The human body is dependent on function and movement to remain healthy. Therefore, the longer an injured body part is immobile, the more difficult the return to normal health. The re-education of the nervous system is dependent on restoring normal movement, normal range of motion and strength, and the correction of functional abnormalities. The pain physician should believe that early and aggressive functional restoration is vital to controlling pain, and restoring function. It is important to move the patient as quickly as possible from dependent, or passive physical therapy modalities, to movement based therapy. However, the patientís pain must be controlled in order to allow functional improvement. Pain control without pressing forward without functional physical therapy, is incomplete treatment. However, physical therapy without adequate pain control is usually impossible because of the discomfort. The early use of aquatic therapeutic exercise, is used to increase the chance of greater movement with less pain.
NERVE BLOCKS: DIAGNOSTIC AND THERAPEUTIC
The physician should be expertly(properly) trained in the placement of medications at specific locations of the spine, nervous system, joints, peripheral nerves, and soft tissues. This is done to treat pain syndromes, or to diagnose the problem that might be causing pain. Some injections are performed in the office, but most are performed at an outpatient surgical facility. Many of the procedures are performed with fluoroscopy, a type of x-ray, so that the needle can be directed specifically to the site in question. If the patient desires, a mild sedative can be given for maximum comfort and relaxation. The patient should expect a discussion of the purpose, risks, side effects, complications, and desired results of injection procedures. When indicated, the following procedures should be expertly performed by a trained physicians.
1. Epidural steroid injections- cervical, thoracic, and lumbar spine
2. Sympathetic Ganglion Blocks- Stellate and Lumbar
3. Sympathetic Plexus Blocks- Celiac and Hypogastric
4. Facet or Hypoapophyseal Joint Injections
5. Selective Nerve Root Blocks- cervical, thoracic, and lumbar spine
6. Peripheral Nerve Blocks
7. Sacro-Iliac Joint Blocks
8. Trigger point Injections
9. Radiofrequency Neurolysis
10. Diagnostic Discography
11. Occipital Nerve Blocks
12. Major Joint or Bursal Injections
13. Intrathecal or Spinal Injection of Medications
14. Placement of Spinal or Epidural Catheters for Spinal Infusions
15. Implantation of Spinal Cord Stimulator
16. Implantation of Intrathecal Catheters and Infusion Pumps
17. Implantation of Peripheral Nerve Stimulators
18. Implantation of Occipital Nerve Stimulators for Headache
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PSYCHOLOGICAL AND BEHAVIORAL THERAPY
The diagnosis and treatment of chronic pain must also include the emotional and psychogenic components of the problem. It is impossible for a human being to experience chronic pain, and not have this impact the individualís perceptions, mood, temperament, hopes, and abilities to deal with other people. Most chronic pain sufferers have a degree of depression and frustration. This is a normal reaction and the opposite reaction would be considered abnormal. The control of pain must include tools to help control and focus the power of the mind toward the problem. Sometimes it is common to use individual and group therapy, biofeedback techniques, hypnotherapy, visualization, and relaxation training to control symptoms.
All of us must eat and drink to survive. However, some pain syndromes can be effected by certain types of food. Chronic headache is particularly associated with chemicals, which are naturally found in some foods. Some patients suffer with obesity, and still others with malnutrition. Obesity can adversely effect a back pain patient, for example. In order to help the patient improve, the obesity must be treated.
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A variety of medications are now in the quiver of the pain specialist. The pain physician can now target specific receptors in the nervous system, and either stimulate or inhibit those receptors as is necessary to control the patientís symptoms. Medications can be used alone or in combination to either diagnose or treat a variety of conditions. These drugs are usually used in a continuum which starts with the weakest medication with the lowest number of side effects. Depending on the effect, the physician advances to stronger medications with potentially more side effects or problems. The categories of medications which can be used are listed below with some examples from each group. This list is not intended to be totally inclusive.
1.OPIOID ANALGESICS- This group of medications can be very useful in some types of pain and not so helpful in others. The weaker opioids include codeine, propoxyphene, and the stronger ones include morphine, oxycontin, and fentanyl. These medications can be given via a variety of routes and dosages.
2.NON-OPIOID ANALGESICS- This group of medications include salicylates like aspirin, the non-steroidal anti-inflammatories or NSAIDS, acetaminophen or Tylenol, and newer medications like tramadol or Ultram. These can be used in combination or alone.
3.ANTI-DEPRESSANTS- Depression is indeed a problem with chronic pain. However, these medications help increase certain natural chemicals in the nervous system such as serotonin and norepinephrine. These chemicals have been shown to decrease pain signals that start at the spinal cord level. This added affect make this group of medications very valuable in the fight against chronic pain. Examples include: Elavil, Serzone, Paxil, Prozac, Zoloft, Effexor, Remeron, Norpramin, and many others.
4.ANTI-SEIZURE- The same drugs that decrease firing potentials in the central nervous system, have the same effects in the peripheral nervous system. Injured nerves can exhibit firing activity which is abnormal, but can be controlled or decreased by this group of medications. Examples include: gabapentin or Neurontin, Tegretol, Dilantin, or Depakote.
5.MUSCLE RELAXERS- These can work centrally or peripherally to relax muscles, which many times spasm due to direct injury, or as a reaction to nerve tissue irritability. They can be very effective in some cases, but can cause sleepiness or sedation. Examples include: Robaxin, Parafon Forte, Flexeril, Soma, or Baclofen.
6.ANTI-ANXIETY- In many cases anxiety can worsen pain and make the patient more miserable than is necessary. A medication which helps the patient relax can improve sleep, muscle spasm, and decrease the perception of painful stimuli. Examples include: Valium, Xanax, Ativan, and Buspar.
7.BLOOD PRESSURE/HEART MEDS- This group of medications which are normally used to control hypertension, can also be used to control abnormalities of the autonomic nervous system. The sympathetic nerves can malfunction in some pain syndromes and worsen some types of pain. Examples include: clonidine, Vasotec, propranolol, and many others.
8.LOCAL ANESTHETICS- This group can be injected into tissue at specific locations for diagnosis or treatment. A short-acting local anesthetic, such as lidocaine, can be injected intravenously, as a test of certain pain receptors. An oral medication, mexilitene, can be given orally if the intravenous dose is effective. Longer acting local anesthetics are being developed for the future, so that a single injection might give months of relief. Examples include: Xylocaine, bupivicaine, Tetracaine.
9.STEROIDS- This group of very potent anti-inflammatories can decrease tissue swelling, and decrease firing of damaged nerve tissue. These medications can be injected directly into tissues such as into the epidural space, joints, trigger points, and other inflamed tissues. In addition, a short burst of oral steroids can be given to attempt to relieve painful symptoms. This group of medications can cause significant problems, or side effects if used excessively or inappropriately. Examples include: prednisone, methylprednisolone, triamcinolone, and dexamethosone.
10.SLEEP MEDICATIONS- Pain is always worse when a patient is sleepless, and thus, exhausted. The anti-depressants can also be used to induce sleep, if dosed properly. In some patients the use of a mild sleep aid can be helpful if used for short periods of time. Examples: Halcion, Ambien, Dalmane, and Restoril.
The pain specialists should or can use all of the medications available for diagnosis, treatment, or control of the patientís pain. The patient should expect a thorough discussion of each medication prescribed, the effect expected, side effects, and possible problems or adverse reactions.
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There is also many experimental treatments out there that are currently being tried in Germany an Mexico which puts the patient in a coma for 2 weeks to re-set the pain triggers in patients with RSDS aka CRPS. It has not been approved by the United States yet, but it could be in the next couple of years.
So don't give up, there are new treatments being tried every day.