Why manage pain?

Your doctor or surgeon is referring you to pain management and you are thinking to yourself why “manage” pain? Isn’t there a reason for my pain that needs to be treated, healed, or fixed? Managing pain won’t help, it will just mask the pain right? Well, lets talk about this. Lets first define what is pain. Pain is a signal transmitted by the nervous system from the input (source of the pain) to the brain. This signal serves a very important and essential biological function. For one, it alerts you that there is some kind of disturbance or damage in the body. Feeling pain also serves to prevent further harm through overuse. Finally, pain helps and promotes maintaining the natural physiological homeostasis (an internal process organisms have to maintain internal stability and adjust to external conditions). So this is the normal, intended purpose of pain , this is when pain is doing what it’s supposed to do, this is the good part of pain. However, either because of abnormal healing or some kind of additional injury or damage, or sometimes because of failed treatment, pain may become chronic. In this case pain becomes a bad thing, it’s no longer doing its intended function, it becomes abnormal. Chronic pain is abnormal, it no longer signaling that there is damage happening to the body and is instead a detriment to physical as well as psychological well-being.

According to the CDC an estimated 20.4% (50.0 million) of U.S. adults had chronic pain. It remains one of the most common reasons adults seek medical care. Per the CDC chronic pain has been linked to restrictions in mobility and daily activities, dependence on opioids, anxiety and depression, and poor perceived health or reduced quality of life. Chronic pain was defined as pain on most days or every day in the past 6 months. Acute pain usually starts suddenly and has a known cause, like an injury or surgery. It normally gets better as your body heals. Chronic pain lasts 3 months or more and can be caused by a disease or condition, injury, medical treatment, inflammation, or even an unknown reason.

It is not uncommon for patients to question the benefit and purpose of pain management or what it even means. There is a lot of misconception and misunderstanding of this branch of medicine which can lead to poor outcomes and missed opportunities to get better.

Often patients think pain management is “just a band aid” or something that will “mask the pain” believing that can lead to more injury because one is not aware of the pain. Others might only know of pain management as just taking pain killers like opioids and are not aware of the other many ways to help pain. In fact the scope and variety of pain management options is more broad then most know and likely includes somethings that one may even have been familiar with but didn’t see it as pain management until they learned more. Comprehensive pain management can be grouped into the following categories:

• medication management (pain medications)
• physical therapies (therapeutic exercise and stretch programs)
• psychological therapies (such as cognitive behavioral therapy, relaxation techniques and meditation)
• mind and body techniques (such as acupuncture, yoga)
• interventional pain management (steroid injections, nerve blocks, radiofrequency ablation, etc.)
• regenerative medicine (PRP, stem cells, etc).

Medication Management

Pain can be managed and controlled with help of medications. There is no perfect nor completely safe pain medication and there isn’t one that will work for everyone. What might help one patient can be completely ineffective for another one. Nor will the side effects be the same as some may experience none and others might be completely sedated on the same dose or worse can get a severe allergic reaction. All medication classes will have significant risks and side effect profiles and must be used responsibly and carefully to avoid harm to patient and society. Here are different classes of medications that can be used in pain management.

NSAIDs: nonsteroidal anti-inflammatories. You know these as advil, motrin, ibuprofen, aleve, etc. Others you may not know that well are prescription strength such as meloxicam, diclofenac, and celebrex. As anti-inflammatories these are helpful with joint and muscle related aches and pains from sprain/strain injuries and arthritis. Less effective for muscle spasms, nerve pain, and chronic pain; although can still be beneficial for some. Risks include gastrointestinal (ulcers, GI bleed, reflux disease), kidney injury, and cardiovascular (heart attack and strokes).

Corticosteroids: steroids like prednisone or methylprednisolone. Steroids can only be used short term. Can be very helpful with acute pain or acute flare ups of pain to quickly lower the inflammation and pain. Long term use or overuse can result in increased risk of infections, low bone density, fractures, and adrenal gland hormone production.

Muscle relaxants: Flexeril, baclofen, tizanidine, etc. Some muscle relaxants can be helpful with painful muscle spasms but most are too sedating making them a poor choice to use during the day. At night time on the other hand it might be a better option and may even help with sleep. Side effects and risks are significant and vary greatly between different muscle relaxants. Almost all will have side effect of drowsiness and fatigue, some can result in dizziness, nausea, headache. Rare but very serious reactions are seizures, heart arrythmia, heart attacks, stroke, severe allergic reaction to name some. Some are even considered to be habit forming.

Neuropathics: The most well known are gabapentin and lyrica. These are anticonvulsants and therefore originally were prescribed to control seizures. However later on it was discovered that at lower doses these medications helped reduce and control pain, specifically neuropathic pain (nerve injury pain). Can also be helpful with chronic pain and fibromyalgia. These medications are not immediately acting on pain, and may take a few weeks for the pain to lessen. While not as sedating as muscle relaxants, neuropathic can also make you feel sleepy and tired. Some patients who have been on the medication for at least a few weeks may no longer feel this effect. Other side effects may include weight gain and swelling in the feet, dizziness and upset stomach to name some. More serious but less common risks include depression, suicidality, severe allergic reaction, withdrawal if stopped abruptly, to name some.

Antidepressants: Selective serotonin and norepinephrine reuptake inhibitor (SNRIs) such as duloxetine (cymblata) are antidepressants that have been found to be effective in treating certain neuropathic and myofascial pain syndromes like fibromyalgia, nerve injury pain, and chronic musculoskeletal pain. Like the neuropathics, these medications are not immediately acting on pain, and may take a few weeks for the pain to lessen. These medications are also not without risk and include a long list of possible side effects and complications. Common side effects can be somnolence, fatigue, constipation, headache, nausea, just to name some. More serious adverse effects are suicidality, depression exacerbation, mania, serotonin syndrome, liver failure. There are many more that I have not listed.

Opioids/narcotics: The opioid pain medications are recognized as the most effective at reducing severe pain and the most widely used. Historically these were used strictly for post operative pain control and in cases of severe acute pain. Then opioid pain medications became commonly used in chronic pain management. While highly effective these medications are unfortunately highly addictive and the CDC guidelines recommend that these are used in lowest possible doses for lowest possible duration only and only when expected benefits for both pain and function outweigh the risks.

Physical Therapy

Psychological Therapy

Having pain is not only painful but can also be very stressful especially when pain becomes chronic, constant, and everyday. Its not hard to imagine how having pain every day without resolution can result in significant stress and suffering. Such stress can then lead to significant challenges to almost all aspects of functioning, daily life, and mental wellbeing. Not only that, it can also lead to significant physical, psychological, occupational and financial cost. When pain does not respond to medical treatment it becomes necessary for chronic pain management to include psychological interventions (psychotherapy) to target improvement in physical, emotional, social, as well as occupational functioning in addition to focusing on treating the pain.

Psychological therapy for chronic pain can be categorized into four types: cognitive-behavioral therapy, operant-behavioral therapy, mindfulness-based therapy, and acceptance and commitment therapy.

Cognitive-behavioral therapy: This therapy approach targets behavioral and cognitive responses to pain. The way we act/behave and think in response to pain can be flawed and counterproductive, making it worse. Cognitive-behavioral therapy helps develop coping skills intended to manage pain and improve psychological functioning. This can include use of structured relaxation, scheduling of pleasurable events, assertive communication, and pacing of behavior in order to avoid prolongation or exacerbation of pain flares. 

Operant-behavior therapy: The goal here is to get rid of (extinguish) abnormal (maladaptive) behavioral responses to pain. This therapy involves behavioral exercises to reduce pain behaviors and to increase healthy behaviors in many areas of life, including medication reduction.

Mindfulness-based stress reduction: This is a type of mediation that is used in pain therapy to try to separate the physical and psychological aspects of pain. Daily exercises in mindfulness is used to increase ones awareness of the body and proprioceptive signals, increase awareness of the breath, and to develop mindful activities.

Acceptance and commitment therapy: This therapy takes the approach that thoughts do not need to be targeted or changed but rather the responses to the thoughts should be altered in order to minimize their negative consequences.

Mind and Body Techniques

Acupuncture. Ancient art used in Asia for centuries to treat many conditions including pain. Most commonly known is Chinese acupuncture. Now becoming more and more widely used in western medicine to treat low back pain, nerve pain, headaches, fibromyalgia, and more. Chinese acupuncture involves use of extremely fine needles that are inserted into the skin at certain points called “acupoints.” It is possible that this results in release of the bodies natural endorphins (the body’s natural pain-killing chemicals). There is also evidence it affects part of the brain that controls serotonin, a brain chemical involved with mood.

How well does acupuncture help manage chronic pain? The evidence supporting its effectiveness at relieving pain is mixed with some studies supportive and others showing its no better then placebo. Most studies have been small and further investigation is needed to better decipher these results.

Yoga. Yoga is a mind-body exercise that has been practiced by people for thousands of years with great emphasis on both physical as well as mental fitness. It combines breath control and meditation with movements to stretch and strengthen muscles. Given its long history there are many variations and styles of yoga. The most common used in the United States is hatha yoga, which also has many variations itself. Yoga has been found to be helpful in many types of chronic pain conditions including low back pain, arthritis, fibromyalgia and migraines. Yoga sessions will start with deep breathing exercises followed by holding certain yoga postures that can be seated, standing and prone. Published studies have shown benefit of yoga including improved mobility, decreased pain, as well as improved mood and psychosocial well being.

Interventional Pain Medicine

Interventional pain management can be helpful for acute, subacute and even chronic pain. Typically its recommended for pain that has not resolved on its own, did not improve with conservative and less invasive treatments (such as physical therapy, exercise, medications, etc), or in cases where the pain is too severe to be able to tolerate and participate in conservative care. Interventional pain management may also be utilized as an alternative to surgery, to delay surgery, or in situations where surgery is contraindicated. Finally it can also be an option for those who have had unsuccessful surgery and continue to have pain.

Common Conditions Treated

• Neck pain
• Back Pain
• Joint pain (Hip, knee, shoulder, sacroiliac, etc)
• Chronic headaches/migraines
• Nerve pain

Interventional Pain Management Treatments

This will of course depend on the diagnosis of pain and may include the following types of procedures.

Epidural injections – injection of steroid and/or anesthetic medications into the epidural space to help treatment/diagnose spine related pain due to disc disease, disc herniation, or spinal stenosis.

Facet joint injections – injection of steroid and/or anesthetic medications into spinal facet joints to help treatment/diagnose spine related pain due to facet joints (joints that connect spinal vertebrae).

Other type of steroid injections – such as knee joint injections, hip joint injections, sacroiliac joint injections, shoulder joint injections, etc.

Nerve blocks, such as medial branch blocks, lateral branch blocks, genicular blocks, etc. Here specific nerves are “blocked” by injecting an anesthetic with primary goal to help diagnose the source of pain.

Radiofrequency nerve ablation – here specific nerves or nerve branches are ablation or destroyed using radiofrequency waves to help stop pain.

Spinal cord stimulation – here electrical impulses are used to stop the transmission of pain signals to the brain.

Often the interventions detailed above are used together with other type of treatments such as physical therapy, occupational therapy, acupuncture, manipulation, medications and lifestyle modification, in order to maximize overall benefit and improvement of the underlying pain condition.

Regenerative Medicine.

The goal of regenerative medicine is try to find a way to replace or restore damaged or degenerated tissue. Most agree that regenerating damaged tissue might be the only way to truly cure an injury rather then just manage it or do surgery. Unfortunately a true cure even with regenerative medicine still remains out of reach as not all who get this treatment remain pain-free. In pain management there are three primary options currently: prolotherapy, PRP, and cell therapy.

Prolotherapy: A type of injection therapy where a substance (usually a sugar alcohol solution) is injected into an injured area (joints, muscle tendons or ligaments) to help stimulate healing. When these tissues are injured or damaged they undergo degeneration due to decrease blood flow. Solutions injected in prolotherapy dehydrate tissues which sends a signal to the brain to increase blood flow to the area. The increased supply of blood allows the injured or damaged tissues to heal. The blood flow will bring in cells and growth factors that stimulate healing which is important for tissue healing. Once the damaged tissue is repaired and healed, the pain will resolve. This may take up to several weeks before optimal results are seen and may require multiple treatments. The procedure is considered very safe, minimally invasive and not very painful. Efficacy rate can vary with some studies showing no statistically significant pain benefit compared to other therapies, although a meta-analysis showed statistically significant benefit has to do with the type of condition (elbow vs shoulder vs knee, etc) and time point on intervention (acute vs subacute vs chronic ).

PRP or Platelet-rich plasma therapy is a type of injection therapy in which your own blood is drawn and then processed in a centrifuge in order to separate the different blood components. Then the layer that is concentrated with the platelets is extracted. The PRP has platelet ingredients that have growth properties that can trigger healing in degenerated or injured tissue. The PRP is then injected into the area that needs treatment like an injured or degenerated joint, muscle, ligament, tendon, or nerve. The way this works is a little similar to prolotherapy. The idea is that as we age or get injured our body degenerates due to lack of blood flow to that area. PRP delivers blood flow concentrated with the ingredients needed for healing. Pain relief is not immediate and may take at least a few months to feel the effect as it takes time for tissues to heal and the inflammation to come down. Evidence of PRP efficacy is mixed and seems to show that its more effective for some specific indications and may depend on composition. There is evidence supporting use of PRP for lateral epicondylitis (tennis elbow). knee osteoarthritis, patellar tendinitis, and plantar fasciitis. However for other conditions such as  rotator cuff tendinopathy, hip osteoarthritis, or high ankle sprains, the evidence is lacking.

Cell therapy uses cells extracted from your bone marrow or fat that can be used to heal damaged or degenerated tissue. The cells that are extracted are types of stem cells that have ability to regenerate different types of tissues including cartilage, bone, tendons, and ligaments. Your body has millions of these stem cells and uses them as one way of repairing itself. The theory behind cell therapy is that if these adult stem cells can be collected and then injected at the site of disease or damaged tissue then under right circumstances healing and regeneration of the tissue can occur. For most part this still remains an experimental therapy and researchers are still working on developing and refining the ability to extract, prepare, and use these stem cells to repair diseased or damaged tissue.

So why manage pain? Most of the time you won’t need to because pain will resolve as expected or there will be a successful treatment. However sometimes there are no good treatment options and other times management is the treatment. Pain management has a specific role to play in certain specific situations and the extent of pain management options is broad and still evolving.