Your life is only as good as the memories you make.

This is so true and I have so many good memories. I am sure I have at least an equal number of bad memories, but I will not dwell on them. If you find yourself wallowing in bad memories STOP.

It may be hard but just stop it. Think of something good that happened. Then think of something else good that happened during your life. Search your past for those great moments.
Then repeat often.

Your life is only as good as the memories you make.  I forgot what life is all about, why we are here. I was to busy living in bad times of the physical pain I am feeling right now. The guilt I feel for not being strong enough for my family to keep things the way they were. The way things were before that split second changed everything in my life and the life of my family.

I vow to remember the good I have done, the good I have seen
and to enjoy the good yet to be.

Will You?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Right (and Wrong) Way to Treat Pain

Chronic pain is a thief. It breaks into your body and robs you blind. With lightning fingers, it can take away your livelihood, your marriage, your friends, your favorite pastimes and big chunks of your personality. Left unapprehended, it will steal your days and your nights until the world has collapsed into a cramped cell of suffering.

Check out the rest of the article By CLAUDIA WALLIS

February 28, 2005 issue of Time Magazine Article  
 Also finish the story here Back in Pain

Chronic pain often presents sufferers with a real "catch 22" dilemma. If they talk about their pain, they risk being perceived and labeled as hypochondriacs, or even worse, fakers or malingerers. On the other hand, if they hide their pain, others don't believe the pain is significant. It is enough to tax the patience of the most stoic person....
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

This site contains resources to inform you and hopefully help lower the level of your pain. Please check out the site and let me know what you would like to see or any information you would like to know to improve the site. I have put a lot of work into this site and will add features as I can. I sincerely hope this site will help you cope with the pain and stress and I will continue trying to offer what I can to help people, if you can please help out with a donation even a small donation will be greatly appreciated and can make a big difference. If there are any questions you have I will do my best to answer or help you find the answer. I hope you get the information to help for you or someone you know.

Thank you

God Bless and good luck

*Health Disclaimer*
Any information given about conditions, treatments, and products are not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on MY BACK PAIN.

Back Pain and Fractures

Compression and Wedge Fractures

Thomas A. Zdeblick, M.D.
Professor and Chairman Orthopaedic Surgery
University of Wisconsin
Madison, WI, USA

What is a Compression/Wedge Fracture?

A compression fracture is a common fracture of the spine. It implies that the vertebral body has suffered a crush or wedging injury. The vertebral body is the block of bone that makes up the spinal column.

Each vertebral body is separated from the other with a disc. When an external force is applied to the spine, such as from a fall or carrying of a sudden heavy weight, the forces may exceed the ability of the bone within the vertebral body to support the load. This may cause the front part of the vertebral body to crush forming a wedge shape. This is known as a compression fracture. If the entire vertebral body breaks, this is considered a burst fracture and is discussed elsewhere. The compression fracture may range from mild to severe in terms of severity. A mild compression fracture causes minimal pain, minimal deformity and is often treated with time and activity
modification.

Severe Pain
A severe compression fracture may be such that the spinal cord or nerve roots are involved, as they are draped over the sudden angulation of the spine. This may cause severe pain, a hunched forward deformity (kyphosis) and rarely neurologic deficit from spinal cord compression.

Risks - Osteoporosis - Trauma
The risk for spinal compression fracture increases with age. Osteoporosis is the most common risk facture for compression fractures. Osteoporosis is a condition in which there is thinning of the bones, weakening them. This may be due to a lack of calcium in the diet, certain medications, old age, inactivity or genetic factors. In general, some trauma occurs with each compression fracture. In cases of severe osteoporosis, the trauma may be minimal, such as, stepping out of a bathtub or lifting a heavy object. Moderate trauma is usually required to create a fracture in patients with mild to moderated osteoporosis. This may range from falling off a chair to an automobile accident. A normal spine may also suffer from a compression fracture when there is a severe forward bending injury. This most commonly occurs from a fall from a height or an automobile accident.

Nerve Injury
Neurologic injury is rare with compression fractures. The degree of neurologic injury is usually due to the amount of force present at the time of injury. If there is severe angulation of the spine secondary to a wedge fracture, this may stretch the spinal cord and create injury. This would then lead to loss of strength and sensation, as well as reflexes. In most patients with osteoporotic compression fractures, there is no neurologic injury but only pain from the fracture. However, if left untreated the fracture angulation may worsen and lead to late paralogic injury.


Diagnosis
A compression fracture is usually diagnosed by the history, physical exam and x-rays. In any patient over the age of 60 with the acute onset of sudden low back pain, a compression fracture should be suspected. Physical exam will usually note tenderness directly over the area of pain as well as mild kyphotic deformity (e.g., a sudden angulation forward or hunched over appearance). Plain x-rays will demonstrate the wedge shape of the vertebral body on a lateral view. A CAT scan is occasionally needed to help differentiate a compression fracture from a burst fracture.

Occasionally an MRI scan is obtained to rule out disc herniation along with a compression fracture. MRI scan may also help differentiate pathologic compression fractures, that is, those that involve a tumor, from a typical osteoporotic compression fracture. In any patient with a known history of cancer, a compression fracture should tip off the physician to look for evidence of a metastatic lesion and pathologic fracture. If osteoporosis is suspected, a Bone Mineral Density (BMD) test may be ordered. This test helps determine the severity of the bone thinning. In addition, laboratory tests to look at blood count and thyroid function may be indicated as well. A decision as to whether to treat osteoporosis should be made by the
patients' primary physician.

Burst Fractures:Defined and Diagnosed

Thomas A. Zdeblick, M.D.
Professor and Chairman Orthopaedic Surgery
University of Wisconsin
Madison, WI, USA

What is a Burst Fracture?

A burst fracture is a descriptive term for an injury to the spine in which the vertebral body is severely compressed. They typically occur from severe trauma, such as a motor vehicle accident or a fall from a height. With a great deal of force vertically onto the spine, a vertebra may be crushed.

If it is only crushed in the front part of the spine, it becomes wedge shaped and is called a compression fracture. However, if the vertebral body is crushed in all directions it is called a burst fracture. The term burst implies that the margins of the vertebral body spread out in all directions. This is a much more severe injury than a compression fracture for two reasons. With the bony margins spreading out in all directions the spinal cord is liable to be injured. The bony fragment that is spread out toward the spinal cord can bruise the spinal cord causing paralysis or partial neurologic injury.

Also, by crushing the entire margin of the vertebral body the spine is much less stable than a compression fracture.

Nerve Injury
Neurologic injury from a burst fracture ranges from no injury at all to complete paralysis. The degree of neurologic injury is usually due to the amount of force that is present at the time of the injury and the amount of compromise of the spinal canal. With a greater amount of force, more bony fragments can be forced into the spinal canal causing greater loss of spinal cord function. This may cause loss of strength, sensation or reflexes below the level of the injury.

Typically, in a burst fracture that occurs at the junction of the thoracic and lumbar spines paralysis of the legs and loss of control of the bowel and bladder may result. In an incomplete spinal cord injury only partial paralysis or reflex loss is seen. With mild burst fractures only transient symptoms may be present or no neurologic injury may be present.


Severe Pain
Burst fractures cause severe pain. Typically, this is pain at the level of the fracture, that is, in the back. However, pain may also be present in the legs following the distribution of the affected nerves. Many patients complain of an electric shock type sensation into their legs when there is spinal cord compression. Most patients with a burst fracture are unable to walk immediately after the injury. Seldom, the patient may walk away from an accident and still have a burst fracture. However, often the amount of pain that is present is severe enough that patients know it is a good idea not to walk.


Diagnosis
At the scene of the accident, patients complaining of severe back pain should not be placed into a seated for flexed position. They should be kept lying flat and transported in the flat position. A patient who stands or sits with a burst fracture may increase their neurologic injury. Burst fractures require immediate medical care by an orthopedic or neurosurgeon trained in spinal surgery. The patient should be transported to an emergency room and x-rays obtained.

The diagnosis of a burst fracture is usually made by x-rays and a CAT scan. Occasionally, an MRI scan may be ordered as well, in order to assess the amount of soft tissue trauma, bleeding or ligament disruption. The review of the CAT scan and x-rays allows the treating physician to make a determination as to the level of the fracture, whether it is a compression fracture, burst fracture or fracture dislocation, and to determine the amount of spinal canal compromise and spinal angulation. All of these factors enter into the treatment decision process.

The physical exam should be performed to document both spinal deformity, that is, angulation of the spine or tenderness of the spine at the level of fracture, as well as, a neurologic exam.

Neurologic exam should include testing of the muscle strength, sensation and reflexes of the lower extremities, as well as, testing of bowel and bladder sphincter control.

The Human Pain Effect
By Me

The effects of chronic pain can be devastating to the way of life not only to the person in pain but also for family and friends. Chronic pain over time can bring the strongest person to their knees. Anyone can block pain for a short period of time say a month or two to heal a broken bone or let a painful condition heal, but when the pain continues past that it can make the pain feel like it is getting worse because it takes more energy and it slowly will just wear you down. This does not make you weak it makes you human.

We can handle the pain for short periods of time because we know the pain will go away, pain always goes away. Right?

Unfortunately the answer is no sometimes pain does not go away. Chronic pain is pain that lasts well past the time of normal healing. You may have a serious injury that at first you handle without much problem (like a broken bone) because you can block the pain by keeping your mind focused elsewhere or by just biting your tongue. But the longer the pain lasts the more energy it takes to block the pain. Explained another way imagine pain as something you can see so you try to ignore the pain by not looking at it and keep your eyes looking away. But as time goes by and the pain does not go away it will take more and more effort to not look at it. Eventually the pain will wear you out. Over time instead of looking away from the pain you get to the point where all you can see is the pain, it will completely consume you before you even realize it happened. A example I use is imagine a pro football player who breaks his wrist. They set it put it in a cast and the next week he goes out and plays with the cast on. People are amazed that he can play in so much pain. But if that level of pain is still there the next year he won't be playing because it is to painful. Even though it is the same level of pain he played with before.

It will wear you down over time.
It seems that having chronic pain can actually create changes in the nervous system. What is Chronic Pain Video-ACPA So what do you do after the pain has already consumed you and you feel helpless. Get involved, the biggest mistake I think I made was not getting involved and letting the doctors take care of me. I actually thought doctors knew everything and the miracles of modern medicine could fix me. Wrong. Doctors know about anatomy but you know how your body feels better than the best doctor ever could. Get involved and get informed. Find out about your condition and talk to your doctor. Unfortunately not all doctors will listen or take your concerns as seriously as you may like. In that case you need to have a serious talk with your doctor or find a doctor who will listen which is not always easy. Also many doctors do not won't to admit that they do not have all the answers. Many seem to think they do. But I would rather have a doctor that is honest with you and tells you "I don't really know but we will find out" than have a doctor more or less guessing and contradicting other doctors "guesses". I have seen a lot of doctors over the years and have only had one doctor say "I don't know". It was unrelated to my back but I liked the honesty.

One thing that seems to be very effective at keeping your mind active and alert is debating friends family or anyone. This is something I used to do on a regular basis before my injury just because it was fun. Slowly I drifted away becoming mentally stagnant without even realizing it. After years of mental stagnation I finally woke up after a heated debate with a friend I had not seen in a while. For so long I had tried to have in depth discussions with mild success because the pain would always affect my thought process making it difficult to concentrate or hold my thoughts together. So whenever you are having a good day get comfortable and talk to someone and get your mind working. You will be glad you did.

Barriers to Seeking Pain Relief
 Read the Ten Steps below for relief

Many people with chronic pain don't seek pain relief, or even tell their doctors about their pain. Most often, the reasons for keeping pain a secret are based on fears or myths:

Fear of being labeled as a "bad patient." You won't
find relief if you don't talk with your doctor about the pain
you feel.
Fear that increased pain may mean that the disease
has worsened. Regardless of the state of your disease,
the right treatment for pain may improve daily life for you
and your family.
Fear of addiction to drugs. Research has shown that
the chance of people with chronic pain becoming addicted
to pain-relieving drugs is extremely small. When taken
properly for pain, drugs can relieve pain without addiction.
Needing to take medication to control your pain is not
addiction.
Lack of awareness about pain therapy options. Be
honest about how your pain feels and how it affects your
life. Ask your doctor about the pain therapy options
available to you. Often, if one therapy isn't effectively
controlling your pain, another therapy can.
Fear of being perceived as "weak." Some believe that
living stoically with pain is a sign of strength, while seeking
help often is considered negative or weak. This perception
prevents them seeking the best treatment with available
therapies.

Don't let fears and misconceptions keep you from talking to your doctor and other members of your health care team about getting adequate pain relief. Help and relief are possible, but only if you discuss your symptoms with your doctor.

Ten Steps From Patient to Person

American Chronic Pain Association

Making the journey from patient to person takes time. The isolation and fear that can overwhelm a person with chronic pain grows over time. And the return to a fuller, more rewarding life also takes time. It a journey with many phases. The ACPA describes these phases as Ten Steps. The Ten Steps For Moving From Patient To Person.

STEP 1: Accept the Pain
Learn all you can about your physical condition. Understand that there may be no current cure and accept that you will need to deal with the fact of pain in your life.

STEP 2: Get Involved
Take an active role in your own recovery. Follow your doctor's advice and ask what you can do to move from a passive role into one of partnership in your own health care.

STEP 3: Learn to Set Priorities
Look beyond your pain to the things that are important in your life. List the things that you would like to do. Setting priorities can help you find a starting point to lead you back into a more active life.

STEP 4: Set Realistic Goals
We all walk before we run. Set goals that are within your power to accomplish or break a larger goal down into manageable steps. And take time to enjoy your successes.

STEP 5: Know Your Basic Rights
We all have basic rights. Among these are the right to be treated with respect, to say no without guilt, to do less than humanly possible, to make mistakes, and to not need to justify your decisions, with words or pain.

STEP 6: Recognize Emotions
Our bodies and minds are one. Emotions directly affect physical well being. By acknowledging and dealing with your feelings, you can reduce stress and decrease the pain you feel.

STEP 7: Learn to Relax
Pain increases in times of stress. Relaxation exercises are one way of reclaiming control of your body. Deep breathing, visualization, and other relaxation techniques can help you to better manage the pain you live with.

STEP 8: Exercise
Most people with chronic pain fear exercise. But unused muscles feel more pain than toned flexible ones. With your doctor, identify a modest exercise program that you can do safely. As you build strength, your pain can decrease. You'll feel better about yourself, too.

STEP 9: See the Total Picture
As you learn to set priorities, reach goals, assert your basic rights, deal with your feelings, relax, and regain control of your body, you will see that pain does not need to be the center of your life. You can choose to focus on your abilities, not your disabilities. You will grow stronger in your belief that you can live a normal life in spite of chronic pain.

STEP 10: Reach Out
It is estimated that one person in three suffers with some form of chronic pain. Once you have begun to find ways to manage your chronic pain problem, reach out and share what you know. Living with chronic pain is an ongoing learning experience. We all support and learn from each other.

Helpful Hint: Consider going to a pain management clinic or a pain management specialist. NCPOA can help provide you with information about where to find these clinics and specialists. However, since we cannot evaluate the qualifications of these clinics and specialists, we can only give information, not recommendations. Our article ""Choosing a Pain Clinic or Specialist"" can help you make an educated choice best suited to your individual needs.

In My Opinion

By Me

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

In the future I will go into much more detail about my dealings with doctors, lawyers, insurance and courts in the meantime e-mail me with your horror stories or successes.

1. Sleeping-my first suggestion is a mattress I like the Memory Foam Mattress , 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.
Grand King Memory Foam Mattress
Grand Queen Memory Foam Mattress
15" Grand Plush Memory Foam Mattress - Suede & Cashmere Cover - Twin

2. Back support sitting-my suggestion for lower back and upper back support is the is the Obus Backrest Orthopedic Support high back rest for home, auto or office. Check out different styles. Mine 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. Electric Mobility Scooter- I have found that a 3-Wheel Travel 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. Also a Walker can be useful for stability.

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. Back Brace - 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. Spine- Back Realignment Device Note-you would not want to wear the brace to much because you have to work your muscles or they will atrophy.


Pain Resources
What is Chronic Pain
National Institute of Craniofacial Research
American Council for Headache Education
Amer. Pain Foundation
Chronic Pain Outreach
Pain Care Providers

Resources

* Health Encyclopedia
* Scooter Rentals
* FONAR Upright MRI
* Doctor Check

Articles on Medication

* Case for Opiates
* New Strategies for Managing Acute Pain Episodes in Patients With Chronic Pain
* Botox Injections

Medical Articles
Making Breaking Commitments
Chronic Pain and the Family
Neurostimulation-
(Spinal Cord Stimulation)
Chronic Pain in Primary Care
Acupuncture Help's Pain
PubMed
Medscape Search
Pain Pump (Intrathecal Drug Pump)

UNDERSTANDING CHRONIC PAIN

Your life is only as good as the memories you make.

This is so true and I have so many good memories. I am sure I have at least an equal number of bad memories, but I will not dwell on them. If you find yourself wallowing in bad memories STOP.

It may be hard but just stop it. Think of something good that happened. Then think of something else good that happened during your life. Search your past for those great moments.
Then repeat often.

Your life is only as good as the memories you make.  I forgot what life is all about, why we are here. I was to busy living in bad times of the physical pain I am feeling right now. The guilt I feel for not being strong enough for my family to keep things the way they were. The way things were before that split second changed everything in my life and the life of my family.

I vow to remember the good I have done, the good I have seen
and to enjoy the good yet to be.

Will You?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Right (and Wrong) Way to Treat Pain

Chronic pain is a thief. It breaks into your body and robs you blind. With lightning fingers, it can take away your livelihood, your marriage, your friends, your favorite pastimes and big chunks of your personality. Left unapprehended, it will steal your days and your nights until the world has collapsed into a cramped cell of suffering.

Check out the rest of the article By CLAUDIA WALLIS

February 28, 2005 issue of Time Magazine Article  
 Also finish the story here Back in Pain

Chronic pain often presents sufferers with a real "catch 22" dilemma. If they talk about their pain, they risk being perceived and labeled as hypochondriacs, or even worse, fakers or malingerers. On the other hand, if they hide their pain, others don't believe the pain is significant. It is enough to tax the patience of the most stoic person....
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

This site contains resources to inform you and hopefully help lower the level of your pain. Please check out the site and let me know what you would like to see or any information you would like to know to improve the site. I have put a lot of work into this site and will add features as I can. I sincerely hope this site will help you cope with the pain and stress and I will continue trying to offer what I can to help people, if you can please help out with a donation even a small donation will be greatly appreciated and can make a big difference. If there are any questions you have I will do my best to answer or help you find the answer. I hope you get the information to help for you or someone you know.

Thank you

God Bless and good luck

*Health Disclaimer*
Any information given about conditions, treatments, and products are not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on MY BACK PAIN.

Back Pain and Fractures

Compression and Wedge Fractures

Thomas A. Zdeblick, M.D.
Professor and Chairman Orthopaedic Surgery
University of Wisconsin
Madison, WI, USA

What is a Compression/Wedge Fracture?

A compression fracture is a common fracture of the spine. It implies that the vertebral body has suffered a crush or wedging injury. The vertebral body is the block of bone that makes up the spinal column.

Each vertebral body is separated from the other with a disc. When an external force is applied to the spine, such as from a fall or carrying of a sudden heavy weight, the forces may exceed the ability of the bone within the vertebral body to support the load. This may cause the front part of the vertebral body to crush forming a wedge shape. This is known as a compression fracture. If the entire vertebral body breaks, this is considered a burst fracture and is discussed elsewhere. The compression fracture may range from mild to severe in terms of severity. A mild compression fracture causes minimal pain, minimal deformity and is often treated with time and activity
modification.

Severe Pain
A severe compression fracture may be such that the spinal cord or nerve roots are involved, as they are draped over the sudden angulation of the spine. This may cause severe pain, a hunched forward deformity (kyphosis) and rarely neurologic deficit from spinal cord compression.

Risks - Osteoporosis - Trauma
The risk for spinal compression fracture increases with age. Osteoporosis is the most common risk facture for compression fractures. Osteoporosis is a condition in which there is thinning of the bones, weakening them. This may be due to a lack of calcium in the diet, certain medications, old age, inactivity or genetic factors. In general, some trauma occurs with each compression fracture. In cases of severe osteoporosis, the trauma may be minimal, such as, stepping out of a bathtub or lifting a heavy object. Moderate trauma is usually required to create a fracture in patients with mild to moderated osteoporosis. This may range from falling off a chair to an automobile accident. A normal spine may also suffer from a compression fracture when there is a severe forward bending injury. This most commonly occurs from a fall from a height or an automobile accident.

Nerve Injury
Neurologic injury is rare with compression fractures. The degree of neurologic injury is usually due to the amount of force present at the time of injury. If there is severe angulation of the spine secondary to a wedge fracture, this may stretch the spinal cord and create injury. This would then lead to loss of strength and sensation, as well as reflexes. In most patients with osteoporotic compression fractures, there is no neurologic injury but only pain from the fracture. However, if left untreated the fracture angulation may worsen and lead to late paralogic injury.


Diagnosis
A compression fracture is usually diagnosed by the history, physical exam and x-rays. In any patient over the age of 60 with the acute onset of sudden low back pain, a compression fracture should be suspected. Physical exam will usually note tenderness directly over the area of pain as well as mild kyphotic deformity (e.g., a sudden angulation forward or hunched over appearance). Plain x-rays will demonstrate the wedge shape of the vertebral body on a lateral view. A CAT scan is occasionally needed to help differentiate a compression fracture from a burst fracture.

Occasionally an MRI scan is obtained to rule out disc herniation along with a compression fracture. MRI scan may also help differentiate pathologic compression fractures, that is, those that involve a tumor, from a typical osteoporotic compression fracture. In any patient with a known history of cancer, a compression fracture should tip off the physician to look for evidence of a metastatic lesion and pathologic fracture. If osteoporosis is suspected, a Bone Mineral Density (BMD) test may be ordered. This test helps determine the severity of the bone thinning. In addition, laboratory tests to look at blood count and thyroid function may be indicated as well. A decision as to whether to treat osteoporosis should be made by the
patients' primary physician.

Burst Fractures:Defined and Diagnosed

Thomas A. Zdeblick, M.D.
Professor and Chairman Orthopaedic Surgery
University of Wisconsin
Madison, WI, USA

What is a Burst Fracture?

A burst fracture is a descriptive term for an injury to the spine in which the vertebral body is severely compressed. They typically occur from severe trauma, such as a motor vehicle accident or a fall from a height. With a great deal of force vertically onto the spine, a vertebra may be crushed.

If it is only crushed in the front part of the spine, it becomes wedge shaped and is called a compression fracture. However, if the vertebral body is crushed in all directions it is called a burst fracture. The term burst implies that the margins of the vertebral body spread out in all directions. This is a much more severe injury than a compression fracture for two reasons. With the bony margins spreading out in all directions the spinal cord is liable to be injured. The bony fragment that is spread out toward the spinal cord can bruise the spinal cord causing paralysis or partial neurologic injury.

Also, by crushing the entire margin of the vertebral body the spine is much less stable than a compression fracture.

Nerve Injury
Neurologic injury from a burst fracture ranges from no injury at all to complete paralysis. The degree of neurologic injury is usually due to the amount of force that is present at the time of the injury and the amount of compromise of the spinal canal. With a greater amount of force, more bony fragments can be forced into the spinal canal causing greater loss of spinal cord function. This may cause loss of strength, sensation or reflexes below the level of the injury.

Typically, in a burst fracture that occurs at the junction of the thoracic and lumbar spines paralysis of the legs and loss of control of the bowel and bladder may result. In an incomplete spinal cord injury only partial paralysis or reflex loss is seen. With mild burst fractures only transient symptoms may be present or no neurologic injury may be present.


Severe Pain
Burst fractures cause severe pain. Typically, this is pain at the level of the fracture, that is, in the back. However, pain may also be present in the legs following the distribution of the affected nerves. Many patients complain of an electric shock type sensation into their legs when there is spinal cord compression. Most patients with a burst fracture are unable to walk immediately after the injury. Seldom, the patient may walk away from an accident and still have a burst fracture. However, often the amount of pain that is present is severe enough that patients know it is a good idea not to walk.


Diagnosis
At the scene of the accident, patients complaining of severe back pain should not be placed into a seated for flexed position. They should be kept lying flat and transported in the flat position. A patient who stands or sits with a burst fracture may increase their neurologic injury. Burst fractures require immediate medical care by an orthopedic or neurosurgeon trained in spinal surgery. The patient should be transported to an emergency room and x-rays obtained.

The diagnosis of a burst fracture is usually made by x-rays and a CAT scan. Occasionally, an MRI scan may be ordered as well, in order to assess the amount of soft tissue trauma, bleeding or ligament disruption. The review of the CAT scan and x-rays allows the treating physician to make a determination as to the level of the fracture, whether it is a compression fracture, burst fracture or fracture dislocation, and to determine the amount of spinal canal compromise and spinal angulation. All of these factors enter into the treatment decision process.

The physical exam should be performed to document both spinal deformity, that is, angulation of the spine or tenderness of the spine at the level of fracture, as well as, a neurologic exam.

Neurologic exam should include testing of the muscle strength, sensation and reflexes of the lower extremities, as well as, testing of bowel and bladder sphincter control.

The Human Pain Effect
By Me

The effects of chronic pain can be devastating to the way of life not only to the person in pain but also for family and friends. Chronic pain over time can bring the strongest person to their knees. Anyone can block pain for a short period of time say a month or two to heal a broken bone or let a painful condition heal, but when the pain continues past that it can make the pain feel like it is getting worse because it takes more energy and it slowly will just wear you down. This does not make you weak it makes you human.

We can handle the pain for short periods of time because we know the pain will go away, pain always goes away. Right?

Unfortunately the answer is no sometimes pain does not go away. Chronic pain is pain that lasts well past the time of normal healing. You may have a serious injury that at first you handle without much problem (like a broken bone) because you can block the pain by keeping your mind focused elsewhere or by just biting your tongue. But the longer the pain lasts the more energy it takes to block the pain. Explained another way imagine pain as something you can see so you try to ignore the pain by not looking at it and keep your eyes looking away. But as time goes by and the pain does not go away it will take more and more effort to not look at it. Eventually the pain will wear you out. Over time instead of looking away from the pain you get to the point where all you can see is the pain, it will completely consume you before you even realize it happened. A example I use is imagine a pro football player who breaks his wrist. They set it put it in a cast and the next week he goes out and plays with the cast on. People are amazed that he can play in so much pain. But if that level of pain is still there the next year he won't be playing because it is to painful. Even though it is the same level of pain he played with before.

It will wear you down over time.
It seems that having chronic pain can actually create changes in the nervous system. What is Chronic Pain Video-ACPA So what do you do after the pain has already consumed you and you feel helpless. Get involved, the biggest mistake I think I made was not getting involved and letting the doctors take care of me. I actually thought doctors knew everything and the miracles of modern medicine could fix me. Wrong. Doctors know about anatomy but you know how your body feels better than the best doctor ever could. Get involved and get informed. Find out about your condition and talk to your doctor. Unfortunately not all doctors will listen or take your concerns as seriously as you may like. In that case you need to have a serious talk with your doctor or find a doctor who will listen which is not always easy. Also many doctors do not won't to admit that they do not have all the answers. Many seem to think they do. But I would rather have a doctor that is honest with you and tells you "I don't really know but we will find out" than have a doctor more or less guessing and contradicting other doctors "guesses". I have seen a lot of doctors over the years and have only had one doctor say "I don't know". It was unrelated to my back but I liked the honesty.

One thing that seems to be very effective at keeping your mind active and alert is debating friends family or anyone. This is something I used to do on a regular basis before my injury just because it was fun. Slowly I drifted away becoming mentally stagnant without even realizing it. After years of mental stagnation I finally woke up after a heated debate with a friend I had not seen in a while. For so long I had tried to have in depth discussions with mild success because the pain would always affect my thought process making it difficult to concentrate or hold my thoughts together. So whenever you are having a good day get comfortable and talk to someone and get your mind working. You will be glad you did.

Barriers to Seeking Pain Relief
 Read the Ten Steps below for relief

Many people with chronic pain don't seek pain relief, or even tell their doctors about their pain. Most often, the reasons for keeping pain a secret are based on fears or myths:

Fear of being labeled as a "bad patient." You won't
find relief if you don't talk with your doctor about the pain
you feel.
Fear that increased pain may mean that the disease
has worsened. Regardless of the state of your disease,
the right treatment for pain may improve daily life for you
and your family.
Fear of addiction to drugs. Research has shown that
the chance of people with chronic pain becoming addicted
to pain-relieving drugs is extremely small. When taken
properly for pain, drugs can relieve pain without addiction.
Needing to take medication to control your pain is not
addiction.
Lack of awareness about pain therapy options. Be
honest about how your pain feels and how it affects your
life. Ask your doctor about the pain therapy options
available to you. Often, if one therapy isn't effectively
controlling your pain, another therapy can.
Fear of being perceived as "weak." Some believe that
living stoically with pain is a sign of strength, while seeking
help often is considered negative or weak. This perception
prevents them seeking the best treatment with available
therapies.

Don't let fears and misconceptions keep you from talking to your doctor and other members of your health care team about getting adequate pain relief. Help and relief are possible, but only if you discuss your symptoms with your doctor.

Ten Steps From Patient to Person

American Chronic Pain Association

Making the journey from patient to person takes time. The isolation and fear that can overwhelm a person with chronic pain grows over time. And the return to a fuller, more rewarding life also takes time. It a journey with many phases. The ACPA describes these phases as Ten Steps. The Ten Steps For Moving From Patient To Person.

STEP 1: Accept the Pain
Learn all you can about your physical condition. Understand that there may be no current cure and accept that you will need to deal with the fact of pain in your life.

STEP 2: Get Involved
Take an active role in your own recovery. Follow your doctor's advice and ask what you can do to move from a passive role into one of partnership in your own health care.

STEP 3: Learn to Set Priorities
Look beyond your pain to the things that are important in your life. List the things that you would like to do. Setting priorities can help you find a starting point to lead you back into a more active life.

STEP 4: Set Realistic Goals
We all walk before we run. Set goals that are within your power to accomplish or break a larger goal down into manageable steps. And take time to enjoy your successes.

STEP 5: Know Your Basic Rights
We all have basic rights. Among these are the right to be treated with respect, to say no without guilt, to do less than humanly possible, to make mistakes, and to not need to justify your decisions, with words or pain.

STEP 6: Recognize Emotions
Our bodies and minds are one. Emotions directly affect physical well being. By acknowledging and dealing with your feelings, you can reduce stress and decrease the pain you feel.

STEP 7: Learn to Relax
Pain increases in times of stress. Relaxation exercises are one way of reclaiming control of your body. Deep breathing, visualization, and other relaxation techniques can help you to better manage the pain you live with.

STEP 8: Exercise
Most people with chronic pain fear exercise. But unused muscles feel more pain than toned flexible ones. With your doctor, identify a modest exercise program that you can do safely. As you build strength, your pain can decrease. You'll feel better about yourself, too.

STEP 9: See the Total Picture
As you learn to set priorities, reach goals, assert your basic rights, deal with your feelings, relax, and regain control of your body, you will see that pain does not need to be the center of your life. You can choose to focus on your abilities, not your disabilities. You will grow stronger in your belief that you can live a normal life in spite of chronic pain.

STEP 10: Reach Out
It is estimated that one person in three suffers with some form of chronic pain. Once you have begun to find ways to manage your chronic pain problem, reach out and share what you know. Living with chronic pain is an ongoing learning experience. We all support and learn from each other.

Helpful Hint: Consider going to a pain management clinic or a pain management specialist. NCPOA can help provide you with information about where to find these clinics and specialists. However, since we cannot evaluate the qualifications of these clinics and specialists, we can only give information, not recommendations. Our article ""Choosing a Pain Clinic or Specialist"" can help you make an educated choice best suited to your individual needs.

In My Opinion

By Me

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

In the future I will go into much more detail about my dealings with doctors, lawyers, insurance and courts in the meantime e-mail me with your horror stories or successes.

1. Sleeping-my first suggestion is a mattress I like the Memory Foam Mattress , 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.
Grand King Memory Foam Mattress
Grand Queen Memory Foam Mattress
15" Grand Plush Memory Foam Mattress - Suede & Cashmere Cover - Twin

2. Back support sitting-my suggestion for lower back and upper back support is the is the Obus Backrest Orthopedic Support high back rest for home, auto or office. Check out different styles. Mine 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. Electric Mobility Scooter- I have found that a 3-Wheel Travel 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. Also a Walker can be useful for stability.

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. Back Brace - 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. Spine- Back Realignment Device Note-you would not want to wear the brace to much because you have to work your muscles or they will atrophy.


Pain Resources
What is Chronic Pain
National Institute of Craniofacial Research
American Council for Headache Education
Amer. Pain Foundation
Chronic Pain Outreach
Pain Care Providers

Resources

* Health Encyclopedia
* Scooter Rentals
* FONAR Upright MRI
* Doctor Check

Articles on Medication

* Case for Opiates
* New Strategies for Managing Acute Pain Episodes in Patients With Chronic Pain
* Botox Injections

Medical Articles
Making Breaking Commitments
Chronic Pain and the Family
Neurostimulation-
(Spinal Cord Stimulation)
Chronic Pain in Primary Care
Acupuncture Help's Pain
PubMed
Medscape Search
Pain Pump (Intrathecal Drug Pump)

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]

Psychotherapy

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

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]