Saturday, November 03, 2012

Methods of Treatment

The management of chronic pain can be divided into pharmacologic and nonpharmacologic therapeutic modalities.

Pharmacologic Treatment

Medications used for the treatment of pain are listed in Table 1.
Nonsterioidal anti-inflammatory drugs (NSAIDs). With increasing doses, all NSAIDs reach a limit to their maximum analgesic effect.[1] Although their effectiveness has been proved in acute pain syndromes that are inflammatory, their efficacy in controlling chronic pain is not well established.[2,3] Although some patients with chronic pain may respond better to one NSAID than to another, the value of these agents is related only to their adjunctive effects when combined with other treatments. A new class of NSAIDs has been introduced that selectively inhibits cyclooxygenase 2 (Cox 2) while sparing Cox 1.[9] Celecoxib is the first of the family of this new class of medication that selectively limits some of the side effects of the traditional NSAIDs.[10] Table 2 compares the incidence of side effects between the nonselective and Cox 2 selective NSAIDs.[11,12]
Aspirin and other salicylates. These drugs inhibit homeostasis and prolong bleeding time, and a single dose of aspirin can precipitate aspirin-sensitive asthma. Multiple doses can also lead to gastropathy and salicylism.[3] The adverse effects of aspirin are similar to those of all NSAIDs except for the risk of precipitating asthma and anaphylactoid reactions in aspirin-sensitive patients.
Acetaminophen. This drug is effective in most types of pain and can also exhibit its effect in single analgesic doses.[6] Although acetaminophen does not cause the characteristic side effects of NSAIDs, an overdosage can cause serious and fatal hepatic complications. Patients who do not have active liver disease and patients who do not abuse alcohol are also advised to lower acetaminophen exposure to minimize its potential hepatic toxicity.[3,13]
Combinations. Nonsterioidal anti-inflammatory drugs and acetaminophen can be given with opioids for an additive analgesic effect and to lower opioid doses. However, there is no evidence that NSAIDs have an additive effect when used with each other.[4,11]
Opioids. Up to about a decade ago, it was the understanding that opioids played no role in the management of chronic nonmalignant pain. It has now become more acceptable that opioids are one facet of well-integrated treatment of chronic pain. Table 3 summarizes the analgesic potency of some opioids in comparison with morphine.
Opioid agonists. These compounds include propoxyphene, codeine, oxycodone, hydrocodone, morphine, hydromorphine, meperidines, methadone, fentanyl, and levorphanol. Codeine, oxycodone, and hydrocodone are generally available in combinations with aspirin or acetaminophen.[3,13] Because of aspirin's effects on renal function and acetaminophen's hepatotoxicity, a limit on the analgesic effects of the accompanying opioid could occur, thus leading to the use of one opioid alone or to the use of another opioid.[13] Morphine, hydromorphine, and fentanyl have unique properties that can be tailored to benefit each individual pain sufferer.[16] Of particular value is fentanyl, which has been used in transdermal, sublingual, and intranasal forms. The transdermal form is absorbed slowly, requiring 12 to 24 hours to peak, and then gives persistent serum levels for as long as 17 hours after patch removal.[17]
Partial agonists and mixed agonist-antagonists. Buprenorphine is a partial agonist, pentazocine, nalbuphine, and butorphanol are mixed agonist-antagoinsts. These agents in general have limited use in the treatment of chronic pain because of their ceiling analegsic effect (ie, as their dose increases the analgesic effect remains the same).[15,16]
Tramadol. This analgesic opioid can be used in healthy adults at a dosage of up to 400 mg/day in divided doses every 4 to 6 hours, and dosage adjustment is necessary only in elderly patients more than 75 years of age for whom the maximum dose is 300 mg daily.[18] Tramadol has been reported to have a potential for drug abuse and may interact with the selective serotonin reuptake inhibitors (SSRIs). Seizures have been reported in patients using SSRIs and tramadol combinations.[18]
Opioid dose requirements vary widely among patients. When the optimal adequate analgesic dosage is reached through titration, it is usually effective for an average of 4 hours. It should be given on a regular schedule, with the provision that the patient can refuse a dose if not in pain.[13] "By-the-clock" administration of analgesics is much more effective than waiting for the next episode of pain to occur before administering the next dose, and an order for a supplementary dose between regular doses should be available for backup or breakthrough pain.[6,19]
The main adverse effects of opioids include sedation, dizziness, grogginess, nausea, vomiting, and constipation. Constipation needs to be addressed at the onset of treatment with the initiation of an appropriate bowel regimen. Insomnia, which is a frequent complaint of patients with chronic pain, may worsen with opioid treatment and needs to be addressed with early intervention.[15]
Tolerance is common with long-term use of opioids. Patients will first have shorter duration of analgesia and then an increase in pain levels.[14] Cross-tolerance exists among all of the opioid agonists, but it is not complete, and switching to another opioid starting with half the equianalgesic dose may be helpful.[13] Patients maintained on opioids for an extended period will have physical dependence and withdrawal phenomenon if the medication is abruptly discontinued or if an opioid antagonist is administered.
It is important to differentiate between opioid dependence and addiction. Addiction is a psychologic disorder and implies an overwhelming involvement with the use of the drug and extraordinary efforts to secure its supply (including robbery and other crimes). Increased risks of relapse into drug use after discontinuance and precipitation of opioids' withdrawal also occur in addicted patients. The majority of patients who are treated with opioids for acute pain or cancer pain rarely become addicted to the mood-altering or euphoric effects of the opioids. The only absolute contraindication for opioid use is allergy. Opioids can be lethal in cases of drug overdosage because of their respiratory depressant effects. Patients without pulmonary disease who are maintained on opioids for a long time become tolerant to their respiratory depressant effect, but the addition of general anesthetics, neuroleptics, sedative-hypnotics, tricyclic antidepressants, or other central nervous system (CNS) depressants would increase the risk of respiratory depression.[13,15]
When making the decision to treat chronic pain with opioids, primary care physicians need to comply with the Drug Enforcement Administration regulations, as well as individual state guidelines. It is also important to know that most of the state medical boards have now accepted the use of opioids in chronic nonmalignant pain as described in the guidelines issued by the American Pain Society.[20]
Antidepressant mdications. Most patients with chronic pain could benefit from antidepressants, especially if they have comorbid psychiatric conditions such as depression, sleep disorders, psychologic factors affecting physical conditions, anxiety, somatization disorder, or somatoform pain disorder.[7,8] Antidepressants have also proved to be effective in treating a variety of painful conditions such as cancer, arthritis, headache, diabetic neuropathy, postherpetic neuralgia, phantom limb pain syndrome, postoperative pain, peripheral neuralgia, chest wall pain, fibromyalgia, vasculitic neuropathy, and low back pain.[7,8] In addition, antidepressants have been effective and widely used for the treatment of atypical facial pain and have some usefulness in treating trigeminal and glossopharyngeal neuralgia.[8,21] Although the antidepressant effect takes several weeks, pain relief may occur within a week.[22,23] Side effects of tricyclic antidepressants (TCAs)[7] include anticholinergic effects of dry mouth, blurred vision, urinary retention, constipation, orthostatic hypotension, sexual dysfunction, tremors, disturbed sleep, and rarely nocturnal myoclonus.[23] The anticholinergic and quinidine-like effects of TCAs make them relatively contraindicated in patients with cardiac conditions.[22,23] The sedative properties of TCAs may also require dosage scheduling to be tailored to each individual patient. Tricyclic antidepressants have a relatively narrow therapeutic/toxic dose ratio and can be lethal in case of overdosage.[8,23] Trazodone, with its main side effect of orthostasis and a low incidence of priapism, is an alternative antidepressant for treatment of chronic pain.[24] The SSRIs have a milder side effect profile, which may include headache, somnolence, nervousness, nausea, fatigue, tremor, and sexual side effects.[25]
Anticonvulsants and benzodiazepines. The value of anticonvulsants such as phenytoin, carbamazepine, valproate, and gabapentin in decreasing neuropathic pain have been well established.[26] Several clinical studies have documented the effectiveness of these medications in treating chronic pain associated with diabetic neuropathy and postherpetic neuralgia, as well as sharp and lancinating pain.[7,26] Gabapentin, which has minimal side effects, is considered a breakthrough primary adjunct agent for chronic pain management and can offer the best advantage in most clinical settings.[27] The CNS effects of anticonvulsants, especially ataxia and drowsiness, tend to be dose related and occur early in treatment. Sedation can be usually managed by giving most of daily dose at bedtime. Careful monitoring of side effects is indicated if the anticonvulsants are administered with other CNS depressants, especially in the elderly. When anticonvulsants are used for the treatment of chronic pain, the dose is titrated and increased as tolerated, depending on the emergence of side effects rather than on the anticonvulsant blood levels.[7] Another anticonvulsant, clonazepam, is a benzodiazepine that can be administered in small divided doses of up to 4 mg daily. Clonazepan has shown effectiveness in the treatment of chronic lancinating pain, with the advantage of having fewer side effects.[28]
Antihistaminics. Hydroxyzine and other antihistaminics in injectable doses of 50 to 100 mg have potentiated the analgesic effect of opioids during acute exacerbation of chronic pain.[3,6] Although antihistaminics are rarely used, they are considered a rescue in drug-seeking patients only.[8]
Corticosteroids. These agents rarely have a use in chronic pain, but their anti-inflammatory effects can achieve analgesia in some patients with chronic pain and inflammatory diseases (eg, rheumatoid arthritis) or in patients who have tumor infiltration of nerves.[8,11]
Membrane-stabilizing agents. Tocainide and mexiletine are oral agents that can at times be used to treat chronic neuropathic pain. Mexiletine is usually preferred over tocainide, which has been associated with the development of anemia. Some patients with chronic pain may respond to the analgesic effects of intravenous lidocaine. Lidocaine-sensitive pain is diagnosed by administering a 100 mg bolus dose intravenously or 4 mg/kg over 30 minutes. The analgesic effect is then monitored with the use of a visual analogue scale.[29]
Topical agents.[30] Capsaicin is a commonly used topical medication that can reduce pain sensations in some patients. It is available as a nonprescription medication in 0.025% and 0.075% concentrations. This medication acts on the depletion of an endognous peptide through the release of substance P, which is involved in the transmission of pain messages from the peripheral organs to the CNS. It takes several weeks for capsaicin to achieve a result. It can cause some irritations with burning, and patients need to wash their hands thoroughly after touching the cream or lotion. It must also be kept away from eyes and mucous membranes. Capsaicin is usually most effective when used as an adjunct to systemic medications.
Among the volatile solvents such as chloroform or ether, paste of aspirin has been also used as an adjunctive agent for topical management of postherpetic pain. The NSAIDs indomethacin and diclofenac may be also used topically, and they presumably decrease the elevated postaglandin tissue levels that occur with cutaneous pain.
Clonidine.[30,31] This a2-adrenergic agonist produces analgesia when administered intrathecally, epidurally, or systemically. It is useful in patients who have tolerance to opiates. It is available in both the oral form and a transdermal patch.
Muscle relaxants. Agents that lead to muscle relaxation, such as methocarbamol, baclofen, and cyclobenzapine, have been used to decrease generalized muscle pain in patients who have fibromyalgia as well as chronic pain due to increased muscle spasm.

Pain Clinics

The role of pain clinics in managing chronic pain as a disease with its own incidence, epidemiology, assessment, and treatment is becoming an important facet of the heritage and practice of medicine.[1] The interdisciplinary pain clinics use multiple modalities such as physical therapy, exercise, vocation evaluation, and individually designed rehabilitation programs.[27] Pain clinics function as an interface between primary care, psychiatry, neurology, psychology, behavioral medicine, and occupational and physical therapy.[3,4] In addition to their cost effectiveness, pain clinics play a role in reducing unreasonable expectations by taking patients off the multiple and sometimes conflicting pain medications and promoting the resumption of tolerable physical activities.[8]

Surgical Treatment of Chronic Pain

Before the use of invasive surgical procedures for the treatment of chronic pain, local anesthetic nerve blocking can be done to aid in localizing the source of pain and can also achieve therapeutic benefits.[32] Several surgical procedures, including sympathetic blockade can be done at the stellate, lumbar, or celiac ganglia.[32] Procedures such as injecting absolute alcohol or phenol and the neruosurgical cordotomy or rhizotomy, which permanently destroys neural structures, can also predict the prognostic effect of local anesthetic. These procedures allow the patient to temporarily experience the sensation that will follow the permanent procedure.[32] If local anesthetics and sympathetic blockade fail to provide long-term pain relief, then electrical stimualtion of the spinal cord or "dorsal column stimulation" can be introduced as another option for relief of intractable pain.[32,33] Radiofrequency ablation and newer minimally invasive surgical procedures can also substantially reduce chronic pain.[33] Narcotics delivered neuroaxially either into the epidural space or distally (intrathecally) into the spinal fluid can also offer pain relief when other forms of treatment have failed.[3,33] The key for a good prognostic outcome in surgical intervention is the proper selection of patients. A frank discussion of each procedure should be conducted with both patient and family, with special emphasis on side effects and the realistic expectations of benefits of the procedure.[30] It is important to understand that surgical procedures and ensuing pain control will not necessarily treat the underlying medical conditions.[30,32]

Nonpharmacologic Treatment of Chronic Pain

Transcutaneous electrical nerve stimulation (TENS). In selected patients the appropriate use of TENS can achieve some reduction of pain.[2] Although TENS units allow patients to restore their sense of self-control and reduce the risks associated with systemic medications, in long-term studies their use has not been shown to enhance functioning.[6,13]


Individual and group psychotherapy engages patients with chronic pain in developing cognitive and behavioral coping skills and can be effective in limiting the psychologic disability that is induced by pain.[1] Efforts to improve a patient's ability to cope are usually more effective when they include family members and significant others.[4,6] Education, counseling, relaxation training, biofeedback, and conflict resolution over autonomy and care are necessary components in addition to the technical aspects of any psychotherapeutic interventions.[3,8] Hypnosis can also be used in some selected cases of chronic pain.[8,27]

Spiritual Intervention

Spiritual support for the patient with chronic pain is another facet of the multimodal treatment approach. The spiritual dimension of treatment incorporates the patient's religious beliefs and spiritual orientation into regaining hope and developing a sense of control over pain through prayer, meditation, church or synagogue attendance, and other devotional practices.[34]


Rehabilitation efforts should aim at allowing patients to perform their normal activities within a year of pain onset.[7] Delays resulting from the performance of diagnostic evaluations, and pursuing workers' compensation may adversely affect the enhancement of functioning. In workers' compensation cases, the patient especially needs to obtain impairment evaluation and functional capacity examination to initiate immediate interventions that could achieve maximal medical improvement.[13,27] The interdisciplinary team approach to rehabilitation combines palliative care and physical rehabilitation and explores multiple treatment methods tailored to each individual patient's particular circumstances.[3,13]

In My Opinion

I will give you my opinion of products and treatments I have found helpful. I will also pass along suggestions from others. I will update often so check back also click here to read the ten steps to get your life back. Ten Steps

There are many items that can make Daily Living easier. From help Dressing to Bath & Body Aids. Little things can make a big difference to those in pain.

1. Sleeping-My first suggestion is a mattress I like the Temper-pedic the memory foam molds to your body and while being soft still gives you the support you need and the neck pillow is made of the same material and helps with headaches.
1. Free 13 week in home trial
2. Free Tempur-pedic neck pillow ($125 value)
3. Interest free financing
Just call 1-800-955-9259 and mention offer Code GP10C3 and Referral # 2229441

Also a
Memory Foam and Toppers is a less expensive alternative. Sleep Better Sleep Wave

2. Back support sitting
-my suggestion for lower back and upper back support is the is the Obus high back rest for home,auto or office. It gives excellent support for the upper and lower back and supports the ribs and head and comes with a lumbar pillow that I have found can be used as pillow for the neck and head(for people with upper back problems). The back rest is available at the Relax the Back Store so depending on the severity of your back problem it will help support your back and make it easier to sit upright for longer periods.3. Mobility Scooters- I have found that a mobility scooter can really help when it comes to travel or interaction with family and friends. While I personally was very embarrassed to have to use a scooter (I still am) sometimes you have to just do it if it will help you get out and interact with your family. They can be rented for short periods if necessary.4. Botox injections-It is not just for wrinkles. Botox can be used to deaden the muscles in your back which can relieve some of the pain by relaxing the muscles that are causing pain or irritating the nerves. I have only had one treatment so I cannot tell you how well it works over time. Unfortunately after one treatment the rules changed and the Workers Compensation insurance now says there is no scientific study showing benefit even though it was helping. Out of luck whether it helps or not.5. Acupuncture-I have tried this and think it was helpful but I did not get much benefit the first time I tried it years ago. I tried it last year in conjunction with the Botox although for the same reasons as the Botox the Workers Compensation insurance changed the rules and now I am out of luck even though it helps.6. Braces & Supports-I have a brace for the upper back but it does not fit correctly but if you can get one that fits and supports to keep your back immobilized then you will be able to do more. Note-you would not want to wear the brace to much because you have to work your muscles or they will atrophy.

Friday, November 02, 2012

Pain Links

American Academy of Medical Acupuncture
American Association of Oriental Medicine

Arthritis Pain
Arthritis Foundation

Back Pain
American Back Society

Cancer Pain

American Cancer Society
Cancer Research and Prevention Foundation
National Cancer Institute

Chronic Pain
The Mayday Pain Project
American Pain Foundation
American Chronic Pain Association
For Those in Pain
National Chronic Pain Society
National Pain Foundation
Partners Against pain

American Diabetes Association

Geriatric Pain

Administration on Aging
The American Geriatric Society

Head, Neck and Facial Pain
American Academy of Head, Neck and Facial Pain
American Academy of Orofacial Pain
American Dental Association
Trijeminal Neuralgia Association
TMJ Association

American Fibromyalgia Syndrome Association
Fibromyalgia Network
National Fibromyalgia Association
National Fibromyalgia Partnership
South Carolina Fibromyalgia Support Group

General Health
American Council on Science and Health
American Holistic Health Association

Headache Pain
American Councel for Headache Education
American Headache Society
National Headache Foundation

Pain Information & Treatment

Pediatric Pain
American Academy of Pediatrics
Pediatric Pain-Science Helping Children

Pelvic Pain
International Pelvic Pain Society
Vulvar Pain Foundation

American Counseling Association
American Psychological Association

Reflex Sympathetic Dystrophy
For Grace
Reflex Sympathetic Dystrophy Syndrome Association

Academy of Orthopaedic Surgeons
Phone: 847-823-7186
Phone: 800-346-2267

Physical Therapy Association
Phone: 800/999-APTA (2782)

American Chronic Pain Association
Phone: (916) 632-0922
Fax: (916) 632-3208

American Pain Society
Phone: 847/375-4715
Fax: 847-375-6315

Academy of Pain Management
Phone: (209) 533-9744

California Orthopedic Institute
Phone: (818) 901-6600

Products for Pain

A good mattress will protect the back for the many hours that you are in bed. A mattress that properly supports the body will also be a very important element in helping relieve stress on the muscles and joints of the back. The most important information needed for finding a correct mattress to support the back involves knowing what position you sleep in.

I have owned a Tempur-pedic mattress for over a year and it really helps,if you are interested in one you can get a Three for Free offer.
1. Free 13 week in home trial
2. Free Tempur-pedic neck pillow ($125 value)
3. Interest free financing
Just call 1-800-955-9259 and mention offer Code GP10C2 and Referral # 2229441

Pill Cases & Splitters
Make carring medication easier and it will be less likely you will forget to bring your medication when you go out. If you have ever had to leave an outing early because you forgot to bring your medications you will understand.

Finding the Right Chair or Seat Insert Cushion
Whether you sit for minutes or hours, you can't underestimate the value of proper posture while sitting. It has been demonstrated that at times there can be as much as six times the amount of stress on your back when you sit than while laying down. Fortunately you can lower the amount of stress placed on the spine with proper back support. To accomplish this, first you must decide whether the chair you use presently is adequate for your needs. A good chair will be able to provide your lower back with proper lumbar pressure. This pressure will keep the curve of the spine in this area supported in the normal position. When a proper lumbar support is not provided with your chair, an insert lumbar cushion can accomplish this. The size of the cushion is very important, as too much lumbar support can compress and irritate the spine. A good working ergonomic type of chair can be adjusted to allow tilting and height control of the seat and chair back. Here are some tips for adjusting your chair properly: Adjust the height of the chair to allow your feet to rest comfortably on the floor. Adjusting the tilt angle of the seat will change the position of your pelvis, thereby shifting the back towards or away from the seat back. Tilting the front of the seat downward will bring your lower back into extension and thus increase the lower lumbar curve. Tilting the front of the seat upward will bring your lower back into flexion and thus decrease your lumbar curve. Combine the seat angle tilt with the seat back tilt for optimal support of the back. If the seat back height can be adjusted, make sure the small of your back fits with the part of the seat back which curves outward to support the lower back. If these adjustments still do not support the spine properly, you will definitely need a lumbar insert cushion or more ergonomically correct chair. Insert cushions will need to have height adjustability to fit correctly. This is usually achieved with a strap that allows you to set the height of the cushion to the thickest part against the small of your back. Each person's spine curves differently, so another important feature that some back support cushions provide is the ability to adjust the size of the lumbar thickness to customize the fit.

Back braces can be necessary when an injury creates instability to the spinal column, as it will protect the back from further injury. Soft back braces can be useful for support of fatigued muscles and allow temporary relief to the irritated tissue in the initial stage of injury. However, wearing a back brace for prolonged periods after the area has finished with the initial healing stage can also weaken the back musculature over time, as the muscles will rely on the brace to keep good posture. While too much movement of the back may cause exacerbation of the Spondylolisthesis, completely preventing movementof the area has been shown to hinder the healing process. The best solution is to find a brace that puts pressure directly over the irritated area only, thereby protecting the tissue, but also allowing the rest of the back muscles to still be used. Short term use of a back brace will not cause any weakening of the back muscles. If the muscles are completely not used for prolonged periods they will weaken over time. To avoid this, once the injury has healed sufficiently enough, use a back brace only to support the back during any activity that requires protection for the spine. It can be noted that the use of a brace while sleeping should not cause the muscles to weaken, but many patients find that overusing the brace can become irritating to the skin underneath. Most of the patients we survey tell us that using a back brace which puts direct pressure over the irritated area provides instant relief.

Lumbar (low back) traction can be accomplished through various products which keep the pelvis stationary while using gravity to force separation of the vertebrae and thereby open the spinal canals that the nerves exit through. However, the multifidous muscle which attaches to the lumbar vertebrae may not allow the separation of the vertebrae if the muscle is in too much spasm. Some types of traction allow for better separation when the multifidous muscle is in spasm. One such type of traction is performed by doctors of chiropractic through applying pressure manually to the spine while a flexing table tractions the spine in
a downward motion. This is especially useful when the vertebrae have slipped forward on one another as they will be temporarily moved back to their normal position during this process. In the earlier stages, light traction can provide an unloading of the spine, thereby releasing the nerve pressure between each segment created from a decrease in circulation and an increase of inflammation within the joint space. In later stages, traction combined with body movement may also help to break up scar tissue build up between the joints. When the muscles are in too much spasm to allow for this type of traction, upright types of traction units can enable a person to move their body during the therapy to avoid further muscle spasm, while providing a relieving therapy to the spine. Home traction units may be beneficial, but caution should be taken not to apply too much traction too quickly to the back, as this may initiate a spasm to the surrounding musculature. Therefore, only traction units which can gradually increase the separating of the vertebrae and allow unloading of the spine without reaching too much drastic pull would be recommended. For home use we recommend a seated traction therapy where a person is able to move the body to help avoid any muscle spasm of the back while taking pressure off the spine