Although pain is a part of life, there is much that doctors and other health care providers can do to reduce the severity of acute or chronic pain. Pain that is persistent, severe, continuous, or intermittent can destroy the will to live and interfere with adequate treatment when it is not controlled.
Chronic pain has its roots in social behavior and norms. People with painful conditions tend to be generalized in the same terms as "street addicts" when it comes to decisions that govern their ability to receive appropriate treatment and pain-relieving medicine. While the "street addict" who is psychologically sick and abuses drugs for recreation, the patient in pain is psychologically healthy and requires medicine and other measures as long as his or her symptoms remain.
Educating health care providers about pain diagnosis
A real problem in the appropriate diagnosis of painful conditions lies in the education of doctors and other health care workers. Pain has traditionally been treated as a symptom, which is appropriate in terms of acute injury or medical disease. Often, however, when injury has healed or the disease has subsided, such individuals might be left with chronic pain; and because of the disability it causes, this pain can be considered a disease in itself.
Pain management requires multidisciplinary approach
It was Dr. John J. Bonica, an Italian, who recognized that many of the thousands of wounded servicemen he managed during the end of World War II had pain long after their original injuries had healed. Their chronic pain affected the back, head and neck, abdomen, muscles, nerves, and limbs, and did not respond to traditional treatment. He realized that a multidisciplinary approach was required to satisfactorily control these symptoms. This approach required a combination of special diagnostic methods, as well as psychological assessment before treatment could begin.
Because the source of pain is often elusive, diagnostic techniques tend to look at altered function and tend also to be divided into those relying on a mechanical, chemical, or nerve related response.
The traditional tests used to diagnose painful conditions include X-rays, magnetic resonance imaging (MRI), electromyography (EMG), and nerve conduction studies. However, tests that are often performed in pain management centers are directed toward eliminating or reducing pain as an endpoint.
For example, while EMG and nerve conduction studies might tell health care providers what is wrong with a particular nerve or nerves, blocking these structures with a local anesthetic can help the health care provider distinguish between pain that might be arising within a nerve or nerves, or from the structures that they serve. Such tests might involve the sequential blocking of a peripheral nerve, the nerve root from which it arises, or a structure within the spinal canal, for example.
Often, because there is an interplay between different types of nerves — such as sympathetic, motor, and sensory fibers — some of the injection techniques are used to distinguish their respective roles in the production of pain by having as an endpoint a change in function or pain. For example, blocking the ability of a particular muscle or joint to move.
Certain conditions, such as reflex sympathetic dystrophy — which is now known as complex regional pain syndrome (CRPS) — are associated with a disturbance of the circulation to the skin and deeper structures. Diagnostic tests can be done to observe the change in temperature when sympathetic nerves, which control this circulation, are blocked. In this instance, thermography is used to measure these temperature changes dynamically and can be a great help in establishing a diagnosis.
Similarly, as anybody who has backaches knows, chronic pain symptoms might continue after otherwise satisfactory surgery when a mechanical defect is repaired.
Pain arising from structures around the spine has multiple causes, often without satisfactory evidence by the different imaging techniques. A common pain (backache) that remains after surgery can be identified by muscle dysfunction and can be confirmed by the use of trigger point injections, which can also facilitate its treatment.
The sympathetic nervous system has been shown to participate in many pain conditions, not infrequently after a pre-existing injury. Unless this is recognized through appropriate diagnostic testing, this type of pain will remain, no matter how many analgesics (pain killers) and other treatments are used.
Because chronic pain has such an impact on pain sufferers, it is important that the doctor understands the behavioral effects it can also have. A clinical psychologist/psychiatrist can discuss these aspects with the patient. Often, patients are convinced that their major problem is somatic and might be reluctant to accept that a component of their symptoms has a psychosomatic basis.
Depression resulting from severe, chronic pain is probably the most common psychological problem in pain patients. Many of the pain questionnaires that are used to assist in the diagnosis of chronic pain attempt to determine the impact of this pain on the workplace, home, social interaction, and physical activity. These questionnaires are taken together with the normal history and physical exam in making a diagnosis of chronic pain. Much of the history and physical exam is used when evaluating a patient with chronic pain. This has a functional basis and differs from the type of "history" and "physical" that are directed toward a "disease-based" diagnosis.
Multidisciplinary diagnostic approach
In the course of a "diagnostic workup," patients with chronic pain might be seen by four or five different health care workers during their first visit. These might include a pain doctor, who could be an anesthesiologist, internist, rheumatologist, neurosurgeon, or neurologist, as well as an occupational therapist, physical therapist, and psychologist. Because of the serious consequences of chronic pain for an individual — and society in general — it is important to establish an early diagnosis and create a management plan that can either eliminate or help the individual function with his or her pain. It is true that many of the chronic pain conditions affecting injured workers relate to the delay in diagnosis and effective treatment. Factors such as secondary gain due to the fear of being terminated from work (or worse, placed on social disability) materially influence a patient's response to his or her injury and chronic pain.
A large component of disability affecting the United States population is rooted in delayed diagnosis, misdiagnosis, inappropriate treatment, and discoordination of industrial and health care systems. It is hoped that interdisciplinary pain care in pain management centers will work closely with spine centers, rehabilitation medicine etc., to facilitate the management of patients with chronic pain. Ultimately, the employer and insurance industry also need to be involved.
However, as in all good medical practice, good treatment planning can only be based on accurate diagnosis. Chronic pain is a disease and for its successful management, requires the recognition of a source and therefore, diagnosis.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 9/29/2008...#4323