Pain Management

Article Highlights

• Pain consists of nerve signals that blaze from any part of the body through the nervous system to the brain
• Chronic pain is persistent pain that keeps recurring, or pain that lasts for 12 weeks or longer
• Lower back pain is considered the single leading cause of disability worldwide
• Pain can only be mitigated, using medications, medical procedures, and lifestyle adaptations

Overview

There are hundreds of ways you can feel pain, from stubbing your index finger to cutting yourself while slicing vegetables. Like stress, pain is with us from the day we are born, and it remains with us like a faithful companion up to our last day on earth. As newborns, it is the pain of hunger, or of lack of warmth, that instinctively propels us to cry out in search of remedies.

Pain – and chronic pain- is a very personal and subjective experience, each one of us feeling it in our own individual way. And while some of us tolerate pain better than others, it is safe to assume that none of us are particularly enamored with it. Yet pain is vital for our existential safety, for imagine what would happen to you without pain if you dipped your foot into boiling water, or placed a hand on a hot stove. Sudden pain like that flashes an alert that triggers an instant and reflexive reaction, courtesy of your nervous system, and it prevents you from further injury.

Alternatively, pain can point to a source that needs attention, like a twisted ankle or a burgeoning headache. Or it can be:

• Steady and chronic pain, as with some diseases like fibromyalgia and cancer
• Sharp pain, like when you break a bone or pass a kidney stone
• A constant and throbbing sensation with chronic pain, like when you have a migraine
• Pulsating, such as when you have a raw tooth
• Or acutely incapacitating, such as with symptoms of appendicitis

Here are some of the more clinical descriptions for the pain that you may feel:

• achy
• tender
• dull
• thud
• stiff
• stabbing
• shooting
• burning
• throbbing

And while there is no cure for pain, it can be mitigated by various different means that include lifestyle adaptations, physical therapy, pain medications, medical procedures, and psychotherapy.

What Is Chronic Pain?

Chronic pain is the most widespread reason that sends us to the doctor. It is thought that 1.5 billion people around the world suffer from chronic pain, and in the U.S. alone, more than 100 million people are believed to be living with chronic pain, for the most part relying on pain medication for treatment.

Whereas acute pain of the type we have already mentioned warns us of potential injury, chronic pain is pain that keeps recurring, or one that persists for a long period of time (three months or longer is the often-used benchmark in clinical studies). Lower back pain, for example, can be unremitting and chronic, and like various other types of chronic pain, it is usually resistant to medical interventions. It can generally only be alleviated with medications and other treatment techniques like therapeutic massage, acupuncture, and physical therapy.

What causes chronic pain?

Chronic pain can originate in any part of the body and can cause a variety of different reactions. It has been likened to a malfunctioning neon fixture that keeps buzzing intermittently as it flickers on and off, with no relief in sight.

Chronic pain can result from acute pain, as for example when an eighty-year old person breaks a hip, with painful treatments for the rest of their life. It can alternatively rear its ugly head on its own, when there’s been no injury or visible cause, perhaps after an illness. In these and other cases, pain relief comes through a variety of treatments, though mostly through pain medications. Here are some likely culprits that often result in chronic pain:

• Cancer
• Sciatica, spondylosis, or other forms of nerve compression
• Pain from nerve damage (neuropathy)
• Pain from emotional distress (psychogenic pain)
• MS (multiple sclerosis)
• TMJ (joint dysfunction)
• Post-trauma or post-surgical conditions
• Inflammation
• Lupus
• Migraine
• Fibromyalgia
• Arthritis

Other causes of pain

Pain may also be the result of underlying health conditions, including:

• Severe, sustained weariness that’s often accompanied by pain known as chronic fatigue syndrome
• Fibromyalgia: hard to discern generalized pain mostly affecting muscle groups and bones
• Chronic inflammation in the gastrointestinal tract, known as inflammatory bowel disease
• A bladder pressure disorder known as interstitial cystitis
• Painful clicking or locking of the jaw, known as temporomandibular joint dysfunction
• Chronic vulva pain that is difficult to diagnose, known as vulvodynia

Types of chronic Pain

No matter how the pains are caused, they all share similar mechanisms in how the sensation is detected and transmitted, and treatment techniques are more or less the same for all, including prescription opioids and other pain medications. There are various types of chronic pain, as follows:

Nociceptive Pain

This is the most prevalent type of pain and is triggered when nociceptors around the body detect damaging or potentially dangerous stimuli. Nociceptors are sometimes called “pain receptors”, and they play a critical role in how you feel and react to pain. They are sensitive receptors that, once they spot harmful stimuli, they transmit messages through the nervous system to the brain for a reaction back the same way. They are only activated when something happens to launch them, and they serve as alerts from any part of the body, telling you that you have a problem that requires your immediate (and commonly reflexive, knee-jerk) attention.

There are three categories of nociceptors:

• Chemical: When for example a cut occurs and becomes infected, your blood will carry chemicals to fight the infection. These chemicals activate the nociceptors and generate pain.
• Temperature: If you stick a hand in boiling water, nociceptors transmitting pain are spontaneously triggered.
• Mechanical: this is for example when you inhibit or stretch a ligament beyond its natural capacity, triggering receptors that carry pain to the brain.

Nociceptive pain is commonly described as aching or throbbing pain, such as in fibromyalgia, headache, and arthritis.

Neuropathic pain

This is associated with damage to the neurons in the body. It is caused by nerves that are not functioning optimally and that transmit erratic messages of pain to the central nervous system and ultimately to the brain. The type of pain generated is often described as shooting pain, as it is transmitted in an uncharacteristic manner causing unusual feelings of pain. Examples might include:

• Phantom limb pain (following an amputation)
• Sciatica (irritation in the sciatic nerve)
• Diabetic neuropathy (damage to the peripheral nervous system)
• Post-mastectomy pain (pain disorder following breast cancer surgery)

Somatic pain

This is often referred to as “tissue pain”, or “skin pain”, or “muscle pain”, since those are the areas where sensory nerves detect the pain. This is what you feel when for example you cut your skin, stretch a muscle, or fall down the staircase and hurt yourself.

Visceral pain

This is also a type of nociceptive pain, referring to pain spotted by sensitive nerves in internal organs (such as in the thoracic, pelvic, or abdominal viscera organs). It is frequently described as generalized pain caused by firmness around the organs, and it is also known to radiate to other areas, making it hard to accurately locate and diagnose. An example of that is pain in the heart that is felt in the left arm and neck.

Psychogenic pain

This is an umbrella term used to describe a pain disorder associated with psychological issues such as strong emotions, fears, depression, distress, and obsessive thought patterns or behaviors. When severe enough, these can cause pain that is accompanied by fatigue and muscle aches. Symptoms of this type of pain include:

• Headache
• Muscle pain
• Back pain
• Knee and joint pain
• Stomach pain
• And other pains

Treatment for psychogenic pain includes various medications, including opioids, antidepressants, as well as psychotherapy.

Idiopathic pain

This is also referred to as pain of unknown origin as it has no identifiable cause. While this type of pain cannot relate to nociceptive, neuropathic, or psychogenic causes, and while it cannot be detectable by current medical knowledge, it is nevertheless real and prevalent among people who have a prior pain disorder such as fibromyalgia or cancer.

An example of persistent idiopathic pain would be facial pain in the form of burning pain in the face with no identifiable nerve or tissue damage. Again, treatments for pain relief consist mostly of pain medications, physical therapy, and psychotherapy for relief of mental anguish.

Low back pain (LBP) statistics

According to the Global Burden of Disease, low back pain is the single leading cause of disability worldwide. Here are some facts relating to low back pain in America:

• It is thought that over 30 million Americans complain from lower back pain at any given time.
• Half of the American workforce reveal they’ve had back pain in the past year.
• At the level of the most readily identifiable costs, which by no means represents all cost expenditures, Americans spend over $50 billion a year on back pain.
• Nearly a third of female adults suffer from lower back pain compared with a quarter for men, yet men claim their pain affects work 33% more so than women.
• 54% of U.S. citizens who have lower back pain conduct their work while sitting.
• Most causes of back pain are not associated with serious conditions like cancer, arthritis, broken bones, and the like.
• Back pain is on top of the list of reasons why we visit our doctor every year, and it is also one of the top causes of work-related absenteeism.

Causes of chronic low back pain

Studies have revealed that 90% of people with lower back pain in America never find out what caused their pain. Only 10% of Americans can attribute their lower back pain to an identifiable cause. The other fact that raises eyebrows is that the vast majority of cases of low back pain is when that pain is chronic, meaning that it either persist and recurs regularly, or that it lasts for longer than 12weeks.

There are literally dozens of causes for lower back pain. Here is a short list of only list those with the highest incidence in America:

Lumbar herniated (slipped) disc

This can occur at any level in your spine when the soft center of a lumbar disc tears through the harder outer layer and pressures the closest nerve root.

Degenerative disc disease

Part of the aging process is that vertebral discs lose their jelly-like mass and wear down, restricting their ability to resist pressures. They can thus transfer pressure to the disc wall that may tear and become painful or weak (and may lead to herniation).

Spinal Osteoarthritis

This is also referred to as spondylosis or degenerative arthritis of the spine, and it is associated with aging and obesity. It is slowly progressive, and it may cause stiffness in the back and neck. Younger people may develop it as well, mostly through injury or heredity.

Lumbar spinal stenosis

This is a medical condition in which the spinal canal where the nerve roots are located narrows, compressing the spinal cord and nerves, and causing pain.

Facet joint dysfunction

This is also known as osteoarthritis. The facet joints have cartilage around the discs and are surrounded by capsular ligaments that enhance your back’s flexibility and enable you to bend and twist.

Spondylolisthesis

This condition of the back occurs when one vertebra slips over the adjacent one. The pain ensues when the affected nerves are compressed.

Sciatica

This nerve is your body’s longest nerve and one of the most important ones. It begins at your spinal cord, runs through your hips and buttocks, and then branches down each leg, and it is caused by a variety of low back conditions, including lumbar degenerative disc disease.

Compression fracture

This is mostly due to weak or brittle bones such as from osteoporosis that cause a fracture in the cylindrical vertebra.

Deformity

This is the forward curvature of the upper body, known as thoracic Kyphosis. This combination of forward and reverse curves in the spine allows people to sit and stand upright. This deformity can cause lower back pain if it leads to the breakdown of the discs, facet joints, sacroiliac joints, or stenosis.

There are naturally many other risk factors for pain in general and lower back pain in particular. Among those, the most prominent include:

• Tumors
• Autoimmune disease
• PMS (Premenstrual Syndrome)
• Pelvic inflammatory disease (PID)
• Infection
• Prostatitis
• Kidney stones
• Endometriosis
• Cervical dysplasia
• Fibromyalgia
• And other conditions

Treatment of low back pain with medications

There are almost more drug medications for pain, both over the counter and prescription drugs, than there are types or causes of pain. Here is a brief listing, starting with NSIADS:

NSIADS

Non-steroidal anti-inflammatory drugs (NSAIDs) are used in pain management techniques to alleviate the symptoms of pain. These are pain suppressant drugs that function by way of a chemical process in which they block the effects of Cox 1 and Cox 2. Those are special enzymes that help produce prostaglandins, which in turn cause inflammation that results in pain. Examples of NSIADs drugs are such brand names as Celebrex, Motrin, Advil, Indocin and several other medications.

ANTIDEPRESSANTS

Here are some of the effects of depression and the pain depression causes:

Exhaustion, fatigue, and sleeplessness

Many people with depression find it hard to get to sleep or have fitful nights. Research has shown that over 80% of people with depression suffer from some kind of insomnia, while hypersomnia (oversleeping) is also possible. Irrespective, people with depression appear close to exhaustion, dragging themselves through as few chores as possible, their body movements slow and lethargic.

Digestive and metabolism problems

Depression usually means loss of appetite and weight, although some individuals may find solace in binging on food and gaining weight. One might also feel nauseous with either bad diarrhea or even worse constipation.

Migraines and aches in the joints and muscles

Depression can make any chronic pain worse, including migraine headaches, back and other pains. This is particularly regrettable, since it is frequently the case that it was the initial pain that contributed to the depression.

The current standard for dealing with depression is by the use of antidepressant medication (ADM). The main benefit of these drugs in pain management techniques is that they relieve the symptoms for as long as patients keep taking the drugs -they bring about a near absence of symptoms. However, they usually have to be prescribed for life, especially for patients who have a history of chronic depression, for going off the medication may throw the patient into a severe depression with a risk factor 3 to 5 times that of the general population.

Commonly used antidepressant drugs include:

• Celexa (citalopram)
• Zoloft (sertraline)
• Paxil (paroxetine)
• Lexapro (escitalopram)

ANTI-ANXIETY SSRIs

Selective Serotonin Reuptake Inhibitors (SSRIs), are a relatively new class of anti-depressant and anti-anxiety medication, usually prescribed in pain management techniques together with psychotherapy. The issue with SSRIs is, once again, that once one stops taking the medications, the anxiety disorder can rear its ugly head again, in full force, requiring additional pain management and pain relief techniques.

SSRIs are commonly used drugs for the treatment of Generalized Anxiety Disorder (GAD) as well as various other anxiety and phobia disorders. Such drugs include:

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Fluvoxamine (Luvox)
• Escitalopram oxalate (Lexapro)
• Citalopram (Celexa)

ANTI-SEIZURE MEDICATIONS

The Food and Drug Administration (FDA) has approved only a few anti-seizure drugs for the treatment of chronic pain. These include:

• Carbamazepine (Tegretol) for trigeminal neuralgia, diabetic neuropathy pain and postherpic neuralgia
• Gabapentin (Neurontin) for postherpetic neuralgia, or shingles pain, and also diabetic neuropathy
• Pregabalin (Lyrica) specifically for postherpic neuralgia and diabetic neuropathy.
• And various other anti-seizure medications.

CORTICOSTEROIDS

Corticosteroid drugs have been shown to reduce spontaneous discharge in an injured nerve, which reduces neuropathic pain. Prednisone or prednisolone are often used for pain relief although the most commonly prescribed corticosteroid for pain is Dexamethasone.

PRESCRIPTION OPIOIDS

High-strength painkillers known as opioids represent the most widely prescribed class of medications in the United States, despite their propensity for addiction and other harmful health conditions. And over the last decade, the number of prescriptions for the strongest opioid drugs has increased nearly fourfold, with only limited evidence of their long-term effectiveness or risks among pain relief techniques.

The rising use of legal prescription opioids, primarily painkillers such as Oxycodone and Hydrocodone (Oxycontin and Vicodin), have taken patients from pain care to increased opioid addiction. Deaths and other harmful health conditions from these prescription drugs and heroin have spiked, and pain treatment surveys suggest that hundreds of thousands of patients nationwide may be on potentially dangerous dosages.

Treatment of chronic pain without medications

There’s no commonly accepted pain relief program to tell people with back pain how to manage the condition effectively. People with low back or other chronic pain can only be encouraged to seek relief through a variety of treatments that may include:

COGNITIVE-BEHAVIORAL THERAPY (CBT)

Contingency Management and Cognitive Behavioral Therapy (CBT) are behavioral pain management treatments designed to help modify the patient’s expectations and behaviors related to pain, to increase skills in coping with various life stressors, to help restore a degree of normalcy to brain function, and to ultimately improve overall health. Moreover, psychotherapy treatments such as cognitive-behavioral therapy (CBT) have shown relatively good results, especially when applied in concert with pharmacotherapies.

PHYSICAL THERAPY

When applied correctly, physical therapy can be the corner stone and highly beneficial part of a pain management program. Physical therapists have at their disposal various possible treatments and techniques such as electrical stimulation, muscle-release techniques, heat, ultrasound, to aid your back muscles and soft tissues for pain relief. Physical therapy typically aims at boosting your flexibility and improve posture by strengthening back and abdominal muscles. By providing pain relief and enhancing flexibility, this type of pain management program has also been known to bring about improved overall health.

EXERCISE

If you have back or joint pain, there will be times when all you want to do is lie in bed all day. Lying in bed used to be what doctors prescribed the most, although it has been shown in many studies that it is exercise and staying flexible that does your back pain, and overall health, the most good. There are many simple exercises that can be performed in 20 to 30 minutes as part of your daily routine. If you are just starting out, even a simple act of sitting upright on an exercise ball for 30 minutes a day will engage your core muscles.

The muscles in your abs and back play a critical role in supporting your lower spine. These muscles don’t get a good workout during the course of a normal day—they need to be specifically targeted through exercise.

OTHER PAIN-RELIEVING OPTIONS

Here is a short list of what else you can do to mitigate the pain that you may be living with:

• Surgery
• Cortisone injections
• Stretching
• Chiropractic care
• Massage and manipulation
• Losing weight (for overweight people)
• Acupuncture
• Yoga, meditation and other relaxing techniques
• Cold and hot therapy

Final thoughts on lower back pain

We aren’t ever guaranteed lives without pain, and we can usually tolerate a little pain and still function relatively well. But when lower back pain becomes a scourge, debilitating us, or even merely interfering with our ability to be happy and thrive, then the pain needs to be addressed.

Postural problems are recognized as one of the most common causes for the prevalence of low back pain. Postural problems, along with leading a sedentary life filled with inactivity, piles on the pressure on your back and invites spinal abnormalities along with distorted muscles. Whether you are young, middle-aged or older—and especially if you are overweight—you could so easily develop lower back pain if you don’t stretch and exercise on a regular basis.