the screening questionnaires are simple and easy to use and do help identify neuropathic pain. That is an important first step because it can be very difficult to sort out pain types and pain patterns without a starting point like this.

    I work in a pain clinic and we use the Neuropathic Pain Scale (NPS) as part of the intake testing. We are specifically looking for any evidence that the patients’ pain is coming from the nervous system. What do other groups use? Is the NPS the best choice?

    As you have probably discovered, nerve pain (also known as neuropathic pain) can be difficult to diagnose and measure. For some time now, neuroscientists have been working on finding easy and simple ways to identify and quantify neuropathic pain. So far, they have come up with several screening tools in the form of questionnaires.

    These include the Leeds Assessment of Neuropathic Symptoms (LANSS), the Neuropathic Pain Questionnaire (NPQ), the Douleur Neuropathique en 4 Questions, DN4, ID-Pain, and painDETECT. Each one measures type of sensations experienced by patients. Most are self-administered (the patient fills out the form). A few are clinician-administered (the examiner asks the questions and completes the form).

    The Neuropathic Pain Scale is one of the most commonly used tools to assess pain quality (intensity, frequency, duration). But it doesn’t cover all the symptoms patients with neuropathic pain might report.

    A second tool called the Neuropathic Pain Symptom Inventory (NPSI) was developed to help overcome the limitations of the Neuropathic Pain Scale (NPS). Both the NPSI and the NPS are self-report (the patient fills out the form). The Neuropathic Pain Symptom Inventory assesses a wider range of possible neuropathic pain types and has been tested in more than 25 large international multicenter trials.

    Right now, it doesn’t seem as though there is a one-test-fits-all for screening neuropathic pain. But these screening tools represent a step in the right direction for at least recognizing what’s going on in the patient’s body. They provide a piece of the diagnostic puzzle but the information gained must be used in context of the whole patient.

    Can you tell me the difference between regular acupuncture and electronic acupuncture? I see our local healing center offers both. I’m just wondering if either of these might help me with my chronic low back pain. After all these months of pain, pain, and more pain, I’m desperate enough to try just about anything.

    Acupuncture has been used in various forms for thousands of years. Records show that sharp stones were once pressed against the skin in areas of pain to help give relief. Since that time, silver sticks and fine stainless steel needles have been used as well.

    Fine needles of various materials (e.g., gold, titanium, stainless steel) are still in use by modern acupuncturists. But the use of electrical stimulation has been added to the technique in the last 10 to 20 years. The electrical impulse provided through the needle enhances the stimulation.

    For those who do not want to have needles placed through the skin, flat rubber electrodes can be used as well. This technique is called transcutaneous electrical acupoint stimulation or TEAS.

    The exact effects of stimulation with and without electrical impulses (and by employing needles versus electrodes) is under scientific investigation. At this point, there are more unknowns than knowns. Who does it work for? Can anyone and everyone benefit? What settings are best? When should electrical stimulation be used? At what intensity and for how long?

    It’s likely that each medical condition treated has specific points that are most effective. Some of those points are already known for problems like chronic low back pain. And it’s possible that individual variability exists.

    In other words, each patient when matched by age, gender, body type, and condition or problem will respond slightly differently when the same acupuncture technique is applied.

    Your expectations and sensitivity to the treatment may be directly related to the results as well. If you seek the services of an acupuncturist, he or she will be able to assess your situation and make recommendations.

    I am the manager of a large civilian rehab center. Without a VA center in our area, we are starting to see a large number of returning soldiers for chronic pain problems. What can be done to prevent this painful suffering or at least manage it for our returning soldiers?

    Pain relieving medications are the first line of treatment. Sometimes more than one drug is used in combination called multimodal pharmacology. Tylenol still remains a very effective nonnarcotic pain reliever.

    Nonsteroidal antiinflammatory drugs (NSAIDs), antineuropathic (nerve pain) medications, antidepressants, along with opioids (narcotics) are available tools used for pain control. The idea of getting early control over pain is to prevent chronic pain from imprinting nerve pathways with a permanent pain signal.

    Other management tools for chronic pain in this group of combat casualties can include physical and occupational therapy, biofeedback therapy, relaxation training, and counseling. Complex regional pain syndrome has its own treatment protocol prescribed and supervised by the physical therapist.

    Various methods are used in an effort to stop the pain signals at the level of the nerve. Injections of numbing agents and steroids may be helpful. Nerve blocks, pulsed radio waves to the nerve plexus (place where nerves converge together), and various types of electrical stimulation have been used with varying levels of success.

    Many times it takes a concentrated effort of many team members to help suffering soldiers find the right mix of medications and management techniques to gain control of their pain. This type of program is referred to as a comprehensive interdisciplinary pain protocol.

    More and more health care professionals are training in some of the treatment techniques referred to as energy medicine. Craniosacral therapy, myofascial release, Reiki, BodyTalk, Touch for Healing, the Rosen or Alexander techniques are just a few of these therapies. Finding alternative ways to address pain is one approach that may prove very helpful.

    Do you think people with fibromyalgia are hypochondriacs? I have two friends and two family members with this diagnosis and they never stop complaining about it. I can’t help but wonder if all that yammering just keeps them focused on the problem and not the solution.

    One of the universally recognized key features of this condition we call fibromyalgia is widespread body pain. The person with fibromyalgia often says, “It hurts all over.” With pain everywhere and a host of other symptoms that characterize fibromyalgia, we might all find ourselves complaining (or at least commenting) on our situation.

    But there is an interesting observation that has been made from studies about patients with fibromyalgia. They do tend to report their symptoms and seek medical care earlier and more often than patients with other pain-related problems.

    You may be observing the phenomenon of over-reporting (as this behavior is referred to). The younger generation might call this TMI (too much information). They tend to count up all their symptoms — maybe because there ARE so many but perhaps because they are people who are just more focused on their bodies. The debate about this is ongoing.

    On the whole, people with fibromyalgia don’t sleep well, don’t feel well, and have psychologic, physical, and emotional distress. Put that all together and we might find ourselves unable to do anything but complain, too.

    I have a friend who is constantly complaining about her back pain. Yet she’s out there running marathons and never seems to stop driving herself. It just seems like there’s a disconnect between what she says and what she does. Can you help me understand this? I find I’m losing patience with her whining given the fact that she can do things I can’t do and I don’t have any pain.

    People with chronic low back pain often have to learn to live with it because all efforts to get rid of it or control it have failed. There seem to be two different ways people with chronic low back pain respond to their situation.

    They either avoid activities that might cause pain or they persist in being extremely active despite their pain. Like your friend, this second approach lends itself to what looks like “overdoing it.” Pain experts suggest these behaviors called avoidance and persistence are the result of self-discrepancy.

    What is self-discrepancy? Let me explain it like this. Even without pain, you have probably experienced self-discrepancy at times in your life. Some people refer to this as the “split-mind.” You perceive yourself one way but think you should be (or think) different. There are several different ways self-discrepancy plays a role in our lives.

    There’s the actual self or how you really are in your natural state. That is compared with your ideal or perfect self — the way you would like to be. Then there’s the “ought” self (i.e., I ought to be …you fill in the blank here). And finally, the “feared” self. The feared self is the one you are most afraid of being like or becoming (i.e., becoming someone you do not want to be).

    Any of these discrepancies or conflicts can result in emotional distress such as anxiety, depression, and pain. In addition to emotional experiences, the person may develop these other behaviors mentioned earlier (avoidance or persistence). It sounds like your friend may be overdoing it as a way of coping based on her internal thoughts and beliefs.

    The good news is persistence behavior doesn’t seem to have any negative effect on outcomes, disability, or quality of life. In other words, it won’t hurt to overdo in this fashion and may possibly help. If you find yourself in a place where your patience is wearing thin, you may want to consider stepping back for a time and taking a breather in the relationship. It may help both of you!

    I had my sacroiliac joint injected with a steroid and got good pain relief for about six months. Now my surgeon wants to use radio waves instead of the steroid. What’s the difference?

    Identifying pain that is coming from the sacroiliac joint can be quite a challenge. For one thing, the symptoms aren’t always present just in the sacral area. Pain is often felt in the low back, leg, pelvis, or buttocks instead. That’s because the nerves to the sacrum and sacroiliac area are complex and vary from one person to the next.

    Injecting a steroid with a numbing agent into the sacroiliac joint is both a diagnostic test and a treatment. If it successfully stops the pain, then you know the source of the pain was the sacroiliac joint. And once the pain is alleviated, your treatment has been successful!

    But because the cause of the underlying problem has not been identified, the chances are your pain will eventually return. A second steroid injection is often offered as a treatment option. It worked once (and for quite a long time), so the chances are it will work again — and maybe for an even longer time.

    For chronic, confirmed sacroiliac joint pain, an alternate treatment approach is the use of radiofrequency denervation (also known as radiofrequency ablation). The surgeon inserts a long, thin probe into the area under the guidance of a type of real-time X-rays called fluoroscopy. The offending nerve(s) are hit with high voltage radio waves that heat up the tissue and destroy the sensory nerve (the one that sends pain messages).

    Radiofrequency can be delivered in several different forms (e.g., conventional, pulsed, cooled-probe, bipolar). The pulsed form doesn’t cause a rise in tissue temperature. Instead, it sets up an electromagnetic field around the nerve. The result is pain relief that may last six months or more. But because the nerve remains intact, the painful symptoms can come back.

    The cooled-probe technique allows the target tissue to be heated up while keeping the surrounding tissue cool. This method makes it possible to heat up a slightly larger area than the conventional probe but without damaging other nerves in the area. There is also less tissue trauma with the cooled-probe because of the way the needle enters the tissue (perpendicular rather than parallel).

    Whereas a steroid injection most often targets the joint, radiofrequency denervation directly attacks the nerve(s) to the joint. Diagnostic SI joint steroid injections are usually performed before radiofrequency ablation is recommended.

    The pain clinic I’m going to for my low back pain has finally figured out it’s coming from my sacroiliac joint. They have suggested doing radiofrequency ablation on the nerves that are causing the pain. How well does this treatment work?

    Pain from the sacroiliac joint can be referred to the low back pain, leg, sacrum, pelvis, or buttocks. It can be difficult to trace and even more problematic getting rid ot it.

    For the last 10 years, radiofrequency denervation (using radio waves to destroy nerve tissue) has been used when other more traditional treatments have failed. Early results were favorable and now studies done over the last 10 years are being analyzed and reported on.

    Whenever a new form of treatment arrives on the scene, physicians want to know: 1) How well does it work? and 2) Who would benefit most from this treatment? Let’s start with the answer to the second question. Patient selection is always a key factor in the success of any treatment like this.

    What we know so far is that people with sacroiliac joint pain who get some relief from a steroid injection into the joint seem to respond best to radiofrequency ablation. Younger patients have the best results.

    How well does it work? That’s harder to say for a number of reasons. First, the SI joint can vary considerably from patient to patient. Likewise, the number, size, shape, and location of the nerves are equally variable.

    Finding the nerve affected most can be a challenge. Then getting to the involved nerve is the next dilemma. Some of the nerves are right on the bone, while others are embedded in the soft tissues around the joint. Often, there’s more than one nerve that is involved requiring more than one procedure.

    And evaluating the results of studies already published isn’t as clear and easy as physicians would like. For example, different surgeons use different techniques, select their patients using different criteria, and have different standards by which to judge “success” or “failure”. Those kinds of differences make it difficult to compare one study to another and/or report overall trends for this treatment technique.

    Radiofrequency does have some potential in the successful treatment of chronic sacroiliac joint pain. The most effective nerves to target for most patients are between the L5 and S3 levels. Cooled-probe radiofrequency seems to have the best outcomes but more studies are needed to compare the different techniques.

    The pain center where I go for treatment and follow-up for complex regional pain syndrome of the foot wants me to be in a study that measures severity of the problem. I’m not sure I want to join in the fun. What good will it do?

    Many health care professionals are looking for ways to identify which treatment approaches work best. Sometimes it’s possible to even figure out who is most likely to benefit from each different type of treatment. That is a win-win situation for everyone.

    Without the participation of people like yourself who already have a known diagnosis of complex regional pain syndrome (CRPS), it can be difficult to gather the evidence needed to support one method over another.

    A recent study published results on the development of a severity score for CRPS. The test consisted of a checklist of signs and symptoms common with this condition. Self-reported symptoms included differences in temperature, skin color, sweating, and swelling from one side (involved side) to the other (uninvolved side).

    A second section of the test evaluates signs observed by the examiner such as
    exaggerated levels of pain with pinprick test, differences in skin temperature felt by the examiner, and decreased range-of-motion of the involved part (hand, foot).

    Higher test scores meant more severe pain and other symptoms. Patients with CRPS had much higher test scores than the patients in the nerve pain but non CRPS group. Statistical analysis showed that this new scoring system for severity of CRPS is reliable and valid. In other words, it can be used dependably to identify people with CRPS and provide a picture of the severity of their condition. Used over time, it can also show changes or fluctuations in individual cases.

    This type of tool may help health care professionals plan and modify treatment for patients with CRPS. Having a consistent severity score will help improve communication among all the health care professionals working with people who have CRPS.

    Researchers involved in this project do not see this tool as a replacement for current pain scales in use to measure treatment outcomes. But the scoring system may be helpful when conducting research on this condition as it can show changes in symptoms with treatment. It may even function as a predictor of who will get better with different types of treatment.

    Perhaps the proposed study at your center has similar goals and purposes. Consider asking the people who are conducting the study what the intent of the study is and how the results will be used. It may be something that doesn’t benefit you directly but could help others in the future.