Pain Management


About pain management

Pain management combines techniques that help patients reduce or better tolerate pain. Today, expert physicians known as pain specialists have many options to help patients ease pain.

Pain results from the interaction between three components of the nervous system: the peripheral nerves, spinal cord and brain. Nociceptive pain occurs when nerve receptors that sense tissue damage are stimulated by an unpleasant sensation. Neuropathic pain is caused by damage to the peripheral nervous system or central nervous system.

There are two major types of pain:

Acute pain

Short-term pain that is often related to recent disease, inflammation, trauma or surgery. It usually passes quickly once a patient recovers from injury and often requires little treatment. Sources of acute pain include bruises, cuts, strains, sprains and fractures.

Chronic pain

Persistent and long-term pain due to disease, degeneration or an injury that did not completely heal. In some cases, chronic pain can occur despite a lack of an apparent cause. Common causes of chronic pain include:

  • Arthritis
  • Back pain
  • Neck pain
  • Other joint pains
  • Recurrent migraines
  • Fibromyalgia
  • Myofascial pain syndrome
  • Chronic fatigue syndrome
  • Systemic lupus erythematosus
  • Complex regional pain syndrome
  • Sickle cell anemia
  • Cancer pain
  • AIDS pain
  • Neuropathic pain
  • Cranial neuralgias
  • Post-shingles pain (postherpetic neuralgia)

People who develop significant pain often find that it overwhelms many aspects of their lives. Their personal relationships and work productivity may suffer, and their appetite may be reduced. Pain limits the mobility of some patients and prevents them from performing daily tasks. In many cases, pain also takes an emotional and psychological toll, fostering irritability, depression and feelings of hopelessness or even suicide. Experts in pain management refer to the presence of three symptoms related to pain – suffering, sleeplessness and sadness – as the “terrible triad.”

Untreated or undertreated pain can create an extreme rise in pain levels and patient anxiety. Pain management is best achieved by regular administration of pain medicine, or other treatments, to control the pain. When pain is under control, the patient’s quality of life is greater and the vicious cycle of ever-increasing pain can be alleviated. Patients whose pain is under control find they are less stressed physically and emotionally and are better able to sleep, focus on work and enjoy social activities and relationships with loved ones.

The best way to treat painful symptoms is to seek medical care to help alleviate the pain and diagnose the cause. Patients usually will see their primary care physician first to get a diagnosis and receive initial treatment. Some disorders will require consultation with a specialist to determine a cause. However, severe acute pain and chronic pain are often best treated by a pain specialist. These physicians are experts in all aspects of pain, including its causes, how the body reacts to pain signals and how medications or other treatments can dull or eliminate pain.

Many physicians who specialize in treating pain are anesthesiologists. These are the medical professionals who make sure that patients do not experience pain during and after surgery or other procedures, such as childbirth. In addition, many neurologists are skilled in pain management, especially for neuropathy, neuralgia and migraines and other headaches.

Physicians specializing in pain management usually have advanced training in the field of pain medicine (e.g., pain fellowship training), as well as certifications from a variety of boards, such as the American Board of Anesthesiology or the American Board of Pain Medicine.

In some cases, the anesthesiologist will lead a team of medical professionals dedicated to managing a patient’s pain. These may include physicians such as neurologists, orthopedists, oncologists and psychiatrists. It may also include other medical personnel such as nurses, physical therapists, occupational therapists and psychologists. This kind of treatment is known as multi-disciplinary approach to pain and has been seen to be most effective for various chronic pain conditions.

Other specialists who treat pain conditions include:

  • Rheumatologists, who specialize in rheumatic conditions such as arthritis and lupus
  • Physiatrists and sports medicine physicians, who specialize in musculoskeletal conditions such as tennis elbow and shin splints

Diagnosis, treatment and pain management

In diagnosing the cause of pain, the physician will review the patient’s medical history and should perform a physical examination. Patients will be asked to describe their pain in detail – location, duration, aggravating or relieving factors. Patients may also be asked to fill out a pain assessment questionnaire that helps the physician to determine how pain is affecting their life.

Diagnosis may be a lengthy process for some disorders, such as fibromyalgia. A wide range of diagnostic tests may be used, such as blood tests, urine tests, x-rays, radionuclide imaging or CAT scan (computed axial tomography).

Many treatments are available to alleviate pain. In many cases, they will be combined as part of a treatment plan to treat the underlying condition and the pain that results.

Over-the-counter and prescription medications are used to manage pain. These include:

Painkillers that do not decrease inflammation include two main categories:

  • Non-narcotic. Drugs such as acetaminophen relieve minor headaches and mild to moderate pain.
  • Opioids. These morphine-like drugs treat severe acute pain and some forms of severe chronic pain, such as cancer pain.

Anti-inflammatory drugs

Reducing pain and inflammation, these drugs come in two main categories:

These drugs are primarily used to treat depression, but some of them have also been shown to relieve the pain associated with certain disorders, such as diabetic neuropathy.

The U.S. Food and Drug Administration (FDA) has advised that antidepressants may increase the risk of suicidal thinking in some patients, and all people being treated with them should be monitored closely for unusual changes in behavior.

Injection therapy may be an option. Local anesthetics and/or corticosteroids can be injected around nerve roots or into muscles and joints. Such injections can reduce swelling, irritation, muscle spasms and abnormal nerve activity. For example, local anesthetics and corticosteroids can be injected in epidural space (the area between the protective covering of the spinal cord and vertebrae) for back pain. With nerve blocks, local anesthetics and/or corticosteroids can be injected to block a group of nerves (known as a plexus or ganglion) from causing pain in a specific organ or body region. For instance, a nerve block may be injected around the sciatic nerves for sciatica pain.

Several health professions contribute to pain management, including:

  • Physical therapy (PT). A program including exercise, stretching and training in posture and ergonomics can reduce pain, resolve gait disturbances and increase a patient’s mobility and function.
  • Occupational therapy (OT). This treatment helps individuals who have difficulty carrying out self-care, work or leisure activities. The difficulties may be due to pain, injury or illness, developmental or learning disabilities, psychosocial dysfunctions or age.
  • Exercise therapy. Exercise can strengthen muscles and increase range of motion. It also causes the body to release chemicals such as endorphins and enkephalins, which block pain signals from reaching the brain. Exercise therapy is offered by professionals such as exercise physiologists and certified trainers. It is also a common part of PT and OT.
  • Manipulation therapy. A variety of treatments use human touch or mechanical devices to improve body movement. Manipulation therapy is used to treat a variety of injuries, conditions and diseases such as back pain, neck pain, headaches and fibromyalgia. Types include:
    • Chiropractic
    • Massage therapy
    • Osteopathy
  • Cognitive behavioral therapy. These methods help patients to use body and mind to deal with pain, and include deep breathing, imagery and mediation.
  • Psychological support. Patients who experience pain often suffer associated mental anguish. Feelings such as anger, sadness and hopelessness can overwhelm patients who are suffering from pain. They can even lead to feelings of suicide, especially in depressed patients. These feelings can change the patient’s mood and personality and interfere with relationships and work and sleep patterns. Counselors and support groups can help patients to better cope with their condition.

Many modalities (physical therapeutic agents) are used in pain management. Some, such as heating pads or cold packs, can be used at home. Others, such as ultrasound therapy, require the expertise of a professional such as a physical therapist or occupational therapist.

Classes of modalities include:

  • Thermotherapy. Heat improves circulation, relaxes muscles and decreases stiffness. Types include ultrasound therapy, which can break down scar tissue.
  • Cryotherapy. Therapeutic use of cold reduces inflammation and swelling.
  • Hydrotherapy. Treatment using water is often incorporated into exercise therapy, thermotherapy and cryotherapy.
  • Electrical therapy. These techniques use mild electrical currents to stimulate nerves and muscles. Examples include transcutaneous electrical nerve stimulation (TENS), microcurrent electrical therapy (MET) and interferential electrical stimulation (IFC).

Some patients find relief from complementary and alternative techniques such as acupuncture, acupressure, biofeedback or hypnotherapy. Patients are advised to consult their physician before trying alternative methods, including nutritional supplements.
Surgery is usually a last resort for patients who do not respond to other therapies.

Examples include:

  • Arthroscopy. Arthroscopic surgery, involving small incisions, is less invasive than traditional operations.
  • Arthroplasty. Joint replacement, especially of the knees, is a common treatment for severe osteoarthritis. A fracture caused by osteoporosis may require a hip replacement.
  • Spine surgery. Types include fusion, discectomy, laminectomy and vertebroplasty and kyphoplasty.
  • Carpal tunnel release. Wrist surgery is sometimes recommended for carpal tunnel syndrome.

Seeking pain management

Patients who wish to see an expert in pain management can ask their physician to recommend a pain specialist. In some cases, patients may find these experts at a local pain treatment center. These may be referred to by several names, including pain clinic, pain management center, pain unit or pain service. In some cases, these facilities are attached to a hospital or medical center. In other cases, they are stand-alone facilities.
Services offered vary, so it is important for patients to find a facility that has the right expertise for treating their condition. A patient’s primary physician is usually the best resource for finding the appropriate pain experts.

However, patients may als

  • Call local hospitals or medical centers to find out if they are affiliated with a pain treatment center. If there is no nearby center, patients can contact their primary care physician, who may be able to make a referral to a local pain specialist.
  • Call local schools of medicine affiliated with nearby state universities or private colleges. Find out if these facilities offer pain treatment.
  • Use the Internet to contact organizations such as the American Society of Anesthesiologists or the American Academy of Pain Medicine to find out more about potential local pain-management resources.

Before receiving any care, patients should be sure the prospective pain specialist has the proper accreditation, preferably from a national organization such as the American Board of Anesthesiology or the American Board of Pain Management. Patients should also contact their health insurance company to see which costs will be covered.

The goal of therapy is usually to improve the quality of life and to reduce pain if possible. Before treatment begins, clients should be allowed to state their desired outcome.

A pain management program should also include:

  • Use of a pain analog scale before and after treatment. This is a pain assessment technique in which patients describe their pain on a scale of zero to 10, with zero representing an absence of pain and 10 representing unbearable pain.
  • Establishment of measurable goals and regular review of a patient’s progress toward achieving those goals.
  • Interaction and communication between the therapist and the patient. The patient should be allowed to offer feedback about the therapy.

Issues related to pain

Medical and technological advances have made pain more manageable today than ever before. However, in many instances pain goes untreated, undertreated or mistreated. Some patients believe that they must live with their pain. Others are afraid to request pain medications for fear of becoming addicted to them, even though this rarely occurs when medications are used properly.

In addition, many physicians have had little training in pain care and may be unaware or not fully informed of treatments that can help to relieve pain. When used properly under the close supervision of a physician, medications such as opioids can be used to treat pain without causing dependency and addiction.

It is important for patients to seek advice from a pain physician earlier in the course of the pain. Patients should not be embarrassed about their pain or afraid to voice their concerns out of fear of appearing weak or complaining. Pain that goes untreated may worsen other health problems, delay recovery and interfere with the healing process. Untreated pain worsens not only overall pain control but also the patient’s qualify of life. It is important that patients seek out proper care and not give up until they find an effective method of pain relief.

Questions for your doctor on pain management

Patients may wish to ask their doctor the following questions about pain management:

  • What are my options for pain relief?
  • Which medications can help treat my pain?
  • When over-the-counter drugs don’t help, which prescription drugs can?
  • Which allied health professions and treatments can help alleviate my pain?
  • Which modalities can help treat my pain?
  • Which types of heat therapy, cold therapy or other modalities can I safely use at home?
  • How can I tell which complementary and alternative treatments are legitimate and which are useless or harmful? Do you recommend any alternative treatments for me?
  • What is a pain specialist? Should I see one to help reduce my pain?
  • Where can I find a good pain specialist?
  • What should I look for in a sound pain management program?