How to: Develop Your Perfect Pain Plan

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Our four-point program will have you feeling better fast.

Elizabeth Brogan’s pain problems started in the spring of 2000, when the horse she was riding stopped short before a jump, throwing her over the top of the animal. Brogan landed on her back, which had slammed into the jump pole. Thankfully, she hadn’t broken any bones, and with the help of anti-inflammatory medication and muscle relaxers, most of the pain was gone within a few weeks. Everything was fine, or so it seemed.

Five years later, Brogan had another blow to her back when she wrenched it while carrying a concrete block in the backyard of her new house. Then in 2006, she injured it again while lifting a heavy box at work. With each injury, the discomfort worsened; with the final one, it stayed put.

To find relief, Brogan, a legal assistant in Washington, D.C. at the time, saw two orthopedists, a physical therapist, a neurologist, a chiropractor and a psychologist. Yet treatments such as Vicodin and selective endoscopic discectomy, a procedure that removed damaged portions of the discs in her lower back, gave her little respite. After years of frustration and discomfort, she grew depressed, cried almost daily, and slept poorly, never able to find a position in bed that didn’t hurt.

“I was ready to give up,” she says.

But she didn’t. In December of 2007, Brogan complied when her orthopedist suggested she see pain specialist Mehul Desai, M.D., director of the George Washington University Pain Center. The center takes an interdisciplinary treatment approach that includes both traditional and alternative therapies. Brogan showed up with her inch-thick medical file and was shocked when she learned that Desai had actually read it.

“Most new doctors would toss it aside, never even looking at it, or give it just a quick glance,” she says. Even more surprising was Desai’s conclusion after reviewing her case. “He was optimistic that he could help. That was a major turning point,” she says. “I had been told so many times to just deal with it, there was nothing more anyone could do. I walked out of there with hope.”

PIECES OF THE PUZZLE
It wasn’t long before Desai’s treatment plan started giving Brogan real relief. “I’ve improved about 50 percent since I began seeing him,” she said. Before seeing Desai, she had been a steady eight on a pain scale of one to 10. “Now, I live comfortably around the four to five range,” she said. “The pain is still constant, but less.”

Overall, Brogan feels well enough to get on the treadmill and elliptical, and strength train at her gym. Not only that, she can now sit comfortably for longer than 10 minutes to stretch. This increase in sitting tolerance was key for her at work, and also socially. “I could begin to enjoy going out to the movies, going out with friends, and playing poker, which my husband and I enjoy,” she said. “I was always one to not let my pain limit my life, so I would do these things before and just suffer with the pain. But now I can do them and have much less pain.”

So which treatment did the trick? There wasn’t just one solution. In fact, there were many. Desai first performed intradiscal electrothermal therapy (IDET), an outpatient procedure in which a catheter is threaded through a needle and into a disc, then heated to destroy pain receptors and seal tears in the outer layer of the disc. He also prescribed Brogan a new drug regimen that included longer-acting pain medications and an antidepressant. She began a physical therapy program that incorporated Pilates to build abdominal and back strength, exercise to boost overall health and mood, and regular stretching to loosen tight muscles and decrease spasms. Brogan also bought a more comfortable bed, and continued seeing her psychologist to ease her depression. Also key: She followed Desai’s protocol to the letter.

Desai doesn’t see Brogan’s pain management plan as anything out of the ordinary. Like a growing number of pain specialists, he realizes that a single drug or other treatment approach may help chronic pain patients for a while, but in most cases the right plan attacks on several fronts.

“I believe that most patients with chronic pain need a multidisciplinary approach in order to truly assess the complexity of their symptoms and create an individualized treatment plan,” Desai says. In other words, to get maximum relief and improved day-to-day functioning, the perfect pain plan should include a variety of approaches.

Think of it as a puzzle you and your healthcare providers put together with the pieces that best fit you. “When you get the mix right, the payoff can be tremendous. A 50 percent to 75 percent improvement in pain and function may be achievable,” Desai said.

MORE THAN MEDS
“Pain medication is usually the first, though too often the only, line of attack. There’s no one drug that’s 100 percent, and there’s also no free lunch drug with no side effects,” says Robert Jamison, Ph.D., a clinical psychologist at the Pain Management Center at Brigham and Women’s Hospital, in Boston. “No one’s cornered the market on treating chronic pain.”

“It is worth noting,” Jamison says, “that sometimes medication is all that is needed.” If you are getting good relief from a single drug or a combination of medications, there may be no reason to try other approaches. However, many of the alternatives are natural, inexpensive, and non-invasive, like exercise and counseling, and tend to benefit other parts of your life as well. A multifaceted approach can be particularly useful for people who have had poorly controlled pain for a long time.

“It’s important to realize that some clinicians perhaps do not take the time to coordinate multidisciplinary care,” notes Jamison. “And there may be additional costs to absorb if your health insurance won’t cover all the treatments. That’s disappointing,” Jamison says, “because much of the evidence suggests that multidisciplinary programs are cost-effective.” A 2006 review of medical studies in the Journal of Pain concluded that comprehensive pain programs that incorporate multidisciplinary treatments offer the most efficacious and cost-effective treatment for persons with chronic pain.

In other words, if you can manage it, there’s good reason to believe that a pain plan that fights discomfort on many fronts, not just one or two, will work better, and end up costing less in the long run. But not all doctors have caught on to a holistic approach, or they’re hamstrung by blink-and-you’ll-miss-it appointments, which leave them with no time to talk through the benefits of exercise or stress management. This means the burden falls on those with pain (yep, that’s you) to take the lead. To get you started, our experts helped to craft a four-point pain plan that should have you feeling better soon.

1) PARTNER WITH A PAIN EXPERT
Simply put, if your medical care isn’t significantly decreasing your pain and improving your quality of life, it’s time to look elsewhere. “You are your own best advocate,” Desai says. “Fight for yourself.” Ask your primary care doctor for a referral to a nearby pain specialist, or contact the nearest university medical center.

“Ideally, you want a health care provider who is familiar with multiple modalities (not just drugs and/or surgery) for treating pain, and who is willing to collaborate with your other care providers,” Jamison says. “Also, look for someone who understands your condition and is willing to listen.” It may not be easy to find someone like Desai who talks directly with Brogan’s other doctors and therapists to coordinate and evaluate her care, but your doctor should at least be willing to help you find other providers, like an acupuncturist or a massage therapist, and you should expect her to check in regularly to see how all parts of your treatment plan are working.

Once you’ve found a qualified pain professional, arrive at your first appointment armed with your medical records and a pain journal detailing your history as far back as possible. Expect the specialist to do a comprehensive assessment. He or she will likely ask about potential causes, duration and severity of pain, how well prior treatments have worked and your current quality of life. If the doctor doesn’t ask about these, bring them up yourself. Don’t be afraid to ask questions and be willing to consider new treatments such as physical therapy, different medications, massage and stress reduction, until you find a combination that works.

“Be careful not to fall into the trap of becoming your own worst enemy,” Jamison cautions. In other words, don’t see someone who specializes in a multidisciplinary approach if you’re not ready to try one. Some patients simply refuse to follow treatment advice or fail to limit activities that exacerbate their pain, such as lifting heavy weight or sitting for extended periods. When the pain persists, they become depressed and defeated and throw in the towel. But when you’re truly ready to do your part to make real and lasting changes in your life, pain relief is a lot more likely to follow.

2) COMMIT TO A HEALTHY LIFESTYLE
It may not be easy, but breaking unhealthy habits is essential. A couch potato existence is bad for body and mind, and usually means more discomfort. “A sedentary lifestyle seems to lead to obesity, which can lead to pain,” Desai says. “This lifestyle also hurts your motivation to get better. Smoking works against you, too. Not only can lighting up increase the perception of pain,” explains Desai, “it also may worsen degenerating joints and spinal discs.”

Aim for at least 2.5 hours a week of moderate physical activity, or 1.25 hours of vigorous activity weekly, plus strength training two or more days a week. Modify as needed based on your limitations and overall health. A 2008 study published in the journal Arthritis Care & Research found that people with arthritis who participated in the Arthritis Foundation Exercise Program, which included an hour of low-impact physical activity twice a week for eight weeks, had less pain, fatigue and stiffness than non-exercisers.

Bob Miller, 66, of Scottsdale, Arizona, credits physical activity with helping to keep his knee pain at bay. A sports injury as a teenager led to several surgeries, arthritis, and year of suffering.

“I find the most important thing I can do is exercise,” says Miller, who hikes, bikes, uses the elliptical trainer five or six days a week and strength trains two or three days weekly. “It keeps the muscles of the leg strong and reduces the amount of stress on my knee,” he explains.

Kevin Stone, M.D., an orthopedic surgeon in San Francisco who replaced the meniscus cartilage in Miller’s knee, says exercise also helps arthritis patients by increasing blood flow to the joints, flexibility, range of motion and levels of feel-good chemicals known as endorphins. The last boost is critical – when patients are happier, they generally experience less pain.

Chances are you already know the drill about eating a nutritious diet. Load up your meals with unprocessed foods, such as fresh fruits and vegetables and whole grains, and watch your portion sizes. Healthful eating will only enhance the benefits of any pain-control plan.

3) TRY DRUG-FREE OPTIONS
While medications like pain relievers, muscle relaxers and antidepressants can be a godsend for patients with chronic pain, they’re not a cure-all for most. Natural, non-pharmaceutical approaches such as physical therapy, counseling, exercise and stretching, hot/cold compresses and stress management can be wonderful complements to traditional medicine.

Keep in mind that not every alternative therapy will work for you or will work in the same way. Because pain perception can vary greatly from one person to another, not everyone will respond similarly to natural approaches (or drugs, for that matter). What’s more, natural therapies tend to work more gently on the body, and their effects are often more gradual.

Some natural approaches have more evidence showing they’re both safe and effective in easing pain. “Physicians tend to prefer alternative strategies for which there is the most scientific evidence,” says Russell Portenoy, M.D., chairman of the department of pain medicine and palliative care at Beth Israel Medical Center, in New York City. “This includes mind-body approaches such as guided imagery acupuncture, therapeutic massage, and in some cases, chiropractic.” Research has found, for example, that massage seems to work best to reduce pain in people with lower back pain, shoulder injuries or headaches. Alternative therapies with little or no scientific backing include homeopathy, herbs, crystals and magnets, experts say.

Pain specialists often embark on a period of trial and error to see what therapies help. For someone with chronic back pain, Desai is likely to incorporate physical therapy, acupuncture, yoga and Pilates. For fibromyalgia, he may recommend biofeedback, hypnosis, and water therapy. If you’re lucky, you’ll find a specialist who spends a fair amount of time getting to know your body, mind and spirit, so he can customize your treatment plan.

“It’s critical that I understand everything about a patient – how they sleep, what medicines they do and do not respond to, levels of anxiety, length of time with a particular pain condition and complicating factors,” says Mayssa Sultan, a Brooklyn-based acupuncturist.

4) STAY VIGILANT
“If you’ve had pain for a while, you already know that there are no quick fixes. You are dealing with a very challenging chronic illness,” Portenoy says. When you find a perfect or even pretty good pain plan, realize that it may not stand the test of time. Underlying medical conditions may worsen, requiring an adjustment to your treatment. Likewise, drugs or other therapies may lose their effectiveness, and need to be adjusted or eliminated altogether. So be sure to stay aware of your pain, other symptoms, and drug side effects. If you notice that you’re feeling worse or experiencing complications, talk with your doctor right away.

“Think of your pain plan as dynamic rather than static,” Desai says. “It’s very common to need adaptions to a plan,” he says. How often you need to re-think your approach depends, of course, on how you’re feeling. “The treatment plan is always fluid,” he stresses.

“Above all, stay proactive in your care,” says Elizabeth Brogan. “Don’t give up.” She knows first-hand that it’s not always easy to find the right doctors and therapists, or the most effective treatments. But she’s also living proof that persistence really can pay off.

Written by Jacqueline Stenson, a health writer in Glendale, California
Originally published in Pain Solutions Magazine, Fall 2009 (edited in 2017)
Photo credit: Marcusarm at Stockfreeimages.com

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