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In order to treat pain, it is important to attempt to define it. Webster's
Dictionary defines pain as a sensation of hurting or strong discomfort in some
part of the body caused by injury, disease, or functional disorder and transmitted
through the functional nervous system. Furthermore, it is the sensation that
one feels when hurt mentally or physically, especially distress, great anxiety,
anguish, grief, etc. The International Society for the Study of Pain Management
defines pain as an unpleasant sensory and an emotional experience associated
with actual or potential tissue damage or described in terms of such damage.
Chronic pain is defined as pain which lasts for more than three months and
is associated with significant impairment of activities of daily living and/or
work activities. Thus, pain is not merely to be identified with nociception.
Patients have affective responses to pain. Ongoing pain may result in different
problems to different people. Functional impairments may vary depending upon
the patient's individual physical and emotional response to pain as well as
the responsibilities involved in their life and vocational activities.
Goals in pain management certainly involve the complete remediation of the
nociceptive etiology whenever possible. However, there are times when the focus
is on managing the pain. Functional goals must be addressed. This may include
activities of daily living, homemaking, recreation, sexuality, childcare and
vocational issues. Treatment must be done with appropriate utilization of medical
services. Appropriate medication usage is urged. Psychological support must
be delivered when needed. At times, marital support may be required. The patient
must be educated about the nature of their problem. Good biomechanics and ergonomics
as well as a therapeutic exercise program is encouraged.
There are five basic options utilized in the treatment of pain. These options
include addressing lifestyle issues, therapeutic exercise program, medications,
injections, and potentially surgery. Beyond these mainstream options, there
are a variety of alternative strategies including acupuncture, manipulation,
and herbal remedies.
Lifestyle issues may include tobacco cessation, weight reduction and substance
absence. Patients who smoke decrease blood flow to the intervertebral discs.
Smoking has been associated with an increase in back pain over time. Furthermore,
should a fusion be required, there is less chance of success. Patients who cough
may also induce a valsalva which can cause disc herniations. Patients who are
injured often gain weight over time. This is secondary to inactivity as well
as a variety of medications including anti-depressants and membrane stabilizers
which may induce weight gain. Once the patient has gained a significant amount
of weight, it becomes very difficult to lose it since they are not able to be
as active because of their pain. Finally, unauthorized drug usage and alcohol
usage may contribute toward dysphoria and other functional impairment. All these
issues must be addressed in conjunction with the other treatments.
Exercise is certainly the backbone of treatment in the conservative management
of spinal disorders. Patients with axial pain should be mobilized within two
to seven days. Patients with radicular pain should not be at bed rest for a
prolonged basis. In general, the patient should be mobilized within a comfortable
level as rapidly as possible. Bed rest causes deconditioning and muscular and
joint stiffness. Exercises to strengthen and stretch the back should be initiated
as rapidly as possible. These exercises should not induce severe axial or radicular
pain. Modalities including moist heat, ice and electrical stimulation can be
utilized to decrease discomfort so the patient can begin to exercise. Patients
who exercise improve aerobic endurance which improves muscle endurance. The
body fatigues less and good biomechanics are maintained. In general, patients
who exercise improve their overall health care and rate pain as less severe.
Exercise can assist with weight reduction.There is some evidence that aerobic
activity increases discal nutrition. Finally, patients feel good about trying
to help themselves. The patient enters a partnership with the physician in attempting
to improve their condition.
There are a variety of other techniques that can be used therapeutically to
support exercises. Good body mechanics should be taught to the patient. Specific
instruction in body mechanics should involve activities at home including homemaking
and childcare. Recreational activities should be addressed. Finally, vocation
should be addressed. The patient's workstation should be ergonomically correct.
Work tolerance and vocational counseling may be appropriate as well.
Medications are often utilized in the treatment of spinal disease. Non-steroidal
anti-inflammatories should be taken on a straight rather than on an as needed
basis in order to obtain an anti-inflammatory effect. The patient must observed
carefully to make sure that they do not have gastrointestinal distress. Peptic
ulcer disease is certainly a risk with non-steroidal anti-inflammatories. Long
term usage requires monitoring of renal and liver function. Narcotics may well
be appropriate in the acute patient. In general, these should be delivered on
a regular as opposed to a PRN basis. Patients must be observed for side effects
including sedation, constipation, urinary dysfunction and dysphoria. There is
a place for the treatment of chronic pain with narcotics as well. In general,
patients should be monitored appropriately and the goals of narcotic usage should
be addressed thoroughly. Pain management and improved function may be included
among these goals. Tricyclic anti-depressants may be utilized for pain and sleep.
Anticholinergic side effects must be monitored carefully. Cardiac, GI, and urinary
side effects are common. Weight gain may be significant. Membrane stabilizers, such as the anti-seizure medications,
may be useful for the treatment of neuropathic pain.
Spinal injections may be quite effective. Epidural steroid injections may be
delivered via a transforaminal or a translaminar approach. The use of fluoroscopy
is advised able to assure proper placement of the medication. These injections
have been proven to give significant pain relief for leg more than back pain
and the patient may get relief for up to three months. No more than three to
four injections per year may be delivered. Other sites which may cause pain
in the spine include facet or sacroiliac joints. Diagnostic and therapeutic
injections may be delivered under fluoroscopy to these sites. In general, spinal
injection treatments should be accompanied by an active treatment program which
involves learning good biomechanics and proper exercise techniques.
Finally, there are times when surgical options should be considered. Patients
with leg pain secondary to a mechanical impingement of the nerve root may respond
dramatically to the surgical decompression. This becomes emergent if the patient
has evidence a neurogenic bowel or bladder. Progressive weakness is also an
indication for more acute surgery. Patients who are recalcitrant to conservative
management over eight to twelve weeks are surgical candidates as well. Patients
with lower extremity pain which is produced by chemical radiculitis as opposed
to a mechanical impingement do not respond very well to surgery. Patients with
axial pain secondary to spondylolisthesis may be candidates for surgery if they
do not respond to conservative management as well. Finally, there are times
when lumbar fusion for discogenic pain may be appropriate.
Up to ninety percent of patients with pain secondary to a spinal etiology are
able to respond to conservative management. Each patient must be assessed on
an individual basis so that a program specific to their needs can be created
for them. There are certainly times when we are not able to completely resolve
pain. In these cases, pain and function must be addressed so that we can maximize
the patient's quality of life.
Reprinted with Permission
© 2002, Rothman Institute
All rights reserved
925 Chestnut Street, Philadelphia PA 19107-4216
(215) 955-3458
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