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Managing pain: Attitude, medication and therapy are keys to control

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    Managing pain: Attitude, medication and therapy are keys to control

    Managing pain: Attitude, medication and therapy are keys to control

    Pain is universal. You can trace its trail through time - from a toothache evident in the fossil remains of a human jawbone to today's drugstore shelves packed with pain relievers. Almost half of all Americans seek treatment for pain each year - 7 million from newly diagnosed back pain alone.

    Pain is complex. Sometimes it's beneficial. A sharp stab alerts you to injury when you burn your finger, hurt your back or break a bone. But other pain - the day-after-day ache of arthritis or the anguish of cancer - serves no useful purpose, and its relentlessness can become overwhelming.

    Above all, pain is unique. The varieties of misery are as many as its sufferers. Your pain is an interplay of your own particular biological, psychological and cultural makeup.

    New insights into these components are changing the concept of pain management. Pain is no longer seen as just a companion of disease or injury. It can become a damaging process in its own right that requires early and aggressive treatment.

    In addition, effective management increasingly focuses on your attitude as well as your medication and other therapies. You must understand the reasons for your pain and how to control it. By working closely with your doctor and healthcare team, you can learn to manage your pain and enjoy a more fulfilling family, work and leisure life.

    Exercise, relaxation techniques and physical, occupational and psychological therapies play important treatment and prevention roles. And new drug delivery systems can keep some types of pain under continuous control. But despite these advances, some painful conditions are still inadequately treated.

    The physical sensation

    Most pain originates when special nerve endings, called nociceptors (no-sih-SEP-turs), detect an unpleasant stimulus. You have millions of nociceptors in your skin, bones, joints, muscles and internal organs. As many as 1,300 nociceptors may reside in just 1 square inch of skin.

    Some nociceptors sense sharp blows, others heat. One type senses pressure, temperature and chemical changes. Nociceptors can also detect inflammation due to injury, disease or infection. Nociceptors use nerve impulses to relay pain messages to networks of nearby nerve cells (your peripheral nervous system). Messages then travel along nerve pathways to your spinal cord and brain (your central nervous system). Each cell-to-cell relay is almost instantaneous, thanks to chemical facilitators called neurotransmitters. These chemicals flow from one nerve cell to the next in less than a thousandth of a second.

    Some nerve pathways are faster than others. One type makes connections with many surrounding nerve cells en route. They transmit more slowly. You feel this type of pain as dull, aching and generalized. Another type relays impulses almost instantaneously and signals sharp pain focused in one spot.

    Scientists believe that pain signals must reach a threshold before they're relayed. This "gate control" theory holds that specialized nerve cells in your spinal cord act as gates that open to allow pain messages to pass, depending on the strength and nature of the pain signal as well as the surrounding stimuli (context).

    A message-routing section in your brain

    Pain signals travel from your peripheral nerves to your spinal cord to your thalamus, a message sorting-and-switching station in your brain. The thalamus sends two types of messages. One goes to your cerebral cortex, the thinking part of your brain, which assesses the location and severity of damage. The second is a "stop-pain" message back to the spinal cord to stop sending any more pain messages. Once alerted, your brain doesn't need additional warning. But sometimes, this mechanism fails and pain persists.

    Meanwhile your cerebral cortex relays the pain message it received to your brain's limbic center. Your limbic center produces emotions such as sadness or anger in response to pain messages. Your limbic center can affect the way your cerebral cortex perceives pain messages and can lessen or intensify your pain. Your cerebral cortex also sends messages to your autonomic nervous system, which controls vital body functions such as breathing, blood flow and pulse rate.

    Several types of proteins and hormones produced in your brain or nervous system (neurotransmitters) can increase or decrease pain signals. A substance called prostaglandin speeds transmission of pain messages and makes nerve endings more sensitive to pain. And a protein called substance P continuously stimulates nerve endings at the injury site and within your spinal cord, increasing pain messages. Serotonin and norepinephrine (nor-ep-i-NEF-rin) seem to decrease pain by causing spinal cord neurons to release natural pain relievers called endorphins.

    The emotional component

    Pain is not simply a matter of passing messages up and down your spinal cord. When a pain signal reaches your brain, it passes through a filter of your personal experience. Your emotional and psychological state at the moment, memory of past pain experiences, outlook and stress level all affect how you interpret a pain message and your ability to tolerate it. Your upbringing and cultural attitude toward pain also play a role. And your age, level of information about your pain and even lack of sleep may have an impact.

    The emotional responses of shock, fear and anxiety can increase your perception of pain. For example, a minor pain sensation, such as a dentist's probe, combined with anxiety can cause undue pain.

    But your emotional state can also diminish major pain messages. One pain study compared survivors of a major battle in World War II with men in the general population of a major U.S. city, matched injury for injury. The combat veterans required less pain relief than those in the general population.

    People who learn from upbringing and cultural background that the normal response to pain is great suffering and distress actually experience more pain than do people who grow up in an environment where pain is often ignored. The common expressions "suffer in silence," "bite the bullet," "grin and bear it" and "no pain, no gain" point to American cultural patterns that discourage acknowledgment of pain.

    Types and characteristics of pain

    In general, doctors divide pain into two general categories - acute and chronic.

    Acute. Acute pain is temporary and is related to the physical sensation of tissue damage. It can last from a few seconds to several months but generally subsides as normal healing occurs. Examples include a burn, a fracture, an overused muscle or pain after surgery. Cancer pain may be long lasting but acute due to ongoing tissue damage.

    Chronic. Chronic pain lingers long beyond the time of normal healing. Some chronic pain is due to damage or injury to the nerve fibers themselves (neuropathic pain). Although it may begin as acute pain, neuropathic pain often develops gradually and becomes chronic pain, which is difficult to treat.
    Chronic pain can result from diseases, such as shingles and diabetes, or from trauma, surgery or amputation (phantom pain). It can also occur without a known injury or disease. Like a gate that's blocked open, nerves continue to send pain messages even though there is no continuing tissue damage.

    Chronic pain ranges from mild to disabling and can last from a few months to many years. Significant emotional and psychological components may develop. The essential ingredient is that the chronic pain changes your behavior. For example:

    You experience the actual physical sensation of acute pain - the immediate, sharp stab in arthritic finger joints as you try to open a lid. Next is the emotional response - your anger and frustration with fumbling fingers. Eventually, behavior changes may occur. You may avoid using aching fingers and hands. Your hands become weak from inactivity, and you depend on others for assistance.

    Chronic pain can result in lowered self-esteem, sadness, anger and depression. Over the long term, a sense of helplessness to control chronic pain can lead you to develop characteristic "pain behavior." Behavioral changes can become habitual - crutches that can undermine your ability to effectively manage your pain.

    Evaluating pain

    Pain is subjective, but there are ways to measure it. Doctors may use questionnaires, have you fill out a pain-rating scale or have you select words that best describe your pain.

    When repeated attempts to find a cause fail and treatments aren't effective, you may benefit from a team approach offered by a pain clinic. A thorough evaluation may involve specialists in anesthesiology, neurology, psychology and psychiatry, rheumatology, physiatry and physical therapy. The goal is to treat all facets of your pain.

    Specialized tests can evaluate how your body senses nerve impulses and how the impulses travel through your nervous system. Imaging techniques, such as X-rays, computerized tomography (CT), magnetic resonance imaging (MRI), bone scans and ultrasound, may help detect problems in bones, muscles, joints and soft tissue.

    Treat pain early and aggressively

    For many years, standard practice called for treating moderate to severe acute pain with injections of opioid medication, as needed. This method often resulted in delays and widely varying levels of pain relief. Your pain rose and fell based on the dose timing. For most people, pain relief was effective only part of the time. Even today, pain is often undertreated.

    Inadequate pain control can occur for many reasons. The choice, dose and timing of medication are critical in obtaining effective relief. Also, patients and their doctors may be unduly concerned about the use of opioids in treating acute pain. But addiction is rare when opioids are used for short-term relief of acute pain. It may become a problem when opioids are inappropriately used for chronic pain relief, although addiction is not an issue in treating pain from a terminal illness.

    The difference between narcotics and opioids is that narcotics - a regulatory term used by the Drug Enforcement Agency - includes such chemicals as marijuana, cocaine and LSD as well as morphine. The term is not specific to medical use, as is opioid .

    Adequate acute pain control following surgery is important because it can allow you to recover your strength faster and start walking earlier. This can help you avoid problems, such as pneumonia and blood clots, due to inactivity.

    Inadequately treated acute pain can prolong recovery and make you more susceptible to chronic pain. Continued pain messages enhance subsequent pain responses. Peripheral pain receptors become more sensitive. And continued pain may cause long-lasting modifications in nerve cells along spinal cord pain pathways. These changes make established pain harder to suppress.

    As pain persists, feelings of anxiety, stress, anger, helplessness and depression can worsen. Tension and pain may initiate a downward pain spiral that's difficult to break. Early, aggressive treatment and working with your doctor to prepare a pain plan can help prevent this.

    Pain-relieving medications

    Pain treatment often includes medications and nondrug therapies. Over-the-counter pain-relieving (analgesic) drugs include:

    NSAIDs. Nonsteroidal anti-inflammatory drugs, or NSAIDs (en-SAYDS), are used to treat acute pain from inflammation, such as from arthritis. They relieve pain by inhibiting production of pain-intensifying neurotransmitters activated by tissue damage. NSAIDs include aspirin, ibuprofen (Advil, Motrin), naproxen sodium (Aleve) and ketoprofen (Orudis, Oruvail). All can cause gastrointestinal bleeding. All are also available in prescription form. The newer COX-2 inhibitors rofecoxib (Vioxx) and celecoxib (Celebrex) are other useful medications for some circumstances.
    Acetaminophen. Acetaminophen (Tylenol, generics) is used to treat pain and control fever, but it has only a limited effect on inflammation. It doesn't cause gastrointestinal bleeding like the NSAIDs, but prolonged, high-dose use can cause liver damage.

    Drugs available only by prescription include:

    Opioids. These drugs are the most effective medication for moderate to severe pain. They're used for cancer pain as well as acute pain when the cause is known and other medications are ineffective. Opioids play an important role in the treatment of pain associated with terminal illness.
    Opioids include drugs derived from opium (opiates), such as morphine and codeine, and synthetic opioids, such as oxycodone hydrochloride (Oxycontin, Roxicodone), tramadol (Ultram), methadone (Dolophine) and meperidine (Demerol). Side effects include drowsiness, nausea, constipation and mood changes. Addiction does not occur when patients take opiates for pain as instructed by a physician.

    Antidepressants. These medications may offer some relief for people with chronic pain, whether or not they also have depression. Amitriptyline (Elavil), trazodone (Desyrel) and imipramine (Tofranil) are examples of drugs that may be used with other analgesics. The medications aren't addictive. They're especially useful for neuropathic, head and cancer pain. Side effects include drowsiness, constipation, dry mouth and weight gain.
    Anticonvulsants. Developed for epilepsy, these drugs, such as phenytoin (Dilantin), carbamazepine (Tegretol, Carbatrol) and gabapentin (Neurontin), also can help control chronic nerve pain. Side effects include drowsiness and confusion.

    Other drugs may be used for specific types of pain. Oral or injected corticosteroid medications may help relieve pain due to inflammation and swelling. Excessive or prolonged use can result in widespread problems, such as bone thinning, cataracts and increased blood pressure.

    Capsaicin (Zostrix), a topical cream made from an extract of red peppers, can help relieve skin sensitivity resulting from shingles. It's also used to treat pain from arthritis, cluster headaches, diabetic neuropathy and pain after mastectomy. You may have an initial burning sensation where the cream is applied. Benefits are temporary, so you'll need repeated application. Capsaicin probably relieves pain by interrupting transmission of pain messages from nociceptors.


    Short-lived acute pain generally responds to medication and goes away with healing. But persistent pain can lead to depression, inactivity, deconditioning and increased dependence on others.

    Chronic pain can interfere with sleep and eating habits, exercise, social activity and work. Breaking this cycle usually requires a coordinated approach offered in a pain rehabilitation program. Physical, occupational and behavioral therapies, and assistance with the psychological components of chronic pain, are the cornerstones of successful treatment. Here are some strategies for coping with chronic pain:

    Relaxation techniques. Stress increases muscle tension and worsens pain. Relaxation techniques - such as meditation and yoga - involve activities in which you focus on something other than your pain. You can do many at home. Listening to music, visualizing a relaxing scene, trying a new hobby or visiting a friend also may help. These techniques can alter peripheral and central pain processes and are especially effective for chronic headache and muscle tension.
    Biofeedback also may help by teaching you to be aware of autonomic pain responses such as skin temperature, muscle tension, blood pressure and heart rate, and how to modify these responses. Ask your doctor about where to find help in learning relaxation and biofeedback techniques.

    Occupational therapy. This helps you return to ordinary tasks around your home and work. Focusing on home responsibilities, work or volunteer activities - perhaps for limited hours at first - is a first step in pain rehabilitation.

    Physical therapy and exercise. You may fear exercise will increase pain, but if you start gently and increase gradually, exercise usually doesn't cause injury or additional pain. A regular program should include stretching, strengthening activities and aerobic exercise, such as walking, swimming or cycling. Slow stretching can relax muscles and release tension. If you have chronic back pain, you may get enough relief from muscle-strengthening exercises alone, thereby avoiding surgery.

    Family therapy. Chronic pain can change personalities and unravel relationships. The person with pain feels guilty, and family members become stressed taking on additional responsibilities and new roles. The key is to maintain your normal responsibilities and roles as much as possible.

    back / hip pain

    id just like to say what a great article that was and i totally agree though experience that exercising really dose help with back pain.
    for a while i struggled with what i thought to be back pain, i went to my doctor and he informed me that it was my weight that was causing the problem. i took this as gospel, so i tried to loose some weight although im really not half as big as some folk out there. eventually the pain became too much to exercise too strenuously. i eventually went to a chiropractor and she actually confirmed it was my hip joint that was the route of the problem and the exercises i had been doing had been aggravating the problem. i was then put on a course of stretch and strengthening exercises to build and loosen up the joint. i also bought a memory foam mattress (i know it was a little bit of a treat) and was advised to sleep with a pillow between my legs, this worked and now i have regained my mobility.

    Thanks for you time reading


      The foam mattresses sleep hot, but they are worth it for muscles which ache.
      Last edited by dejerine; 18 Jul 2007, 11:07 PM.


        yeah ill be honest I've never slept so well since buying this thing.
        my sister in law also did the same. she dose a lot of horse riding and she used to have muscle ache in her shoulder but the mattress really
        sorted it out

        Thanks for your time


          Originally posted by dejerine
          The foam mattresses sleep hot, but they are worth it for muscles which ache.
          That was a concern of mine, even though I found them comfortable. The "hot" factor was especially a concern since my wife is in her 40's, we don't need anything that will accentuate her "warm moments" in coming years. We wound up recently buying a gel-based bed, called an Intellibed. It's more expensive than the foam beds, but we both love it. The gel section is covered with a layer of materials that breath, so that makes it much nicer than a foam bed in respect to retained heat.


            The "sleeping hot" was a concern of me as well, I don;t deal with heat well lower than my level of injury.
            T7-8 since Feb 2005


              I found the heat factor to be a pain soother more than anything. My fiance and i have always dealt with heat well, so i can see where you are coming from. There are other mattresses available that perhaps would be better suited and dont increase the heat so much. My advice would be to talk with your local bed store, check the web and forums, gain as much info as possible and then try some out.
              Thanks for your time


                My nor shi septers are killing me

                NIce... but SCi CP pain aint of this earth...
                Mike (Florida)

                Cant we get 1 do over?


                  To Antiquity... That information was great. It also put into prospective exactly what I was trying to think of to tell my doctor, which I always forget while I am there. I wrote it down so I can ask him about it. L2 burst fracture ~ 2 - 15 inch rods screws and a cage, in my back, is my PAIN problem. I took 12 notes from your post to bring up to my doctor. I would just like to say thank you for helping me remember.
                  What a Dream


                    Memory Foam

                    Hi Yes i to bought a memory foam mattress, i also found it to hot but i have the perfect answer
                    I overcame this by reducing the quilt tog value down to 4.5 tog, what you have to remember is that the foam below the body has now increased in Tog value, so heat is retained and makes you hot, Now you must reduce the Tog value of your quilt, because heat rises.
                    The Memory Foam Mattress was a wonderfull purchase, it helped my back no end, i cant recommend one enough. the model i purched came first in the WHICH Report, it was called "Memory Flex From Health Beds" it was a great Memory Foam Mattress. and i have just bought another for the spare bed.


                      How do you clean them?

                      I have a three inch topper, but if I put it on my bed, I can't use the self-turning feature of my mattress, plus I'll be so high I can't reach my phone. I just want to make pads from it.

                      Proofread carefully to see if you any words out.



                        Originally posted by dejerine View Post
                        The foam mattresses sleep hot, but they are worth it for muscles which ache.

                        i agree with the mattress part, i have a 3000.00 mattress, i hate to leave home and sleep some where else its wonderfull but hot. It was a splurge but did help a bit. i also had to use a mattress pad to absorb some of the heat, between the mattress and the body next to me i was HOT!! there are lots of companies out there now that are not as expensive, spring air, and even corsicana have pillow tops and memory foams that will help tons.


                          sleep perfect

                          I couldn't handle the heat of the foam and got a Sleep Perfect air with a pillow top. Not quite as good as the foam, but soo much cooler and very good about minimizing pressure points.


                          The Ketamine Kitty

                          All the tears, all the pain, all the rage through the night (apolgies to the rewrite) RR

                          Next time I die make sure I'm gone,
                          don't leave 'em nothing to work on JT

                          And I ain't nothin but a dream JM