General Pain Management
What is pain?
Often the cause of pain is obvious, a broken leg, or a bruise. But there are times when the source of pain is unseen, for example a slipped disc. Occasionally it is very difficult to find the exact cause of a person’s pain.
Health professionals use different terms for different types of pain.
– Short-term pain is called Acute Pain. An example is a sprained ankle.
– Long-term is called Persistent or Chronic Pain. Back trouble or arthritis are examples.
– Pain that comes and goes is called Recurrent or Intermittent Pain. A toothache could be one.
Many acute pains are like an alarm telling us something is wrong. Most minor ones are easy to treat; others may be a sign of something more serious. For example the pain of a broken leg will make us rest the leg until it heals. Here the pain is helpful.
By contrast chronic pain often serves no useful purpose. Medical assessment and diagnosis does not usually lead to the pain going away and over time it may affect what we can including ability to work and sleep patterns may be interrupted. It can affect mood and relationships with our family and friends too.
Pain signals from injury normally travel to the brain via specialized nerve fibers and the spinal cord.. These nerves also process the pain signals. All together they work like a very powerful computer.
Sometimes this computer system can go wrong. The messages get confused and the brain cannot understand the signals properly. Thia is one reason for chronic pain, which can be very difficult to treat because we cannot just re-boot the system.
Pain usually causes strong emotions and these can interact with our other feelings. If we are angry, depressed or anxious, our pain may be worse. Alternatively if we are feeling positive and happy, our pain may be less and we are able to cope better. This shows that pain is never “all in the mind” or “purely in the body” – it is a complex mix depending on many factors.
A slight pain can become amplified.rather like in a football crowd: one person starts a chant or a song and very quickly the whole stand has joined in. When this happens with pain, doctors call it central sensitization and is one of the reasons why the severity of pain experience may have little relationship to the size of the cause of pain.. The ‘chant’ can last for hours, days or even years.
One of the ways in which pain signals are regulated within the nervous system is by the release of tiny quantities of neurotransmitter chemicals – over one hundred types have been discovered.
The balance of neurotransmitters in the nerves can affect the amount of pain that is experienced. By doing something that we enjoy like having a good laugh or exercising, we can strengthen our ‘good’ neurotransmitters and so limit pain. However, if we are depressed or moody, lack motivation and are not active the bad neurotransmitters take over and our pain can get worse. Pain killers are sometimes used to strengthen these ‘good’ neurotransmitters.
Many of the modern techniques used by medical people have helped us to understand and treat pain better. But there is still a lot that needs to be learned.
Pain doctors understand that pain is a very personal experience with only the person in pain being able to say how much pain they are in.
Assessment of a patient’s pain by healthcare professionals needs to be thorough and include many aspects health, emotions and functioning in life.
What is chronic pain?
Chronic pain is pain that continues a month or more beyond the usual recovery period for an injury or illness or that goes on for months or years due to a chronic condition. The pain is usually not constant but can interfere with daily life at all levels.
What is musculoskeletal pain?
A pulled hamstring, a broken bone or an arthritic joint are examples of musculoskeletal pain. It is pain that is felt in the muscles or bones (skeleton) of the body.
What is nociceptive pain?
This is pain that results from actual injury and damage to tissues including inflammation. The pulled hamstring, broken bone and arthritic joint are all damaging (noxious) situations.
What is neuropathic pain?
This is pain that results from damage to the nerves – muscles and bones may not be directly affected.
For example:
Sciatica where a nerve is irritated or compressed in the bottom of the back giving pain down the leg,
Shingles where virus damage to a nerve causes extremely painful sensitivity of the area of skin supplied by that nerve.
Diabetes and Multiple Sclerosis can damage the nerves at multiple points resulting in more widespread pains.
What is referred pain?
A pain is referred when somebody gets a pain in one part of their body, but the cause is in another part of their body. Strange but true!
Pain in the left arm caused by a heart attack, and sciatica are both examples of referred pains.
How can I find a doctor who specializes in pain management?
As a start, you can visit the following sites: American Academy of Pain Medicine or American Board of Pain Medicine.
Is my pain all in my head?
This question is often asked by people who have been told that they will have to learn to live with their pain. At times, it is difficult to pin down a specific physical cause for the pain. But that does not lessen the suffering. When we experience any pain, it is in both our bodies and minds. We cannot separate the physical and psychological affects any situation has on us.
What is interventional pain management?
Interventional pain management, as a subspecialty of pain management, offers a wide spectrum of modern pain blocking techniques and technologies, including those where injection therapies and spinal cord stimulators are used.
What is important, is that interventional pain management treatments are able to alleviate pain without the use of prescription drugs.
We believe that pain management should be personalized, compassionate and cost effective, and it is the source of pain that must be targeted, not just the symptom.
Such approach brings a long term pain relief and allows patients to return to their jobs and daily activities.
It is worth remembering that modern medicine knows many pain management techniques but only the best pain management doctor will have the necessary expertise to determine which pain management technique is right for you.
What are the signs that I need to see a pain management doctor?
It’s time to see a pain specialist if the following relate to you:
– Persistent pain for more than three weeks
– Medications are not reducing pain
– You want to stop taking medications for pain
– You want to switch to an alternative treatment
– Struggling to perform daily activities
– You are not having a good night sleep due to pain
Why is pain management important?
Untreated or inadequately managed pain can lead to adverse physical and psychological outcomes for the patient and his or her family.
Common psychological responses to pain (especially chronic pain) include anxiety and depression. The inability to escape from pain may create a sense of helplessness and even hopelessness, which may predispose the patient to a more chronic depression. Patients who have experienced inadequate pain management may be reluctant to seek medical care for other health problems*.
Thus, it is vital that pain sufferers do not delay seeking professional help and receive adequate and effective pain management treatment.
Specific Pain Conditions
What are some of the potential causes of lower back pain?
Lumbar Sprains and Strains are very common causes of low back pain. They may be caused by injury to the muscles, tendons or ligaments of the lower back, such as a sudden twisting or pulling movement or chronic overuse of lower back muscles. The treatment is usually conservative, including rest, medications, ice or heat, or physical therapy.
Herniated / Bulging Discs — The disc is the cushion between the vertebrae of your spine. A disc can rupture and extend beyond its normal boundary. When a disc herniates / bulges out, the spinal nerves can become compressed, possibly resulting in pain or numbness down the leg. Depending on the severity, treatment may require measures such as epidural or nerve block injections or possibly surgery, including minimally invasive techniques.
Lumbar Facet Joint Syndrome — Facet joints are joints located on both sides of the spine at the back of each vertebra. Facet joints attach to the vertebrae above and below to form a unit, allowing movement of the spine. Lumbar facet syndrome is usually felt in the lower back, but pain can be referred causing sciatica-like symptoms. Facet pain can be treated with facet injections, also called medial branch nerve blocks, or radio frequency ablation, which is used for longer lasting relief of facet pain.
Spinal Stenosis is narrowing of the spinal canal or where the nerve roots exit and can cause sciatica-like symptoms if the nerve roots are compressed. Disc problems and arthritis can be causes of spinal stenosis. Possible treatment options include epidural injections or surgery if conservative measures fail.
Sacroiliitis is an inflammation of your sacroiliac joint. That’s the joint where your hip joins the spine. Trauma or arthritis can lead to inflammation of the joint and give you symptoms that can mimic sciatica. One way to diagnose and treat this condition can be with an injection using x-ray guidance for more precise location.
Piriformis Syndrome is a less common, sometimes controversial diagnosis used for a cause of buttock / leg pain caused by the irritation of the piriformis muscle. This muscle is in your buttock region and usually lies above the sciatic nerve as it exits the spine and goes down your leg.
What are some of the potential causes of neck pain?
Most of the conditions mentioned for low back pain are similar to potential causes for neck or cervical pain as well. Sprains and strains are the most likely causes of neck pain. Other causes include cervical disc problems, spinal stenosis, facet syndrome, etc.
Osteoarthritis of the spine (also known as spondylosis) is a common disorder causing progressive deterioration of the spine and can cause new bone formation called osteophytes (bone spurs) that decrease range of motion of the neck and lead to pain.
Spinal stenosis causes the foramen to narrow where the nerve roots exit the spine, possibly compressing and entrapping nerve roots, which can lead to neck, shoulder, and arm pain and numbness.
Whiplash can occur in a motor vehicle accident involving a hyperextension and / or hyperflexion injury of the neck.
What is Sciatica?
Sciatica is a term for pain along the sciatic nerve. It is usually a sharp, burning pain originating in the buttock that travels down the back of thigh and can go down the lower leg to the foot. Herniated discs in your back or spinal stenosis are common causes of sciatica. An MRI of the lower back or electrodiagnostic studies may help in making the diagnosis. Treatment options range from conservative measure to injections to surgical options in severe cases.
What is cervical radiculopathy?
Often called “a pinched nerve in the neck”; cervical radiculopathy is a dysfunction of a nerve root of the cervical spine which can lead to pain, numbness or weakness depending on the severity of the condition. In the younger population it is often secondary to disc bulge / herniation and in the older population secondary to degenerative changes of the joints and discs causing irritation or compression of the nerve root.
What Is a Migraine? What Causes Migraines?
Migraines are a moderate to severe throbbing pain in the head (usually on one side, but sometimes both), that often includes nausea, dizziness, facial tingling or numbness, visual disturbances, or sensitivity to light, sound, or smell. They can happen as often as several days per week. Each person may have their own combination of symptoms, and they can change from one migraine to the next. While no one knows for sure why migraines happen, newer treatments target a specific protein that appears to contribute to migraines. Migraines are much more common in women, which suggests that hormones like estrogen may play a role. A genetic link may also increase your risk, as migraines appear to run in families. Researchers continue to search for the root cause of migraines.
What is a tension-type headache? What causes it?
Tension-type headaches occur randomly and are often the result of temporary stress, anxiety, fatigue, or anger. Symptoms include soreness in your temples, a tightening band-like sensation around your head (a “vice-like” ache), a pulling feeling, pressure sensations, and contracting head and neck muscles. The headache begins in your forehead, temples, or the back of your head and neck.
What is a cluster headache? What causes it?
Cluster headache gets its name because the attacks come in groups. The pain arrives with little, if any, warning and is usually on one side of the head. A tearing or bloodshot eye and a runny nose on the side of the headache may also accompany the pain. Cluster headache, believed to be caused by chemical reactions in the brain, has been described as the most severe and intense of any headache type.
What is a sinus headache? What causes it?
When a sinus becomes inflamed, usually as the result of an allergic reaction, a tumor, or an infection, the inflammation will cause a localized pain. If your headache is truly caused by a sinus blockage, such as an infection, you will probably have a fever. An x-ray will confirm a sinus blockage.
What is a rebound headache? What causes it?
A pattern of taking acute headache medications too often (more than two days per week) or in excessive amounts (more than the label or a doctor advises) can lead to a condition known as “rebound headache.” With rebound headache, your medications not only stop relieving pain, they actually begin to cause headaches.
How do I find out more information about my pain problems?
Most chronic pain conditions have an organization that is designed to provide specific information about cause, treatment, and research.
Testing and Treatment
What are some of the diagnostic tools for low back and neck pain?
Obtaining a proper history and physical is critical to determine a correct diagnosis and the best course of treatment. A physical examination will include observation for posture, misalignment, examination of range of motion, palpation or feel the curvature of the spine, vertebral alignment, and detect muscle spasm. The neurological examination involves testing reflexes, muscle strength, detecting sensory and / or motor changes, and determines pain distribution.
Radiographic studies can aide in diagnosis of spine pain. An x-ray or CAT scan can reveal disc space narrowing, fractures and osteoarthritis. MRI can be used to detect bulging discs and herniations.
Electrodiagnostic studies also known Nerve conduction / EMG studies are another tool in determining cervical or lumbar radiculopathy among other diagnoses to help assist in proper diagnosis and treatment.
Should I have an X-ray or MRI scan?
This is difficult to answer for an individual. In general, X-rays take a picture of the bones. They are used for diagnosing cancer, tumours, rheumatoid arthritis and osteoporotic collapse.
An MRI scan is also a picture of the body and is more useful for examining the soft tissues such as muscles and nerves.
However, x-rays and MRI often do not show the cause of a pain and may identify changes that are of no relevance so they must be interpreted carefully.
What is a multidisciplinary treatment (MDT)?
A MDT approach offers a variety of skills taught by trained staff to help a person better manage his or her pain. These programs may not offer a cure, but they can help to improve the quality of life and at the same time reduce the overwhelming control that pain can have of daily life.
What things besides medical treatment might help me?
There are a number of techniques that can help with managing your pain. Some are:
– deep breathing
– relaxation
– positive imagery
– thought distraction
– heat or cold compresses (or a combination of the two)
– reducing stress in your life
– remaining positive
– exercise
– mindfulness techniques
What about alternative medicine treatments?
In some cases, alternative medicine treatments are suggested to help the patient exercise a measure of control over the pain. They include the use of herbs, acupuncture, acupressure and chiropractic sessions.
What are acute and preventive medications for migraine?
Acute medications – sometimes referred to as acute abortive medications – are used to treat the pain of the headache after it has started. Examples of acute abortive medications include over-the-counter medications, NSAIDs, ergots, and triptans.
Preventive medications for migraine – sometimes referred to as “prophylactic” treatments – are used to reduce the frequency, severity, and length of migraine attacks. Most preventive migraine medications were initially developed to treat other diseases, such as seizures, depression, or hypertension. Examples of preventive medications include antiepileptic medications, antidepressants, beta-blockers, calcium channel blockers, and NSAIDs (nonsteroidal anti-inflammatory drugs).
Why have I been prescribed anti-depressants for my pain?
It has been known for some years, that some antidepressants may help pain, particularly neuropathic pain. They act through complex mechanisms, which may include inhibition of the two nerve transmitters, noradrenaline and 5-HT.
I’ve been prescribed narcotics because of chronic pain, and the bottle says I should avoid operating heavy machinery and driving when I take them. Can you tell me why? Is there anything else I should avoid, like herbal supplements?
Narcotic pain medications (also known as opioids) tend to make people dizzy and drowsy. That is why people taking them are warned not to do things that could be dangerous if you were not 100% alert. Many people who use narcotic medications for chronic pain report that these side effects lessen or go away after a few days or weeks on the medication. However, even if you feel alert, driving might not be safe or legal in your area. Consult your health care team about whether you should restrict your activities while taking narcotics.
You should avoid other things that can make you sleepy or dizzy while taking this medication. Sleeping pills, tranquilizers, muscle relaxants, antihistamines, and even alcohol can make the side effects worse. Even if you usually do not have these side effects, you can get them when you add another medication or alcohol to your routine. Also remember that even over-the-counter medications and herbal supplements might cause these problems when taken with narcotic medications.
In particular, the herbal supplements kava and valerian should not be used with narcotic medications. Kava is typically used as a pain reliever, muscle relaxant, anti-anxiety treatment, or anticonvulsant. Valerian has similar uses as a mild sleep aid, pain reliever, and muscle relaxant. Both of these supplements can intensify the drowsiness and dizziness of narcotic medications.
Tell your doctor about all medications and herbal supplements you take, including over-the-counter medications and vitamins. Read the labels of your medications and consult your health care team if you have concerns. If you have any side effects, be sure to tell your doctor—you might just need a different dose of the medication.
I have a difficult time swallowing large pills, and in the past, I’ve crushed the pills up and mixed them into food to make them easier to take. Are there any medications that I shouldn’t do this with?
You should be very cautious about crushing pills. Many pills have a special timed-release coating that allows small doses of the medication to be absorbed over time as the coatings dissolve. Crushing a pill destroys its coating, and releases a much larger dose all at once, which can lead to dangerous side effects or even death.
Talk to your pharmacist about whether your medications are available in a different form. Your doctor might be able to change the prescription to a liquid, or to several smaller pills that are easier to take. If you have to use a large pill, ask your doctor or pharmacist if it is safe to crush it or dissolve it in food. To be safe, it’s important to ask about every medication, and even for refills if the pill changes from one manufacturer to another.
Do you recommend chronic opioid therapy?
Unfortunately, the evidence for long term chronic opioid therapy is poor in most situations due to well-established side effects, including immunosuppression, endocrine abnormalities, constipation, sedation depression, and worsening pain from opioid-induced hyperalgesia. While we will prescribe opioids in certain situations when clinically indicated, we extensively evaluate our patients, keep dosages low, and seek other ways to control pain.
We do not recommend opioid therapy for fibromyalgia, headache, self-limited illness, uncomplicated back and neck pain, uncomplicated musculoskeletal pain, or abdominal and pelvic pain.
What is an epidural steroid injection?
Epidural steriod injections are one of a number of procedures or injections that may be offered for some types of nerve pain originating in the spine. The doctor offering you the injection should give you detailed information about it if this treatment is being considered.
What is radiofrequency ablation?
Radiofrequency ablation (RFA) is a procedure using radio waves or electric current to generate sufficient heat to interrupt nerve conduction on a semi-permanent basis. The nerves are usually blocked for 6-9 months, although it may last as short as 3 months or as long at 18 months or longer. RFA disrupts nerve conduction, specifically interrupting the conduction of pain signals. In turn, this may reduce pain, and other related symptoms.
What is spinal cord stimulation?
Spinal cord stimulation (SCS) devices are approved by the U.S. Food and Drug Administration (FDA) to target and treat chronic pain of the arms, legs and trunk, or pain resulting from failed back surgeries. SCS therapy uses an implanted device and thin wires with electrodes to deliver low levels of electrical energy to nerve fibers, replacing the pain with a tingling sensation called paresthesia. SCS is not a cure, but it can be successful in reducing chronic pain that is the result of dysfunction or damage to the nervous system caused by injury, disease or localized trauma (e.g., an infection or surgery). Pain is a reaction to signals sent from a pain source through the nerves in the spinal cord to the brain. SCS interrupts the pain signals’ pathway to the brain by delivering low-intensity electrical impulses to selected nerve fibers along the spinal cord. SCS replaces areas of pain with what has been described as a more pleasant tingling sensation.
With treatment will all my pain be relieved?
The degree of pain relief you may experience from interventional pain management treatment is difficult to predict. Most patients report a reduction in their level of pain of 50% to 100%. Our goal is to help our patients achieve the highest level of pain control possible to facilitate a return to a productive, satisfying life style.
I’ve been told that there is a difference between physical dependence and addiction to pain medications, but I don’t understand. Can you explain the difference to me?
It’s very common for people to be confused about the difference between physical dependence and addiction. The main difference is that addiction includes a psychological (or mental) craving for the medication that can lead to self-destructive behavior. Physical dependence only means that your body needs the medication and you have symptoms when you do not take it. People become physically dependent on many kinds of medicines, including insulin, antidepressants, and others. It is a normal part of using some medications.
When you use a pain medication, after a while your body becomes used to having that chemical on a regular basis. Your body needs that medication to function normally. If you stop taking it or lower the dose, your body reacts badly, with physical withdrawal symptoms like headaches, nausea, shakes, and other more serious problems. This is physical dependence, and it is not at all the same as addiction.
Addiction is a psychological problem that causes people to lose control over their use of a medication. People with this problem sometimes think the drug is the most important thing in their lives. They might raise their dosage or continue using the medication without their doctors’ permission, or seek other sources of medication that their doctors don’t know about. They take the medication even when they know it is not good for them, and they might do risky and irresponsible things to get the medication.
Depending on the type of medication you use, physical dependence might be unavoidable. Talk to your health care professional if you are concerned about dependence or if you feel you might need to increase or decrease your dosage.
Addiction is avoidable. If you think that you might be taking a pain medication that you do not need for pain, talk to your doctor about safely reducing the dose. Also, if you become preoccupied with the medication, thinking about how soon you can take more or worrying excessively that you might run out, that can be a warning sign to talk to a health care professional about changing your treatment.
Working With Your Doctor
How can I arrange to see a doctor at the Guardian Medical Care – Center for Pain & Headache Medicine?
Please contact the office at 912-324-4080 or 912-540-6880 to schedule your appointment. Fax any past medical history, including imaging, to 912-324-4097.
Will my insurance pay for pain management?
Guardian Medical Care – Center for Pain & Headache Medicine works with many major insurance carriers. However, it is your responsibility to check with your insurance carrier before your appointment.
What can I expect from a visit with a Pain Management Doctor?
Coming to your appointment prepared will help the doctor to assess your condition more efficiently and effectively. Some things you can do to prepare yourself for your appointment include:
What do I need to bring with me the day of my appointment?
– Insurance cards and a picture I.D. are required.
– For your convenience, it is recommended you print and complete the New Patient Forms. Completing these forms in advance and taking them with you to your appointment will minimize your wait time.
– Keep a pain journal. Note when your symptoms seem to be worse, what activities exacerbate your pain, and what alleviates your pain.
– Bring a record of what medications you have tried to alleviate your pain. Make sure to include over the counter medications as well as medications you have been prescribed by other doctors.
– Bring any previous x-rays, CT scans, and MRI films with you to the doctor. The doctor may request previous records from other doctors you have seen.
– Bring a list of your current medications. It is important for the doctor to know all of your medications, even those which are not for your pain condition. Also include any over the counter medications, dietary supplements, vitamins, or minerals.
– Think about how your pain affects your life; does it prevent you from participating in your regular activities? Is there anything you would like to be able to do that your pain currently prevents you from doing?
– Bring a list of questions you may have for the doctor.
The doctor will complete a history and physical exam. The doctor will need to know what other medical conditions you have (for example; diabetes, hypertension, thyroid problems, etc.). It is also important to note when the pain started. Your healthcare provider will ask about the location of the pain, the severity of the pain, activities which influence your pain, whether the pain is accompanied by weakness, and the type of pain (aching, burning, stabbing, etc.)
Other symptoms the doctor may ask you about which seem related or unrelated to pain but may be a result of your condition may include sleep patterns and emotional status, recent infections, and stomach or bowel symptoms.
After completing the history and physical exam, the healthcare provider may order additional tests such as radiographic images (including x-rays, MRIs, etc.) or blood tests. Chronic pain is a complex process that requires a combination of treatments in order to achieve the best results. A multimodal treatment plan tailored to the patient will be developed that may include medications, possible procedures, assistance with emotional aspect of pain, and physical therapy. Developing a treatment plan which is likely to provide the most benefit given your treatment options and preferences requires a joint effort between you and your healthcare provider. The treatment of chronic pain requires a continuing and active effort from both the individual suffering from the chronic pain and the healthcare team.
What can I do personally to get relief from pain?
In treating pain, doctors regard the patient as a valuable member of the medical team. Without the patient’s full and focused cooperation throughout the entire process of diagnosis and treatment, there is little chance of success.