Reviving An Ancient Therapy To Manage Chronic Pain

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By Nicholas A. Grumbine, DPM

Controlling pain has become a sophisticated, albeit inexact science. Artful pain assessment, integrated care, the titration of medications and the effective use of therapies and modalities are tailored for each patient. Indeed, meticulous clinicians must avoid tunnel vision and take the proper steps in diagnosing and treating chronic pain.
Just as a specific and accurate diagnosis of chronic pain is necessary for effective treatment, obtaining a detailed history on the type of pain is essential. Note the mode of injury or deformity onset, the onset of pain and assess the type of pain as to consistency, duration and intensity. Have the patient describe the pain. Is it burning, cramping, stabbing, shooting and/or aching? Is there itching and/or soreness? Assess the patient’s past self-treatments as well as prior professional treatments as to the amount of improvement and their duration of relief. Determine if there are any activities that exacerbate the symptoms or put them in remission. Note environmental responses like weather, activities, shoe gear and the time of day that symptoms occur. No detail is too small.
Identify the location(s) of the pain and provide detailed maps for the areas. Determine areas of normal and abnormal functions. Perform a thorough systems assessment. Evaluate gait and limitations of function. Note trigger points of pain, areas of dysfunction and guarding. Make a generalized differential and working diagnosis. Confirm the diagnosis with testing and further examination for details.

As far as diagnostic testing goes, X-rays, CT scans, MRI scans, stress examinations and fluoroscans give details to the extent of pathology in bone and soft tissues. EMG and nerve conduction testing will give detailed assessment of the nervous system and the muscle function. Technetium scans and vascular studies will give detailed systems assessment.
Medications that control chronic pain include antispasmodic/seizure medications like Neurontin and Topamax. These medications are effective for neuropathies and sympathetic mediated pains. Sleep medication helps the tolerance of pain and stress. Antidepressants, tranquilizers, anti-anxiety medications and mood elevators help to control pain and reduce the secondary changes to chronic pain. Muscle relaxors, peripheral vasodilators and antiinflammatories reduce chronic pain. Oral and interstitial steroids and local anesthetics are effective for immediate relief.
Pain medication is necessary but can be overemphasized. Narcotics in modern chronic pain control are best used for breakthrough pain and acute pain relief. There is little long-term benefit for a patient to control the causes of chronic pain or resolve the painful stimuli with sustained narcotic use. The chronic use of narcotics for pain control is only a temporary band-aid. Chronic pain produces a fear in the patient and a panicked feeling that the pain will return or increase. The anticipation of the pain recurring sustains the patient’s use of narcotics and dependency results.

Understanding The Sources Of Pain
It’s important to understand that pain has three sources of stimuli: somatic, sympathetic and the pain reflex arc, and the higher brain centers for pain perception. There is an initiating or primary source of pain that triggers the pain stimuli. A common starting source of pain may be injury, surgery, fracture, hematoma, periostitis, contusion, instability, joint dislocation or infection. Chronic pain results when there is delayed healing. Secondary scarring, extensive swelling, delayed union and non-union, synovitis, adhesion and contractures, nerve entrapment, hypertrophic scarring and degenerative joint disease are all causes of painful delayed healing.

Secondly, the autonomic nervous system will normally filter pain stimuli through the spinal reflex arc. Chronic pain produces an overload of the sympathetic system, exaggerates pain and produces referred pain sites, and secondary symptoms and signs.
Finally, the upper motor functions and brain perceptions will heighten rather than dampen the pain stimuli. Brain functions that perceive emotions of anxiety, fear, stress and depression produce a chemical response that will magnify the pain. There is a release of chemicals, hormones, histamines, adrenaline and epinephrine that will exaggerate pain. There is a loss of sleep, a decrease in serotonin levels and suppression of natural endorphins.

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