Date: Fri 20-Oct-1995

Publication: Hea

Author: SHANNO

Illustration: C

Location: 12

Quick Words:

chronic-acute-pain-arthritis

Full Text:

(Health Monitor)

Chronic Pain:

What Do You Do When There Is No Cure?

(with cuts)

By Shannon Hicks

Pain comes in many forms from many sources, but for the most part it is an

inconvenience. "Acute pain" comes from an injury; the injury heals, the pain

goes away.

Chronic pain is something altogether different. For one reason or another,

injuries - from simple bumps to severe burns - can result in a lifetime of

abnormal pain, what doctors call "chronic pain." The harshest difference

between acute and chronic pain is this: While acute pain can be cured, chronic

pain is almost incurable. It can only be made more bearable to live with.

Yet according to Dr Brian Peck, MD, of the Arthritis Center of Connecticut,

the treatment of chronic pain is a "very satisfying experience."

Acute pain is a natural protective mechanism in our bodies. It has a purpose:

It warns of injury. If you put your fingers too close to fire, for instance,

the message of pain tells your brain to pull your finger away before it

becomes burned.

If an injury has already occurred, pain is also a body's defense mechanism.

The pain of a twisted ankle, for instance, prevents you from using your ankle

so you won't cause further damage. Tendons and muscles tighten up and cause

pain by going into spasms, which in turn prevents you from using that area

until it has time to heal itself. This is the primary function of pain.

The definition of "chronic pain," however, is pain that serves no purpose. It

is abnormal pain. It is a frustrating pain, both for the physician trying to

help a patient, and just as much so for the patient.

Chronic pain can be caused by anything that causes damage to one or more parts

of the nervous system, because a normally-functioning nervous system will not

send out the message of pain all the time. Nerve damage can be the result of a

serious burn - a third-degree burn - or a crush can cause such damage to

nerves they do not heal properly. When they do heal, the scarred area is so

disrupted it cannot grow back normally.

Neurons, located in the spinal cord, are nerve cells with axons. At the end of

the axon are dendrites, like fingers on an arm. A nerve communicates with

other nerves, muscles or tissue through chemical activity at the dendrites. If

a nerve is severed at its axon, it will regrow, to some extent, but it is

extremely slow.

When a nerve has been cut cleanly, axons grow at the rate of one inch per

month. But if the injury is a burn or a crush, when the nerve regrows, the

scarred area is so disrupted it cannot grow back normally. It grows instead

into an abnormal mass, called a neuroma, which can be a source of altered

sensation, painful or otherwise.

If the autonomic nervous system (which controls things not usually thought

about, i.e. breathing, heart rate, temperature, fear responses) is damaged, it

also may begin to function abnormally. Blood vessels, for example, can begin

to open and close when they should be responding in the opposite manner.

Injuries can be simple - bumping a shoulder into a door; repetitive lifting of

a heavy object - yet they may cause such injuries to a ganglion (a mass of

nerve tissue) that the electrical firing pattern misfires so that when it

isn't supposed to, the blood vessels in your hand will squeeze down and

contract, get cold and white, for no apparent reason.

Or they may go the other way: The blood vessels could open wide up, getting

swollen and burning hot. This is called reflex sympathetic distrophy. A

patient like this could end up walking around with his or her arm in constant

pain.

Another very common type of nerve injury that leads to chronic pain is in

diabetics. The blood flow to nerves are very important, and because patients

of diabetes already have blood vessels that become "blocked up," they don't

carry oxygen well to extremities such as fingers or toes. So the tiny nerves

these vessels serve can become more easily damaged, which leads to a condition

called diabetic peripheral neuropathy. Diabetics with this ailment can

sometimes have such burning, painful feet they cannot put shoes or even socks

on their feet, they cannot walk. This is a result of diabetes leading to

chronic pain.

Chronic pain can be brought on by either injury or disease. It is not

congenital, or inherited. Diseases such as diabetes, arthritis, poor

circulation, osteoporosis, alcoholism and poisoning are the more common causes

of chronic pain; arthritis and osteoporosis are the most common culprits of

chronic pain.

There are many different kinds of arthritis, one of the most common being

osteoarthritis, a degenerative joint disease. Although it is most commonly

associated with age, it is not caused by age, says Dr Peck.

"Although age is not actually the cause [of osteoarthritis], all of the causes

of it do add up and become more important as age goes on," Dr Peck says. "For

example, injury to a joint or having a hereditarily-defective collagen [part

of cartilage] can develop into arthritis. So it does occur more with age,

although it is not an age-specific disease."

Another common type is rheumatoid arthritis, which is an immune disease.

Arthritis causes pain by having abnormal structures that patients have to

constantly use, explained Dr Peck.

Cartilage is probably one of the most perfect tissues that has ever evolved,

Dr Peck believes. "It's so perfectly spongy that when you step on it, it

compresses and all the fluid rushes out of it into the joint space, and then

you release your weight and it springs back and sucks up all its fluid again.

A million times a day, throughout your whole life... it goes on.

"All of a sudden, along comes a motorcycle accident or a fall down the stairs,

and a fracture line appears, due to the trauma, across the face of the

cartilage," the doctor continued. "You have an imperfect surface.

"All of the walking, and everything you try to do normally, grates across that

edge and it starts to wear away, just like a tire on the front of your car.

And that leads to arthritis. The simplest little thing.

"And once it is there, every movement in this perfect machine is never normal

again. You can never make it normal again."

There are drugs, physical therapy, injections into the joint - different

resources which help restore some function to the afflicted joint - but it is

never really normal again.

So what do patients have to look forward to once chronic pain has set in? Why

do doctors even try to treat patients, knowing that with all its advances,

today's medical establishment can only rarely cure patients living with

chronic pain?

If It's Incurable,

Why Keep Going?

Treatment of chronic pain is far different than treatment courses for chronic

pain. A broken bone, a bruise, a light burn and the like will all heal.

Acute pain hurts for a while, but it naturally heals so it can be treated with

bandages, pain killers or rest. There is little danger of a patient becoming

addicted to any pain killers, asserts Dr Peck, because the pain isn't going to

last that long.

In the word of chronic pain management, however, doctor and patient have come

to realize that, to a point, it is not going to go away completely.

By the time a patient walks into the office of a chronic pain specialist, he

or she has been suffering for quite some time. There may have already been

surgery performed, various tried and failed treatments, and, almost

guaranteed, some form of prescription pain-killers have been attempted.

Depression due to being limited from a former lifestyle may also be setting in

as well.

It is because all this has failed that many people wait too long before

seeking out a chronic pain specialist.

Chronic pain management is a field that uses multiple forms of therapy,

usually physical, in its attempt to-

(a) reduce chronic pain;

(b) improve function;

(c) prevent or avoid disability;

(d) avoid drug toxicities; and

(e) avoid depression.

"It's real easy to throw some narcotics at someone, because that works, right

away," said Dr Peck. "They make you feel good mentally, too, because of the

narcotic effect.

"But that leads to real problems [in long-term patients]," he continued. "And

that's the difference between the forms of treatment." The first job of a

doctor in this case, then, is to step in and find the way to work around a

narcotics dependency.

Pain management usually begins with taking charge and regulating any narcotics

patients are already on. This does not mean stopping the use completely, just

using better control.

Using coanalgesics - drugs that will interact better with what is already in

the patient's system - the physician will then introduce anti-depressants

and/or anti-inflammatories (to reduce swelling). Most people have significant

relief once this level of treatment is introduced.

Around this time, patients are also introduced to physical therapy.

"Probably the single most important treatment for all forms of

muscular-skeletal disease and pain is exercise," Dr Peck stated. Exercise will

prevent atrophy of any muscles, which causes even more pain. Physical therapy

is always part of the plan.

For patients with even stronger pain, management next introduces anti-seizure

medicines. For people who suffer fits or convulsions, this medication

decreases nerve impulse. Injections can also come into play. Nerve blocks can

reach places where nerves are malfunctioning, and re-set the nerve.

"Patients are being taught to change their lifestyle," says Dr Peck. "They are

not going to come in here and have me cut something out, throw it away, and

it's all better. That's not how it works."

Patients are going to go through some tough times, but working with their

caregiver and building a trusting relationship is what ultimately leads to a

pain that may be ongoing, but much more manageable.

"People say `How can you treat things that don't get better?'" Dr Peck said.

But the doctors and their patients already know the answer:

It is very satisfying to have someone enter an office on a walker or crutches,

or with fingers that can no longer button a blouse, to have a procedure

performed - most of which is relatively simple - and see the patient leave the

building holding the cane under their arm. The pain is lessened; confidence

has returned.

"That makes your day," he said. "To see their faces after a mildly painful

procedure, to walk out happy and do all of the things most of us take for

granted... that's why we keep going."

Dr Brian Peck is medical director of the Arthritis Center of Connecticut,

located in Waterbury, and director of its rheumatology division. A practioner

for 20 years in acute and chronic pain, he was recently certified by the

American Academy of Pain Management, a newly-created credential that requires

a combination of experience, formal lecture and materials study, and a

comprehensive examination.