• Pain is an unpleasant sensory and emotional experience.
• Acute pain results from disease, inflammation, or injury to tissues and comes on suddenly. The cause of acute pain can usually be diagnosed and treated. The pain is confined to a given period and severity.
• Chronic pain persists over a more extended period than acute pain and is resistant to most medical treatments. It often causes severe problems for patients.
• There are hundreds of types of pain. Common pain syndromes include arthritis, back pain, central pain syndrome, cancer pain, headaches, head and facial pain, muscle pain, myofascial pain syndromes, neuropathic pain, reflex sympathetic dystrophy syndrome (RSDS), sciatica, shingles, and other painful disorders of the skin, sports injuries, spinal stenosis, surgical pain, temporomandibular disorders, trauma, and vascular disease or injury.
• No test can measure pain intensity, no imaging device can show pain, and no instrument can locate pain precisely. The patient’s description of the type, duration, and location of pain may be the best aid in diagnosis.
• Tests used to determine the cause of pain include electrodiagnostic procedures such as electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies; imaging, especially magnetic resonance imaging (MRI); neurological examination; or X-rays.
• The goal of pain management is to improve function, enabling individuals to work, attend school, or participate in day-to-day activities.
• The most common treatments for pain include analgesic pain relievers (aspirin, acetaminophen, and ibuprofen), acupuncture, anticonvulsants, antidepressants, migraine headache medicines, biofeedback, capsaicin, chiropractic, cognitive and behavioral therapy, counseling, COX-2 inhibitors, electrical stimulation, exercise, hypnosis, lasers, magnets, nerve blocks, opioids, physical therapy and rehabilitation, R.I.C.E. — Rest, Ice, Compression, and Elevation, and surgery.
• It is believed that pain affects men and women differently. This may be due to hormones, psychology, and culture.
Pain is a feeling triggered in the nervous system. Pain may be sharp or dull. It may come and go, or it may be constant. You may feel pain in one area of your body, such as your back, abdomen, or chest, or you may feel pain all over, such as when your muscles ache from the flu.
Pain can help diagnose a problem. Without pain, you might seriously hurt yourself without knowing it, or you might not realize you have a medical problem that needs treatment. Once you take care of the problem, the pain usually goes away. However, sometimes pain goes on for weeks, months, or even years. This is called chronic pain. Sometimes chronic pain is due to an ongoing cause, such as cancer or arthritis. Sometimes the cause is unknown.
Fortunately, there are many ways to treat pain. Treatment varies depending on the cause of pain. Pain relievers, acupuncture, and sometimes surgery are helpful.
SOURCE: NIH: National Institute of Neurological Disorders and Stroke
It may be the fiery sensation of a burn moments after your finger touches the stove. Or it’s a dull ache above your brow after a day of stress and tension. Or you may recognize it as a sharp pierce in your back after you lift something heavy.
It is a pain. It warns us that something isn’t quite right in its most benign form that we should take medicine or see a doctor. At its worst, however, pain robs us of our productivity, well-being, and, for many of us suffering from extended illness, our very lives. Pain is a complex perception that differs enormously among individual patients, even those who appear to have identical injuries or illnesses.
In 1931, the French medical missionary Dr. Albert Schweitzer wrote, “Pain is a more terrible lord of mankind than even death itself.” Today, pain has become a universal disorder, a serious and costly public health issue, and a challenge for family, friends, and health care providers who must support the individual suffering from the physical and emotional consequences of pain.
Ancient civilizations recorded on stone tablets accounts of pain and the treatments used: pressure, heat, water, and sun. Early humans related pain to evil, magic, and demons. Relief of pain was the responsibility of sorcerers, shamans, priests, and priestesses, who used herbs, rites, and ceremonies as their treatments.
The Greeks and Romans were the first to advance a theory of sensation, the idea that the brain and nervous system have a role in producing pain perception. But it was not until the Middle Ages and well into the Renaissance-the 1400s, and 1500s-that evidence began to accumulate in support of these theories. Leonardo da Vinci and his contemporaries believed that the brain was the central organ responsible for sensation. Da Vinci also developed the idea that the spinal cord transmits sensations to the brain.
In the 17th and 18th centuries, the body’s study-and the senses-continued to be a source of wonder for the world’s philosophers. In 1664, the French philosopher Rene Descartes described what is still called a “pain pathway.” Descartes illustrated how particles of fire, in contact with the foot, travel to the brain. He compared pain sensation to the ringing of a bell.
In the 19th century, the pain came to dwell under a new domain-science-paving the way for advances in pain therapy. Physician-scientists discovered that opium, morphine, codeine, and cocaine could be used to treat pain. These drugs led to aspirin’s development, to this day, the most commonly used pain reliever. Before long, anesthesia-both general and regional-was refined and applied during surgery.
“It has no future but itself,” wrote the 19th-century American poet Emily Dickinson, speaking about pain as the 21st century unfolds. However, pain research advances create a less grim future than that portrayed in Dickinson’s verse. This lot includes a better understanding of pain, along with significantly improved treatments to keep it in check.
What is pain? The International Association for the Study of Pain defines it as An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
It is useful to distinguish between two basic pain types, acute and chronic, and differ significantly.
• Acute pain, for the most part, results from disease, inflammation, or injury to tissues. This type of pain generally comes on suddenly, for example, after trauma or surgery, accompanied by anxiety or emotional distress. The cause of acute pain can usually be diagnosed and treated. The pain is self-limiting; that is, it is confined to a given period and severity. In some rare instances, it can become chronic.
• Chronic pain is widely believed to represent the disease itself. It can be made much worse by environmental and psychological factors. Chronic pain persists over a more extended period than acute pain and is resistant to most medical treatments. It can—and often does—cause severe problems for patients. A person may have two or more co-existing chronic pain conditions. Such conditions can include chronic fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction, and vulvodynia. It is not known whether these disorders share a common cause.
Hundreds of pain syndromes or disorders make up the spectrum of pain. There are the most benign, fleeting sensations of pain, such as a pinprick. There is the pain of childbirth, the pain of a heart attack, and the pain that sometimes follows a limb’s amputation. There is also pain accompanying cancer and the pain that follows severe trauma, such as that associated with head and spinal cord injuries. A sampling of common pain syndromes follows, listed alphabetically.
Arachnoiditis is a condition in which one of the three membranes covering the brain and spinal cord, called the arachnoid membrane, becomes inflamed. Several causes, including infection or trauma, can result in inflammation of this membrane. Arachnoiditis can produce disabling, progressive, and even permanent pain.
Arthritis. Millions of Americans suffer from arthritic conditions such as osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and gout. These disorders are characterized by joint pain in the extremities. Many other inflammatory diseases affect the body’s soft tissues, including tendonitis and bursitis.
Back pain has become a high price paid by our modern lifestyle. It is a startlingly common cause of disability for many Americans, including both active and inactive people. Back pain that spreads to the leg is called sciatica and is a prevalent condition. Another common type of back pain is associated with the spine’s discs, the soft, spongy padding between the vertebrae (bones) that form the spine. Discs protect the spine by absorbing shock, but they tend to degenerate over time and sometimes rupture. Spondylolisthesis is a back condition that occurs when one vertebra extends over another, causing pressure on nerves and, therefore, pain. Also, damage to nerve roots (see Spine Basics in the Appendix) is a severe condition called radiculopathy, which can be extremely painful. Treatment for a damaged disc includes drugs such as painkillers, muscle relaxants, and steroids; exercise or rest, depending on the patient’s condition; adequate support, such as a brace or better mattress and physical therapy. In some cases, surgery may be required to remove the disc’s damaged portion and return it to its previous condition, especially when it is pressing a nerve root. Surgical procedures include discectomy, laminectomy, or spinal fusion.
Burn pain can be profound and poses an extreme challenge to the medical community. First-degree burns are the least severe; with third-degree burns, the skin is lost. Depending on the injury, pain accompanying burns can be excruciating. Even after the wound has healed, patients may have chronic pain at the burn site.
Central pain syndrome-see “Trauma” below.
Cancer pain can accompany the growth of a tumor, cancer treatment, or chronic problems related to cancer’s permanent effects on the body. Fortunately, most cancer pain can be treated to help minimize discomfort and stress to the patient.
Headaches affect millions of Americans. The three most common types of chronic headaches are migraines, cluster headaches, and tension headaches. Each comes with its telltale brand of pain.
• Migraines are characterized by throbbing pain and sometimes by other symptoms, such as nausea and visual disturbances. Migraines are more frequent in women than in men. Stress can trigger a migraine headache, and migraines can also put the sufferer at risk for stroke.
• Cluster headaches are characterized by excruciating, piercing pain on one side of the head; they occur more frequently in men than women.
• Tension headaches are often described as a tight band around the head.
Head and facial pain can be agonizing, resulting from dental problems or disorders such as cranial neuralgia. One of the nerves in the face, head, or neck is inflamed. Another condition, trigeminal neuralgia (also called tic douloureux), affects the largest cranial nerves (see The Nervous Systems in the Appendix) and is characterized by a stabbing, shooting pain.
Muscle pain can range from an aching muscle, spasm, or strain to the severe spasticity that accompanies paralysis. Another disabling syndrome is fibromyalgia, a disorder characterized by fatigue, stiffness, joint tenderness, and widespread muscle pain. Polymyositis, dermatomyositis, and inclusion body myositis are painful disorders characterized by muscle inflammation. They may be caused by infection or autoimmune dysfunction, and are sometimes associated with connective tissue disorders, such as lupus and rheumatoid arthritis.
Myofascial pain syndromes affect sensitive areas known as trigger points, located within the body’s muscles. Myofascial pain syndromes are sometimes misdiagnosed and can be debilitating. Fibromyalgia is a type of myofascial pain syndrome.
Neuropathic pain can result from injury to nerves, either in the peripheral or central nervous system (see The Nervous Systems in the Appendix). Neuropathic pain can occur in any part of the body and is frequently described as a hot, burning sensation, which can be devastating to the affected individual. It can result from diseases that affect nerves (such as diabetes) or trauma, or because chemotherapy drugs can affect nerves, it can be a consequence of cancer treatment. Among the many neuropathic pain, conditions are diabetic neuropathy (which results from nerve damage secondary to vascular problems that occur with diabetes); reflex sympathetic dystrophy syndrome (see below), which can follow injury; phantom limb and post-amputation pain (see Phantom Pain in the Appendix), which can result from the surgical removal of a limb; postherpetic neuralgia, which can occur after an outbreak of shingles; and central pain syndrome, which can result from trauma to the brain or spinal cord.
Reflex sympathetic dystrophy syndrome, or RSDS, is accompanied by burning pain and hypersensitivity to temperature. Often triggered by trauma or nerve damage, RSDS causes the affected area’s skin to become characteristically shiny. In recent years, RSDS has come to be called complex regional pain syndrome (CRPS); it was often called causalgia in the past.
Repetitive stress injuries are muscular conditions that result from repeated motions performed in the course of normal work or other daily activities. They include:
• writer’s cramp, which affects musicians and writers and others,
• compression or entrapment neuropathies, including carpal tunnel syndrome, caused by a chronic overextension of the wrist and
• tendonitis or tenosynovitis, affecting one or more tendons.
Sciatica is a painful condition caused by pressure on the sciatic nerve, the main nerve that branches off the spinal cord and continues down into the thighs, legs, ankles, and feet. Sciatica is characterized by pain in the buttocks and can be caused by several factors. Exertion, obesity and poor posture can all cause pressure on the sciatic nerve. One common cause of sciatica is a herniated disc (see Spine Basics in the Appendix).
Shingles and other painful disorders affect the skin. Pain is a common symptom of many skin disorders, even the most common rashes. One of the most vexing neurological disorders is shingles or herpes zoster. This infection often causes agonizing pain resistant to treatment. Prompt treatment with antiviral agents is essential to arrest the infection, which, if prolonged, can result in an associated condition known as postherpetic neuralgia. Other painful disorders affecting the skin include:
• vasculitis, or inflammation of blood vessels;
• other infections, including herpes simplex;
• skin tumors and cysts, and
• tumors associated with neurofibromatosis, a neurogenetic disorder.
Sports injuries are common. Sprains, strains, bruises, dislocations, and fractures are all well-known words in the language of sports. Pain is another. In extreme cases, sports injuries can take the form of costly and painful spinal cord and head injuries, which cause severe suffering and disability.
Spinal stenosis refers to a narrowing of the canal surrounding the spinal cord. The condition occurs naturally with aging. Spinal stenosis causes weakness in the legs, and leg pain usually felt while the person is standing up and often relieved by sitting down.
Surgical pain may require regional or general anesthesia during the procedure and medications to control discomfort following the operation. Control of pain associated with surgery includes presurgical preparation and careful monitoring of the patient during and after the procedure.
Temporomandibular disorders are conditions in which the temporomandibular joint (the jaw) is damaged. The muscles used for chewing and talking become stressed, causing pain. The condition may result from several factors, such as an injury to the jaw or joint misalignment. It may give rise to various symptoms, most commonly pain in the jaw, face, and or neck muscles. Physicians reach a diagnosis by listening to the patient’s description of the symptoms and by performing a simple examination of the facial muscles and the temporomandibular joint.
Trauma can occur after injuries in the home, at the workplace, during sports activities, or on the road. Any of these injuries can result in severe disability and pain. Some patients who have had an injury to the spinal cord experience intense pain ranging from tingling to burning and, commonly, both. Such patients are sensitive to hot and cold temperatures and touch. A touch can be perceived as intense burning for these individuals, indicating abnormal signals relayed to and from the brain. This condition is called central pain syndrome. The damage is in the thalamus (the brain’s center for processing bodily sensations), thalamic pain syndrome. It affects as many as 100,000 Americans with multiple sclerosis, Parkinson’s disease, amputated limbs, spinal cord injuries, and stroke. Their pain is severe and is extremely difficult to treat effectively. A variety of medications, including analgesics, antidepressants, anticonvulsants, and electrical stimulation, are available to central pain patients.
Vascular disease or injury — such as vasculitis or inflammation of blood vessels, coronary artery disease, and circulatory problems-all have the potential to cause pain. Vascular pain affects millions of Americans and occurs when communication between blood vessels and nerves is interrupted. Ruptures, spasms, constriction, or obstruction of blood vessels and a condition called ischemia in which blood supply to organs, tissues, or limbs are cut off can also result in pain.
There is no way to tell how much pain a person has. No test can measure pain intensity, no imaging device can show pain, and no instrument can locate pain precisely. Sometimes, as in headaches, physicians find that the best aid to diagnosis is the patient’s description of the pain’s type, duration, and location. Defining pain as sharp or dull, constant or intermittent, burning, or aching may give the best clues to the cause of pain. These descriptions are part of the physician’s pain history during the preliminary examination of a patient with a problem.
Physicians, however, do have several technologies they use to find the cause of pain. Primarily these include:
• Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. Information from EMG can help physicians tell precisely which muscles or nerves are affected by weakness or pain. Thin needles are inserted in muscles. A physician can see or listen to electrical signals displayed on an EMG machine. With nerve conduction studies, the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) placed on the skin over the muscles. The first set gives the patient a mild shock that stimulates the nerve that runs to that muscle. The second set of electrodes is used to record the nerve’s electrical signals. From this information, the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes — one set for stimulating a nerve (these electrodes are attached to a limb) and another set on the scalp for recording the speed of nerve signal transmission to the brain.
• Imaging, especially magnetic resonance imaging or MRI, provides physicians with pictures of the body’s structures and tissues. MRI uses magnetic fields and radio waves to differentiate between healthy and diseased tissue.
• A neurological examination in which the physician tests movement, reflexes, sensation, balance, and coordination.
• X-rays produce pictures of the body’s structures, such as bones and joints.
Acetaminophen is the essential ingredient found in Tylenol® and its many generic equivalents. It is sold over the counter, in a prescription-strength preparation, and 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 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 the pain. Nonprescription or over-the-counter pain relievers are generally used for mild to moderate pain. Prescription pain relievers, sold through a pharmacy under a physician’s direction, are used for more moderate to severe pain.
Anticonvulsants are used to treat seizure disorders but are sometimes prescribed for the treatment of pain. Carbamazepine, in particular, is used to treat several 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 to treat pain and, along with neuroleptics and lithium, belong to a category of drugs called psychotropic drugs. Also, anti-anxiety drugs called benzodiazepines 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, should be used only under a doctor’s care as with all prescription medicines.
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 particular electronic machine, the patient is trained to become aware of, follow, and 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 treating 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) to dissolve material around the disc, thus reducing pressure and pain. The procedure’s use is minimal, in part because some patients may have a life-threatening allergic reaction to chymopapain.
Chiropractic care may ease back pain, neck pain, headaches, and musculoskeletal conditions. It involves “hands-on” therapy to adjust the relationship between the body’s structure (mainly the spine), and it’s functioning. Chiropractic spinal manipulation includes the adjustment and manipulation of the joints and adjacent tissues. Such care may also involve therapeutic and rehabilitative exercises.
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 essential 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 useful for individuals with arthritis. For many years, scientists have wanted to develop a drug that works and morphine without its adverse side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) work by blocking two enzymes, cyclooxygenase-1 and cyclooxygenase-2, which promote the production of hormones called prostaglandins, causing 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 chronic pain cases. 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 heart attack and stroke risk. 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. Deep brain or spinal cord stimulation is the modern-day extension of age-old practices. 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 can then 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 can 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 the brain’s surgical stimulation, 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 regimens 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 help reduce stress, thereby alleviating pain. Exercise has been proven to help many people with low back pain. It is essential, 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. In contrast, others feel that the individual can simply 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 involve 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. Still, like many other treatments, this method is not without controversy.
Magnets are increasingly popular with athletes who swear by their effectiveness to control sports-related pain and other painful conditions. Usually worn as a collar or wristwatch, magnets’ use 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.
Nerve blocks employ 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, 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 and 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, to treat 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 affect 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 determine the efficacy of active treatments. Although placebos have no direct effect on the underlying causes of pain, evidence from clinical studies suggests 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 in patients after administering a placebo. Some experts believe the effect is psychological and that placebos work because the patients believe or expect them to do. Others say placebos relieve pain by stimulating the brain’s 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 severe conditions may require surgery or physical therapy, including exercise, joint movement or manipulation, and stimulation of muscles.
Although not always an option, surgery 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. Although the operation can cause the spine to stiffen, resulting in lost flexibility, the procedure serves one critical purpose: protecting the spinal cord. Other pain processes 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. 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. Still, both physician and patient may decide that the surgical procedure will be sufficient to justify 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 microvascular decompression procedure, in which tiny blood vessels are surgically separated from surrounding nerves.
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