Chronic Pain Treatment Guide | Cleveland Clinic

Overview

Manage your pain and enjoy life again

Chronic pain can rule your life, interfering with your ability to work, sleep and enjoy your family and friends. When chronic pain disrupts your quality of life and does not improve with standard treatments such as aspirin or ibuprofen, Cleveland Clinic's Spine and Pain Medicine team is here to help. There are many safe, proven and effective treatments available that can help reduce your chronic pain. The sooner you seek treatment, the sooner you can start enjoying life again.

Collaborative Approach

Helping Patients Reclaim Their Lives Through a Collaborative Approach

Because chronic pain affects so many aspects of an individual’s life, pain medicine specialists collaborate with other Cleveland Clinic departments to develop and offer a multidisciplinary approach to address care plans for each patient.

Pain conditions we typically treat

Cleveland Clinic’s Spine and Pain Medicine team treats chronic pain related to any type of disease, injury or accident including:

Back and neck pain, including herniated discs, spinal stenosis, osteoarthritis and tumors
Complex regional pain syndrome (CRPS)
Muscle and joint pain and arthritis
Headache
Sports injuries
Disorders of the nervous system, including shingles and occipital and trigeminal neuralgia (facial pain)
Peripheral neuropathy, including diabetic neuropathy and chemotherapy-induced neuropathy
Cancer pain
Pain associated with osteoporosis and vertebral compression fractures
Post-surgical pain syndromes, including post-thoracotomy pain, post-mastectomy pain, and post-herniorrhaphy pain
Chronic pain after spine surgery

Back Pain

When oral pain medications or physical therapy fail to help patients with back pain – or when there are ongoing signs of weakness – seeking further evaluation from a pain specialist is the best course of action.

Pain medicine specialists base treatments and therapy on the underlying cause of the patient’s back pain.

Here is a rundown of common back pain causes and the interventions that can be done to manage the pain:

Lower back pain is often caused by degeneration of the posterior facet joints. Diagnostic nerve blocks are done to confirm the diagnosis. If this is the cause of your pain, pain specialists will often do a radiofrequency ablation (RFA) of the nerves for longer term relief. Radiofrequency ablation is a procedure using radio waves, or electric current, to generate sufficient heat to interrupt nerve conduction. In some cases, persistent low back pain is due to muscular weakness involving the multifidus muscles and can be treated with an implantable neurostimulation device.
Myofascial muscular pain - is one of the most common causes of back pain and happens when tight or sensitive areas in the muscles, called trigger points, develop due to stress, overuse, or poor posture. These trigger points can cause pain in the muscle itself or refer pain to other parts of the body. Treatment often involves a combination of approaches to relieve tension and improve muscle function. Physical therapy and specific exercises can help stretch and strengthen the affected muscles, improving posture and preventing flare-ups. Trigger point injections, which deliver medication directly into the painful spots, can also provide relief by relaxing the muscle and reducing inflammation. Together, these treatments aim to break the pain cycle and restore healthy movement.
When the nerve roots in the spine are compressed or irritated by herniated or bulging discs or narrowed nerve openings (radiculopathy), this can lead to pain that goes down the leg, with or without weakness and/or numbness. If there is no improvement with oral medications, epidural steroid injections can be considered to alleviate pain and facilitate physical therapy and an earlier return to work.
Discogenic pain – can be managed with new treatments including allogenic nucleus pulposus matrix injection. There are additional research studies being conducted with stem cell injections to treat degenerative discs.
Vertebrogenic pain – can be managed with a new treatment that ablates the basivertebral nerves within the vertebral body.
Multifidus Muscle Dysfunction - The multifidus is a deep muscle along your spine that plays a key role in keeping your back stable and supported. When this muscle stops working properly—often due to injury or long-term back pain—it can lead to ongoing discomfort and weakness. ReActiv8 is a medical device designed to help "wake up" the multifidus muscle by gently stimulating the nerves that control it. This stimulation encourages the muscle to work again like it should, helping to reduce pain and improve movement over time. It's especially helpful for people with chronic low back pain that hasn't responded well to other treatments.
Compression fractures – can be managed with braces, medications, and time. However in some cases, interventional treatments involving injection of methyl methacrylate into the vertebral body to stabilize the fracture (vertebroplasty or sacroplasty) or restore the height of the vertebral body (kyphoplasty) provide a more rapid reduction in pain and return to function.
For persistent pain after spine surgery, called persistent spinal pain syndrome or post-laminectomy syndrome, diagnostic or therapeutic injections are often the first step if a patient has not responded to oral medications alone. These are usually done in combination with physical therapy and medical management. If these provide temporary or insufficient relief, permanent implantation of a spinal cord stimulator can be considered and trialed.
For spinal stenosis, oral medications are tried first and if there is no improvement, interventions are warranted. The first option is epidural steroid injections along with physical therapy. Decompression surgery also has traditionally been considered. A procedure called PILD (percutaneous interlaminar lumbar decompression or commonly known as MILD procedure) is available for certain patients. Cleveland Clinic studies have shown great improvements in standing time and walking distance for patients who have had this procedure.
For intractable back pain, certain pain medications can be infused around the spinal cord through an implanted programmable pump to provide adequate relief of the pain. Typically, this is done as a last resort.

We take a multidisciplinary approach to pain management, combining expertise from spine specialists, pain medicine, physical therapy, and pain psychology to tailor treatment options to each patient’s needs.

Headaches

Pain medicine and headache specialists work with the patient to determine the type of headache – tension, migraine, cluster or cervicogenic – and to identify potential causes. This approach to treating headaches may include prescription medication to abort or reduce the frequency and/or severity of headaches, psychotherapy and stress reduction techniques. When the type of headache is diagnosed correctly and the factors that contribute to it are identified, treatment can be highly effective in reducing the frequency and severity of headache and helping people return to their normal activities.

Depending on the source and type of headache, treatment procedures include:

Specialized nerve blocks
Medication injections
Epidural blood patches
Stimulation therapy

These highly sensitive procedures, done near the nerves causing the pain, can alleviate headaches in some patients for six months or more.

In some instances, pain medicine specialists will do blocks in conjunction with radiofrequency ablation (RFA). RFA uses an electric current to heat up a needle, which creates a targeted lesion on the nerve to help block the sensation of pain. In all cases, diagnostic blocks are performed to ensure that the headache pain is relieved. If pain relief is successful, RFA is an ongoing treatment option.

Botox^® injections are another procedure that can be done to alleviate pain. In 2010, the FDA approved Botox for the treatment of migraine headaches. This involves Botox injections in different areas of the head and neck as needed. Pain relief typically lasts three to four months after a treatment, and the procedure can be done three to four times a year. Pain management specialists often work in collaboration with neurological specialists who also perform Botox treatments.

Other treatment options for headaches may include implantation of peripheral nerve stimulators. This is a technique using electrodes along the course of peripheral nerves to control pain. These devices are a safe and effective way to help alleviate severe pain

Complex Regional Pain Syndrome (CRPS)

Most cases of CRPS develop after an injury to a limb. Up to eight to ten percent of adults can develop CRPS after bone fracture, particularly wrist (i.e., Colles).

Because CRPS can cause the arm or leg to stiffen over time, the pain usually worsens without treatment and makes movement more and more difficult. For these reasons, early diagnosis and the right treatment are critical.

Using innovative procedures, specialists from Cleveland Clinic’s Spine and Pain Medicine team collaborate with the Comprehensive Pain Recovery Program to provide sophisticated diagnosis and design a comprehensive pain management plan.

Treatment integrates a range of medical, interventional, physical, occupational and psychological therapies – such as biofeedback, relaxation techniques and group therapy.

Some patients require advanced interventions, such as nerve blocks or spinal cord stimulators to modulate the pain to facilitate participation in physical therapy and to gain improved function.

Pediatric Pain

According to The American Pain Society, 15 to 20 percent of children experience chronic pain. This includes children with chronic diseases such as cancer or cystic fibrosis who experience pain related to their disease or its treatment. Treating pediatric pain is complex. The most effective programs target the underlying disorder causing pain, relieve symptoms such as sleep disturbances, anxiety or depression, and restore function so that children can return to normal activities.

The Spine and Pain Medicine team collaborates with specialists from the Pediatric Pain Rehabilitation Program at Cleveland Clinic Children’s to determine the best treatment plan for children with chronic pain. This may involve a comprehensive inpatient program in addition to physical therapy, medications and in some cases interventional therapies.

Cancer Pain

Cancer experts estimate that as many as 50 percent of cancer patients may experience pain, and in people with advanced cancer, the percentage could be as high as 90 percent. Yet, cancer pain is often undertreated, mainly because patients and physicians are not aware of all of the effective options available.

Because cancer is a complex progressive disease, treating cancer pain is challenging.
Cleveland Clinic spine and pain medicine specialists work hand in hand with oncologists and palliative care specialists in the Cleveland Clinic Taussig Cancer Institute to diagnose and treat cancer-related pain. They also treat patients referred by other hospitals, cancer centers and community-based physicians.

Cancer pain may result from the tumor itself or from the radiation or chemotherapy used to treat cancer. Today, thanks to advanced pain management techniques, many patients can be spared severe pain.

In general, 80 to 85 percent of patients do respond to narcotic treatment to manage the pain caused by cancer. Different techniques can help the 15 to 20 percent of patients who don’t respond to these regimens or who have serious side effects from these narcotic medications such as nausea, vomiting, sedation and constipation.

Such interventional pain management modalities aim to target the pain generators or the nerves that transmit the pain signals. Pain medicine specialists can use diagnostic nerve blocks followed by therapeutic nerve blocks (ablations) to help patients.

Nerve blocks can help identify pain generators by delivering a very small dose of medicine directly to the nerve where the pain is generated or transmitted.

Intraspinal drug delivery systems (IDDS) may be implanted in cancer patients to deliver the pain medications directly into the spinal fluid within the spinal cord. With IDDS systems the amount of medication is 1/300th of the equivalent of an oral dose.

The ISDD systems have been around since the early 1990s, but they have advanced greatly over the last decade. Today, patients can have an implanted pump which allows the patients themselves to administer on-demand doses of the medication with the guidance and prescription of the treating physician.

When certain nerve blocks do not last, we consider neurolytic blocks. For pain associated with spine metastases, we offer patients cooled radiofrequency ablation with cementoplast.

Shingles

This painful rash, caused by the varicella-zoster (chickenpox) virus, ranges from mild to severe. In some people, the pain continues long after the rash has disappeared, a condition known as postherpetic neuralgia. These patients require more intensive treatment to relieve pain and restore quality of life.

Postherpetic neuralgia hurts the same way and in the same places as shingles – usually on the chest or abdomen. The pain can be continuous or come and go. Often it erupts from an extreme sensitivity to touch, even the brush of clothing.

Age is a major factor. After age 60, the occurrence of postherpetic neuralgia increases significantly. Shingles are also seen frequently in people with weakened immune systems, such as those with cancer, HIV or organ transplants.

Many live with postherpetic neuralgia for months or even years. Common treatments for shingles include:

Medication. There are several drugs that can calm overstimulated nerves. Lidocaine patches often are the first line of treatment. The patch sticks to the affected area of skin and slowly releases a numbing medicine. Its effect is temporary, but it is enough for some patients.

Other pain-relief drugs include antidepressants and anticonvulsants, which calm the excitability of nerve cells that process pain. For severe cases, prescription opioids may be an option.

Nerve blocks. Nerve blocks are injections of numbing medication into the nerves sending out pain signals. For some patients, nerve blocks last for months. Those patients may need only a few injections per year. But for some patients, the blocks last a few short weeks or days. We recommend alternative treatments if relief lasts only a couple of days.

Our specialists may recommend doing the full implant if after one to two weeks, the patient’s pain is reduced by at least half, and they are using less pain medication.

The full implant includes a battery-powered, internal stimulator. It can run up to 10 years before the need to replace the battery with another surgery.

To prevent postherpetic neuralgia, you first need to prevent shingles. A shingles vaccine is available – and recommended for adults aged 60 and older, even if the patient already had chickenpox or shingles – or the chickenpox vaccine. One shot can reduce the risk of shingles by 50 percent.

If you get shingles, see a doctor – immediately. The sooner you get antiviral medication, the better. It’s particularly effective within three days of detecting the pain or rash. Early treatment can reduce the course of shingles and the severity of your symptoms and potentially reduce your chance of getting postherpetic neuralgia.

Chronic Abdominal Pain

Chronic abdominal pain can arise from many contributing factors. Frequently the cause of the pain is known and treatments by a primary care, gastroenterology or surgical team may be directed toward treating the cause, which helps to alleviate the pain. Sometimes, despite an extensive work-up by these teams, the cause of the pain may not be clear, but the pain may be debilitating just the same. Patients with abdominal pain – from a known or unknown diagnosis – are often referred to a pain management clinic for evaluation and ongoing treatment.

Appointments

Our Spine and Pain Medicine team accepts patients by referral from other physicians or on a self-referral basis. Check with your insurance plan to determine if a referral is necessary.

To schedule an appointment with a pain medicine specialist, call 216.444. PAIN (7246), or toll-free 800.392.3353.

Virtual Second Opinion

If you cannot travel to Cleveland Clinic, help is available. You can connect with Cleveland Clinic specialists from any location in the world via a phone, tablet, or computer, eliminating the burden of travel time and other obstacles. If you’re facing a significant medical condition or treatment such as surgery, this program provides virtual access to a Cleveland Clinic physician who will review the diagnosis and treatment plan. Following a comprehensive evaluation of medical records and labs, you’ll receive an educational second opinion from an expert in their medical condition covering diagnosis, treatment options or alternatives as well as recommendations regarding future therapeutic considerations. You’ll also have the unique opportunity to speak with the physician expert directly to address questions or concerns.

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Why Choose Us?

Cleveland Clinic pain and spine specialists are part of Cleveland Clinic’s Neurological Institute. We tailor treatment plans to our patient’s needs, taking into account the extent of the problem and the patient’s overall health. Using this type of multidisciplinary approach means you will get the care you need right away.

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