Online Health Chat with Dr. Jahangir Maleki
Tuesday, February 23, 2010
Cleveland_Clinic_Host: Pain touches us all, usually as a warning sign of injury or disease, which is also known as acute pain. This type of pain normally subsides following medical care and recovery. But according to the National Institutes of Health, 40 million Americans are unable to find relief for their pain. In these individuals the pain has become chronic.
Chronic pain frequently follows an acute pain condition such as an injury to the musculoskeletal system. A normal sign of chronic pain is its persistence beyond the usual duration of the healing that is required for an acute illness; as such there is no correctable cause for the chronic pain and it remains unresponsive to conventional treatments. Common conditions that are frequently associated with chronic pain include diseases of the spine with lower back or neck pain, headache disorders, Fibromyalgia, Reflex Sympathetic Dystrophy, Post Herpetic Neuralgia and many other disorders of the nervous system.
Cleveland Clinic’s Neurological Center for Pain offers a comprehensive approach to Multidisciplinary Diagnosis, Management and Successful Rehabilitation of individuals suffering from chronic pain disorders. Following a detailed evaluation and assessment process a patient centered plan of care is established and reviewed with the patients and/or their designated relatives! If necessary further diagnostic medical tests are recommended and identification of a treatable cause of the pain is always pursuit!
Depending on individuals needs, previous responses to treatment and personal preferences a variety of effective treatment options are available to patients. These include many non-surgical modalities such as specialized education and training in advanced physical rehabilitation techniques and psychological self-management skills as well as a combination therapy with medications. In certain cases more invasive procedures such as inpatient or outpatient interventional pain management options including nerve blocks, spinal or intravenous injections and/or infusions with anesthetics are also considered.
Cleveland Clinic also offers the Chronic Pain Rehabilitation Program. This unique, 3-4 week program is intensive and interdisciplinary, with day-long clinics focused on all aspects of physical rehabilitation, medication and psychological management, which addresses all aspects of chronic pain including the pain related disability, deconditioning, stress, suffering, depression, sleep disorder and anxiety. The comprehensive approach helps jump-start participants’ long-term management of chronic pain.
Jahangir Maleki, MD, PhD is a Pain Management Specialist in the Neurological Center for Pain. Dr. Maleki specializes in all aspects of the diagnosis and management of chronic pain disorders including interventional pain procedures.
Dr. Maleki attended medical school at the University of Heidelberg, in Germany. After his graduation he was trained in the specialty of psychiatry in Germany, followed by training in Neurology, Clinical Neurophysiology and Interventional Pain Management at MCP Hahnemann University (currently Drexel University College of Medicine) in Philadelphia, PA.
To make an appointment with Dr. Maleki or any of the other specialists in the Neurological Center for Pain at Cleveland Clinic, please call 216.636.5860 or call toll-free 866.558.2264. You can also visit us online at clevelandclinic.org/chronicpain
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Jahangir Maleki. We are thrilled to have Dr. Maleki here today for this chat. Let’s begin with the questions.
Albert: Is there a difference in the way chronic pain and acute pain feels?
Speaker_-_Dr__Jahangir_Maleki: Acute and chronic pain can feel exactly the same; however, their presentation is individually different.
Most pain practitioners define the difference between acute and chronic pain in chronological terms, i.e. a pain that lasts more than 3-6 months, or the time required for the healing of the primary inciting event that has caused the acute pain.
This differentiation is not perfect. Usually a chronic pain starts as an acute condition, but due to multiple other circumstances it transforms into chronic pain. Left untreated or with the addition of previous history of pain and other undiagnosed medical conditions; an acute pain can turn into chronic pain. The transition from acute to chronic pain is unique to each patient according to their condition.
Guernsey: How would I know if I have a chronic pain issue verses another underlying condition that is causing my pain?
Speaker_-_Dr__Jahangir_Maleki: Unfortunately, like everyone else, chronic pain patients can also develop acute medical conditions which may or may not be in the same location as their distribution of chronic pain. Usually, one with chronic pain realizes the extent, distribution, intensity and pattern of pain fluctuation which would be different than a new evolving condition.
However, one needs to be cautioned about ongoing treatments that can, under certain circumstances, mask the presentation of other medical conditions.
Marge: Are there specific symptoms to indicate I may have a chronic pain condition?
Speaker_-_Dr__Jahangir_Maleki: As we discussed, the duration of the pain is one indicator of transition into chronic pain. However, in many instances, one can appreciate the resistance to therapy, added disability, spread of pain from the original source, increased suffering and secondary development of pain behavior, anxiety, sleep disorders and, under other circumstances, depression and increasing social isolation.
Frequently, one will also notice other, usually, non-painful stimuli resulting in increased pain and maintaining the cycle of chronic pain.
stimpysan: In 2006 I had a cervical discectomy with fusion at C6-C7. When it herniated in 2003 I thought I was having a heart attack because of the chest and arm pain. I've had neck, chest, left arm, lower back and right leg pain ever since. I've been given almost everything to try to deal with the pain. The latest was tramadol and I've developed AFIB in the last month. I also had a recent MRI of my neck and I have a recurrent herniation at C6-C7 and it's still fused. What pain treatment would you recommend that isn't harmful to your heart and won't cause the AFIB to get worse. I have almost constant neck pain and nerve pain in my chest, arm and leg.
Speaker_-_Dr__Jahangir_Maleki: I would suggest that you have a comprehensive evaluation by a neurologist to assess other pain generators which may be outside of the spine. I would also look for the presence of brachial plexus entrapment, which is a very common condition in chronic neck and upper body quadrant pain. With this condition, pressure on the brachial plexus nerves results in arm symptoms. The nerves can get entrapped which causes pain, numbness and weakness in left arm.
I would also add, at the same time, if the pain has been present for a long time, with all likelihood, you may also have "central sensitization,' which refers to a heightened alertness of nerve cells within the spinal cord and brain, which can lead to a perception of increased pain with normal activities. This would also explain the spread of pain to areas other than the primary injured site or into different limbs, without an actual injury.
Due to the distribution of the pain, it appears that you could have nerve related pain and the management would include neuropathic pain medications, rather than taking narcotics.
I would also emphasize appropriate physical therapy and, if required, psychological measures to improve coping skills and long-term management.
shawn: Is there a pain management program at Cleveland Clinic that has experience in treating the condition of adhesive arachnoiditis relating to long term pain control for quality of life activity?
Speaker_-_Dr__Jahangir_Maleki: Certainly. Our initial comprehensive evaluation includes a detailed assessment and localization of pain generators. Depending on the individual's condition and their previous response to treatments, we may curtail or amend the treatment approach according to the patient's need.
We have had success treating patients with this condition, including ones who have had invasive procedures in the past, such as intrathecal drug delivery.
chef: I have fibromyalgia, ME, post 2 neck surgeries on c5, c6, c7, and now gastroparesis. The doctors say that pain meds will and do make my gastroparesis worse. This is very concerning and discouraging, any ideas?
Speaker_-_Dr__Jahangir_Maleki: An easy way of overcoming your problem would be the administration of opiates through an intrathecal pump, since the medication delivered is a much lower concentration and works only at a central nervous system level.
However, in my experience, patients have significant relief lasting for a few months only, i.e. it is like putting a Band-Aid on a leaky pipe. A long term and lasting solution would include a comprehensive approach to diagnosis and management of your chronic pain disorder.
Madonna: Can you help me with the pain from fibromyalgia? Is there any treatment exercise or anything else that will help Fibromyalgia? Is there medication that would help it? Would Prozac be prescribed to help the pain of this disease?
Speaker_-_Dr__Jahangir_Maleki: Fibromyalgia is a chronic pain condition which relates to central sensitization and is manifested clinically in widespread pain throughout much of an individual's body. The pain is usually increased with application of active and passive pressure to muscles and once flared up, even to skin and subcutaneous tissue. Changes in barometric pressure, humidity and environmental temperature can also result in flare-ups in pain.
Due to the chronic nature of the condition, subjects suffer from significant immobility related deconditioning, changes in lifestyle and development of chronic fear and anxiety from movement, which usually elicits pain.
As such, the best and most lasting option includes a multi-disciplinarian approach to pain management. The rehabilitation consists of ongoing physical, pharmacological and psychological modalities to suppress symptoms and improve an individual's function in a long term fashion.
Yes, if you make an appointment, we can help you with your pain!
charyvon: I have severe peripheral neuropathy(PN) in my feet, legs and hands since 1995. I’ve been taking gabapentin (Neurontin®) since 1999. Hydrocodone and Trileptal® were added in 2007. My PN pain is kept tolerable by this combination of drugs. I have had resistant hypertension for the past year. My blood pressure is often >200/100 in spite of as many as 5 blood pressure drugs. All tests to date have been normal. Could my PN and/or drugs be causing or contributing to my high blood pressure?
Speaker_-_Dr__Jahangir_Maleki: Usually not. Indeed, most patients with peripheral neuropathy also suffer from failure of the autonomic nervous system, which controls blood pressure, i.e., you could have low blood pressure.
A persistent hypertension requires a further medical diagnostic work-up while you are undergoing the treatment for the pain.
sajasaj: What are probable causes of pain in neck when trying to rotate it (limited to less than 30 degrees in either direction which sometimes makes driving a car difficult when looking over my shoulder to view blind spots of traffic behind). And what can be done to increase rotation ability of the neck? Also, I often have pain in right hip area when walking, causing a limp. At other times the hip seems to work normally. What might be the cause, and what can be done to correct? Thank you!
Speaker_-_Dr__Jahangir_Maleki: Restriction in range of motion can either be related to structural pathology, such as arthritis of the cervical spine joints, or related to spasms of the muscles on either side of the neck. As such, you will need a detailed medical evaluation and diagnostic imaging to assess for structural and/or functional deficits.
The above applies also to your hip. Frequently, lumbar spine pathology presents as intermittent hip or lower extremity pain.
stimpysan: I have been told to take many types of vitamins and supplements for pain and nerve pain. Do any of them actually work?
Speaker_-_Dr__Jahangir_Maleki: I will not say that these vitamin or supplement treatments do not work, however, there is no current scientific data showing that they do. If you gain more than 50% relief, feel free to continue. However, be aware that, at times, high doses of fat-soluble vitamins can result in elevated body vitamin levels and cause potential harm.
Olympia: Are there any types of medications that are ideal for treating chronic pain that won’t result in addiction?
Speaker_-_Dr__Jahangir_Maleki: Yes, non-addictive medications are used in the treatment of chronic pain. A detailed analysis of chronic pain reveals multiple underlying mechanisms that generate pain. As such:
- Pain related to muscle spasms should be addressed with muscle relaxants.
- Neuropathic pain should be treated with membrane stabilizing medications.
- Localized hypersensitivity can be managed with topical agents.
Matt: I have chronic back pain. The meds I have been given have increased the severity of my Hyperhidrosis. Vicodin, acetaminophen, hydrocodone - basically, all of them! What can I do?
Speaker_-_Dr__Jahangir_Maleki: Please see response to Olympia's questions as well as to other responses in regards to the comprehensive treatment of chronic pain. Opiates should not be the only tool used in finding relief.
Biofeedback & Pain Management
Kate31: What is the role of biofeedback in pain control and how does it work?
Speaker_-_Dr__Jahangir_Maleki: Biofeedback is used to help individuals focus and actively modulate one's physiological signal, such as skin conductivity, temperature or muscle spasm.
As such, it can help with learning how to control one's body's response and them relax as well as improve one's skill in achieving a state of relaxation much faster.
Choosing a Physician
Marge: What type of doctor should I see if I think I am suffering from chronic pain?
Speaker_-_Dr__Jahangir_Maleki: Unfortunately chronic pain can affect any part of the body. As such, different health care providers specialize in diagnosing and treating acute, as well as, chronic conditions related to their area of expertise. What is frequently under-diagnosed and under-treated are conditions that evolve in conjunction with chronic pain and affect the person as a whole. For example, a patient with chronic neck pain may end up suffering from a significant degree of pain related sleep disorders, anxiety and depression which will remain undiagnosed if no comprehensive assessment is in place.
There are several medical boards that offer specialization in pain medicine. These include American Board of Rehabilitation Medicine, American Board of Anesthesiology, American Board of Neurology and Psychiatry.
None the less, depending on background training, they will have a different approach to diagnosis and management.
Therefore, there are a number of specialists that you can see. However, be sure that specialist uses a multidisciplinary approach to diagnosis and treatment.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Jahangir Maleki is now over. Thank you again Dr. Maleki for taking the time to answer our questions about the diagnosis, treatment and management of chronic pain disorders.
Speaker_-_Dr__Jahangir_Maleki: Thanks you for allowing me to answer these questions for you. Best of health and don't stop looking for remission of your chronic pain!
- To make an appointment with Dr. Maleki or any of the other specialists in the Neurological Center for Pain at Cleveland Clinic, please call 216.636.5860 or call toll-free 866.558.2264. You can also visit us online at clevelandclinic.org/chronicpain.
- A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.
- If you need more information, contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
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