Health and Pain Mind

For patients with pain who fail conservative therapies, simple to complex interventional therapies such as nerve blocks, epidural steroid injections, intraspinal drug administration, or trigger point injections may be helpful. These therapies are typically provided by anesthesiologists with advanced training in pain management.

Nerve Blocks and Epidural Steroid Injections
Nerve blocks can relieve pain by inhibiting the impulses that travel along specific nerves in the body. To achieve a block, the doctor usually injects a local anesthetic along the course of a nerve or nerves. Although this is called a “temporary” block, in the best outcome, pain relief lasts for a long time. In very selected cases, the doctor can inject a solution that damages the nerve and produces a more permanent block.

Sympathetic nerve blocks inhibit the nerves of the sympathetic nervous system, which are responsible for increasing heart rate, constricting blood vessels and raising blood pressure in response to stress. Sympathetic nerve blocks can be useful in treating some pains due to nerve damage, such as some types of complex regional pain syndrome (also called reflex sympathetic dystrophy or causalgia).

Blocks of somatic nerves can be targeted to any area of the body. In some cases, nerve blocks fail to provide pain relief, or provide only a brief respite.

Epidural steroids, administered through injection, can help to interrupt the passage of painful impulses through nerves.

Spinal Infusion
Intraspinal drug administration involves the delivery of low doses of analgesic drugs, such as morphine or clonidine, through a catheter inserted directly into the spine. This approach is used often to manage cancer pain.

Triggerpoint Injections

Acupuncture
Acupuncture is an ancient method for relieving pain and controlling disease, used in China for thousands of years. It appears to be effective for some patients with chronic pain.

Thin gold or metal needles, gently twirled for ten to twenty minutes, can be used to stimulate acupuncture points, which relieve pain in specific parts of the body (for example, a point on the leg targets stomach pain). Patients usually feel a tingling, warm sensation, similar to that of transcutaneous electrical nerve stimulation. Acupuncture points can also be stimulated with deep massage (acupressure), electric currents (electroacupuncture), or lasers.

The risk of side effects is low. Side effects can include post-needling pain, bleeding, bruising, dizziness, fainting, and local skin reactions. Rarely, organ damage can occur with deep needling techniques. Infection because of inadequately sterilized needles is a hazard; disposable needles are recommended.

Acupuncture is not recommended for patients with serious blood clotting problems. Acupuncture should be used with caution by pregnant women.

Massage
Massage can be a useful addition to a pain management program, especially for patients who are bedridden.

Massage can:

	Stimulate blood flow
	Relax muscles that are tight or in spasm
	Promote a feeling of well-being

Muscles can be stroked, kneaded or rubbed in a circular motion. A lotion can reduce friction on the skin.

Massage is not recommended in cases of swollen tissue. It should be used in addition to, and not instead of, exercise by patients who can walk.

Transcutaneous electrical nerve stimulation (TENS) is a method of applying a gentle electric current to the skin to relieve pain. Studies have shown that it can be effective in certain cases of chronic pain.

A small box-shaped device, which patients can put in their pocket or hang on their belt, transmits electrical impulses through wires to electrodes taped to the skin in the painful area. Patients describe the sensation of TENS as buzzing, tingling or tapping.

The patient should experiment with the placement of the electrodes and the timing, intensity, amplitude and frequency of the electrical current to find the most effective setting. Pain relief usually lasts beyond the period when current is applied. TENS can become less effective at relieving pain over time.

TENS is usually safe and well tolerated. However, it is not recommended on inflamed, infected or otherwise unhealthy skin, over a pregnant uterus (except for obstetric pain relief), or in the presence of a cardiac pacemaker.

Therapeutic Exercise
Exercising is important because it can:

	Strengthen weak muscles
	Mobilize stiff joints
	Help restore coordination and balance
	Promote a sense of well-being
	Decrease anxiety and stress
	Keep the heart healthy
	Help maintain an appropriate weight

A physical therapist, exercise physiologist or certified athletic trainer can help patients get started safely and learn exercises designed specifically to target problem areas. Even bedridden patients can benefit from range-of-motion exercises.

Heat Therapy
Heat therapy can reduce pain, especially the pain of muscle tension or spasm. Sometimes patients with other types of pain benefit.

Heat therapy acts to:

	Increase the blood flow to the skin
	Dilate blood vessels, increasing oxygen and nutrient delivery to local tissues
	Decrease joint stiffness by increasing muscle elasticity

Heat should be applied for 20 minutes. Patients can use hot packs, hot water bottles, hot and moist compresses, electric heating pads, or chemical and gel packs carefully wrapped to avoid burns. Patients can also submerge themselves or the painful part in warm water.

Heat therapy is not recommended on tissue that has received radiation treatment. Pregnant women should avoid using hot tubs or any method that subjects the developing baby to prolonged heat.

Deep heat delivered to underlying tissue by short wave diathermy, microwave diathermy or ultrasound is also sometimes used to relieve pain. Deep heat should be used with caution by patients with active cancer and should not be applied directly over a cancer site.

Cold Therapy
Cold therapy, which constricts blood vessels near the skin, sometimes can relieve the pain of muscle tension or spasm. Other types of pain also benefit in some cases. It can also reduce swelling if applied soon after an injury.

Ice packs, towels soaked in ice water or commercially-prepared chemical gel packs should be applied for 15 minutes. Cold sources should be sealed to prevent dripping, flexible to conform to the body, and adequately wrapped to prevent irritation or damage to the skin.

Non-pharmacological treatments (treatments that do not rely primarily on medication to achieve their effect) offer a variety of approaches to pain relief. Most are non-invasive.

Simple, relatively safe non-pharmacological approaches include:

Physiatric Approaches
Non-invasive Stimulatory Approaches
Psychological Approaches
Complementary/Alternative Approaches

In most cases, these techniques should be used in addition to, not instead of, other approaches to pain relief.

More invasive non-pharmacological treatments include:

Anesthesiologic Approaches
Invasive Stimulatory Approaches
Surgical Approaches

Pharmacological Therapies (Medication)

	Non-opioid pain relievers
	Opioids
	Adjuvant medications (drugs whose primary purpose is not for pain but rather for other conditions)
	Topical treatments (drugs are applied directly to the skin, as a patch, gel, or cream) Because the effects of a medication can vary widely from person to person, treatment of pain needs to be tailored to fit each individual. Some patients may need to try many different kinds of treatments before they find the right balance between pain relief and side effects. Patients should be sure their doctors are aware of all medications they are taking, even for conditions unrelated to their pain or over-the-counter drugs such as aspirin. Many medications should not be taken together because they increase or decrease each other’s effects or produce new adverse reactions. Of course, the doctor should also be informed if the patient is pregnant or breast-feeding.

Following are the definitions for terms commonly used in the diagnosis and treatment of arthritis.

Analgesic: Pain relief medication.

Arthralgia: Pain in the joints.

Arthritis: Inflammation of the joints. There are more than 100 kinds of arthritis.

Autoimmune: A process by which a person’s immune system attacks the body’s own tissues. Rheumatoid arthritis is an autoimmune disease.

Bacteria: Microscopic, one-celled organisms.

Cartilage: Firm, whitish substance at the ends of bones. It acts as the body’s “shock absorbers.”

Collagen: Substance making up the body’s connective tissues.? It gives cartilage its “bounce.”

Corticosteroid: Powerful steroid medication that reduces inflammation.

Glucosamine: An amino sugar occurring in vertebrate tissues including that of marine creatures, from which it’s harvested.

Glucosamine sulfate: A form of glucosamine that has been shown to reduce arthritis pain and rebuild damaged joints.

Gout: A painful inflammation primarily of the big toe, characterized by an excess of uric acid in the blood that leads to crystalline deposits in the small joints.

Ligament: A band of strong connective tissue that connects bones and holds organs in place.

Osteoarthritis: A type of arthritis in which cartilage wears out and joints become stiff and painful.

Prostaglandins: Hormone-like substances that play a part in inflammation.

Proteoglycans: Mortar-like substances made from protein and sugar that are the building blocks of cartilage.

Rheumatoid arthritis: A major form of the disease in which the body’s immune system attacks joints, causing hot, painful swelling and deformity.

Seeking help and advocating for yourself are the first steps to treating your pain. Your physician’s goals in treating you are to reduce your pain, improve your physical functioning, reduce your psychological distress and improve your overall quality of life.11 There are many different ways to treat depression and anxiety related to pain. Your physician may suggest one or more of the following therapies to reduce your psychological distress:

• medication,
• cognitive-behavioral therapy,
• stress management (eg, relaxation techniques, hypnosis, biofeedback),
• supportive counseling, and
• family counseling.12

It’s important to remember that being depressed is not a sign of personal weakness—depression and anxiety are related to chemical imbalances in your brain.13 Depressive and anxiety disorders are illnesses that can be treated. Taking medication and going to therapy to treat your depression is the same as taking antibiotics to treat an infection—the necessary steps you take to get better.

It’s also important to keep in mind that not every medication or therapy works immediately or even works in every person. Medications used to treat depression often take up to six weeks to be effective. If you and your physician decide a particular therapy isn’t effective for you, you may need to try different medications or different combinations of therapies to find the right ones for you. Try not to become frustrated or give up—you and your physician need to work together to achieve results.

Counseling and behavioral therapy—alone or combined with medication—are effective and important techniques in treating depression and pain.14 They also require your active participation in your care and recovery. Following are some suggestions for actively participating in your care and helping you and your physician work together to treat your pain and your depression:

• Keep a diary and record changes in your pain and emotions. Visit the My Pain section of http://www.nationalpainfoundation.org keep pain journal online. You can print it out and bring it with you to your doctors’ appointments to remind yourself of how you were feeling and when you were feeling better or worse.
• Identify a support network. Support persons could include family members, friends, support groups. The National Pain Foundation’s My Community area is an online support group for persons in pain.
• Educate yourself through books, reputable Web sites, and organizations.
• Set realistic treatment goals.
• Stay active—with your doctor’s advice and approval, begin an exercise program, try yoga, or other stretching activities.
• Try the stress management techniques you learn in counseling and use them regularly. Guided imagery, hypnosis, biofeedback, and relaxation techniques really can work if you work at using them.

Depression is an illness, and ignoring it will not make it go away. Seek the treatment you need to get better and be involved in your care—

Pain and depression are inexorably linked in a complex way. Pain causes depression—depression causes pain. About 30% of patients with persistent pain conditions suffer from clinical depression related to their pain, and almost all persons will experience some mood changes. 75% of patients with clinical depression present to their doctors because of physical symptoms, including pain.1 People in pain who have symptoms of depression experience more impairment associated with pain than those who do not have depressive symptoms.2

To successfully treat your chronic pain, you and your physician need to examine the emotional factors that may influence your pain level and physical disability. One of the first steps to treating pain is recognizing that depression often accompanies pain and that increases in pain or widespread pain (ie, pain in many areas of your body) can be a symptom of depression. Understanding this aspect of your pain experience may help you identify your own symptoms and seek the care you need to lessen your pain.