Date: Fri 20-Oct-1995
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.