Saturday, June 11, 2011

Dealing with Pain: Chronic Pain

As pain is a major issue for many living with chronic disease, the next several posts will explore the different types of pain and what strategies are yielding results.

Today’s focus is on chronic pain, which can accompany an illness or injury, or it may be a disease unto itself. The National Institutes of Health, in their definition of chronic pain, states chronic pain persists. Pain signals keep firing in the nervous system for weeks, months, even years. There may have been an initial mishap -- sprained back, serious infection, or there may be an ongoing cause of pain -- arthritis, cancer, ear infection, but some people suffer chronic pain in the absence of any past injury or evidence of body damage. Many chronic pain conditions affect older adults. Common chronic pain complaints include headache, low back pain, cancer pain, arthritis pain, neurogenic pain (pain resulting from damage to the peripheral nerves or to the central nervous system itself), psychogenic pain (pain not due to past disease or injury or any visible sign of damage inside or outside the nervous system). A person may have two or more co-existing chronic pain conditions. Such conditions can include chronic fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction, and vulvodynia. It is not known whether these disorders share a common cause.

One of the best descriptions of what chronic pain is, causes and treatments I’ve seen of late comes from Elliot Krane MD, the director of Pain Management Services at Lucile Packard Children’s Hospital at Stanford. Recently he spoke at the TED Conference about “The Mystery of Chronic Pain.” He said Now most of the time, you think of pain as a symptom of a disease. And that's true most of the time. It's the symptom of a tumor or an infection or an inflammation or an operation. But about 10 percent of the time, after the patient has recovered from one of those events, pain persists. It persists for months and oftentimes for years. And when that happens, it is its own disease.

…. How can the nervous system misinterpret an innocent sensation like the touch of a hand and turn it into the malevolent sensation of the touch of the flame. Well you probably imagine that the nervous system in the body is hardwired like your house. In your house, wires run in the wall, from the light switch to a junction box in the ceiling and from the junction box to the light bulb. And when you turn the switch on, the light goes on. And when you turn the switch off, the light goes off. So people imagine the nervous system is just like that. If you hit your thumb with a hammer, these wires in your arm -- that, of course, we call nerves -- transmit the information into the junction box in the spinal cord where new wires, new nerves, take the information up to the brain where you become consciously aware that your thumb is now hurt.

But the situation, of course, in the human body is far more complicated than that. Instead of it being the case that that junction box in the spinal cord is just simple where one nerve connects with the next nerve by releasing these little brown packets of chemical information called neurotransmitters in a linear one-on-one fashion, in fact, what happens is the neurotransmitters spill out in three dimensions -- laterally, vertically, up and down in the spinal cord -- and they start interacting with other adjacent cells. These cells, called glial cells, were once thought to be unimportant structural elements of the spinal cord that did nothing more than hold all the important things together, like the nerves. But it turns out the glial cells have a vital role in the modulation, amplification and, in the case of pain, the distortion of sensory experiences. These glial cells become activated. Their DNA starts to synthesize new proteins, which spill out and interact with adjacent nerves. And they start releasing their neurotransmitters. And those neurotransmitters spill out and activate adjacent glial cells, and so on and so forth, until what we have is a positive feedback loop.

It's almost as if somebody came into your home and rewired your walls, so that the next time you turned on the light switch, the toilet flushed three doors down, or your dishwasher went on, or your computer monitor turned off. That's crazy, but that's, in fact, what happens with chronic pain. And that's why pain becomes its own disease. The nervous system has plasticity. It changes, and it morphs in response to stimuli.

Well, what do we do about that? …We treat these patients in a rather crude fashion at this point in time. We treat them with symptom-modifying drugs -- pain-killers -- which are, frankly, not very effective for this kind of pain. We take nerves that are noisy and active that should be quiet, and we put them to sleep with local anesthetics. And most importantly, what we do is we use a rigorous, and often uncomfortable, process of physical therapy and occupational therapy to retrain the nerves in the nervous system to respond normally to the activities and sensory experiences that are part of everyday life. And we support all of that with an intensive psychotherapy program to address the despondency, despair and depression that always accompanies severe, chronic pain.

The future holds the promise that new drugs will be developed that are not symptom-modifying drugs that simply mask the problem, as we have now, but that will be disease-modifying drugs that will actually go right to the root of the problem and attack those glial cells, or those pernicious proteins that the glial cells elaborate, that spill over and cause this central nervous system wind-up, or plasticity, that so is capable of distorting and amplifying the sensory experience that we call pain.

If you are living with chronic pain, the following steps can help put you on the path to relief. Keep in mind that everyone is different and it may take some trial and error to find the best approach for you.

Step 1: Assess whether you are dealing with a chronic pain problem. The Mayo Clinic’s Pain Rehabilitation program provides a series of questions to ask yourself about whether the pain is sufficient for you to make a commitment to a pain rehabilitation program. These questions are a good way to also determine if in fact you are dealing with chronic pain. These questions include:
• Is my life focused on pain or other symptoms and what I am not able to do, rather than what I am able to do?
• Are my doctors telling me there is nothing further they can do to relieve the pain/symptoms? Do they tell me I need to get on with my life?
• Am I truly concerned about the long-term effects of taking pain medications?
• Is my family's well-being affected because of my impaired functioning?
• Is my recovery from injury or illness taking much longer than my doctors or I expected?
• Am I not able to commit to social events with family or friends because my pain/symptoms may be worse that day?
• Is my mood affected by pain/symptoms and activities I am not able to do?
• Has my attendance at school/work been affected?

Step 2: If you haven’t already done so, see a medical provider and determine if there is an underlying issue that might be contributing to your pain. Surgery or other treatment may effectively treat the problem. If there is no root issue that can be dealt with, most insurance companies will require a 3 to 6 month existence of chronic pain before they will pay for a pain program.

Step 3: If you have a pain issue relating to a condition, such as fibromyalgia, arthritis, vulvodynea, Lyme Disease, get in touch with the condition specific organization, e.g. the American Arthritis Association. These groups will have information on pain management. In addition, they can help direct you to support groups, in-person and on-line, where you can talk to others about what has worked for them.

Step 4. Enroll in a pain program/Pain rehabilitation. Many hospitals offer pain clinics and some will offer in patient rehabilitation programs. While there are differences, almost all will offer some form of the following:
- Medications (nonsteroidal anti-inflammatory drugs, such as Motrin or Aleve; non-aspirin pain relievers, such as Tylenol; corticosteroids; antidepressants) It is important to note that many pain programs take people off medications as they find the meds can be part of the problem. Further, if you have several other medical conditions, medication management can become problematic.
- Injections, nerve blocks, electrical stimulation
- Physical therapy
- Complementary and alternative medicine (CAM): Acupuncture, massage, Reiki, relaxation and stress management techniques
- Psychology support and counseling
- Case management and social services

Because pain programs can differ, be sure to ask about their success rate in treating people with your specific issues.

Additional Resources
Mindfulness Based Stress Reduction (MBSR): Developed at the University of Massachusetts Medical School by Dr. Jon Kabat-Zinn in 1979, programs are now offered all over the world. The eight week course has been proven to significantly improve stress, pain and illness. Sessions are usually once a week for two and a half hour s per week and one all day session. The program usually lasts for eight weeks. Many pain clinics offer MBSR.

American Pain Foundation an online resource for people with pain, their families, friends, caregivers and the general public. This site is devoted to patient information and advocacy, and provides many links to additional resources.

American Pain Society a multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering.

National Pain Foundation Treatment Options, Personal Pain Inventory, Personal Pain Journal, Links, Education, Support, etc.

American Chronic Pain Association

American Chronic Pain Association’s Consumer Guide to Pain Medication and Treatments 2011

WebMD’s Pain Management Health Center

No comments:

Post a Comment