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Managing Pain Spring 2014

The Relationship between Chronic Pain and Mood Disorders

Studies show that between 30 and 50 percent of those with chronic pain also suffer from mood disorders such as depression and anxiety. Here, Cleveland Clinic physicians Bruce Vrooman, MD, a pain management specialist, and Giries Sweis, PsyD, a psychologist, explain the connection between the two illnesses and how both can be treated.

What is chronic pain?

Pain is considered chronic if, in general, it lasts longer than three months, which is beyond the usual healing time for an illness or injury, Dr. Vrooman explains. At this point, it can be considered a disease in its own right.

The total cost of chronic pain in the U.S. is estimated at $600 billion a year, including health care and lost productivity.

Does pain cause depression and anxiety, or vice versa?

It can work both ways, according to Dr. Sweis, and can create a cycle where one worsens the other. For example, someone in pain from an injury may reduce their activity because they’re afraid of being reinjured. If this keeps them from improving their physical condition, they may actually become deconditioned and more susceptible to injury, he noted. Or, chronic pain might cause sleep problems, feelings of helplessness, and worthlessness related to work or financial issues, and this can lead to depression. In addition, research into factors that predict whether acute pain will become chronic has implicated depression.

How are these overlapping illnesses treated?

A comprehensive approach to treatment involves a thorough evaluation to determine what might be contributing to both the pain and the mood disorder.

In situations where biological factors, such as arthritis, are contributing to pain, Dr. Vrooman says that treating the pain may improve the associated depression. Treatment may involve medication, physical therapy or interventional therapies, such as nerve blocks.

Other cases are best treated by addressing the psychological component with counseling or with medications that may help improve both pain and depression, he noted.

Dr. Sweis lists the following as additional examples of the options for treating both pain and depression:

  • Cognitive behavioral therapy to help patients develop coping skills so they can manage their pain
  • Relaxation training, which helps reduce the stress response that often worsens pain and increases the symptoms of depression and anxiety
  • Hypnosis to help patients reach a relaxed state that may allow for positive suggestions
  • Exercise and physical activity, which can boost a patient’s mood as well as improve pain and function
  • Self-help groups that provide psychological support
  • Education for both the patient and family

“Patients should be encouraged to treat their pain and depression, and to engage in activities rather than withdraw from them,” emphasizes Dr. Vrooman. “It is important that patients realize what they can do rather than focusing on what they cannot do at that point in time.”

To make an appointment with Dr. Vrooman or another pain management specialist, call 216.444.PAIN (7246). To reach Dr. Sweis or another psychologist, call 216.636.5860.

Knot in your neck?

4 Ways to Relieve Trigger Point Pain

Hunch over a computer keyboard all day and you might feel tightness in your neck. Hit two buckets of golf balls and you might feel pain in your shoulder. Sit in an awkward position for too long and you might feel tension in your back.

Sore muscles usually feel better after a day or two of rest. But if you have recurring muscle pain — particularly in your neck, shoulders or back — and you literally can put your finger on the spot where it originates, you may have a trigger point.

Eek! marks the spot. Identifying trigger points

Trigger points are tight knots of muscle fiber that can’t relax. According to Daniel J. Leizman, MD, a specialist in Cleveland Clinic’s Department of Pain Management, trigger points are predominantly in the trapezius muscle, which stretches from the base of your skull, down to the middle of your back and over to your shoulder.

“You could have multiple trigger points in one muscle, maybe a few inches apart,” says Dr. Leizman. “Muscle often feels denser and tighter at a trigger point — more rope-like. When you push on it, pain spreads throughout the muscle area.”

De-stress your muscle

Trigger point pain is fairly common, he says. Fortunately, there are some equally as common ways to relieve it, possibly saving you a trip to the doctor.

  • Rub it out. Massage the trigger point and try to loosen up those taught muscle fibers.
  • Soothe the hurt. Anti-inflammatories can help wipe out muscle pain. So can a heating pad or ice pack. Yes, either temperature variation may work.
  • Find the root. Try to identify what’s “stressing out” your muscle. Then correct it so the knot in your muscle has a chance to “unwind.” Maybe it’s poor posture or an awkward workspace or falling asleep in the lounge chair. “Repetitive strain can make muscle fibers seize up,” says Dr. Leizman. “Even mental stress can cause muscle tension and trigger points.”
  • Get moving. Aerobic exercise is very effective at combating trigger points, says Dr. Leizman. Try jumping jacks, swimming or other arm movements that engage the muscles in your shoulders and neck. “Not only are you stretching the muscles, you’re increasing their blood supply, pumping in good nutrients and filtering out toxins,” says Dr. Leizman.

If these tips don’t relieve your neck, shoulder or back pain, and the pain interferes with your daily activities, it’s time to see a doctor.

“Sometimes physical therapy can help alleviate the trigger point. Sometimes a trigger point injection is needed to relax the muscle fibers and stimulate healing,” says Dr. Leizman.

But the best treatment is preventing trigger points. Be aware of good posture and body mechanics. And find healthy ways to alleviate stress.

“Stress is a normal part of life,” says Dr. Leizman. “We all need ways to manage it well, both mentally and physically. Exercise can do that all at once.”

For an appointment with Dr. Leizman or another specialist in Cleveland Clinic’s Department of Pain Management, call 216.444.PAIN (7246).

4 Things to Know about Nerve Blocks

For many suffering with severe pain, nerve blocks have become part of their treatment plan. These injections of local anesthetic and steroid directly to the area of the nerve affected can help with pain control and improve function and quality of life. Often the goal is to help a patient to avoid surgery and be more active in physical therapy.

Paul Shin, MD, of Cleveland Clinic Pain Management at Medina Hospital provided these insights for patients who are considering having a nerve block. He performs blocks for neck and spinal pain. He says your doctor will help you determine the best procedure for the pain you have, but in general, here is what you can expect if you have a nerve block.

1. Fear of the injection is almost always worse than the injection itself.

Patients are often hesitant when it comes to needles. Some of the procedures for arthritic conditions may have up to six needles, which can cause people to be apprehensive, but most procedures are well tolerated and brief, lasting just 5 to 15 minutes. We use a local anesthetic and the smallest needles possible; IV sedation may be available as well. The injections are performed with the aid of the fluoroscope, which is a low powered x-ray that can visualize the bony structures. This enables accurate placement of the needle and reduces complications. The majority of your time will be spent preparing and recovering from the procedure afterwards. We typically ask patients to arrive one hour beforehand to register, complete paperwork and prepare the site for the block. Following the procedure you will rest in the recovery area with a nurse monitoring you for 30 to 60 minutes.

2. Everyone will have a different response to the nerve block.

For some, having a nerve block will produce immediate relief while others will need a series of injections before it helps the pain. It’s very unpredictable. This is because pain is a personal perception and everyone responds differently. In addition, if you have had chronic pain for 10 or more years, there may be multiple pain generators. There are many anatomic structures and the pain may be emanating from more than one joint or nerve. In the spine for example, it’s possible that your first injection will take away some of the pain and you may require a different injection at a later time. It is anticipated that the nerve block/epidural will improve your pain but may not eliminate all of it. This means that the sooner you can get an injection before your pain becomes chronic, the better your result. In addition, injections are typically combined with other forms of treatment such as physical therapy to increase your chances of getting better.

3. Post-procedure discomfort

There may be some post-procedure discomfort or soreness that will improve in the days following the injection. It is important to differentiate this pain from your pre-procedural pain. Following the procedure, you will be asked to keep a detailed pain report for the first 24 to 72 hours. The response to the first injection is likely to determine your future treatment plan. Initially, we do our best to pinpoint the nerve from which the pain is emanating. The local anesthetic doesn’t last long and for some it may take a while for the steroid to work and provide a longer term benefit. The peak effect of the steroid will usually be between three and 10 days. It is slowly released into the body, and there may be an interval before you start to feel the improvement.

4. Injection frequency will vary

Based on your medical history and physician preferences, the procedure can usually be repeated from three to six times in a 12-month period. Medical conditions such as diabetes will mean that the injection needs to be less frequent. The exact number of injections that can be performed in a given patient will be determined by your physician.

Ultimately, the goal of nerve block injections is to decrease pain, increase your function and, for some patients, allow more aggressive physical therapy. They work well for many patients and there is no need to be afraid with a skilled pain management specialist.

Paul Shin, MD, practices in the Medina Hospital Pain Management Department. For an appointment with him or another Cleveland Clinic Pain Management specialist who performs nerve blocks, please call 216.444. PAIN (7246).

OTC Meds and Supplements for Chronic Pain

People with chronic pain often turn to over-the-counter (OTC) oral medications. These include Tylenol®, non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen and Aleve®, as well as Advil®. Hong Shen, MD, cautions that long-term use of these medications can be harmful, especially if you are older and/or have other medical conditions.

“These over-the-counter medications are used for short-term relief only,” says Dr. Shen. “If used over a long period of time, they can cause damage to the liver and kidneys, and they can increase the risk of heart attack or stroke. They can also cause stomach ulcers or bleeding and have serious interactions with other drugs.” As an example, she points to NSAIDs, which if used with other blood thinners, can cause excessive bleeding.

For long-term pain relief, there are some lower risk OTC treatments. Dr. Shen recommends two approaches – using topical medications and your diet along with nutritional supplements. These can help with pain caused by arthritis, bursitis, fibromyalgia and other inflammation.

Topical medications

Topical pain killers include sprays, patches and creams that can be applied over painful muscles or joints. These remedies often provide a mild burning or cooling sensation, which feels good and helps to distract us from the feeling of pain. These items often include ingredients of menthol, camphor, salicylates or capsaicin, all of which can penetrate the area of your skin and help to relieve the pain. Dr. Shen says these topical medications are safer than oral medications.

Nutritional supplements and diet

“My favorite treatments are nutritional supplements and an anti-inflammatory diet,” says Dr. Shen. “These remedies may take longer to work than medications, but in the long run they can have a big impact on reducing the inflammation that causes pain.”

Nutritional supplements that can help knee arthritis include fish oil along with glucosamine products. Fish oil contains two omega-3 fatty acids—DHA and EPS. A typical daily dosage of omega-3 would be about 1 to 2 grams of OTC fish oil. To determine the right dose for you, Dr. Shen recommends talking to your doctor first. “Too much omega-3 can also cause bleeding, so you have to be careful,” she notes.

An anti-inflammatory diet is one that includes lots of green leafy vegetables and fruits as well as some fish. At the same time, you need to avoid too much sugar and white flower in foods, both of which cause inflammation in your body. In addition, foods rich in omega-3, curry and ginger, all serve as anti-inflammatories.

“I always tell my patients to treat their food as medicine,” Dr. Shen explains. “And over time, they are often amazed at what a healthy diet can do to relieve their pain. It serves as an ant-inflammatory in the body and will help to keep you trim.”

Dr. Shen says keeping an optimal weight for your frame is the single best way to relieve pain, especially in the lower extremities. “Excess weight on your joints was once considered to be the cause of osteoarthritis,” she says. “But more recent studies show that body fat is actually metabolically active and capable of producing hormones and chemicals that increase levels of inflammation; this is what leads to osteoarthritis and pain. Lose a few pounds and you will feel better.”

Dr. Shen provides care at the Pain Management Center at Lutheran Hospital. For an appointment with Dr. Shen or another Cleveland Clinic Pain Management Specialist, call 216.444.PAIN (7246).