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

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.

Many people with cancer experience pain. Thirty to 40 percent of patients in active cancer therapy and 70 to 90 percent of patients with advanced cancer report pain.

Cancer pain can be caused by:

	Tumors pressing on organs, nerves or bone
	Treatment such as surgery, chemotherapy or radiation
	Other conditions related to the cancer, such as stiffness from inactivity, muscle spasms, constipation and bedsores
	Conditions unrelated to the cancer, such as arthritis or migraine

In most cases, cancer pain can be controlled through relatively simple means. Doctors usually use medications, which are prescribed according to a plan that was first described by the World Health Organization and is called the Analgesic Ladder approach to cancer pain management.

Other ways to alleviate cancer pain include:

	Surgery, radiation or chemotherapy to shrink tumors causing pain
	Antibiotic therapy or drainage for pain caused by infection
	Psychological therapies, and social and spiritual support, to influence the perception of pain
	Other pain treatments

Beth Israel Medical Center, a major cancer care provider in New York City, has hundreds of cancer specialists in its network including top-rated surgeons, medical oncologists, physicians, radiation oncologists, radiologists, and oncology nurses.

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—

Chronic pain affects all aspects of life. It affects your quality of life as it limits your physical functioning, your ability to perform activities of daily living, and your ability to work. It has social consequences for your marital and family relationships, it may limit intimacy with your partner, and it may prevent interaction with friends. Chronic pain has societal consequences in terms of increased health care costs, increased disability costs, and lost productivity that is a consequence of missed workdays.

Given the pervasiveness of pain, it’s no wonder that chronic pain affects your psychological well-being as well.3 Research indicates that as number and severity of a patient’s physical symptoms increase, the number and severity of psychological complaints increase.4 In other words, the more places you feel pain and the more severe the pain, the more likely you are to have a depression or problems such as difficulty sleeping or anxiety and the more severe these symptoms are. Some of the signs and symptoms related to depression reported by chronic pain patients treated at pain clinics include:

• physical deconditioning,
• sleep disturbance,
• reduced sexual activities,
• family stress,
• work issues,
• legal issues,
• financial concerns,
• decreased self-esteem,
• fear of injury, and
• altered mood, including irritability, anxiety, and depression.5

Why do pain and depression co-exist so often? Scientists have been studying this relationship through neurosciences and epidemiology and have made important discoveries. First of all, both depression and the suffering of pain are located in the same area of the brain.6 Second, the same chemical messengers are involved in regulating pain and mood.7 What are the mechanisms that affect these parts of the brain and these chemical systems? We find that depression runs in families, so that the stress of having pain may trigger the chemical changes in the brain leading to depression in persons who may be vulnerable because of a family tendency (genetic) to depressive illness. More commonly, however, a person has no family vulnerability to depression, but may get “worn down” by all the stress, losses and problems encountered by having pain over many months.8 Either way, this “wearing down” is biochemical, such that certain important chemicals (similar to vitamins) that are responsible for regulating both pain and mood appear to be functionally depleted. This is why the same medications that are helpful in depression may also effectively treat pain, because they enhance the pain and mood regulating effects of these chemical systems in your brain.

Approximately 40% to 60% of patients being treated at pain clinics report experiencing symptoms of depression.9 Unfortunately, people experiencing pain do not always receive the treatment they need to combat their depression and their pain, especially if they do not see physicians with the training and background to treat both together (eg, pain medicine specialists, psychiatrists, or primary care physicians with this training). Given the nature of today’s health care system, most Americans receive mental health care by visiting their primary care physician, but research studies indicate that 50% of patients who are clinically depressed are not diagnosed by their primary care physicians.10 So be on the lookout for depression in yourself and loved ones and seek treatment before the negative effects occur.

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.

Pain so often is accompanied by loss—loss of function, loss of employment, loss of money, loss of friends and relationships to name just a few—it’s no wonder that people in chronic pain have an increased incidence of depression, anxiety, and sleep disturbances. It is natural to feel emotions ranging from fear, anger, denial, disappointment, guilt, and loneliness to hope and optimism. Every person reacts differently to pain at different times, which can make relationships and pain control difficult. The effect emotions and psychosocial well being have on pain cannot be ignored as emotions have a direct effect on your health. Taking care of the emotional aspects of chronic pain is necessary to treat your overall pain condition.