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Issue Date: August 2004 Issue


A Window On Pain

Here's what you need to know about dealing with chronic pain.
Eileen Beal

The Most Common Causes of Chronic Pain

Most situations that cause chronic pain are not well understood. However, they are usually not life threatening either.

Arthritis (all forms)

Tension, migraine and cluster headaches

Neck and back disorders (especially of the lower back)

Cancer (due to the malignancy affecting tissue, organ or bone)

Damaged or diseased nerves (due to trauma, diabetes)

Complex Regional Pain Syndrome (usually due to tissue trauma or disease)

Gastrointestinal disorders (Irritable Bowel Syndrome, colitis)

Pelvic/bladder disorders

Shingles (post-herpetic pain)

Soft-tissue disorders (Fibromyalgia, burns)

Amputation (phantom pain)

Sedentary lifestyle

Sources and Resources

Books:

• "Healing Images for Children," by Nancy Klein

• "The Pain Relief Handbook: Self-help methods for mastering pain," by Dr. Chris Wells

• "The Truth About Chronic Pain," by Arthur Rosenfeld

• "The War on Pain," by Dr. Scott Fishman

Web sites:

• American Academy of Pain Medicine, (847) 375-4856, www.painmed.org

• American Cancer Society, 1-800-252-5302 www.cancer.org

• American Chronic Pain Association, 1-800-533-3231 www.theacpa.org

• American Council for Headache Education, 1-800-255-ACHE www.achenet.org

• American Headache Society, (856) 423-0043 www.ahsnet.org

• American Pain Foundation, 1-888-615-7246 www.painfoundation.org

• American Pain Society, (847) 375-4715 www.ampainsoc.org

• Arthritis Foundation, 1-800-283-7800 www.arthritis.org

• Brain Injury Information Network www.tbinet.org

• Cancer Pain www.cancercare.org

• International Association for the Study of Pain, (206) 547-6409 www.iasp-pain.org

• Mayday Pain Project www.painandhealth.org

• National Chronic Pain Outreach Association, (504) 862-9437 www.chronicpain.org

• National Fibromyalgia Association, (714) 921-0105 or (423) 638-6692 www.fmaware.org

• National Foundation for the Treatment of Pain, (713) 862-9332 www.paincare.org

• National Headache Foundation, 1-888-NHF-5552 www.headaches.org

Twelve years ago, Rick Bergmann, then a volunteer firefighter, was struck in the back by a bucking water hose and slammed into the side of a fire truck. "The accident broke four ribs — right off my spine — in the lower part of my back and damaged four disks," he says.

Bergmann was off work for 12 weeks, 10 of them spent sitting in a recliner. "I could feel the ribs clacking around in my back," he recalls. "Eventually, the ribs reattached, but the pain never went away. And it kept getting worse and worse and worse."

The agony took over his life. "I lost my job at a truck company in Canton," he says. "And dealing with it was rough on my family."

Medications — which ruined his stomach — dulled the pain for a while. So did trigger-point heat therapy. "Kind of like acupuncture, but more modern," explains Bergmann. Spinal-block injections also helped.

But the pain always came back — with a vengeance.

Last summer, Bergmann's physician referred him to the Pain Management Program at MetroHealth Medical Center. The program director, Dr. Mohan Kareti, evaluated Bergmann and then performed radio ablation, a procedure using pulsed electrical current to short-circuit the back nerves causing his pain.

Bergmann says the result has been "like a miracle" for him: "Before, on the pain scale [of 0-10], I was about an 8. Now, I'm around 2 or 3 [and] there's been no lessening of the effect.

"I just wish I'd known about it 12 years ago."

Pain is your friend

Pain, per se, isn't a bad thing. In fact, what physicians call acute pain is a necessary survival tool. This is the kind of pain you experience when you step on a tack or need to have your appendix removed.

"Acute pain is a warning to the organism that something is seriously wrong and needs to be addressed — immediately," says Dr. Thomas Chelimsky, an associate professor of neurology at Case Medical School and director of autonomic disorders at University Hospitals.

While acute pain can range from mild annoyance to jaw-clenching severity, it usually goes away once the underlying cause is treated or resolved.

But acute pain can morph into chronic pain, the kind that ruled Rick Bergmann's life for a dozen years, when "normal" pain from an injury, surgery or disease lingers, escalates or comes and goes intermittently.

Chronic pain can arise from ongoing tissue damage, as is the case with arthritis. Or it may be due to changes in the nerves at the site of the trauma, injury or disease that create false pain messages to be sent to the spinal cord and brain. These messages can include blood-vessel constriction or muscle contractions, as well as throbbing, stinging, jabbing, tingling or burning sensations.

"For people with chronic pain, it's as if the body's fire alarm continues to ring after the fire has gone out," explains Dr. Edward Covington, director of the Chronic Pain Rehabilitation Program at The Cleveland Clinic.

But the sensation of pain is just the physical side of chronic pain. The psychological characteristics can be equally devastating. "There's usually a decrease in sleep that can cause fatigue, depression, anxiety and irritability," says anesthesiologist David Sfeir, director of pain management at Southwest General Hospital. "When you are exhausted and depressed and anxious and irritable, the pain feeds on itself and you hurt even more."

It really is all in your head

Diagnosing chronic pain is easy. Physicians take a medical history and do a physical that, more often than not, includes orthopedic and neurological exams. To rule out other causes — such as anemia or other diseases — they might also do blood and urine tests, X-rays and/or CAT or MRI scans.

But the most important tool for diagnosing chronic pain is patient perception, according to Dr. Michael Knight, medical director at Menorah Park Center for Senior Living, where about 80 percent of residents are dealing with chronic pain. "Pain is very subjective," he explains. "If someone tells you they are in pain — and tells you where they are hurting, how much it hurts and how it affects them on a daily basis — they are in pain."

Because chronic pain is such a subjective medical condition, however, a diagnosis of chronic pain is often viewed with skepticism, especially by the insurance industry. Insurers can't get their hands around the fact that it's a multifactorial condition: Genetic predisposition, personality type, gender, hormone levels, lifestyle, age and other elements all play a role in how people perceive pain.

It's also a highly individual condition. "Everyone experiences pain differently," notes Sfeir.

Not only do people feel pain differently, but those with the same conditions — for instance, low back pain, cluster headaches or the phantom pain that can affect those who have lost a limb — tend to respond to treatments differently and seek treatment from different specialists. Chelimsky and Sfeir note that as the reason that there are so many different kinds of successful treatments.

Sfeir says, "Because there are so many different types and levels and symptoms of pain, I've stopped telling my patients that something doesn't work. If it works for them, it works."

An abundance of treatments

"Chronic pain advertises itself long before it becomes chronic, but people don't recognize what's happening," says Kareti. "The earlier they get the problem attended to, the better the outcome."

Treatment for chronic pain depends on the level of pain being experienced when help is sought. Unfortunately, most people seek treatment only once pain reaches the moderate or severe level — and is therefore more difficult to treat.

In general, treatment begins with over-the-counter or prescription medications, such as aspirin; nonsteroidal anti-inflammatory drugs, such as Motrin, Celebrex or Vioxx; bed rest; heat or cold packs; acupressure; and/or physical therapy.

Covington stresses that physical therapy is critical because patients need to learn new ways to do things and regain muscle tone and strength so the pain won't come back.

If the above regimen doesn't turn things around, antidepressants and anticonvulsants or long-acting narcotic-based medications, such as methadone or OxyContin, may be used to alleviate pain in conjunction with minimally invasive procedures such as acupuncture, or tissue and nerve stimulation using low-intensity electrical current (to block nerves from generating and transmitting pain signals).

If pain is still not brought down to an acceptable level — say, from 8 to 5 — interventional techniques, such as steroid injections, or procedures that numb, block or dull the signals being sent to the brain can be used.

If all else fails, the next step may be an invasive technique such as spinal-cord implants or surgery to sever nerves causing the pain.

Pain-management centers

While moderate or intermittent chronic pain usually responds to one of the above regimens, the best way to treat severe chronic pain — which affects 11 percent of the population and is the nation's leading disabler — is with a coordinated, multidisciplinary program. This puts the patient into a center full time for three to four weeks and treats the physical, psychological and emotional manifestations of the condition with therapies both standard (medications, tissue manipulation, implants) and not-so-standard (guided imagery, biofeedback, psychiatric counseling).

Not only do multidisciplinary programs decrease the physical pain and psychological distress associated with chronic pain, they also decrease the disability associated with it. "With a program, the average return-to-work rate is 67 percent, compared with 24 percent for patients receiving conventional medical care," says Chelimsky.

However, insurance won't pay the $8,000 to $14,000 price tag for this kind of program. That's why University Hospitals, which was seeing excellent success in treating patients, closed its Pain Center last September. Chelimsky was the center's director.

Perhaps the Decade of Pain Control and Research Act, passed in 2001, and the Pain Care Policy Act, now wending its way through Congress, will change things. Time will tell.

Crystal-ball Gazing

One of the most promising (and well-funded) areas of chronic-pain research is new medications. What scientists hope to create are nonsteroidal anti-inflammatory drugs that don't irritate the stomach and medications that mimic the pain-blocking, prevention and/or dulling properties of opiates (such as morphine) without their negative side effects. They are also assessing the pain-controlling utility of drugs already in existence.

"Many of the antidepressants and anti-seizure medications have pain-relieving qualities," observes Sfeir. "The challenge is to find which ones work ... best for chronic pain."

Another area of interest is biofeedback, which, Chelimsky notes, "teaches coping mechanisms and encourages behavioral modifications, too."

The search for minimally invasive surgical interventions is also getting attention. "There's a lot of work going on right now with implants [for dispensing medications or pain control] and deep-brain stimulation," says Dr. Emod Mikhail, director of the pain management center at Euclid Hospital.

Research on better imaging technologies hopes to allow physicians to "see" chemical changes in the body and brain and diagnose the conditions causing pain.

Of course, all the medications and techniques and technologies — new or old — aren't going to do people with chronic pain any good if they don't use them.

And use tends to skew along age lines, says Mikhail.

"The elderly population, they tend to blow pain off till it's so severe they have to seek medical attention. ... A lot of them, when I ask them how long they've lived with their pain, they'll tell me 15 years," he adds. "For my younger patients, it's since May or June — or this year."


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