If osteoporosis has caused a compression fracture, the treatment should address the pain, the fracture, and the underlying osteoporosis to prevent future fractures.
All components of treatment have improved greatly in the last decade, says Michael Schaufele, MD, a physiatrist and professor of orthopaedics at Emory University School of Medicine in Atlanta. "We have better interventional options to treat fractures, and better treatments to prevent future fractures," he tells WebMD.
The majority of fractures heal with pain medication, reduction in activity, medications to stabilize bone density, and a good back brace to minimize motion during the healing process. Most people return to their everyday activities. Some may need further treatment, such as surgery.
Nonsurgical Treatment
Pain from a compression fracture allowed to heal naturally can last as long as three months. But the pain usually improves significantly in a matter of days or weeks.
Pain management may include analgesic pain medicines, bed rest, back bracing, and physical activity.
Pain medications. A carefully prescribed "cocktail" of pain medications can relieve bone-on-bone, muscle, and nerve pain, explains F. Todd Wetzel, MD, professor of orthopaedics and neurosurgery at Temple University School of Medicine in Philadelphia. "If it's prescribed correctly, you can reduce doses of the individual drugs in the cocktail."
Over-the-counter pain medications are often sufficient in relieving pain. Two types of non-prescription medications - acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) -- are recommended. Narcotic pain medications and muscle relaxants are often prescribed for short periods of time, since there is risk of addiction. Antidepressants can also help relieve nerve-related pain.
Activity modification. Bed rest may help with acute pain, but it can also lead to further bone loss and worsening osteoporosis, which raises your risk for future compression fractures. Doctors may recommend a short period of bed rest for no more than a few days. However, prolonged inactivity should be avoided.
Back bracing. A back brace provides external support to limit the motion of fractured vertebrae - much like applying a cast on a wrist fracture. The rigid style of back brace limits spine-related motion significantly, which may help reduce pain. Newer elastic braces and corsets are more comfortable to wear - but don't work, says Wetzel. "There's an old saying, 'The inconvenience of the brace is directly proportional to its effectiveness,'" he tells WebMD.
Osteoporosis treatment. Bone-strengthening drugs such as bisphosphonates (such as Actonel, Boniva, and Fosamax) help stabilize or restore bone loss. This is a critical part of treatment to help prevent further compression fractures.
Surgical Treatment
When chronic pain persists despite rest, activity modification, back bracing, and pain medication, surgery is the next step. Surgical procedures used to treat spinal fractures are:
Vertebroplasty
Kyphoplasty
Spinal fusion surgery
Vertebroplasty and Kyphoplasty
These procedures:
Involve small, minimally invasive incisions, so they require very little healing time.
Utilize acrylic bone cement that hardens quickly, stabilizing the spinal bone fragments and therefore stabilizing the spine immediately.
Most patients go home the same day or after one night's hospital stay.
Vertebroplasty. This procedure is effective for relieving pain from compression fractures and helping to stabilize the fracture. During this procedure:
A needle is inserted into the damaged vertebrae.
X-rays during the procedure help ensure that it's done with accuracy.
The doctor injects a bone cement mixture into the fractured vertebrae.
The cement mixture hardens in about 10 minutes.
The patient typically goes home the same day or after a one-night hospital stay.
Kyphoplasty: This procedure helps correct the bone deformity and relieves the pain associated with compression fractures. During the procedure:
Through a half inch cut in the back, a tube is inserted into the damaged vertebrae. X-rays help ensure the accuracy of the procedure.
A thin catheter tube - with a balloon at the tip -- is guided into the vertebra.
The balloon is inflated to create a cavity in which liquid bone cement is injected.
The balloon is then deflated and removed, and bone cement is injected into the cavity.
The cement mixture hardens in about 10 minutes.
"These procedures are amazing, when you look at how well patients do," says Rex Marco, MD, chief of spine surgery and musculoskeletal oncology at the University of Texas Health Science Center at Houston. "They're often in terrible, terrible pain, and it's not going away. But with two small incisions we can take care of something that needed a huge operation in the past but without really good results."
"We do everything we can to make the operation go as smoothly as possible," says Marco. "Antibiotics decrease the chance of infection. And a special x-ray machine helps us get the needle into the bone and assure that cement goes into the bone and stays in the bone."
Spinal Fusion Surgery
Spinal fusion surgery is sometimes used for compression fractures to eliminate motion between two vertebrae and relieve pain. The procedure connects two or more vertebrae together, holds them in the correct position, and keeps them from moving until they have a chance to grow together, or fuse.
Metal screws are placed through a small tube of bone and into the vertebrae. The screws are attached to metal plates or metal rods that are bolted together in the back of the spine. The hardware holds the vertebrae in place. This stops movement, allowing the vertebrae to fuse. Bone is grafted into the spaces between vertebrae.
"Spinal fusion is often the last resort," Wetzel tells WebMD. "If the bone is more than 50% compressed in height - if patients are in a great deal of pain -- and if they have had complications from another spinal surgery, we suggest spinal fusion surgery."
The patient's own bone or bone from a bone bank can be used to create a graft. The patient's own bone marrow or blood platelets -- or a bioengineered molecule -- can be used to stimulate growth of bone for the procedure.
Recovery from spinal fusion surgery takes longer than with other types of spinal surgery. Patients often have a three- or four-day hospital stay, with a possible stay on a rehabilitation unit. Patients typically wear a brace immediately after surgery. Rehabilitation is often necessary to rebuild strength and functioning. Activity level is gradually increased. Depending on the patient's age and health status, getting back to normal functioning can happen within two months or up to six months later.
There are drawbacks to spinal fusion surgery. It eliminates the natural movement of the two vertebrae, which limits the person's movement. Also, it puts more stress on vertebrae next to the fusion - increasing the chance of fracture in those vertebrae. Even after healing is complete, patients may need to avoid certain lifting and twisting activities to prevent putting excess stress on the spine.
"But if someone has persistent pain from the fracture - and they have been aggressively treated for osteoporosis - they can do very well with spinal fusion," says Wetzel.
Showing posts with label Pain. Show all posts
Showing posts with label Pain. Show all posts
Saturday, November 10, 2007
How Is Pain Treated?
The goal of pain management is to improve function, enabling individuals to work, attend school, or participate in other day-to-day activities. Patients and their physicians have a number of options for the treatment of pain; some are more effective than others. Sometimes, relaxation and the use of imagery as a distraction provide relief. These methods can be powerful and effective, according to those who advocate their use. Whatever the treatment regime, it is important to remember that pain is treatable. The following treatments are among the most common.
Acetaminophen is the basic ingredient found in Tylenol® and its many generic equivalents. It is sold over the counter, in a prescription-strength preparation, and in combination with codeine (also by prescription).
Acupuncture dates back 2,500 years and involves the application of needles to precise points on the body. It is part of a general category of healing called traditional Chinese or Oriental medicine. Acupuncture remains controversial but is quite popular and may one day prove to be useful for a variety of conditions as it continues to be explored by practitioners, patients, and investigators.
Analgesic refers to the class of drugs that includes most painkillers, such as aspirin, acetaminophen, and ibuprofen. The word analgesic is derived from ancient Greek and means to reduce or stop pain. Nonprescription or over-the-counter pain relievers are generally used for mild to moderate pain. Prescription pain relievers, sold through a pharmacy under the direction of a physician, are used for more moderate to severe pain.
Anticonvulsants are used for the treatment of seizure disorders but are also sometimes prescribed for the treatment of pain. Carbamazepine in particular is used to treat a number of painful conditions, including trigeminal neuralgia. Another antiepileptic drug, gabapentin, is being studied for its pain-relieving properties, especially as a treatment for neuropathic pain.
Antidepressants are sometimes used for the treatment of pain and, along with neuroleptics and lithium, belong to a category of drugs called psychotropic drugs. In addition, anti-anxiety drugs called benzodiazepines also act as muscle relaxants and are sometimes used as pain relievers. Physicians usually try to treat the condition with analgesics before prescribing these drugs.
Antimigraine drugs include the triptans- sumatriptan (Imitrex®), naratriptan (Amerge®), and zolmitriptan (Zomig®)-and are used specifically for migraine headaches. They can have serious side effects in some people and therefore, as with all prescription medicines, should be used only under a doctor's care.
Aspirin may be the most widely used pain-relief agent and has been sold over the counter since 1905 as a treatment for fever, headache, and muscle soreness.
Biofeedback is used for the treatment of many common pain problems, most notably headache and back pain. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature. The individual can then learn to effect a change in his or her responses to pain, for example, by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects. Similarly, the use of relaxation techniques in the treatment of pain can increase the patient's feeling of well-being.
Capsaicin is a chemical found in chili peppers that is also a primary ingredient in pain-relieving creams (see Chili Peppers, Capsaicin, and Pain in the Appendix).
Chemonucleolysis is a treatment in which an enzyme, chymopapain, is injected directly into a herniated lumbar disc (see Spine Basics in the Appendix) in an effort to dissolve material around the disc, thus reducing pressure and pain. The procedure's use is extremely limited, in part because some patients may have a life-threatening allergic reaction to chymopapain.
Chiropractic refers to hand manipulation of the spine, usually for relief of back pain, and is a treatment option that continues to grow in popularity among many people who simply seek relief from back disorders. It has never been without controversy, however. Chiropractic's usefulness as a treatment for back pain is, for the most part, restricted to a select group of individuals with uncomplicated acute low back pain who may derive relief from the massage component of the therapy.
Cognitive-behavioral therapy involves a wide variety of coping skills and relaxation methods to help prepare for and cope with pain. It is used for postoperative pain, cancer pain, and the pain of childbirth.
Counseling can give a patient suffering from pain much needed support, whether it is derived from family, group, or individual counseling. Support groups can provide an important adjunct to drug or surgical treatment. Psychological treatment can also help patients learn about the physiological changes produced by pain.
COX-2 inhibitors may be effective for individuals with arthritis. For many years scientists have wanted to develop a drug that works as well as morphine but without its negative side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) work by blocking two enzymes, cyclooxygenase-1 and cyclooxygenase-2, both of which promote production of hormones called prostaglandins , which in turn cause inflammation, fever, and pain. The newer COX-2 inhibitors primarily block cyclooxygenase-2 and are less likely to have the gastrointestinal side effects sometimes produced by NSAIDs.
In 1999, the Food and Drug Administration approved a COX-2 inhibitor-celecoxib-for use in cases of chronic pain. The long-term effects of all COX-2 inhibitors are still being evaluated, especially in light of new information suggesting that these drugs may increase the risk of heart attack and stroke. Patients taking any of the COX-2 inhibitors should review their drug treatment with their doctors.
Electrical stimulation, including transcutaneous electrical stimulation (TENS), implanted electric nerve stimulation, and deep brain or spinal cord stimulation, is the modern-day extension of age-old practices in which the nerves of muscles are subjected to a variety of stimuli, including heat or massage. Electrical stimulation, no matter what form, involves a major surgical procedure and is not for everyone, nor is it 100 percent effective. The following techniques each require specialized equipment and personnel trained in the specific procedure being used:
TENS uses tiny electrical pulses, delivered through the skin to nerve fibers, to cause changes in muscles, such as numbness or contractions. This in turn produces temporary pain relief. There is also evidence that TENS can activate subsets of peripheral nerve fibers that can block pain transmission at the spinal cord level, in much the same way that shaking your hand can reduce pain.
Peripheral nerve stimulation uses electrodes placed surgically on a carefully selected area of the body. The patient is then able to deliver an electrical current as needed to the affected area, using an antenna and transmitter.
Spinal cord stimulation uses electrodes surgically inserted within the epidural space of the spinal cord. The patient is able to deliver a pulse of electricity to the spinal cord using a small box-like receiver and an antenna taped to the skin.
Deep brain or intracerebral stimulation is considered an extreme treatment and involves surgical stimulation of the brain, usually the thalamus. It is used for a limited number of conditions, including severe pain, central pain syndrome, cancer pain, phantom limb pain, and other neuropathic pains.
Exercise has come to be a prescribed part of some doctors' treatment regimes for patients with pain. Because there is a known link between many types of chronic pain and tense, weak muscles, exercise-even light to moderate exercise such as walking or swimming-can contribute to an overall sense of well-being by improving blood and oxygen flow to muscles. Just as we know that stress contributes to pain, we also know that exercise, sleep, and relaxation can all help reduce stress, thereby helping to alleviate pain. Exercise has been proven to help many people with low back pain. It is important, however, that patients carefully follow the routine laid out by their physicians.
Hypnosis, first approved for medical use by the American Medical Association in 1958, continues to grow in popularity, especially as an adjunct to pain medication. In general, hypnosis is used to control physical function or response, that is, the amount of pain an individual can withstand. How hypnosis works is not fully understood. Some believe that hypnosis delivers the patient into a trance-like state, while others feel that the individual is simply better able to concentrate and relax or is more responsive to suggestion. Hypnosis may result in relief of pain by acting on chemicals in the nervous system, slowing impulses. Whether and how hypnosis works involves greater insight-and research-into the mechanisms underlying human consciousness.
Ibuprofen is a member of the aspirin family of analgesics, the so-called nonsteroidal anti-inflammatory drugs (see below). It is sold over the counter and also comes in prescription-strength preparations.
Low-power lasers have been used occasionally by some physical therapists as a treatment for pain, but like many other treatments, this method is not without controversy.
Magnets are increasingly popular with athletes who swear by their effectiveness for the control of sports-related pain and other painful conditions. Usually worn as a collar or wristwatch, the use of magnets as a treatment dates back to the ancient Egyptians and Greeks. While it is often dismissed as quackery and pseudoscience by skeptics, proponents offer the theory that magnets may effect changes in cells or body chemistry, thus producing pain relief.
Narcotics (see Opioids, below).
Nerve blocks employ the use of drugs, chemical agents, or surgical techniques to interrupt the relay of pain messages between specific areas of the body and the brain. There are many different names for the procedure, depending on the technique or agent used. Types of surgical nerve blocks include neurectomy; spinal dorsal, cranial, and trigeminal rhizotomy; and sympathectomy, also called sympathetic blockade (see Nerve Blocks in the Appendix).
Nonsteroidal anti-inflammatory drugs (NSAIDs) (including aspirin and ibuprofen) are widely prescribed and sometimes called non-narcotic or non-opioid analgesics. They work by reducing inflammatory responses in tissues. Many of these drugs irritate the stomach and for that reason are usually taken with food. Although acetaminophen may have some anti-inflammatory effects, it is generally distinguished from the traditional NSAIDs.
Opioids are derived from the poppy plant and are among the oldest drugs known to humankind. They include codeine and perhaps the most well-known narcotic of all, morphine. Morphine can be administered in a variety of forms, including a pump for patient self-administration. Opioids have a narcotic effect, that is, they induce sedation as well as pain relief, and some patients may become physically dependent upon them. For these reasons, patients given opioids should be monitored carefully; in some cases stimulants may be prescribed to counteract the sedative side effects. In addition to drowsiness, other common side effects include constipation, nausea, and vomiting.
Physical therapy and rehabilitation date back to the ancient practice of using physical techniques and methods, such as heat, cold, exercise, massage, and manipulation, in the treatment of certain conditions. These may be applied to increase function, control pain, and speed the patient toward full recovery.
Placebos offer some individuals pain relief although whether and how they have an effect is mysterious and somewhat controversial. Placebos are inactive substances, such as sugar pills, or harmless procedures, such as saline injections or sham surgeries, generally used in clinical studies as control factors to help determine the efficacy of active treatments. Although placebos have no direct effect on the underlying causes of pain, evidence from clinical studies suggests that many pain conditions such as migraine headache, back pain, post-surgical pain, rheumatoid arthritis, angina, and depression sometimes respond well to them. This positive response is known as the placebo effect, which is defined as the observable or measurable change that can occur in patients after administration of a placebo. Some experts believe the effect is psychological and that placebos work because the patients believe or expect them to work. Others say placebos relieve pain by stimulating the brain's own analgesics and setting the body's self-healing forces in motion. A third theory suggests that the act of taking placebos relieves stress and anxiety-which are known to aggravate some painful conditions-and, thus, cause the patients to feel better. Still, placebos are considered controversial because by definition they are inactive and have no actual curative value.
R.I.C.E.-Rest, Ice, Compression, and Elevation-are four components prescribed by many orthopedists, coaches, trainers, nurses, and other professionals for temporary muscle or joint conditions, such as sprains or strains. While many common orthopedic problems can be controlled with these four simple steps, especially when combined with over-the-counter pain relievers, more serious conditions may require surgery or physical therapy, including exercise, joint movement or manipulation, and stimulation of muscles.
Surgery, although not always an option, may be required to relieve pain, especially pain caused by back problems or serious musculoskeletal injuries. Surgery may take the form of a nerve block (see Nerve Blocks in the Appendix) or it may involve an operation to relieve pain from a ruptured disc. Surgical procedures for back problems include discectomy or, when microsurgical techniques are used, microdiscectomy, in which the entire disc is removed; laminectomy, a procedure in which a surgeon removes only a disc fragment, gaining access by entering through the arched portion of a vertebra; and spinal fusion, a procedure where the entire disc is removed and replaced with a bone graft. In a spinal fusion, the two vertebrae are then fused together. Although the operation can cause the spine to stiffen, resulting in lost flexibility, the procedure serves one critical purpose: protection of the spinal cord. Other operations for pain include rhizotomy, in which a nerve close to the spinal cord is cut, and cordotomy, where bundles of nerves within the spinal cord are severed. Cordotomy is generally used only for the pain of terminal cancer that does not respond to other therapies. Another operation for pain is the dorsal root entry zone operation, or DREZ, in which spinal neurons corresponding to the patient's pain are destroyed surgically. Because surgery can result in scar tissue formation that may cause additional problems, patients are well advised to seek a second opinion before proceeding. Occasionally, surgery is carried out with electrodes that selectively damage neurons in a targeted area of the brain. These procedures rarely result in long-term pain relief, but both physician and patient may decide that the surgical procedure will be effective enough that it justifies the expense and risk. In some cases, the results of an operation are remarkable. For example, many individuals suffering from trigeminal neuralgia who are not responsive to drug treatment have had great success with a procedure called microvascular decompression, in which tiny blood vessels are surgically separated from surrounding nerves.
Acetaminophen is the basic ingredient found in Tylenol® and its many generic equivalents. It is sold over the counter, in a prescription-strength preparation, and in combination with codeine (also by prescription).
Acupuncture dates back 2,500 years and involves the application of needles to precise points on the body. It is part of a general category of healing called traditional Chinese or Oriental medicine. Acupuncture remains controversial but is quite popular and may one day prove to be useful for a variety of conditions as it continues to be explored by practitioners, patients, and investigators.
Analgesic refers to the class of drugs that includes most painkillers, such as aspirin, acetaminophen, and ibuprofen. The word analgesic is derived from ancient Greek and means to reduce or stop pain. Nonprescription or over-the-counter pain relievers are generally used for mild to moderate pain. Prescription pain relievers, sold through a pharmacy under the direction of a physician, are used for more moderate to severe pain.
Anticonvulsants are used for the treatment of seizure disorders but are also sometimes prescribed for the treatment of pain. Carbamazepine in particular is used to treat a number of painful conditions, including trigeminal neuralgia. Another antiepileptic drug, gabapentin, is being studied for its pain-relieving properties, especially as a treatment for neuropathic pain.
Antidepressants are sometimes used for the treatment of pain and, along with neuroleptics and lithium, belong to a category of drugs called psychotropic drugs. In addition, anti-anxiety drugs called benzodiazepines also act as muscle relaxants and are sometimes used as pain relievers. Physicians usually try to treat the condition with analgesics before prescribing these drugs.
Antimigraine drugs include the triptans- sumatriptan (Imitrex®), naratriptan (Amerge®), and zolmitriptan (Zomig®)-and are used specifically for migraine headaches. They can have serious side effects in some people and therefore, as with all prescription medicines, should be used only under a doctor's care.
Aspirin may be the most widely used pain-relief agent and has been sold over the counter since 1905 as a treatment for fever, headache, and muscle soreness.
Biofeedback is used for the treatment of many common pain problems, most notably headache and back pain. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature. The individual can then learn to effect a change in his or her responses to pain, for example, by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects. Similarly, the use of relaxation techniques in the treatment of pain can increase the patient's feeling of well-being.
Capsaicin is a chemical found in chili peppers that is also a primary ingredient in pain-relieving creams (see Chili Peppers, Capsaicin, and Pain in the Appendix).
Chemonucleolysis is a treatment in which an enzyme, chymopapain, is injected directly into a herniated lumbar disc (see Spine Basics in the Appendix) in an effort to dissolve material around the disc, thus reducing pressure and pain. The procedure's use is extremely limited, in part because some patients may have a life-threatening allergic reaction to chymopapain.
Chiropractic refers to hand manipulation of the spine, usually for relief of back pain, and is a treatment option that continues to grow in popularity among many people who simply seek relief from back disorders. It has never been without controversy, however. Chiropractic's usefulness as a treatment for back pain is, for the most part, restricted to a select group of individuals with uncomplicated acute low back pain who may derive relief from the massage component of the therapy.
Cognitive-behavioral therapy involves a wide variety of coping skills and relaxation methods to help prepare for and cope with pain. It is used for postoperative pain, cancer pain, and the pain of childbirth.
Counseling can give a patient suffering from pain much needed support, whether it is derived from family, group, or individual counseling. Support groups can provide an important adjunct to drug or surgical treatment. Psychological treatment can also help patients learn about the physiological changes produced by pain.
COX-2 inhibitors may be effective for individuals with arthritis. For many years scientists have wanted to develop a drug that works as well as morphine but without its negative side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) work by blocking two enzymes, cyclooxygenase-1 and cyclooxygenase-2, both of which promote production of hormones called prostaglandins , which in turn cause inflammation, fever, and pain. The newer COX-2 inhibitors primarily block cyclooxygenase-2 and are less likely to have the gastrointestinal side effects sometimes produced by NSAIDs.
In 1999, the Food and Drug Administration approved a COX-2 inhibitor-celecoxib-for use in cases of chronic pain. The long-term effects of all COX-2 inhibitors are still being evaluated, especially in light of new information suggesting that these drugs may increase the risk of heart attack and stroke. Patients taking any of the COX-2 inhibitors should review their drug treatment with their doctors.
Electrical stimulation, including transcutaneous electrical stimulation (TENS), implanted electric nerve stimulation, and deep brain or spinal cord stimulation, is the modern-day extension of age-old practices in which the nerves of muscles are subjected to a variety of stimuli, including heat or massage. Electrical stimulation, no matter what form, involves a major surgical procedure and is not for everyone, nor is it 100 percent effective. The following techniques each require specialized equipment and personnel trained in the specific procedure being used:
TENS uses tiny electrical pulses, delivered through the skin to nerve fibers, to cause changes in muscles, such as numbness or contractions. This in turn produces temporary pain relief. There is also evidence that TENS can activate subsets of peripheral nerve fibers that can block pain transmission at the spinal cord level, in much the same way that shaking your hand can reduce pain.
Peripheral nerve stimulation uses electrodes placed surgically on a carefully selected area of the body. The patient is then able to deliver an electrical current as needed to the affected area, using an antenna and transmitter.
Spinal cord stimulation uses electrodes surgically inserted within the epidural space of the spinal cord. The patient is able to deliver a pulse of electricity to the spinal cord using a small box-like receiver and an antenna taped to the skin.
Deep brain or intracerebral stimulation is considered an extreme treatment and involves surgical stimulation of the brain, usually the thalamus. It is used for a limited number of conditions, including severe pain, central pain syndrome, cancer pain, phantom limb pain, and other neuropathic pains.
Exercise has come to be a prescribed part of some doctors' treatment regimes for patients with pain. Because there is a known link between many types of chronic pain and tense, weak muscles, exercise-even light to moderate exercise such as walking or swimming-can contribute to an overall sense of well-being by improving blood and oxygen flow to muscles. Just as we know that stress contributes to pain, we also know that exercise, sleep, and relaxation can all help reduce stress, thereby helping to alleviate pain. Exercise has been proven to help many people with low back pain. It is important, however, that patients carefully follow the routine laid out by their physicians.
Hypnosis, first approved for medical use by the American Medical Association in 1958, continues to grow in popularity, especially as an adjunct to pain medication. In general, hypnosis is used to control physical function or response, that is, the amount of pain an individual can withstand. How hypnosis works is not fully understood. Some believe that hypnosis delivers the patient into a trance-like state, while others feel that the individual is simply better able to concentrate and relax or is more responsive to suggestion. Hypnosis may result in relief of pain by acting on chemicals in the nervous system, slowing impulses. Whether and how hypnosis works involves greater insight-and research-into the mechanisms underlying human consciousness.
Ibuprofen is a member of the aspirin family of analgesics, the so-called nonsteroidal anti-inflammatory drugs (see below). It is sold over the counter and also comes in prescription-strength preparations.
Low-power lasers have been used occasionally by some physical therapists as a treatment for pain, but like many other treatments, this method is not without controversy.
Magnets are increasingly popular with athletes who swear by their effectiveness for the control of sports-related pain and other painful conditions. Usually worn as a collar or wristwatch, the use of magnets as a treatment dates back to the ancient Egyptians and Greeks. While it is often dismissed as quackery and pseudoscience by skeptics, proponents offer the theory that magnets may effect changes in cells or body chemistry, thus producing pain relief.
Narcotics (see Opioids, below).
Nerve blocks employ the use of drugs, chemical agents, or surgical techniques to interrupt the relay of pain messages between specific areas of the body and the brain. There are many different names for the procedure, depending on the technique or agent used. Types of surgical nerve blocks include neurectomy; spinal dorsal, cranial, and trigeminal rhizotomy; and sympathectomy, also called sympathetic blockade (see Nerve Blocks in the Appendix).
Nonsteroidal anti-inflammatory drugs (NSAIDs) (including aspirin and ibuprofen) are widely prescribed and sometimes called non-narcotic or non-opioid analgesics. They work by reducing inflammatory responses in tissues. Many of these drugs irritate the stomach and for that reason are usually taken with food. Although acetaminophen may have some anti-inflammatory effects, it is generally distinguished from the traditional NSAIDs.
Opioids are derived from the poppy plant and are among the oldest drugs known to humankind. They include codeine and perhaps the most well-known narcotic of all, morphine. Morphine can be administered in a variety of forms, including a pump for patient self-administration. Opioids have a narcotic effect, that is, they induce sedation as well as pain relief, and some patients may become physically dependent upon them. For these reasons, patients given opioids should be monitored carefully; in some cases stimulants may be prescribed to counteract the sedative side effects. In addition to drowsiness, other common side effects include constipation, nausea, and vomiting.
Physical therapy and rehabilitation date back to the ancient practice of using physical techniques and methods, such as heat, cold, exercise, massage, and manipulation, in the treatment of certain conditions. These may be applied to increase function, control pain, and speed the patient toward full recovery.
Placebos offer some individuals pain relief although whether and how they have an effect is mysterious and somewhat controversial. Placebos are inactive substances, such as sugar pills, or harmless procedures, such as saline injections or sham surgeries, generally used in clinical studies as control factors to help determine the efficacy of active treatments. Although placebos have no direct effect on the underlying causes of pain, evidence from clinical studies suggests that many pain conditions such as migraine headache, back pain, post-surgical pain, rheumatoid arthritis, angina, and depression sometimes respond well to them. This positive response is known as the placebo effect, which is defined as the observable or measurable change that can occur in patients after administration of a placebo. Some experts believe the effect is psychological and that placebos work because the patients believe or expect them to work. Others say placebos relieve pain by stimulating the brain's own analgesics and setting the body's self-healing forces in motion. A third theory suggests that the act of taking placebos relieves stress and anxiety-which are known to aggravate some painful conditions-and, thus, cause the patients to feel better. Still, placebos are considered controversial because by definition they are inactive and have no actual curative value.
R.I.C.E.-Rest, Ice, Compression, and Elevation-are four components prescribed by many orthopedists, coaches, trainers, nurses, and other professionals for temporary muscle or joint conditions, such as sprains or strains. While many common orthopedic problems can be controlled with these four simple steps, especially when combined with over-the-counter pain relievers, more serious conditions may require surgery or physical therapy, including exercise, joint movement or manipulation, and stimulation of muscles.
Surgery, although not always an option, may be required to relieve pain, especially pain caused by back problems or serious musculoskeletal injuries. Surgery may take the form of a nerve block (see Nerve Blocks in the Appendix) or it may involve an operation to relieve pain from a ruptured disc. Surgical procedures for back problems include discectomy or, when microsurgical techniques are used, microdiscectomy, in which the entire disc is removed; laminectomy, a procedure in which a surgeon removes only a disc fragment, gaining access by entering through the arched portion of a vertebra; and spinal fusion, a procedure where the entire disc is removed and replaced with a bone graft. In a spinal fusion, the two vertebrae are then fused together. Although the operation can cause the spine to stiffen, resulting in lost flexibility, the procedure serves one critical purpose: protection of the spinal cord. Other operations for pain include rhizotomy, in which a nerve close to the spinal cord is cut, and cordotomy, where bundles of nerves within the spinal cord are severed. Cordotomy is generally used only for the pain of terminal cancer that does not respond to other therapies. Another operation for pain is the dorsal root entry zone operation, or DREZ, in which spinal neurons corresponding to the patient's pain are destroyed surgically. Because surgery can result in scar tissue formation that may cause additional problems, patients are well advised to seek a second opinion before proceeding. Occasionally, surgery is carried out with electrodes that selectively damage neurons in a targeted area of the brain. These procedures rarely result in long-term pain relief, but both physician and patient may decide that the surgical procedure will be effective enough that it justifies the expense and risk. In some cases, the results of an operation are remarkable. For example, many individuals suffering from trigeminal neuralgia who are not responsive to drug treatment have had great success with a procedure called microvascular decompression, in which tiny blood vessels are surgically separated from surrounding nerves.
Trigger Point Injections
Trigger point injection is a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. During this procedure, a health care professional, using a small needle, injects a local anesthetic that sometimes includes a steroid into a trigger point. With the injection, the trigger point is made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief.
Trigger point injection is used to treat muscle pain in the arms, legs, lower back, and neck. In addition, this approach has been used to treat fibromyalgia, tension headaches, and myofascial pain syndrome (chronic pain involving tissue that surrounds muscle) that does not respond to other treatment.
Surgical Implants
When standard medicines and physical therapy fail to offer adequate pain relief, you may be a candidate for a surgical implant to help you control pain. There are two main types of implants to control pain:
Intrathecal Drug Delivery. Also called infusion pain pumps or spinal drug delivery systems. The surgeon makes a pocket under the skin that's large enough to hold a medicine pump. The pump is usually about one inch thick and three inches wide. The surgeon also inserts a catheter, which carries pain medicine from the pump to the intrathecal space around the spinal cord. The implants deliver medicines directly to the spinal cord, where pain signals travel. For this reason, intrathecal drug delivery can provide significant pain control with a fraction of the dose that would be required with pills. In addition, the system can cause fewer side effects than oral medications because less medicine is required to control pain.
Spinal Cord Stimulation Implants. In spinal cord stimulation, low-level electrical signals are transmitted to the spinal cord or to specific nerves to block pain signals from reaching the brain. In this procedure, a device that delivers the electrical signals is surgically implanted in the body. A remote control is used by the patient to turn the current off and on or to adjust the intensity of the signals. Most people describe the feelings from the simulator as being pleasant and tingling.
Two kinds of spinal cord stimulation systems are available. The unit that is more commonly used is fully implanted and has a pulse generator and a non-rechargeable battery. The other system includes an antenna, transmitter, and a receiver that relies upon radio frequency. The latter system's antenna and transmitter are carried outside the body, while the receiver is implanted inside the body.
Trigger point injection is used to treat muscle pain in the arms, legs, lower back, and neck. In addition, this approach has been used to treat fibromyalgia, tension headaches, and myofascial pain syndrome (chronic pain involving tissue that surrounds muscle) that does not respond to other treatment.
Surgical Implants
When standard medicines and physical therapy fail to offer adequate pain relief, you may be a candidate for a surgical implant to help you control pain. There are two main types of implants to control pain:
Intrathecal Drug Delivery. Also called infusion pain pumps or spinal drug delivery systems. The surgeon makes a pocket under the skin that's large enough to hold a medicine pump. The pump is usually about one inch thick and three inches wide. The surgeon also inserts a catheter, which carries pain medicine from the pump to the intrathecal space around the spinal cord. The implants deliver medicines directly to the spinal cord, where pain signals travel. For this reason, intrathecal drug delivery can provide significant pain control with a fraction of the dose that would be required with pills. In addition, the system can cause fewer side effects than oral medications because less medicine is required to control pain.
Spinal Cord Stimulation Implants. In spinal cord stimulation, low-level electrical signals are transmitted to the spinal cord or to specific nerves to block pain signals from reaching the brain. In this procedure, a device that delivers the electrical signals is surgically implanted in the body. A remote control is used by the patient to turn the current off and on or to adjust the intensity of the signals. Most people describe the feelings from the simulator as being pleasant and tingling.
Two kinds of spinal cord stimulation systems are available. The unit that is more commonly used is fully implanted and has a pulse generator and a non-rechargeable battery. The other system includes an antenna, transmitter, and a receiver that relies upon radio frequency. The latter system's antenna and transmitter are carried outside the body, while the receiver is implanted inside the body.
Pain Management: Treatment Overview
What Are the Treatments for Chronic Pain?
The treatments for chronic pain are as diverse as the causes. From over-the-counter and prescription drugs to mind/body techniques to acupuncture, if one approach doesn't work, another one might. But when it comes to treating chronic pain, no single technique is guaranteed to produce complete pain relief. Relief may be found by using a combination of treatment options.
Drug Therapy: Nonprescription and Prescription
Milder forms of pain may be relieved by over-the-counter medications such as Tylenol (acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and Aleve. Both acetaminophen and NSAIDs relieve pain caused by muscle aches and stiffness, but only NSAIDs can also reduce inflammation (swelling and irritation). Topical pain relievers are also available, such as creams, lotions, or sprays that are applied to the skin in order to relieve pain from sore muscles and arthritis.
If over-the-counter drugs do not provide relief, your doctor may prescribe stronger medications, such as muscle relaxants, anti-anxiety drugs (such as Valium), antidepressants, prescription NSAIDs such as Celebrex, or a short course of stronger painkillers (such as Codeine, Fentanyl, Percocet or Vicodin). A limited number of steroid injections at the site of a joint problem can reduce swelling and inflammation.
In April 2005, the FDA asked that Celebrex carry new warnings about the potential risk of heart attacks and strokes as well as potential stomach ulcer bleeding risks. At the same time the FDA asked that over-the-counter anti-inflammatory drugs -- except for aspirin – revise their labels to include information about potential heart and stomach ulcer bleeding risks.
Patient-controlled analgesia (PCA) is another method of pain control. By pushing a button on a computerized pump, the patient is able to self administer a premeasured dose of pain medicine. The pump is connected to a small tube that allows medicine to be injected intravenously (into a vein), subcutaneously (just under the skin), or into the spinal area. This is often used in the hospital to treat pain.
Sometimes, a group of nerves that causes pain to a specific organ or body region can be blocked with local medication. The injection of this nerve-numbing substance is called a nerve block. Although many kinds of nerve blocks exist, this treatment cannot always be used. Often blocks are not possible, are too dangerous, or are not the best treatment for the problem. You doctor can advise you as to whether this treatment is appropriate for you.
The treatments for chronic pain are as diverse as the causes. From over-the-counter and prescription drugs to mind/body techniques to acupuncture, if one approach doesn't work, another one might. But when it comes to treating chronic pain, no single technique is guaranteed to produce complete pain relief. Relief may be found by using a combination of treatment options.
Drug Therapy: Nonprescription and Prescription
Milder forms of pain may be relieved by over-the-counter medications such as Tylenol (acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and Aleve. Both acetaminophen and NSAIDs relieve pain caused by muscle aches and stiffness, but only NSAIDs can also reduce inflammation (swelling and irritation). Topical pain relievers are also available, such as creams, lotions, or sprays that are applied to the skin in order to relieve pain from sore muscles and arthritis.
If over-the-counter drugs do not provide relief, your doctor may prescribe stronger medications, such as muscle relaxants, anti-anxiety drugs (such as Valium), antidepressants, prescription NSAIDs such as Celebrex, or a short course of stronger painkillers (such as Codeine, Fentanyl, Percocet or Vicodin). A limited number of steroid injections at the site of a joint problem can reduce swelling and inflammation.
In April 2005, the FDA asked that Celebrex carry new warnings about the potential risk of heart attacks and strokes as well as potential stomach ulcer bleeding risks. At the same time the FDA asked that over-the-counter anti-inflammatory drugs -- except for aspirin – revise their labels to include information about potential heart and stomach ulcer bleeding risks.
Patient-controlled analgesia (PCA) is another method of pain control. By pushing a button on a computerized pump, the patient is able to self administer a premeasured dose of pain medicine. The pump is connected to a small tube that allows medicine to be injected intravenously (into a vein), subcutaneously (just under the skin), or into the spinal area. This is often used in the hospital to treat pain.
Sometimes, a group of nerves that causes pain to a specific organ or body region can be blocked with local medication. The injection of this nerve-numbing substance is called a nerve block. Although many kinds of nerve blocks exist, this treatment cannot always be used. Often blocks are not possible, are too dangerous, or are not the best treatment for the problem. You doctor can advise you as to whether this treatment is appropriate for you.
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