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Chronic Pain

Steps to Help

For those coping with chronic pain, there are no shortcuts or easy simplifications for how to get things under control. There is now a process, though, of diagnosis, identification, and case planning that, if comprehensive, can be life saving. The first step is to find an expert in pain management with whom a patient can develop a long term trusting relationship. The pain specialist should work hand in glove with other physicians attending the patient. Usually, the patientís primary care physician or hospital refers a patient to a pain management program. The first step is one of evaluation. This evaluation works two ways. The pain management specialist and team need to examine the patient and review the patientsí history is detail. The patient needs to interview the pain team and ascertain whether or not they are experienced, flexible, and compassionate.

Step 1: Diagnosis- chronic illness often produces a variety of symptoms that are difficult to distinguish. The first step in planning a course of action is to have the best evaluation possible. Very often limited health care insurance, no insurance, HMOís and so on make accurate diagnosis difficult yet it is a vital step. Diagnostic procedures range from rating pain on a pain scale, "drawing" ones pain, X-ray including CAT scan, MRI, physical examination, nerve conductivity tests (EMG), psychological and psychiatric assessments, blood tests, and a complete review of past medical records. Chronic pain patients should get in the habit of getting and maintaining copies of all of their records including past treatments and the results. Patients should also learn the habit of writing down their concerns and bringing their list with them to physician or clinic visits. It is very helpful to bring a steady friend or family member along who not only may remember important points but also can help insure that the patient receives all of the necessary instructions.

Step 2: Case Management Plan- As the diagnosis progresses the patient and the pain team take time to share their observations and suggest various options for treatment. A case management plan should be developed that deals comprehensively with medical aspects, family, social functioning, and both psychological and spiritual well-being. Good pain management plans are generally conservative and proceed step-wise depending upon results. The entire family should be involved in the development and implementation of a pain management plan.

Step 3: Medical Intervention(s)- Depending upon the diagnostic results, the first item to consider is whether a medical and/or surgical intervention is warranted and of what type. Usually, procedures that have a low chance of success or a high rate of adverse consequences are held in reserve while alternative approaches are tried first. In many cases, though, surgical or medical intervention can generate huge improvements in pain control if there is a clear biological basis for the pain that can be corrected. Evaluating potential medical procedures is a numbers game where one looks at the best probabilities of success versus the possible negative consequences. There are few clear choices in deciding on a medical or surgical intervention. Adequate pain control is made difficult to impossible if the underlying medical reasons for the pain are not addressed. This means planning to treat any underlying illnesses. This may mean a number of physician specialists are going to be involved. The pain manager, internist, or the patient themselves can provide critically needed coordination to the extended treatment team.

Step 4: Treatment- Addressing pain control medically can take weeks, months, or even years. Periodic re-assessment is critical. Over time chronic conditions may improve, deteriorate, or change. The best results in pain control happen when a combination of traditional and alternative methods are employed in concert. It is critical for patients to clearly relate to their physicians what has worked for them in the past and what their fears are for the future. Brief descriptions of pain management methods are described below for reference.

  • Stress reduction- chronic illness and pain are extremely stressful. Stress is experienced through the mediation of brain chemicals (neurotransmitters) such as norepinephrine that make pain worse. There are many methods of stress reduction including guided imagery, biofeedback, meditation, breathing exercises, counseling, walks, warm baths, etc. Alcohol use will increase stress. Cannabis usually effectively moderates stress chemistry while tranquillizers such as the benzodiazapenes may cause sedation and addiction.
  • Life Style management- Occupational therapists and others can assist patients to modify the way in which they conduct their activities in order to reduce pain. Knowing the "right" way to stand up from a chair, for instance, can make a difference in pain. The same principles apply to doing chores and work activities including lifting and posture. A host of ingenious devices are available that assist the physically impaired to complete tasks without the pain these tasks used to generate.
  • Physical therapy- Wonderful gains in mobility, range of motion, and pain reduction can often be achieved through participation in a carefully crafted program of physical therapy (PT). PT can involve simple exercises that help restore functionality to effected areas. PT can be accomplished nearly anywhere including in the pool where patients may exercise without experiencing the effects of gravity. PT is a great idea for gradually building up overall strength, improving circulation, and assisting the immune response. Some forms of yoga can be incorporated into a guided physical therapy regime providing for both physical and emotional improvements.
  • TENS (Transcutaneous Electrical Nerve Stimulation)- Sometimes chronic pain that occurs in specific locations of the body may be blocked by signals generated by TENS units worn outside of the body and connected to the skin by patch like leads. The TENS current can be controlled as to strength (amplitude), wave style (pulse), and bandwidth. For some types of pain TENS units are truly helpful while others have had their pain increased by TENS.
  • Acupuncture- The insertion of sterile needles into a variety of key points found to relieve certain types of pain. China has gone so far as to conduct major surgeries using only acupuncture as anesthesia. Relief from acupuncture is usually measured in hours or days at best. Some health practitioners have combined the use of TENS and acupuncture by electrifying acupuncture needles and/or placing TENS leads on acupuncture points.
  • Nutrition- As in most disorders, good nutrition can significantly improve many disease states and help provide the strength needed to cope with chronic pain. A balanced diet that helps maintain normal weight levels, for instance, can help reduce the stress on injured joints and/or the spine. Some nutritional supplements such as glucosamine have provided some relief to arthritis sufferers. Certain teas can be calming. Getting involved in menu planning and cooking is great occupational therapy for chronic pain patients.
  • Self Help- Chronic pain patients are becoming increasingly involved in support groups. These groups may be disease specific or general. Groups can meet locally and/or through the Internet. Sharing experiences and feelings with other patients in similar situations can be very helpful in understanding and coping with chronic pain. Real friendships are often found in dialogue with others who share problems. Support groups are wonderful places to not only make friends but to decrease the terrible social isolation often associated with chronic pain. Spiritual fellowship has also been demonstrated to observably improve health, elevate mood, contribute to increases in the immune response, and help patients cope with pain with less hopelessness and despair.
  • Addressing Depression- Almost all cases of chronic pain involve depression of one degree or another. In depressed states the brain fails to function normally due, in part, to a reduction of key neurotransmitters like Serotonin. A patientís perception of pain is intensified as depression deepens. Cognitive behavioral therapy and/or the use of SSRIís (Selective Serotonin Re-uptake Inhibitors) like Paxil or Zoloft provide real help with depression and help reduce pain.
  • Biofeedback- Chronic pain (and the medicines used to treat it) can produce a pattern of brain electrical activity that is less than functional. Patients may experience a decrease in cognition or mental alertness, confusion, and loss of memory. Biofeedback sessions help the patient focus and lift themselves out of dysfunctional patterns. Once trained patients are often able to replicate the success of their experience with the biofeedback machine without the apparatus.
  • Epidural Injections- In some cases small amounts of a steroid may be injected locally to areas of inflammation responsible for pain. Injections are often provided in a series of three. Many pain specialists utilize active X-ray to guide them to the appropriate injection site. Usually, only one series of epidurals is allowed during a year to minimize the side effects of steroid use. Although localized, epidurals do generate a certain amount of systemic steroids which can be harmful in cases of diabetes, ulcer, and in patients with compromised immune systems.
  • Nerve Blocks- Some nerve centers (i.e. the celiac nerve in the abdomen) may be "turned off" through the injection of steroids directly into a nerve plexus. This procedure may have serious risks and doubtful success. Instead of steroids, an anesthetic agent such as lidocaine or procaine may be injected to an inflamed nerve providing temporary relief. Such injections are often aimed at "trigger points" where pain is focused and localized.
  • Surgical Interventions- These are some of the most controversial procedures for relieving pain. Surgery on the spine, joints, etc. may reduce or eliminate the source of pain but in some cases no improvement or a deterioration of condition results. It is strongly advised to not only consult a "second opinion" but also for patients to become educated about procedures prior to initiating surgery. In general, large University medical centers provide the highest quality surgery programs. Avoid medical "come ons" and promotions. Try to stick to specialists who are highly experienced in the procedures involved.
  • Pain Medications- A host of various medications may be employed to reduce pain to manageable levels. An entire section is devoted to these medicines, how they work, side effects, and alternatives.
  • Adjunctive therapy with medical cannabis- The use of medical cannabis in the control of pain, inflammation, and disease related dysphoria is growing across the globe. A complete discussion of how cannabis can help is included in the detailed section on medications.

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