FAQ Category: Pain

Many chronic pain sufferers have true pain that is not used to gain attention. No doubt your wife is in this group. But traumatic injuries with multiple surgeries can result in pain that just isn’t going to go away.

The nervous system is very complex and poorly understood. Although there are many ways to treat pain, it’s not always successful. Sometimes it takes months and even years to try different methods to see which one works best for each individual.

If your wife has not seen a physical therapist, acupuncturist, or other back pain specialist, it might be a good idea. If she has seen these people (and others) and also tried various pain medications, it’s usually time for a behavioral management program. It sounds like this is the stage she has reached in her quest for help.

This is not necessarily a dead-end. Many studies have shown that a behavioral approach to chronic pain can result in increased function and activity. The pain may not be less, but the patient is able to do more despite the pain.

For example, the team will be able to help her identify and overcome any avoidance behaviors. Avoidance refers to the fact that it’s natural to avoid certain movements or activities if we think it’s going to hurt. But over time, we lose motion and function and the pain is still there.

The program should also help her learn how to pace herself. A steady pace of activity may be better than overdoing it followed by a prolonged rest period. Instead of ups and downs in activity, the person can maintain a level of activity that allows them to engage in daily activities without a crash and burn effect.

It might be best to schedule an appointment with the case manager or key team members. Find out more about the program design and purpose. See where your wife and her goals fit into the scheme of things. Feel free to ask any questions you may have and express your concerns. Without the patient’s cooperation, even the best pain management program won’t have the best results.

There are some conditions that do require a no pain, no gain attitude. But it’s true that many more times this type of approach causes more harm than good. Your rehab specialist will always let you know what works best for the type of problem you’re dealing with.

Unhealthy high-level activity may actually backfire and delay your recovery. The best results seem to come for patients who maintain a steady pace. They don’t go full speed ahead until exhausted and end up in even more pain. If you do this, then need long period of time to recover, your overall progress will be delayed.

A steady state of activity is better than extreme fluctuations. Try to think of replacing the idea of pushing with pacing instead. Focus on going slow and steady.

Work with your therapist to understand how far you can go and how fast. Hold steady to that pace and pay attention to how you feel. Slowing down can actually make it possible to do more with less pain and gain in the long run.

It is true that different people have different concepts of pain. What is excruciating to one person may be bearable to another, and the other way around. What is important is that pain is recognized and accepted for each person.

For example, if you go to the hospital with pain in your stomach, you will likely be asked if the pain is sharp, dull, aching, pressing, centralized, or radiating, among other descriptions. Once the type of pain is established, most doctors and nurses now use a pain scale to see how you are feeling at that moment and how you progress with treatment and time. So, you may be asked, “on a scale of 0 to 10, with 0 being ‘no pain’ and 10 being ‘the worst ever’ pain, how would you rate your pain right now?” This gives the healthcare providers a benchmark with which to work. Later, as your examination is going on, tests are done, or treatment given, you will be asked again so that your progress can be measured against your initial score.

If you are in an establishment that doesn’t seem to be using a pain scale, you can still use it yourself. If asked how your pain is, you can say, “on a scale of 0 to 10….” and then be consistent with describing your pain this way from then on.

Pain isn’t always identifiable. The causes can be hidden or the pain can be psychosomatic, or in the mind. However, that does not mean that the pain doesn’t exist, just that it’s not physical.

If it is possible, try to get your mother referred to a pain clinic where she can be assessed again about what may be causing the pain. If they can’t find any reason for the pain, they still may be able to provide options for her to get some relief. There could be medication or even counseling to help her manage the pain or to find ways to work around it.

Keep advocating for your mother; there are ways to help but you may have to be persistent and do more looking around.

The onset of movement disorders (MDs) in patients with complex regional pain syndrome (CRPS) is being studied by researchers as they try to find the connection between the two. In one study, researchers found that 56 percent of the patients with CRPS developed MDs, but the researchers don’t know why.

Because there is no definite connection yet between the two (CRPS and MDs), doctors don’t know what can be done to prevent MDs from developing in some patients.

People with movement disorders (MDs) can be very uncomfortable with the way the muscles contract and spasm, so research is being done to try to find ways to relieve the pain and the discomfort. Right now, though, there isn’t any treatment for movement disorders, but there are some treatments that can help some patients find relief.

While they don’t work for everyone and may not provide full relief, many patients try alternate treatments, such as acupuncture, biofeedback, and yoga. Some traditional therapies like physiotherapy and occupational therapy may help as well.

Medication can be delivered in many ways, from injections to pills to skin patches and even rectal suppositories. One other method of delivering pain relief is intrathecally. This means that medication is delivered directly to the area in the spine that is causing the pain. People who have severe, chronic pain may be taking opioids like morphine. However, up to 20 percent of patients can’t tolerate or can’t take drugs like morphine. Side effects can include nausea, vomiting and dizziness. By using the intrathecal method, doctors can usually give lower doses and the drug bypasses the stomach, which may help reduce the nausea and vomiting.

A patient who is having an intrathecal drug delivery will have a small catheter, or tube, inserted into the spinal area where the pain is located. A pump is attached and medication is delivered constantly, avoiding the peaks and valleys that can happen when people take oral medications.

Deepwave is a deep tissue pain therapy device. It is classified as a neuromodulation treatment. This means it interrupts the pain signals sent by the nerves to the spinal cord and then up to the brain.

It works by creating a low frequency electric field around the painful area. Two patches called electrodes are placed on either side of the affected tissue.

The electric field created between the two electrodes alters the balance of potassium and sodium. The result is that the nerve can’t send pain messages to the brain. At the same time, scientists think that natural pain relieving chemicals called endorphins are released into the blood stream.

Pilot studies of Deepwave with a small number of patients over a short period of time have been successful. Patients have less pain and can use fewer pain relievers. Patients who have used this device are very pleased with the results. It appears to be a safe and effective treatment for knee OA.

Larger studies over a longer period of time are still needed before this treatment is offered to everyone. The people in your clinic may be part of a study. Ask your doctor if you might be a good candidate for this treatment.

Oxycodone is a narcotic medication used for the treatment of chronic pain. It is reserved for those patients who have tried other nonnarcotic pain relievers without success. Most often, other treatment such as physical therapy is tried first as well.

Doctors know that patients don’t all respond to the same drug in the same way. Most often this is because people metabolize (break down and use) drugs at different rates. Since the same amount of drug is usually prescribed for everyone, half the people get too much drug. The other half doesn’t get enough.

Research has shown that most of the medications like oxycodone used for pain control are metabolized by an enzyme called CYP2D6. Genetic variations of that enzyme cause people to metabolize drugs at different rates.

A small percentage are ultrarapid metabolizers. The drug is broken down and passed out of the body too quickly to do much good. Your sister may fall into this category. Others break it down slowly enough that a steady amount of the drug stays in the body longer. This may describe your situation.

Choosing the right drug for each patient and prescribing the best dose is part of pain management. If she is not getting the pain control she needs, then it’s time to get back with the doctor or pain management team for a re-evaluation.

You may be referring to a blood test that allows genetic analysis to predict and monitor drug effects. The process of choosing the right drug using the best dosage is called pharmacogenomics. Pharmacogenomics is based on a genetic analysis of each condition and each patient. It is still in its infancy stages of development.

Researchers are indeed trying to find ways to predict what drug to choose for each patient based on their genetics. But this practice is not routine yet. Most of the research is in the area of cancer drugs. For example, doctors are trying to avoid using chemotherapy on patients if it’s not going to help. Tests are being developed to tell ahead of time if it will or won’t work for each type of cancer.

In general, we do know there are many factors that affect how a drug is used or metabolized by each individual person. Age, sex, overall health, and even hydration (how much fluid is in the body) can all affect how well the body can break down and use the active chemicals in a drug.

And scientists have discovered certain enzymes that also help (or hinder) the process. For example, an enzyme called cytochrome P450 2D6 (or CYP2D6 for short) has been shown to help metabolize opioid (narcotic) drugs. Any genetic mutation, defect, or duplication of that gene can change the way the body metabolizes the drug.

So far, it looks like people fall into one of four categories. They may be ultrarapid metabolizers. This occurs because they have multiple copies of CYP2D6. They may be poor metabolizers. This means there is no detectable activity of the enzyme. Or they may fall somewhere in between with decreased or poor enzymatic activity.

In the future, pharmacogenomics including genetic analysis will become a routine part of each medical exam. This type of testing may be available if you are being treated in an area where there is a rapid response laboratory or medical research facility.

Without this type of testing, patients and physicians will still have to use the trial and error method of finding the best dose of the right medication for each patient, condition, or disease.

The sacroiliac joint (SI) remains a mystery in many ways. It can be very difficult to tell if pain is coming from the SI or if it is referred from someplace else. For example, problems in either the low back or the hip can cause SI pain.

There can even be SI pain from systemic diseases. Ulcerative colitis, Crohn’s disease, and irritable bowel syndrome can cause SI pain. For women, gynecologic conditions such as endometriosis, uterine fibroids, and ovarian cysts can cause SI pain.

The one sure way to find out if pain is coming from the SI joint is by injecting it. The physician injects a combination of steroid (antiinflammatory) and a numbing agent like Novocaine into the joint.

If the problem is coming from someplace else, the injection will have no benefit. But if the cause of your symptoms is truly from the joint, this treatment will give you pain relief. It may be only temporary pain relief. Some people get lasting relief.

Review of the latest research on pain management reports nothing more up-to-date on the evaluation and management of SI pain. This review is conducted every two years by a committee of pain specialists. It is sponsored by the American Society of Interventional Pain Physicians (ASIPP). The 2007 updates are available on-line at www.guidelines.gov. Just type the letters: ASIPP in the search window.

Chronic back pain can be very difficult to evaluate and treat. There are many things we still don’t know about pain, what causes pain, and how to stop it. In many ways, the nervous system in charge of perceiving pain and sending pain messages remains a complex mystery.

Many pain clinics use a management approach to chronic back pain. The combined efforts of the doctor, psychologist, physical therapist, nutritonist, and others are used to find the best program of intervention and management for each patient.

If you haven’t been working with a team of pain experts, that may be your next step. You may live in an area where a pain clinic has not been developed yet. As a consumer, you may have to put together your own team.

Instead of the physician coordinating all of the services, you would have that role. It will be up to you to communicate with each individual member on the team.

There are many traditional and complementary techniques available now for pain management. On the traditional side, medications are often the first-line of treatment. They range from mild analgesics to powerful narcotics.

From a less traditional approach, there is acupuncture, hypnosis, massage, relaxation therapy, and biofeedback to name just a few. It may take a while to find the right one or the right combination to get maximum benefit, but it can be done.

There are also updated guidelines on the management of chronic spinal pain. These are published by the American Society of Interventional Pain Physicians (ASIPP). They come out every two years. The 2007 update is available on-line at www.guideline.gov. You can also download the document from www.asipp.org/documents/guidelines-2007.pdf.

Complex regional pain syndrome is a condition that often affects people after trauma or orthopedic surgery. An insult to the nerves or tissues can set off an inflammatory response that goes overboard. The nervous system seems to take off and doesn’t slow down. Pain, hypersensitivity, and even bone loss can develop.

Your physician is right about testing. So far, there’s no single diagnostic lab test, X-ray, or other imaging test that identifies this problem quickly and easily. X-rays don’t show changes until late in the progression.

Bone scans do show increased blood flow to the affected area. But the test is only specific and sensitive enough in the early weeks of symptom development. And most doctors don’t routinely suggest this test until many weeks of unresolved symptoms have gone by.

Most of the time, we have to rely on the history (what happened) and clinical signs and symptoms. If a patient doesn’t get better in the expected timeframe, as red flag is raised in the mind of the doctor. Close follow-up is necessary to see changes occurring that point to CRPS.

Early detection and treatment are important in CRPS in order to avoid chronic problems. Unfortunately, this condition is often very difficult to diagnose. if your doctor thinks you may have CRPS, don’t delay getting appropriate treatment.

Studies show that at least 10 per cent of the adults who fracture the radial bone of the wrist develop a condition called chronic regional pain syndrome (CRPS). This used to be called reflex sympathetic dystrophy (RSD).

The condition is caused by trauma or damage to the tissues or nerves. An extreme inflammatory response develops. It causes pain that can become chronic. Many patients report increased sweating of the palm and extreme sensitivity to any touch to the hand and arm. Hair growth is not uncommon. Often it is dark, coarse hair in a swirled pattern.

There is no evidence that this condition is caused by psychologic or personality traits. Psychologic distress is certainly a normal response to a chronic pain condition of this type. Seeing a counselor or psychologist can’t hurt. It may help you learn ways to cope and deal with the pain.

If your father’s doctor has prescribed opioids for his pain relief, it is important that your father take them as needed. If someone does not allow him to take them, he may be suffering unnecessarily.

Opioids are indeed very strong medications, however, when someone starts a new drug, he or she is rarely put on very high doses at the start. The doctors have a lot of leeway as to what type of medication to give, what route (by mouth, injection, etc.), whether to give the drug alone or with another to help enhance the drug’s effect, and the doses given. If someone develops a tolerance to the drug, any of those factors can be adjusted.

Chronic pain is very difficult to treat. A medication that might help one person may not help the next. Of course, usually when someone begins having pain due to a chronic condition, doctors start by prescribing non-opioid medications, or drugs that aren’t restricted. However, if someone isn’t responding to those medications, opioids may be the only answer. As they begin taking the medications, the doses are low and are usually increased as needed.

Don’t forget that chronic pain is not less severe than acute pain and still needs to be treated properly.

Many people take opioids for their pain. Opioids are the medications that are regulated by the government because of the potential of their abuse. Being addicted or hooked on opioids is not the same thing as building up a tolerance to the medications, something that can happen as well.

Someone who has become drug tolerant of their medications has reached a point that the dose he or she is taking is no longer doing its job. It is not unusual for a body to become used to taking a medication and developing this tolerance. At that point, if you want the drug to be effective, you need to speak with your doctor about increasing the dosage or the number of times a day you take the drug.

Addiction is different in that if you’re addicted, you feel like you need the medication rather than just wanting it for pain relief. You think about getting the medication and how to get it if you don’t have any left. You think more about the actual getting of the medication than using it and the pain relief it provides. You may do things to get the medication that you might never have done otherwise.

Like all medications, opioids have side effects:

Nausea: Very common with opioids. If nausea and vomiting are severe but your doctor feels that this is a good medication for you, you may be given an anti-nausea medication. For some people, the nausea goes away after a few doses.
Constipation: Very common as well and should be taken seriously. Be sure to drink plenty of fluids and increase your dietary fiber. You could ask your doctor about laxatives or stool softeners.

Sleepiness

Lightheadedness

Dizziness

Euphoria

Confusion

Urinary retention

Itching

Difficulty breathing in patients who are elderly or who are disabled

Pain and the mechanisms of pain are still a large mystery to experts. Even low intensity stimulation like a massage can be interpreted by the nervous system as painful instead of pleasurable.

If it seems okay at the time but causes painful symptoms later, then there may be some hyperexcitability on the part of the spinal cord. The nerves in the skin and muscles send messages to the brain via the spinal cord. If for some reason, the nervous system is over reacting, then normal, soothing touch can be interpreted as painful or noxious.

Studies of chronic whiplash patients show that this concept of nervous system hyperexcitability may very well explain some of their long-term symptoms. Even after the soft tissues in the neck are healed and there is no tissue damage observed, changes in the nervous system can persist.

Be sure and let your massage therapist know of this reaction. He may have some ways to influence or moderate the nervous system’s response to the treatment.

In today’s health care culture, evidence-based medicine (EBM) is a key byword. EBM refers to the idea that as much as possible, only treatments known to have a positive effect are used. Some treatments make a patient feel better but it’s only temporary. There aren’t any real lasting changes in motion or function.

In order to measure change in a patient’s status, certain tests must be performed each time. There are many such tests that can be used depending on the problem the patient is being treated for. This helps the doctor or therapist judge the status of the patient.

It also helps determine whether a meaningful change has taken place. For example, say you rate your pain as a six on a scale from zero to 10. After your first treatment, it goes down to a five. But you still can’t dress yourself or comb your hair without help. Your pain is improved but a meaningful change in your status hasn’t occurred yet.

If every patient who is treated this way gets slight pain relief but no functional improvement, then the treatment method should be abandoned for something more effective. Testing the patient before and after is the best way to see what makes a difference.