In managing pain successfully, Physician and patient must work together as a team. Just as a patient can not presume to know everything about a condition’s cause and ultimate treatment, a Physician must endeavor to learn and work with the patient who has learned much about the specifics of their case through their many travails therein.
As pain treating Physicians, we are often tasked with helping a patient stay ahead of the pain. This may at points require diligence and steadiness with certain treatments. However, some treatments carry side effects which mandate caution be exercised. The example which best crystalizes this balance is that of appropriate but guarded use of narcotics or similar habit forming medications. The answer of how to navigate such apparent conflicts lies in a compromise through teamwork to delve into the best balance between safety and end results or efficacy.
This requires Physicians to educate patients about risks of escalating side effects and the reasonably expected goal of each medicine type. Similarly the patient, possibly reluctant to lose control of a previously necessary dose or medicine type, must offer up courage and dedication to learn about and trust a new avenue of therapy.
Does one treatment fit all?
Often the answer is not singular, but a blend of treatments designed to attack the condition from new, multivariate directions. An example would be pain that has previously been treated with a narcotic solely, would be viewed more broadly to see if it is responsive to alternative approaches. If it’s conceivable that a particular pain has an array of potential sources, so must the treatment be multivariate. Physical sources include muscle, nerve, disc, ligament, tendon, bursa and bone, among others. Mental or emotional inputs are real and can contribute significantly to a pain state or response to a given treatment. Stress, coping and anxiety are more common than not, either entering a pain scenario as a prelude or as a consequence.
Can an understood body response such as inflammation play a role?
Quite regularly, inflammation is either a source or aggrivant to a given pain state. This being true, Physicians should offer education and introduce remedies targeting such. Specifically, icing or cold packs should be touted and started with specific instructions to gauge results and look for opportunities to gradually reduce the higher side effect medicine if possible. On visit two, taking stock of any progress, the next inflammation targeting treatment should be considered. As an example, once individual risks are discerned, NSAIDS could be introduced. As always, educating and watching the patient for potential side effects of this class of medicines is important, however if helping the pain, such an alternative could reap great rewards. Specifically, an awareness that pain relief is possible through another and less deleterious medicine. Usually a patient who has longstanding pain medicine requirements feels stuck. This providing of an alternative that is successful, safer and devoid of the stigma attached to narcotics can be groundbreaking. Meanwhile, each opportunity to provide reinforcement to a patient looking for an opening to reduce the tolerance forming medication should be seized.
Visit three may allow a clinician an opportunity to offer further inflammation control by way of an injectable anti-inflammatory. The options here are steroidal for the most part, though non-steroidal shots are available and appropriate for some presentations.
Can muscles be modified?
Similar steps can be taken as we introduce approaches that target muscle relaxation. Where step one might be simply stretching, this can be expanded to include physical therapy. Step two may offer modalities such as heat, or possibly assistive technologies like a TENS unit to augment results. Antispasmodic medicines could be added. Finally, invasive avenues such as dry needling or trigger point injections with or without steroids could be entertained.
Can the nerve signals be modified?
Likewise, nerve modifying treatments can be included. It is well documented that certain injuries or disease states can irritate or inflame the nerve. Data supports that the pressure of said inflammation as well as the chemical makeup of such can act to trigger the nerve. Such an irritant alone can drive pain states into existence or increase its intensity. The good news is that inroads are now being made into not only understanding how the source such as inflammation can be treated, but also how to modify the nerve response. Medications useful in this arena include gabapentin (Neurontin) and pregalbin (Lyrica). The precise mechanism of action is not fully elucidated but generally they have actions of calming nerve sensitivity. That is, while on the medicine a given amount of irritant will have less impact on the nerve. This is achieved by adjusting the threshold at which the nerve fires. Less firing, less pain is the principle.
Can the brain interpretation be modified?
The mind modifies all the sensory input throughout the body and as such is an important arena of treatment for pain states. Mind calming has many avenues of approach. The simplest of treatments might be relaxation techniques. Rates and depth of breathing can help reduce anxiety, often lessening pain along with it. Biofeedback helps many use their cognitive reasoning to find positions of relief and train their body in appropriate mechanics to avoid painful fluxes. Groups of medicines target relaxation, stress relief, anxiety, sleep needs and depression. All of such states can have carryover into pain trends and reporting so these classes of medicine can be helpful. As always, careful guidance and physician oversite is advised. Finally in regards to mental approaches to pain, there is a significant role for behavioral insights. Whether through a pain/behavior psychologist or psychiatrist, these techniques and medicines can have a profound positive impact, by identifying pain triggers or their resultant impact.
Is a rapid change in treatment course detrimental?
As are nerves, pain is susceptible to change. Slower or no transitions from one state of alert to another is preferred by both of these entities. As such, what may seem like reasonable treatment at the time may, by virtue of starting and stopping, startle the condition of calm into one of unrest and therefore aggravation or pain. For example, gabapentin should not be stopped abruptly for concerns of taking a relaxed nerve into the opposing state. Just as some medicines as such should not be fluctuated, the effects of alcohol, in and out of the system, especially in significant concentrations or volumes should be avoided. As with any central nervous system depressant, serious side effects may occur, especially in someone simultaneously struggling to balance pain cycles and medicines with their associated physical and emotional challenges.
Is it a team approach?
Yes. It’s imperative that the patient help with the team’s guidance of the plan by noting which of the new approach styles or combinations seems to be most promising.
Likewise, a physical therapist, chiropractor, psychologist or acupuncturist familiar with the case can weigh in on which combination or blend of treatments seems to be gaining traction. For instance, did inflammation control help the patient to tolerate more therapy offerings? Did relaxation and stress reduction techniques allow better acceptance, compliance, and tolerance of a given medical care plan?