Rethinking Pain Management
WE NEED TO TAKE A DIFFERENT APPROACH TO PAIN MANAGEMENT
If there is one thing that I have learned in the many years that I have been practicing in pain management, it is that pain is complicated.
There are many kinds of pain: musculoskeletal pain such as back pain, knee pain, shoulder pain, hand pain and neck pain, headaches of various types such as migraines, muscle tension headaches, cluster headaches, occipital neuralgia, rheumatologic pain from rheumatoid arthritis, psoriatic arthritis, lupus and other auto-immune diseases, neuropathic pain, complex regional pain syndrome, carpal tunnel, cubital tunnel, post-surgical pain, acute and chronic pain, chronic abdominal pain, pain from inflammatory bowel disease, bladder pain, interstitial cystitis, female and gynecological pain, pelvic pain, rectal pain, testicular pain. If there is a body part, there is probably pain associated with it.
One of the reasons that pain is so difficult to treat is that it is an essential function for survival. It is our alarm system that tells us something is wrong. In fact, if you were born without the ability to sense pain as in CIPA Congenital Insensitivity to Pain and Anhydrosis, you would not live past 25. If you are living with chronic pain, it is like living in a constant state of alarm. Pain is complicated and it needs to be treated as such. It can be exhausting to have pain all of the time. The stress response described by Hans Selye describes the physiologic effects of chronic stress including anxiety, depression, muscle tension, memory problems and sleep problems can also occur with chronic pain.
Chronic pain affects lives in significant ways. Chronic pain affects how you sleep, move, work, your relationships and how you feel. It can interfere with your ability participate in activities, your job, going out to dinner and attending events, cooking, doing laundry or showing up on time. I have seen people lose jobs, marriages, be unable to attend weddings and important events, lose the things of hobbies that the love the most such as running or playing a sport. It is not easy to live with chronic pain. It often requires a significant adjustment.
Conventional Approaches to Pain Management
Some of most common reasons for a visit to the doctor is to treat pain: low back pain, headaches, joint pain knee pain, abdominal pain. It is our job to figure out what's causing it and what we can do about it. This leads to imaging X-ray, MRI CT scan, ultrasound, labs and evaluation by specialists, referrals to physical therapy and other treatments.​
Depending on the situation, musculoskeletal pain and back pain is often treated with X-ray and physical therapy and later MRI, EMG and injections, such as steroid injections or epidurals and nerve blocks, possibly followed by more advanced interventions such as medial branch blocks, radiofrequency ablation, in the case of back pain, or even more advanced techniques such as spinal cord stimulators, pain pumps, vertebroplasty or surgery, Knee pain follows a similar course: physical therapy, injections, maybe arthroscopic surgery, joint replacement.
Headaches and evaluated with clinical history and examination, possibly MRI, physical therapy and medication trials, in the case of migraines, botox. Interventional pain management options might include occipital nerve blocks, occipital nerve stimulators, cervical facet injections to address headaches that originate from the neck (cervicogenic headache).​
Rheumatologic and autoimmune diseases such as lupus, are often treated with DMARDS (Disease modifiying anti-rheumatologic drugs) and biologics that address inflammation, and sometimes pain medication.
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These therapies are often effective and necessary in treating pain. But this approach is what is considered a disease focused reductionist approach: it focuses on the disease, not on the state of health. Science has given us great insight into disease using this approach, but unfortunately there are limitations to a disease focused approach to health. Nature is much more complicated.
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Changing the way we think about health
For some people, conventional treatments may not work or may be less than satisfactory. Physical therapy may resolve some back pain but not all. Epidurals may works a few times and then stop working. Treatment with medications for migraine may work most of the time but not all. Biologics and DMARDS sometimes work and their effects wear off, or too often insurance does not cover them.
In conventional medicine, if the standard treatments are not working we are not sure what to do anymore and people often end up on pain medications. This is sometimes necessary and appropriate. At this point, we often tell people there are no other options.
After being in practice for many years treating people with chronic pain, I do think that there are alternatives, but is requires us to think in a different way.
Forms of alternative medicine such as naturopathic medicine, chiropractic care, Ayurveda, acupuncture and traditional Chinese medicine focus on restoring a state of health, improving 'Chi' or using diet, herbs or alignment to restore a state of health. The field of integrative medicine uses alternative forms of medicine with western or conventional medicine. Functional medicine uses the science of genetics, advanced laboratory testing such as nutritional testing and gut microbiome testing to restore a state of health. Incorporating the use of physical therapy, occupational therapy, psychotherapy and pain re-processing therapies can be very helpful in managing pain.
Perhaps we need to give stronger consideration to what makes us healthy when we treat pain rather than solely seeking the source of pain. If we give our bodies the things it needs to heal, we may have better results in treating and preventing pain, whatever the source. For example, if eat fast food every day, you don't sleep, you are in a constant state of stress from your job or your relationships, how can you heal? Is your lifestyle giving your body the best opportunity to repair itself?
Using Alternative Medicine to Manage Pain
Alternative healthcare if often viewed negatively or as non-science based. Ayurveda and, traditional chinese medicine and acupuncture have thousands of years of use in health, yet these important ways to treat health are often viewed with a sense of skepticism and disbelief, and are not treated like "real medicine."
In my opinion, alternative forms of medicine have a place in health care, most importantly because western medicine does not effectively treat everything. Acupuncture and naturopathy are not replacements for neurosurgery or orthopedic surgery, but using alternative therapies to treat unresolved pain and maintain and treat health and improve pain are good uses of alternative medicine. There is a place for conventional medicine and alternative medicine alike. They simply have different roles.
Using Functional Medicine to Address Health
The field of functional medicine has been developing for over 20 years. This field uses laboratory testing and genetics to better understand how our bodies function and seeks to make recommendations for lifestyle interventions to optimize health.
The effects of our diet and nutrition are often unrecognized in health maintenance and pain. Physicians have minimal training in nutrition, which can have a very important role in health. The role of toxins and environmental health, such as mercury toxicity and the role of mold and lyme disease are often addressed by functional or alternative health practitioners.
Having a better understanding of our metabolism, genetics and gut microbiome may help us to improve our health and hopefully to treat pain.
Lifestyle Change Can Have a Significant Impact
The foundation of our health and happiness lies in our diet, exercise, sleep, our relationships and how we manage stress. Everyone can benefit from a better diet, activity and our relationships. The approach of functional medicine is to encourage lifestyle modification to improve health.
Eating a non-processed anti-inflammatory diet may improve symptoms of pain and inflammation. There almost no risks in changing your diet for a period of time to see if these changes can make a significant difference in your health.
Getting adequate sleep and using stress management techniques may decrease levels of cortisol and improve your abilty to heal.
Regular moderate activity and modulate stress and pain and improve levels of fitness, cardiovascular health and muscle strength.
Empowered and Active
Using alternative and functional medicine to treat pain requires active participation. Making changes to diet and lifestyle is not easy, but it can lead to improvements in pain and function. Learning that there are things that you can do to improve your health and function can empower you to take action and improve your health instead of relying on medication alone.