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MANAGEMENT OF PAIN

 

PAIN

Pain is defined both as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Pain may be acute or chronic and they differ greatly.

 

ACUTE PAIN

Acute pain usually arises as a consequence of disease, inflammation or injury to tissues. This pain generally comes on immediately after trauma or surgery. It will be accompanied by anxiety or distress. The cause of any acute pain can usually be diagnosed and treated. The pain fortunately tends to be self-limiting but in some instances it will continue and become chronic.

 

CHRONIC PAIN

Chronic pain is perceived by most as representing a disease process itself. Environmental, societal and psychological factors will make sure pain worse. It is the very nature of the pain and the associated psychological difficulties that lead to severe problems. Although it is often thought that pain particularly chronic pain is directly linked to what is known as functional handicap, that isn’t actually correct. People with all levels of pain can have mild, moderate or severe functional handicap according to a number of other factors.

 

DIAGNOSIS OF PAIN

Pain is subjective. It is an experience that every one of us knows only too well but the extent of that pain and how it impacts on any individual will be different from one person to another. At the moment there isn’t any test that is capable of measuring the intensity of pain. We do not have any imaging procedure that shows pain and we also cannot locate pain precisely.

Pain is often diagnosed according to the characteristics including the chronology as well as the suffering individual’s own description of the type, duration and localisation of the pain.

There are a range of descriptive terms that are used. It is always worth keeping a diary and logging precisely when the pain occurs, how long it lasts, what triggers the pain and what has been done to try and alleviate it.

 

THE CHARACTERISTICS OF PAIN

Pain may be sharp or dull. It can be constant or intermittent. It may be burning or aching, it may be stabbing, jabbing, pounding or pulsing.

 

THE INVESTIGATION OF PAIN

Investigation of pain involves a full history, use of a pain diary and then specific investigations including scanning tests usually magnetic resonance imaging (MRI), plain X-rays, isotope bone scanning and electrical tests called neurophysiology which can involve measuring the functioning of peripheral nerves, nerves roots and muscle function.

 

SPECIFIC PAINS

Pain can arise from so many structures, injuries and diseases that this article would become too unwieldy if all of these were considered.
I have however focused on a few of the most common:

 

BACK PAIN

I suspect we all will get back pain at some time in our lives. If you are one of the fortunate few who have never experienced back pain then you are indeed very lucky.

Back pain arises for many reasons most of which reflect our lifestyle. Sitting for prolonged periods, not looking after our weight and nutrition and failing to undertake a proper programme of back strengthening exercises all lead to an enhanced predisposition to back pain. Regrettably for many people there is a genetic link so that the common disorders of lumbar cervical spondylotic and disc degenerative disease arise as a consequence of who we are, inherited from our parents and likely to generate symptoms for us during our lives.

It used to be thought that degenerative disease of the spine was more likely to occur in people who had active physical jobs as opposed to the desk bound. A recent study of identical twins has shown that this is not correct. People will be just as likely to get lumbar spondylotic and disc degenerative disease if they sit at an office desk all day long as opposed to working on a building site. This only emphasises the importance of genetic factors.
It may be perceived that if back pain has such a great genetic influence then why bother to do anything about it. My usual thinking in the consulting room is to reflect on why we look before we cross the road and a similar thinking applies here. The more we do to look after our backs by regular exercise, good diet, maintaining a proper body weight and attention to posture and sitting position then the less likely we will fall foul of our genetically determined spondylotic and disc degenerative disease.

 

HEADACHE

96% of the world’s population will have a headache at some time in their life. Literally millions of doses of simple painkilling drugs are taken on a daily basis because of headache. Much time is lost from work and there is a great deal of societal negativity towards headache sufferers.

10-20% of all women and 8-14% of all men will have migraines. A much smaller number will have the clinical condition known as cluster headache. A much larger number of people will get tension headaches either of the acute or chronic form. 4% of the population are said to have chronic daily headache which is defined as headache occurring more than 150 days in a year.

Analgesic dependent headache is increasingly being recognised as a major health problem. In effect the more painkillers taken for headache then the more likely headache is to be maintained. I suspect that there is a similar story with regard to neck and back pain as well.

The specific management of headache is beyond the brief of this article but there is a lengthy discussion about this on my website at www.neurologyclinic.org.uk under the Management of Migraine banner.

 

NEUROPATHIC PAIN

Neuropathic pain occurs when a nerve gets injured or diseased. What is forgotten however is that very fine so-called type C nerve fibres supply every part of the body and so nerve pain can arise even from a cut to the skin.

Neuropathic pain may also arise after trauma or secondary to the condition called diabetes mellitus. Many drugs can damage the nerves particularly those used in chemotherapy. Alcohol when drunk to excess may also generate a neuropathy which is painful.

There are a range of specific pain syndromes including complex regional pain syndrome, phantom limb or post-amputation pain and post-hepatic neuralgia, each of which has its own characteristics and specific treatment.

When neuropathic pain becomes established this is then regarded as being a central pain syndrome. Modern thinking shows that the brain does get sensitised to pain. This process of central sensitisation maintains the pain in an individual. My own simple thinking on the subject reflects that the brain learns to give pain so that the brain actually perceives that it is right to give pain. This can occur with waking up in the morning and will go on until the individual goes to bed and may even awaken them during sleep. Pain which has become centrally sensitised in my experience becomes the most difficult pain to treat.

 

THE TREATMENT OF PAIN

The primary goal of pain management is to improve functional difficulty enabling people to return to work, follow their education or participate in any other leisure activity.

With the assumption that there is no primary surgical option then pain treatments fall into four broad categories. These include:

  1. Physical therapies
  2. Injections therapies
  3. Talking therapies
  4. Pharmacotherapy

 

PHYSICAL TREATMENTS

Physical treatments include the treatment programmes adopted by physiotherapists though osteopaths and chiropractitioners also have a role. The physiotherapy treatment involves working directly on the pain as well as building strength around the area that has been damaged or is painful and also working on the overall body strength and general confidence. There is a lot of psychological management within an appropriate physical treatment regime.

Simple physical measures such as heat, cold, exercise, massage, manipulation and vibration in all the various ways that they can be applied will not cure the pain but do provide a percentage relief without there being any obvious side-effects.

 

EXERCISE AND GENERAL REHABILITATION

Exercise and building up strength, stamina and fitness is a fundamental part of pain management. Just because there is pain is not a reason that there should be functional handicap. An individual might as well be active and in pain as at rest and in pain. From years of experience the more people do then the less pain they get. It would seem the greater the distraction then the lesser the pain and the reverse applies.

There is no level of fitness or stamina that is too great and the more therapeutic training that is undertaken then the better the result, both with regard to work, life and leisure.

 

INJECTION TREATMENTS

Injection treatments include acupuncture. There are a number of trials confirming that acupuncture is beneficial in the management of all types of pain. We know that acupuncture releases certain chemicals into the brain and spinal cord that have pain relieving properties. Acupuncture also seems to have an anti-inflammatory mechanism of action though how this is achieved is not known other than enhancing the release of the body’s own natural anti-inflammatory chemicals and neurotransmitters.

Various types of electrical stimulation such as a TENS machine can be used at a basic or superficial level.

If pain becomes incredibly disruptive to life then spinal cord stimulation techniques are available but these do need the involvement of highly specialised teams in major neuroscience centres. Acupuncture shouldn’t be underestimated for its role in pain relief. It can be remarkably effective. If there is going to be benefit then from my experience there should be some improvement within the first six sessions.

Various nerve blocks can be used. These would be discussed with any suffering person by a pain management specialist.

 

TALKING THERAPIES

There are a range of talking therapies, the most well known of which is cognitive behavioural therapy. Reassurance that there isn’t any severe underlying pathology can be very helpful in pain management.

Various biofeedback treatment systems have also been suggested. More formal counselling as opposed to cognitive therapy can also be tried.

 

PHARMACOTHERAPY

The fourth and final treatment modality is drug therapy.

Treatments may simply involve giving analgesic or pain relieving medications. Most people are not aware how limited are the number of choices when it comes to simple analgesia. We all know that there are Aspirin based drugs, Paracetamol based medications, the non-steroidal anti-inflammatory drugs and then finally the opiates.

Within each group there are a number of variations but the background thinking to each group is the same.

All of the simple analgesic medications have potential side-effects. Aspirin for instance can upset the gastric lining and cause bleeding and indigestion. Paracetamol if taken in too large an amount can cause problems with the liver and kidneys and it may also be constipating and generate a degree of depression.

The non-steroidal anti-inflammatory drugs had a lot of publicity recently. There is concern over an increased risk of heart attack and stroke in people who use a lot of anti-inflammatories but the numbers involved are very small compared to the vast number of people who actually use these medications.

There are different strengths of non-steroidal anti-inflammatory drugs known as NSAID’s. There is also a newer class of anti-inflammatory known as the Cox-2 inhibitors. It will be up to your managing doctor to decide which of these treatments is the best choice.

The opiates including Codeine, Tramadol and the various morphine preparations are more powerful analgesic agents. They have a significant number of side-effects. They also tend to sensitise the brain more when used for chronic pain and I personally try and avoid prescribing opiates if at all possible. They do have powerful withdrawal side-effects and whereas they are extremely helpful in the management of post-operative or acute pain they should have a much lesser role in treating and managing people who have chronic pain.

 

MODERN PAIN DRUG THERAPIES

There are now a range of medications that are used to help manage both acute and chronic pain. These medications fall into two main categories, those of the antidepressant drugs and then the anti-epilepsy drugs. Although it is science that tells us that these drugs work in reducing the pain by blocking the pain pathway or the reaction to the pain, it is an art to find the right dose that works in any individual. The doctor and patient must work together as a team in finding the correct dose or doses particularly as more than one group of drug treatments tend to be combined to give an even greater benefit.

Many people are worried about the concept of taking antidepressant drugs. These treatments are not addictive. They are very good at correcting a disordered sleep pattern which is so often seen in people with pain. Energy levels are enhanced, pain is reduced and they do have the side-effect of being an antidepressant drug, raising serotonin levels and improving mood generally. Mood is often low with depression in people with chronic pain and there is often anxiety as well which is helped by these medications.

There are some specific other situations such as migraine headache where there are designer drugs literally that have been manufactured to treat the pathway that is known to be activated in migraine.

There are other drug treatments as well such as the use of a local anaesthetic patch. This contains 5% lignocaine which literally leaches into the skin from the patch and reduces pain. There are anti-inflammatory gels and creams. There is a medication called Capsaicin, a chemical found in chilli peppers that may also reduce pain when rubbed on the skin.

 

CONCLUSIONS

We will all suffer with pain at different times in our life. I think it was William Osler who recognised that the primary role of a physician was to relieve pain but he also said that our first duty as physicians was to do no harm. Trying to get the right balance when treating people with pain is a significant challenge.

The key to any injury or disease process generating pain is to seek medical attention and appropriate physical and other management as quickly as possible.

The sooner that pain is blocked then the less likely that central sensitisation of the nervous system will take place generating more pain by virtue of the pain learning that this is the right thing to do when in fact it isn’t. Useful pain is exactly that. It leads to treatment such as removal of the appendix with appendicitis. Useless pain is a pain that doesn’t tell us anything or lead to specific treatment but just causes discomfort or worry. This is the pain that blights so many lives. There are very few people however who cannot be helped greatly by the treatment regimes outlined above.

A multi-disciplinary approach usually pays greater dividends than random selection of pain treatment without their being a conductor of the pain management programme.

If you are using analgesia for pain then if you are using 6 or 8 tablets of painkillers each week for more than three weeks then you should be seeking guidance from your general practitioner about alternative pain management approaches.