Pain Management

What is pain - Series 2
What is pain?

Pain is "An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage".
Pain has the dubious distinction of being the commonest symptom for which a person approaches medical care.
There are many sources of pain. One way of dividing these sources of pain is to divide them into two groups, nociceptive pain and neuropathic pain. How pain is treated depends in large part upon what type of pain it is.

Nociceptive pain
The body's nervous system is working properly. There is a source of pain, such as a cut, a broken bone or a problem with the spine. The body's system of telling the brain that there is an injury starts working. This information is passed on to the brain and one becomes aware that they are hurting.


What are types of nociceptive pain? Most back, leg, and arm pain is nociceptive pain. Nociceptive pain can be divided into two parts, radicular or somatic.

Radicular pain: Radicular pain is pain that stems from irritation of the nerve roots, for example, from a disc herniation. It goes down the leg in the distribution of the nerve that exits from the nerve root at the spinal cord. Associated with radicular pain is radiculopathy, which is weakness, numbness, tingling or loss of reflexes in the distribution of the nerve.

Somatic pain: Somatic pain is pain limited to the back or thighs. The problem that doctors and patients face with back pain, is that after a patient goes to the doctor and has an appropriate history taken, a physical exam performed, and appropriate imaging studies (for example, X-rays, MRIs or CT scans), the doctor can only make an exact diagnosis a minority of the time. Research has shown that most back pain that does not go away after conservative treatment usually comes from one of three structures in the back: the facet joints, the discs, or the sacroiliac joint. The facet joints are small joints in the back of the spine that provide stability and limit how far you can bend back or twist. The discs are the "shock absorbers" that are located between each of the bony building blocks (vertebrae) of the spine. The sacroiliac joint is a joint at the buttock area that serves in normal walking and helps to transfer weight from the upper body onto the legs..

What is acute pain? Acute pain begins suddenly and is usually sharp in quality. It serves as a warning of disease or a threat to the body. Acute pain might be caused by many events or circumstances, including:
  • Surgery
  • Broken bones
  • Dental work
  • Burns or cuts
  • Labor and childbirth
Acute pain might be mild and last just a moment, or it might be severe and last for weeks or months. In most cases, acute pain does not last longer than six months, and it disappears when the underlying cause of pain has been treated or has healed. Unrelieved acute pain, however, might lead to chronic pain.

What is chronic pain? Chronic pain persists despite the fact that the injury has healed. Pain signals remain active in the nervous system for weeks, months, or years. Physical effects include tense muscles, limited mobility, a lack of energy, and changes in appetite. Emotional effects include depression, anger, anxiety, and fear of re-injury. Such a fear might hinder a person's ability to return to normal work or leisure activities. Common chronic pain complaints include:
  • Headache
  • Low back painBroken bones
  • Cancer pain
  • Arthritis pain
  • Neurogenic pain (pain resulting from damage to nerves)
  • Psychogenic pain (pain not due to past disease or injury or any visible sign of damage inside)
Chronic pain might have originated with an initial trauma/injury or infection, or there might be an ongoing cause of pain. However, some people suffer chronic pain in the absence of any past injury or evidence of body damage.

What is the difference between acute and chronic pain?
  • There might be no known cure for the disease (such as arthritis or phantom pain) that is causing the chronic pain.
  • The cause of chronic pain might be unknown or poorly understood.


How is pain treated? Depending upon its severity, pain might be treated in a number of ways. Symptomatic options for the treatment of pain might include one or more of the following:
  • Non-steroidal anti-inflammatory drugs (NSAIDs), a specific type of painkiller such as Motrin or Aleve
  • Acetaminophen (such as Tylenol)
  • Narcotics (such as morphine or codeine)
  • Localized anesthetic (a shot of a pain killer medicine into the area of the pain)
  • blocks (the blocking of a group of nerves with local anesthetics)
  • Acupuncture
  • Nerve blocks (the blocking of a group of nerves with local anesthetics)
  • Electrical stimulation
  • Physical therapy
  • Surgery
  • Psychotherapy (talk therapy)
  • Relaxation techniques such as deep breathing
  • Biofeedback (treatment technique in which people are trained to improve their health by using signals from their own bodies)
  • Behavior modification
Some pain medicines are more effective in fighting pain when they are combined with other methods of treatment. Patients might need to try various methods to maintain maximum pain relief. Chronic pain might have originated with an initial trauma/injury or infection, or there might be an ongoing cause of pain. However, some people suffer chronic pain in the absence of any past injury or evidence of body damage.

ALTERNATIVE TREATMENT:
If you're a pain sufferer, here's some good news: Plenty of options exist to ease aches, and many of them don't come in pill form. After all, Vioxx only entered the market in 1999, and arthritis, menstrual cramps, post-surgery pain, and other aches and pains soothed by the drug have been around and managed for a much longer time period.
Only a few common alternatives are discussed in this article. There are dozens, if not hundreds, more pain relief approaches out there. Many of them may be snake oil in various shapes and sizes, and we know that has been around for ages.
Before trying any pain relief approaches, it is important to talk with your doctor. Some therapies may not be safe or appropriate for you, even if they are of the nonpharmaceutical kind. Different factors need to be considered before undergoing any treatment, including your medical condition and history.
Also keep in mind that none of the resources available are perfect pain remedies. They may not provide complete pain relief. They do not work the same for everyone. You may have to try a number of different strategies and combine some of them before finding an acceptable level of pain relief. As with any treatment, there may also be risks and side effects.
A benefit of trying out alternative therapies is that you may find a pain relief option that works for you. We all know how priceless pain relief can be. So don't give up on finding respite for your suffering.
Take an active part in your rehabilitation, advises Penney Cowan, executive director and founder of the American Chronic Pain Association. She says people need to ask themselves, "What's my role in regaining control of my life and actually living with this pain?"
"A big part of pain management is feeling like you have to regain control of your life, because the pain has taken over," says Cowan.

DETOXIFICATION THEORY
Medical treatment strategies for opiate addiction have evolved since the 1950's, when methadone was first used to aid withdrawal. Methadone maintenance programs, in which patients are given methadone, another opiate, as a substitute for the drug of dependence, have been a mainstay of opiate addiction treatment for decades. Now other drugs, like buprenorphine, are given in a similar way to be a substitute for the drug of addiction. For the majority of patients this is not an acceptable alternative, because the physical dependence continues, and is often a lifelong commitment. For most patients, the goal of treatment is complete abstinence.

How do you measure pain? It is virtually impossible to measure a person's pain objectively. Most experts say that the best way to find out how much pain a person is enduring is by a subjective pain report. A comprehensive assessment of pain should include:
  • The identification of all the pains. This must include the most important ones.
  • The site, quality, and radiation of pain.
  • What factors aggravate and relieve the pain.
  • When the pain occurs throughout the day.
  • What impact the pain has on the person's function.
  • What impact the pain has on the person's mood.
  • The sufferers' understanding of their pain.
There are many different methods for measuring pain and its severity. Health care professionals say it is important to stick to whatever system or tool you chose for a specific patient all the way through. If a patient is unable to report his pain, such as an infant, or a person with dementia, there are a number of observational pain measures a doctor can use.

Salicylates:
these include aspirin which continues to be a popular medication for many doctors and patients. If your plan to take aspirin more than just occasionally you should consult your doctor. Long term high dosage usage of aspirin carries with it a significant risk of serious undesirable side effects, such as kidney problems and gastrointestinal bleeding. For effective control of arthritis pain and inflammation frequent large doses are needed. Nonacetylated salicylate is designed to have fewer side effects than aspirin. Some doctors may prescribe nonacetylated salicylate if they feel aspirin is too risky for their patient. Nonacetylated salicylate does not have the chemical aspirin has which protects against cardiovascular disease. Some doctors prescribe low dose aspirin along with nonacetylated salicylate for patients who they feel need cardiovascular protection.

PAIN TREATMENT
Pain therapy depends on the type of pain. As mentioned earlier, for clinical purpose pain is divided in to two types - neuropathic pain and nociceptive pain. The drugs effective for pain control are different in these two types of pain.

Pain killers:
    The pain medicines used are categorized in to the following types:
  • Non steroidal anti-inflammatory drugs
  • Alpha 2 adrenergic drugs
  • Steroids
  • Drugs like antidepressants, muscle relaxant and sleeping pills
  • Drugs for neuropathic pain treatment


Non steroidal anti inflammatory drugs:
These are some of the commonly used drugs for pain relief. These are mainly effective for nociceptive pain. Some of the commonly used drugs are acetaminophen, ibuprofen, naproxen, diclofenac and salicylates.
Some of the side effects of these drugs are, gastritis, worsening of asthma and kidney damage if taken for a longer time. The newer COX 2 inhibitors like valdecoxib and rofecoxib have less side effects.

Opioids: Opioids are effective pain relievers for all types of pain including neuropathic pain.Morphine is the original drug of this class. The other drugs include codeine, fentanyl, meperidine, pentazocine and propoxyphene.
Some of the side effects include addiction, respiratory depression and constipation.

Steroids: Steroids are very potent anti inflammatory drugs and have widespread use in medicine for both anti inflammatory and their pain relieving effects. In pain management they are most commonly take by mouth to relieve the pain of arthritis and by injection along with local anesthetics in arthritic joints and in the spinal canal to relive back pain.
Steroids should be used very judiciously. In high doses given for more than a few days, they can have various adverse effects including diabetes, osteoporosis and other damage to bones like avascular necrosis to the femoral head.

Sleeping pills and muscle relaxants: Muscle relaxants are prescribed for pain stiffness and muscle spasm. They also have mild sedative properties.
Some of the drugs of this class are carisoprodol, methocarbomol and diazepam.

EXERCISES FOR PAIN
BACK PAIN. A typical response to experiencing back pain is to take it easy - either staying in bed or at least stopping any activity that is at all strenuous. While this approach is understandable and may even be recommended in the short term, when done for more than a day or two it can actually undermine healing. Instead, active forms of back exercises are almost always necessary to rehabilitate the spine and help alleviate back pain.
More articles on Pain Management are coming soon.

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