LOW BACK PAIN: WHY YOU SHOULD GET PHYSICAL THERAPY FIRST

Over any 3-month period, about 25% of Americans will have low back pain. In most cases, it is mild and disappears on its own. But sometimes the pain lingers, returns, or worsens, leading to a decrease in function and quality of life.

In an era when back pain is often over-treated, due in part to unhelpful imaging scans (like x-rays) that may lead to unnecessary surgery, narcotics, and higher costs, physical therapy is a proven and cost-effective treatment option that you should consider as a first choice.

Studies show that early physical therapy for low back pain significantly lowers the total scope and cost of care.

Here's why you should consider getting physical therapy first:

Back Pain Often Leads to Missed Work and Overly Expensive Treatment

• According to the most recent news release (December 2014) Employee Cost Index from the Bureau of Labor Statistics, more than 200,000 incidents related to back injury were reported in 2013, causing an average of 7 days of missed work.
• Direct costs to treat back problems totaled $30.3 billion in 2007. Of that, $4.5 billion was spent on prescription medications. The average expenditure per person for treatment was $1,589, and $446 for prescription medications.

Physical Therapy Is An Effective, Cheaper First Choice

• Scientific research overwhelmingly points to the effectiveness of conservative treatments, such as physical therapy, for low back pain. Despite this, and published guidelines suggesting conservative treatment as the best first option, physicians still often order imaging scans (like x-rays), prescribe narcotics, and refer patients to other physicians, including surgeons.
• A September 2013 study found that there was no significant difference in outcomes between patients who chose spinal fusion surgery, as compared to those who chose the nonoperative treatment (physical therapy).
• An award winning 2015 study demonstrated substantial potential for lowered costs and reduced health care utilization for patients who received, and adhered to, early physical therapy for low back pain.

HOW PHYSICAL THERAPISTS MANAGE PAIN

As America combats a devastating opioid epidemic, safer, non-opioid treatments have never been of greater need.

Physical therapy is among the safe, effective alternatives recommended by the Centers for Disease Control and Prevention in guidelines urging the avoidance of opioids for most pain treatment.

Whereas opioids only mask the sensation of pain, physical therapists treat pain through movement. How movement? 

The Movement System is the new, widely-accepted way to approach injury and pain by the American Physical Therapy Association. It encompasses all aspects involved with an injury, from the skin to the nervous system - and everything involved, in-between. Most musculoskeletal pain is due to a discrepancy between muscle tightness and weakness which pulls bones into the wrong place to the point where it becomes painful. So what do we do to help?

Here's how:

1. Exercise. A study following 20,000 people over 11 years found that those who exercised on a regular basis, experienced less pain. And among those who exercised more than 3 times per week, chronic widespread pain was 28% less common1. Physical therapists can prescribe exercise specific to your goals and needs.

2. Manual Therapy. Research supports a hands-on approach to treating pain. From carpal tunnel syndrome2 to low back pain3, this type of care can effectively reduce your pain and improve your movement. Physical therapists may use manipulation, joint and soft tissue mobilizations, and dry needling, as well as other strategies in your care.

3. Education. A large study conducted with military personnel4 demonstrated that those with back pain who received a 45 minute educational session about pain, were less likely to seek treatment than their peers who didn't receive education about pain. Physical therapists will talk with you to make sure they understand your pain history, and help set realistic expectations about your treatment.

4. Teamwork. Recent studies have shown that developing a positive relationship with your physical therapist and being an active participant in your own recovery can impact your success. This is likely because physical therapists are able to directly work with you and assess how your pain responds to treatment.

Read more about Pain and Chronic Pain Syndromes.

The American Physical Therapy Association launched a national campaign to raise awareness about the risks of opioids and the safe alternative of physical therapy for long-term pain management. Learn more at our #ChoosePT page.

References

1. Holth HS, Werpen HK, Zwart JA, Hagen K. Physical inactivity is associated with chronic musculoskeletal complaints 11 years later: results from the Nord-Trøndelag Health Study. BMC Musculoskelet Disord. 2008;9:159. Free Article.

2. Fernández-de-las Peñas C, Ortega-Santiago R, de la Llave-Rincón AI, et al. Manual physical therapy versus surgery for carpal tunnel syndrome: a randomized parallel-group trial. J Pain. 2015;16(11):1087–1094. Article Summary in PubMed.

3. Delitto A, George SZ, Dillen LV, et al. Low back pain. J Orthop Sports Phys Ther. 2012;42(4):A1–A57. Free Article.

4. George SZ, Childs JD, Teyhen DS, et al. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military cluster randomized trial. BMC Med. 2011;9:128. Free Article.

Author: Joseph Brence, PT, DPT, FAAOMPT, COMT, DAC

DIAGNOSED WITH OSTEOARTHRITIS

Our last post, ARE YOU AT RISK FOR OSTEOARTHRITIS? focused on the "before" aspect of a diagnosis, and what risk factors increase your chances for a diagnosis. DIAGNOSED WITH OSTEOARTHRITIS is going to focus on the "after" aspect - what to do after you've been diagnosed. 

1. First and foremost: do not self diagnose.

See your primary care physician, or an orthopaedic specialist. A series of tests and health history questions will allow most medical practitioners to be positive about an osteoarthritis diagnosis, but for physical proof, you'll need either an X-ray or an MRI. 

Why an X-ray? More advanced cases of osteoarthritis will be visible in an X-ray.  Severe cartilage degeneration will be visible (or more realistically, will be nonexistent) by recognizing what's out of place in comparison to where they're anatomically in place.  Joints that are suffering from osteoarthritis will look noticeably different in an X-ray compared to that of a healthy joint. 

2. Talk to your doctor about your options.

Depending on the severity of your case, your doctor may present you with a multitude of paths to assess, or potentially just a fair few.

Non-surgical opportunities include but are not limited to: steroid injections to lessen inflammation and reduce pain, physical therapy to strengthen muscles and therefore lighten the load on the joint, or pain medications to allow you to continue functioning with minimal pain.

Surgical opportunities, or joint replacements, are extremely common. Depending on age or the severity of your case, you may be a prime candidate for a partial or total joint replacement. This will require physical therapy to aide your body in returning to full range of motion and strength, but most cases are completely successful and will allow you to return to the lifestyle you enjoy with less pain than in you have had in probably 5 or more years. 

3. In the meantime: less is not more.

While it may feel as though movement is going to aggravate and inflame that joint, lack of movement is consequentially worse. The lack of movement weakens the muscles, and therefore, adding more pressure on the joint when it's loaded. Lack of movement will essentially make it significantly more painful to move - and therefore, making the condition feel much worse. Movement, as well as strengthening, is key to maintaining a quality of life until the correct treatment option for you can be identified and agreed upon. 

4. Ice, and Anti-inflammatories

Icing the joints can lead to some stiffness, but it can also decrease the activity of inflammatory responses that lead to increased swelling from bone-on-bone activity and therefore, decreases the residual pain. Not only does it limit the inflammatory response by constricting the blood flow into that joint, but also allows you to feel relief temporarily until the numbness from the cold entirely wears off. An anti-inflammatory can help aide in minimizing your inflammatory (immune) response, but be sure to talk with your doctor about which anti-inflammatory works best for you and your specific medication protocol. 

MEET THE THERAPISTS

WHAT DO WE SPECIALIZE IN HERE AT CHAMPION PERFORMANCE AND PHYSICAL THERAPY?

You all remember the "MEET THE PHYSICIANS" blog posts, correct? Well, now it's our turn. 
This is just some simple background information regarding what all of our treating therapists specialize in, and where their clinical interests lie, at this location.

Hope Hillyard, DPT

Focus lies within all aspects of orthopaedic rehabilitation and performance, ranging from pre and post-operational treatments, to balance and gait training, to generalized joint and back pain.  Dr. Hillyard's pre and post-operational treatments cover a wide variety of procedures; the most common being ACL reconstruction/meniscus repair, labral repairs of the shoulder and hip, rotator cuff repairs, and total joint replacements of the shoulder, hip, and knee. Her clinical interests include manual and manipulation of the spine, as well as high-level sports medicine rehabilitation with high school through professional athletes. As of 2017, she will be a certified Spinal Specialist by the American Board of Spinal Manipulation. 

Janice Bode, PT

Focus lies within all aspects of orthopaedic rehabilitation, with specialties including the distal lower extremity, foot, and ankle, as well as the back and core. While Mrs. Bode practices with an emphasis in non-surgical rehabilitation to allow her to focus on the cause of pain as opposed to the symptoms, she has established a reputation as one of Kansas City's best physical therapists for post-surgical rehabilitation of the foot and ankle. 

Molly Sauder, PT

Focus lies within the pelvis floor, with treatment protocols established to relieve symptoms from a wide variety of conditions; including incontinence and constipation. Mrs. Sauder also is known for an emphasis in women's health, as a number of her patients are seen to treat pelvic floor dysfunction following vaginal birth. 

Kaitlin Way, PTA

Focus lies within all aspects of rehabilitation and performance, with a similar list of credentials as Dr. Hillyard. Mrs. Way can see any patient of Dr. Hillyard's, as they share a similar professional relationship to that of a medical doctor and their physician's assistant. She has a special clinical interest in high-level recovery for sports medicine injuries, as she is also a certified Weight Lifting Coach and Personal Trainer through the American Council of Exercise, as well as a licensed Cross-Fit coach. Kaitlin has helped to design and establish many of our high-level athlete protocols during the latter aspects of their rehab to continuously challenge them at a level that will benefit them pending their return to sport.

Michael Hill, LMT, PTA, KCTP

Focus lies within massage therapy, with special emphasis on musculoskeletal treatment of sciatica, migraines, and post-operative care and scar management. Michael Hill owns Kinesio Clinic, a massage therapy clinic located within our building. He is also a licensed Physical Therapist Assistant, who is known for having an unusual edge. His ability to treat injuries from a multiple perspectives stems from his education and training in multiple treatment options that result in the same outcome. 

Pamela Carney, PT

Focus lies within holistic treatment of general pain by means of the spirit, body, and soul. She is an independent contractor who uses multiple facilities, including ours. As a board certified craniosacral therapist, she uses a combination of gentle manual therapy with functional exercise to produce physical and mental relief of pain. 

7 THINGS YOU SHOULD KNOW ABOUT PAIN SCIENCE

In the previous post I discussed some common back pain myths, such as the ideas that bulging discs, “bad” posture, or lack of core strength are major causes of back pain. As I noted, the evidence just doesn’t support those claims, and this is somewhat surprising and counterintuitive. However, learning some basics of pain science will go a long way towards making this evidence more understandable.

Pain science has learned a great deal in the last fifty years, but most of this information has had seemingly little impact on the way pain is commonly treated. If you have pain, this is stuff you should know.  By the time you are done reading this post you will know more than many medical providers about pain mechanisms, and maybe even feel a little better as a result, because research shows that pain education can improve outcomes. Here are some basics ideas of pain science.

1.  Pain Is A Survival Mechanism Whose Purpose Is To Protect The Body

Pain is defined as an unpleasant subjective experience whose purpose is to motivate you to do something, usually to protect body parts that the brain thinks (rightly or wrongly) are damaged. If you feel pain, it means that your brain thinks the body is under threat, and that something has to be done about it. In this sense, pain is a survival mechanism of fundamental importance. People born without the ability to feel pain (yes, they really exist) don’t live very long. Your nervous system takes its job of creating pain very seriously, and therefore you can expect that when it thinks a part of the body is being damaged, it will err on the side of giving you a clear incentive to do something about it.

2.  Pain Is An Output Of The Brain, Not An Input From The Body

This is the fundamental paradigm shift that has recently occurred in pain science. Pain is created by the brain, not passively perceived by the brain as a preformed sensation that arrives from the body.

When a body part is damaged, nerve endings are triggered and send warning signals to the brain. But no pain is felt until the brain interprets this information and decides that pain would be helpful in some way - for example to encourage protective behaviors to minimize further damage and allow time for healing. The brain considers a huge amount of factors in making this decision and no two brains will decide the same thing. Many different parts of the brain help process the pain response, including areas that govern emotions, past memories, and future intentions. Therefore, pain is not an accurate measurement of the amount of tissue damage in an area, it is a signal encouraging action. When a professional musician hurts his hand, his brain might consider very different actions than a soccer player with the same injury. And therefore you can believe that he may get a very different pain response.

3.  Physical Harm Does Not Equal Pain.  And Vice Versa.

If you are in pain, you are not necessarily hurt. And if you are hurt, you will not necessarily feel pain. A very dramatic example of tissue damage without pain occurs when a solider is wounded in battle, or a surfer gets an arm bitten off by a shark. In these situations, there is a good chance the victim will not feel any pain at all until the emergency is over. Pain is a survival mechanism, and in cases where pain makes survival even harder, we shouldn’t be surprised that there is no pain. Although most of us have never had our arms bitten off by sharks, we have likely experienced bumps or falls during a sports match or some other minor emergency that we didn’t feel until the game was over. Further, many studies have shownthat large percentages of people with pain free backs, shoulders and knees have significant tissue damage in these areas that can be seen on MRI, such as herniated discs and torn rotator cuffs.

On the other hand, many people suffer from pain when there is no tissue damage at all. Allodynia is a condition where even normal stimuli such as a light touch the skin can cause excruciating pain. This is an extreme example of something that might occur quite commonly on a much smaller scale – the nervous system is sensitive to potential threats, and sounds the alarm even when no real threat is present. 

4.  The Brain Often “Thinks” The Body Is In Danger Even When It Isn’t

The most dramatic example of this is phantom limb pain, when the victim feels pain in a missing body part. Although the painful limb has been gone for years and can no longer send signals to the brain, the part of the brain that senses the limb remains, and it can be mistakenly triggered by cross talk from nearby neural activity. When this occurs, victims might experience incredibly vivid and painful sensations of the missing limb. Amazingly, phantom arm pain can sometimes be cured by placing the remaining hand in a mirror box in a way that tricks the brain into thinking the missing arm is alive and well!  This is an extraordinary demonstration of the fact that the true target for pain relief is often the brain, not the body.

There are many other more commonplace instances where the brain does not know what is going on in the body and causes pain in an area that is clearly not under threat. Any kind of referred pain, where pain is felt a distance from the actual problem is an example of this. Allodynia is another example.

5.  Pain Breeds Pain

One unfortunate aspect of pain physiology is that the longer pain goes on, the easier it becomes to feel the pain. This is a consequence of a very basic neural process called long term potentiation, which basically means that the more times the brain uses a certain neural pathway, the easier it becomes to activate that pathway again. It’s like carving a groove through the snow while skiing down a mountain - the more times the same path is traveled the easier it is to fall into that same groove. This is the same process by which we learn habits or develop skills. In the context of pain, it means that the more times we feel a certain pain, the less stimulus is required to trigger the pain.

6.  Pain Can Be Triggered By Factors Unrelated To Physical Harm

You may have heard the phrase that neurons that fire together wire together.  The most famous example of this principle is Pavlov’s experiment where he rung a bell each time his dogs ate dinner, then later found that he could cause the dogs to salivate at the mere sound of the bell. What happened at the neural level is that the neurons for hearing the bell became wired to the neurons for salivating, because they fired together consistently for some time. The same thing can happen with pain. Let’s say that every time you go to work you engage in some stressful activity such as working on a computer or lifting boxes in a way that causes back pain. After a while your brain will start to relate the work environment to the pain, to the point where you can start feeling the pain just by showing up, or maybe even just thinking about work. It is no surprise that job dissatisfaction is a huge predictor of back pain.

Further, it has also been shown that emotional states such as anger, depression, and anxiety will reduce tolerance to pain. Although it is hard to believe, research provides strong evidence that a significant portion of chronic back pain is caused more by emotional and social factors than actual physical damage to tissues. You may have noticed that when you return to a place you haven’t been for many years, you quickly fall back into old patterns of speech, posture or behavior that you thought you had left behind permanently. Pain can be the same way, getting triggered or recalled by certain social contexts, feelings or thoughts that are associated with the pain. Ever notice that your pain went away went you went on vacation and came back when you returned?

7.  The CNS Can Change Its Sensitivity Level To Pain

There are numerous mechanisms by which the CNS can increase or decrease its sensitivity to a stimulus from the body. The most extreme example of desensitization occurs during an emergency situation as described above, when pain signals from the body are completely inhibited from reaching the brain.

Most of the time an injury will increase the level of sensitization, presumably so that the brain can more easily protect an area that is now known to be damaged. When an area becomes sensitized, we can expect that pain will be felt sooner and more strongly, so that even normally innocuous mechanical pressures can cause pain. There are many complicated mechanisms by which the level of sensitivity is increased or decreased which are far beyond the scope of this article to address. For our purposes, the key point is that the CNS is constantly adjusting the level of volume on the pain signals depending on a variety of factors. For whatever reason, it appears that in many individuals with chronic pain, the volume has simply been turned up too loud and left on for too long.  This is called central sensitization, and it probably plays at least some role in many chronic pain states. It is another example of how chronic pain does not necessarily imply continuing or chronic harm to the body.

Conclusion

When the body is working well, damaged tissues will heal to the best extent possible in a few weeks or months, and then pain should end. Why should it continue if the body has already done its best to heal it?  When pain continues for long periods of time without any real source of continuing harm or damage, there might be a problem with the pain processing system, not the body. Put another way, if you have chronic pain, there is at least some chance that you are not really hurt. Research shows that for some people this is a comforting thought, and serves to reduce anxiety and stress and threat that makes pain worse.

So what else can we do with this info to help get out of pain? The bottom line is that we need to figure out what is causing the CNS to feel threatened and how can we reduce the threat. 

INJECTIONS TO MANAGE PAIN

Introduction

Injections are commonly used by pain specialists, both to help diagnose the painful condition and to help treat the painful condition. 

This guide will help you understand

• the difference between diagnostic and therapeutic injections
• what the common medications injected are intended to do
• the risks and benefits of injections for pain

Rationale

What is the difference between diagnostic and therapeutic injections?

Injections used for pain management can be divided into two categories: diagnostic injections and therapeutic injections.

Diagnostic injections are intended to help your doctor determine what part of the body is causing the pain you are experiencing. The part that is causing the pain is sometimes referred to as the pain generator. Diagnostic injections are used by your doctor to determine the pain generator by a process of elimination. You should also understand that there may be more than one part that is painful. There may be several pain generators.

The process of finding the pain generator begins with a careful history and physical examination. This may lead to a differential diagnosis. The differential diagnosis is a list of all the possibilities that the physician can think of that best fit with the findings from the initial history and physical examination. Once the differential diagnosis list has been determined, the goal is to figure out which item on the list is actually causing your symptoms.

The next step may be to obtain x-rays, MRI scan, or CT scans. Each of these radiological tests gives your doctor information about the structure of your spine, bones and joints. These images may show abnormalities that may account for your pain. For example, a spine x-ray may show Arthritis of the joints of the spine that could be causing the pain that you are experiencing. But, simply because the structural abnormality could be causing your pain does not mean that it is. Structural abnormalities are commonly seen on radiological tests. Many of these abnormalities are not necessarily causing pain.

The rationale behind diagnostic injections is simple: If a structural abnormality identified on the radiological tests is causing your pain, and if your doctor can inject that structure to temporarily numb that and only that specific structure and the pain stops temporarily, then it makes sense that this is what is actually causing your pain.

It is also likely that you may have several abnormalities visible on the radiological tests. It may be unclear which abnormality is the cause of your symptoms. For example, you may have several intervertebral discs that appear worn out on the MRI scan of your lumbar spine. It could be that all of the discs are causing your pain - or it could be that there is only one disc causing your pain. If you are considering surgery, you would want to be sure which disc is causing the pain so that you did not undergo any additional, unnecessary surgery.

Finally, your pain may actually be coming from somewhere else in your body altogether. For example, it is not uncommon for a patient to have a worn out hip joint and a worn out lower back. When a patient with this combination of problems has hip and thigh pain, it is not always obvious whether the pain is coming from the hip joint or being referred from the lower spine - or both. 

By injecting the hip joint with medication to temporarily numb the hip joint and eliminate the pain that is coming only from the hip, the physician can determine what portion of the pain is coming from the hip joint - if any - and what pain is originating from the spine. This helps diagnose the problem accurately and prevent any unnecessary procedures.

Almost all diagnostic injections follow a similar strategy. First, determine what could be causing the pain. Next, inject the structure that is most likely the cause of the pain with a medication that should reduce or eliminate the pain temporarily. If the pain is eliminated, then the structure injected is almost surely the cause of the pain. It is the pain generator.

Unlike diagnostic injections, therapeutic injections are intended to treat your problem. Therapeutic injections are used when your doctor already has a very good idea what structure is the pain generator. This means that therapeutic injections should be expected to reduce, or eliminate, your symptoms for some period of time. Injections rarely eliminate pain permanently. But, some injections may last weeks to months.

Preparations

How do I prepare for this procedure?

To prepare for the procedure your doctor may tell you to remain "NPO" for a certain amount of time before the procedure. This means that you should not eat or drink anything for the specified amount of time before your procedure. This means no water, no coffee, no tea - not anything. You may receive special instructions to take your usual medications with a small amount of water. Check with your doctor if you are unsure what to do. 

You may be instructed to discontinue certain medications that affect the clotting of your blood several days before the injection. This reduces the risk of excessive bleeding during and after the injection. These medications may include the common Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as aspirin, ibuprofen, naproxen and many other medications that are commonly used to treat arthritis. If you are taking any type of blood thinning medication you should let your doctor know. You will most likely need to have this medication regulated or temporarily discontinued prior to the injection. Your doctor will need to determine if it is safe to discontinue these medications in order to have the injection. 

You may need to arrange to have transportation both to and from the location where you will undergo the injection. Wear loose fitting clothing that is easy to take off and put on. You may wish to take a shower the morning of the procedure, using a bactericidal soap to reduce chances of infection. Do not wear jewelry or any type of scented oils or lotions. 

Procedure

What happens during the procedure?

Injections are commonly performed in several different settings. Some simple injections may be done in the office. Other injections that require special equipment may be done in the operating room, the radiology department or a surgery center. 

Many injections are done with the help of fluoroscopic guidance. The fluoroscope is an x-ray machine that allows the doctor to actually see an x-ray image while doing the procedure. This allows the doctor to watch where the needle goes as it is inserted. This makes the injection much safer and much more accurate. Once the needle is in the right location, a small amount of radiographic dye is injected. This liquid dye shows up on the x-ray image, and the doctor can watch where it goes. The medication used for the injection will go in the same place. The doctor wants to make sure the injection will put the medication where it can do the most good. Once the correct position is confirmed, the medication is injected, and the needle is removed. 

The medications that are normally injected during a therapeutic pain injection include a local anesthetic and some type of cortisone, or steroid, medication. A local anesthetic medication, such as lidocaine or bupivicaine, is the same medication that is used numb the area when you are having dental work or having minor surgery, such as a laceration sutured. The medication causes temporary numbness lasting one hour to six hours, depending on which type of anesthetic is used. 

Cortisone is an extremely powerful anti-inflammatory medication. When this medication is injected around inflamed, swollen nerves and connective tissues, it can reduce the inflammation and swelling. Decreasing inflammation reduces pain in joints. Reduced swelling can allow the nerves to function better, reducing numbness and weakness. 

After Care

What happens after the procedure?

If everything goes as planned, you will be able to go home soon after the injection, probably within one hour. After most types of pain injections, you will probably not have any restrictions on activity or diet following the procedure.

When the pain injection is a diagnostic injection, your doctor will be interested in how much the pain is reduced while the anesthetic, or the numbing medication, is working. You may be given a pain diary to record what you feel for the next several hours. This is important for making decisions, so keep track of your pain.

You will be expected to cease all physical activity for 48 hours following your injection, so if you are participating in physical therapy or other therapeutic activity, be sure to let your therapist know you'll have to reschedule any appointments. 

Most doctors will arrange a follow-up appointment, or phone consult, within one or two weeks after the procedure to see how you are doing and what effect the procedure had on your symptoms. 

And remember, injections are not usually a cure for your pain; they are only a part of your overall pain management plan. You will still need to continue working with the other recommendations from your pain management team.

CHRONIC PAIN MANAGEMENT

According to the National Center for Health Statistics chronic pain health care costs and lost productivity has reached nearly $100 billion a year. It affects approximately 76.2 million people - more individuals than diabetes, heart disease and cancer combined.

The primary goals in chronic pain management are to assess, understand and treat your pain condition. Along with physical therapy, there are many aspects of your daily life that can be adjusted to help minimize the effects of chronic pain on your daily lifestyle. 

This sounds simple. It is not simple or easy. The process requires a great deal of time and effort on both the part of the pain management team and you.

This guide will help you understand

• what chronic pain is
• what pain management is
• how chronic pain is managed
• what you can expect from pain management

What is chronic pain?

Chronic pain is sometimes defined officially as pain lasting more than 6 months. It may also be accurate to define chronic pain as pain that has no clear end in sight. It may be something that you will have to learn to live with - or around. Anyone who has lived with chronic pain, or has treated patients with chronic pain, eventually comes to the understanding that the chronic pain is a disease in itself, regardless of what is causing the pain. It is this disease - chronic pain - that pain management specialists treat.

This does not mean that the team will ignore what is causing your pain. The first goal is to assess your pain. This means that your healthcare provider must try to determine, if possible, what is causing your pain..

The first question that should be asked is: "Does the pain have a source that can be eliminated by doing something to you - such as a medical treatment or surgery?"

Usually, the doctors that you have seen before you arrive at a pain management center have already done this. They refer you to the pain management center because they have not found anything that will reliably eliminate your pain. The pain management team will start from scratch and review all the tests and imaging studies that have been done and examine you. Sometimes the pain specialist may uncover new things or make new diagnoses. Usually they do not.

Once your pain management specialists have satisfied themselves that there is no reliable way to eliminate your pain through a medical treatment or surgery, they will begin the process of understanding your pain. This is a complex process. It does not end as long as you have the pain. The pain management team will constantly reevaluate what they think about your pain, how it is affecting you and what is needed to change the approach to helping you live with your pain.

Understanding your pain and treating your pain go hand in hand. How you respond to certain treatments gives your pain specialists a better understanding of your pain. They probably will not get the right, or best, combination on the first try - or the second. But they will continue to work with you to refine the treatment plan so that you get the best plan that can be can offered. Understanding your pain is a never ending process - for you or for your healthcare providers. Have patience both with yourself and with your pain management team.

In the majority of chronic pain patients, the sensation of pain will NOT be eliminated. BUT, with treatment you can drastically change how much the pain affects your life. Chronic pain is a disease that can be managed effectively. You should expect your pain management team to work with you and your primary care provider to effectively manage your chronic pain condition with all of the expertise and tools available as long as you need help.

Once the process of creating a treatment plan with you begins, there are many different options that can be explored. An important thing for you to realize is that these options are divided into two groups: 

• Things people do to you 
• Things you learn to do for yourself

Each of these approaches are important and have value in treating your pain. The goal is to find a balance where you are in control of as much of your treatment plan as possible - while you minimize the treatment options that require something to be delivered that is controlled by someone else. This situation just makes more sense in the long run - because it puts you more in control of managing your pain. It's cheaper, requires less time spent in providers' offices and ultimately it is more effective.

Most chronic pain patients do require some passive modalities -- "things people do to you" - such as medications, massage and injections to deaden the pain at times. Early on this seems to be more important as you learn the skills that will allow you to move beyond dependence on some of these passive modalities. Remember, the main goal is to help you manage your pain in a way that is effective for you. If that requires some passive modalities, then so be it. 

Things People Do To You

In our current healthcare culture, we are used to going to see a practitioner when we are ill and saying, "Fix it!" Most practitioners are quite willing to try to do just that - give you a prescription medication or suggest a surgical procedure that is designed to cure or fix your problem. Our expectation is that everything can be fixed if we just find the real problem and match this with the real cure. 

Pain doesn't necessarily work that way. In fact, most things in healthcare don't really work that way, but we all pretend they do - patients and doctors alike. With the exception of things like appendicitis and broken bones, most healthcare conditions have lifelong effects that must be dealt with sooner or later. In chronic pain, it just happens sooner rather than later. Quit fooling yourself early and get on with the business of managing chronic pain.

Most of the passive modalities in the category of "things people do to you" are temporary fixes rather than cures. They are useful in managing symptoms while you and your providers work on the category of "things you learn to do for yourself". That is not to say that many of these things people do to you are not beneficial. Some may control your symptoms for years. Some may need to be returned to and used even years from now when you are having a flare up of pain. Just don't think of them as a "cure". They are tools in your toolbox. Use the right tool for the job. If a small tap is needed - don't use a sledgehammer. 

Some of the more common things that fall into the "things people do to you" category are:

• Invasive interventions 
• Medications
• Physical modalities

Invasive Interventions

Invasive interventions are treatments that require surgery or some type of procedure that involves physically invading the body - such as an injection. Clearly, many surgical and invasive procedures are done to reduce or eliminate pain. Many are successful - some are not. You may already have had one or several invasive procedures. You may need more in the future. 

Many of the patients in chronic pain management programs are not expecting any invasive procedures in the near future. This is usually because there are no procedures to recommend that have a reasonable chance of success. Your pain specialist never stops considering invasive interventions to help treat your pain because things constantly change. BUT, continuing to look for the ultimate cure can lead to delays in getting down to managing the chronic pain disease itself.

Medications

Medications treat the symptoms of chronic pain - not the disease itself. Nearly every patient with chronic pain will have the following symptoms at some point in their management program:

• Depression 
• sleep difficulty
• Anxiety

Medications can help control these symptoms to a degree. Medications alone are not the answer. Any medication treatment must be combined with other treatments. For example, many studies show that depression responds exceedingly well to exercise and psychotherapy - possibly better than to medications. The same is true for sleep difficulty and anxiety - both cannot be adequately treated with medications alone. 

Anytime a medication is used for control of the symptoms of chronic pain, realize that you must weigh the side effects versus the benefits. All medications have side effects. No medications are risk free. 

Narcotic pain medications are especially difficult to use due to the side effects of physical dependence and addiction. Chronic pain patients use narcotic medications frequently - but do so with a respect for the potential harm that they can cause. The real goal is to treat your pain effectively so that you do not need narcotic pain medications if possible. That is not always achievable.

Medications are one piece of the puzzle - not the total answer. The goal is to use the minimum amount of medication necessary to treat your pain. If that is a lot of medications then fine, if it is none, that's fine too. In general, the less medication the better.

Physical Modalities

Physical modalities include things like massage, acupuncture, ultrasound, TENS and chiropractic. These are treatments that require someone else to touch you, stick a needle in you or manipulate your body. In some cases (such as TENS), you need to attach yourself to some type of machine that does something to you. None of these things are necessarily bad or good. If they help relieve any of the symptoms of chronic pain, then they may be useful. 

Unlike medications and invasive treatments, most of these modalities are relatively risk free. But, similar to medications, these modalities usually provide temporary relief. Pain specialists use these modalities frequently as part of a comprehensive symptom management program. The biggest risk in coming to rely more and more on these passive modalities for reducing symptoms is that you give up some control of your management program.

As is true in every aspect of managing chronic pain, reaching a balance is necessary.

Things You Learn To Do For Yourself

The things you learn to do for yourself to manage your chronic pain are the most important in the long run. 

That bears repeating:

The things you learn to do for yourself to manage your chronic pain are the most important in the long run.

The more pain management skills you master, the more YOU control your chronic pain without relying on other people to do something to you or control your treatment. You become more empowered. You are in charge, not the healthcare provider.

Some of the more common things that fall into "the things you learn to do for yourself" category are:

• Ergonomics 
• Exercise
• Mind body techniques

Ergonomics

Ergonomics is simply a fancy word for describing a relatively simple concept - how we use our bodies to interact with our physical surroundings. Learning about good ergonomics means learning how to get things done without aggravating your underlying condition and causing pain. It is amazing how many people come into a pain program who never realize how many things they do during the day are actually causing problems. Once they learn new ways of doing things and new ways to arrange their home and work environment, their pain decreases.

Exercise

Developing an exercise routine is critical in the management of chronic pain. You will not be able to effectively manage your pain without incorporating some form of exercise as part of your daily routine. This is not a one-size-fits-all approach to exercise. We realize that each patient is different, with a different set of physical problems that affect what type of exercise is reasonable. Everyone will have a different program designed specifically with their unique problems in mind.

Exercise will reduce many of the symptoms of chronic pain. Even small doses of regular exercise cause physiologic changes in the body chemistry that are beneficial. Exercise increases the body's internal pain killing chemicals called endorphins. These chemicals act just like morphine to reduce pain. Exercise is effective in reducing depression and can help burn off the excess adrenaline that causes anxiety. Most chronic pain patients find that they sleep much better when they begin a regular exercise program.

If you allow chronic pain to greatly reduce your activity level, deconditioning of muscles and ligaments occurs. Bones become weaker. Injury is more likely and pain actually increases. Moderate amounts of exercise will protect you from the effects of deconditioning and help you improve your ability to function.

Remember, the goal is not necessarily to become pain free, but to strike a balance between reducing pain and maintaining function. Some degree of discomfort is not necessarily a bad thing. Many people are afraid that discomfort means they are doing some type of damage to their body. That is not necessarily true. A bit of discomfort is warranted to maintain a higher level of function as long as you are not doing further damage. Doing nothing will certainly result in further damage to your body. Part of what you will be learning is how to tell when enough is enough.

Mind Body Techniques

Many of the symptoms of chronic pain disease are actually made much worse by our minds. The way we react to the sensation of pain is a combination of primitive reflexes (designed or evolved to protect us from harmful things) and learned behavior (not necessarily useful to us at all). For example, think about the muscle pain you might have when you have overdone your spring gardening. You know by experience that it is a simple muscle soreness and you are certain it will go away in a few days. You are not too concerned. You ignore it. It goes away.

Now imagine you wake up one morning with a pain for no good reason. It doesn't go away in a few days. You become concerned because you don't know what the pain MEANS. Is it serious? Does the pain mean I am damaging my body when I do things that make the pain worse? You become anxious. This releases chemicals in your body that increase the sensitivity of your nerves to the pain - the pain feels worse! 

All of these changes occur at the subconscious level - so you are not necessarily aware of this change that comes over you. The result is that you are turning the volume up on your pain. Mind body techniques teach you how to turn down the volume on your pain. The pain song might still be playing in the background - but it's more like elevator music than hard rock.

Most mind body techniques try to tap into what we call physiologic quieting. The mind has a great deal of influence over the hormones and chemicals that are released when we are stressed. These are the chemicals that increase the volume of your pain. You can train yourself to reduce the release of these chemicals and turn down the volume. These are very powerful tools to have in your toolbox. No chronic pain management program will be successful without incorporating some of these mind body techniques.