Pain management


Since pain is something that is highly individual in patients with instabilities, and the degree of pain can differ from mild to severe, there is no easy or standardized solution.

General: 

The concept of multimodal pain management is more and more widely used to treat chronic pain patients. Multimodal means that an interdisciplinary team of doctors, and different therapeutic approaches (body and mind) are used together to achieve the best possible success. Sometimes they are combined with physical therapy/movement therapy and alternative concepts, such as dance therapy.

Multimodal pain therapy is also a good idea in case of cervical spine instabilities, BUT it needs to be highly individualized. The different degrees of instability, the different damages and the fact that many cervical spine injured patients are tolerating therapies to a varying degree does make it impossible to refer those patients to a standard rehabilitation program.

People that suffer from cervical spine injuries usually do not fit into any clear categories, and every single one is different! Of course, therapy should never only consist of medication, but more of a combination of pain meds, physical therapy and mental support. Nevertheless, the personal tolerance of physical therapy and mental support may vary greatly between patients and should be planned individually.

The patient should also not be forced into psychotherapy. In how far psychological support is useful/necessary/desired depends on the individual and their specific type of needed support (like family, therapist, support groups). Many can cope well with their limitations, and others need the help of a third party. Insofar professional help should always be offered, but definitely not imposed.

The treatment frequency may also vary from once per week to several times a week. Some patients may even be able to work out every day, while others do not tolerate any exercise at all. This is why a standardized program, for example the usual medical rehabilitation programs, are not always that helpful. It should be discussed with the patient what type of rehabilitation is possible and what parts it should include.

The first priority must be the patient’s well-being!

Chronic pain patients usually know very well what they do, what they can tolerate and what they need. And this is why it is so important that every patient receives a customized treatment program.

With these factors in mind, let’s talk about available medications for the management of pain. 

The choice of medication depends on various factors, such as:

Type of pain (neuropathic, myopathic…)

Intensity of pain

Mechanism of drug (immediately, retard)

Location of action (local, central)

Application form (creme, injection, tablet, drops, powder…)

Dosage

Allergies / Intolerances

 

Types of Analgesics: 

Opoid: weak: Codeine, Tramadol; or strong: Morphine, Fentanyl

Nonsteroidal, anti-inflammatory drugs (NSAIDs), such as Aspirin, Ibuprofen, Diclofenac

Nonacidic analgesics, such as acetaminophen

COX-2 inhibitors, such as Arcoxia

Ketamine

Cannabinoids (in Germany rarely allowed for pain therapy, in other countries, or some states of the US they are used as pain meds)

WHO approach:

WHO pain treatment approach

WHO pain treatment approach

For the treatment of neuropathic pain anticonvulsants, such as Gabapentin, are used. For muscle spasm sometimes even muscle relaxants, such as Baclofen, are used (but carefully!) and some tricyclic antidepressants, like Amitriptyline, can be given. Another alternative pain med is Cannabis, which is rarely allowed in Germany, but in other countries.

Opoide are generally rather ineffective for chronic pain.

Muscle relaxants should be used with great caution because it might increase the instability.

Many patients try to bear the pain without medication for as long as possible, but this is not always a good decision. Of course, the risks and benefits of every drug have to be weighed individually since each drug might be potentially harmful. But tolerating the pain might cost many patients a great amount of their energy, or often also their sleep.

Chronic pain patients should get the advice of a pain management doctor in the early stages of pain!

Some medical practitioners also use medications that have not actually been tested for that particular disorder (off-label), such as Low Dose Naltroxen.

Please keep in mind that all medications ALWAYS have negative effects. But I will not go into details about those. Medication and side effects have to be discussed with an experienced pain doctor.

An additional factor that might increase pain is poor sleep, which in turn leads to daytime fatigue, and again to more pain. Dysautonomia is a disorder which is very common among cervical spine instability patients and it can disrupt sleep and cause pain too. Therefore, all those factors have to be taken into account.

In addition to medication you should consider relaxation techniques, measures to improve quality of sleep or dietary supplements.

Cycle of chronic pain, interrupted sleep and fatigue

Cycle of chronic pain, interrupted sleep and fatigue

 

Dr. Tennant specializes in pain therapy using hormones (especially in patients that are taking opoids), an area which is fairly new to me, but I find it very interesting. The theory behind his concept is logical and based on the stress-resulting secretion of adrenal and sex hormones. Chronic pain puts the body into a kind of permanent stress and therefore often results in deficiency of various hormones in the long term.

Dr. Tennant replaces the deficient hormones, and thereby improves the effect of painkillers, and reduces the level of pain.

The four major hormones that should be tested are: cortisol, testosterone, pregnenolone and ACTH. In addition, progesterone, HCG and DHEA can be tested as well.

The hormones that are decreased or deficient are going to be replaced with pharmaceutically produced hormones until the levels return to normal and the pain is under control. Then the intake is no longer necessary.

Testing those hormone levels may be useful even for patients without opoid therapy, because based on the level of hormones, statements about the quality of pain and the effectiveness of therapy can be made.

Additional to every therapy you should take preventive measures!

This means:

Avoid all triggers, or try to reduce them if possible.

Everyday activities that often lead to further injury:

Shopping. Do not carry weights on one side of your shoulder/arm. Carry only light weights and balance them even on both sides. Avoid standing in line for too long.

Kitchen: Work surfaces should be high enough. Use kitchen chairs if necessary.

Sleeping: Never sleep on your stomach! Use pillows for padding.

Sitting / Standing: Pay attention to your posture.

Transportation: Try to use public transportation at a time where there are not many people around. Use your neck brace on bumpy roads.

Some alternative pain management methods are: 

Traditional Chinese methods such as acupuncture, acupressure, dry needling

Tens, heat, cold

Muscle relaxation by Jakobsen, autogenous training

To improve proprioception you can use balance boards, paddle boards, compression garments and taping.

Future:

Vagus Nerve Stimulation

The vagus nerve is the 10th cranial nerve which plays a main role in the control of the autonomic nervous system, internal organs, the endocrine system, the immune system and many other systems of the body.

Vagus nerve stimulation describes a treatment in which the vagus nerve is stimulated using electric pulses, and it has an observed positive effect on diseases such as depression, epilepsy or migraine. But it is also studied as a possibly helpful treatment for chronic pain patients or in dysautonomia.

Currently, there are two different methods of application:

The surgical application, in which the vagus nerve is directly connected to a small power generator (invasive).

Transcutaneous (through the skin) stimulation of the vagus (non-invasive). This method is currently being tested in POTS patients.

Vagus nerve stimulation has not been established for the treatment of pain, but probably offers much hope for the future.

Also VNS might have positive impact on MCAS and POTS:

Kirchner A, Stefan H, melt M, Haslbeck KM, Birklein F. Influence of vagus nerve stimulation on histamine-induced itching. Neurology. 2002 July 9; 59 (1): 108-12.

More exciting results:

Kirchner A, Stefan H, K Bastian, Birklein F. Vagus nerve stimulation Suppresses pain but has limited effects on neurogenic inflammation in humans. European journal of pain. 2006 Jul 1; 10 (5): 449-.

Busch V, F Zeman, Heckel A, F Menne, Ellrich J, Eichhammer P. The effect of transcutaneous vagus nerve stimulation on pain perception-an experimental study. Brain stimulation. 2013 Mar 31; 6 (2): 202-9.

Kirchner A, Birklein F, Stefan H, HO craftsmen. Left vagus nerve stimulation Suppresses experimentally induced pain. Neurology. 2000 Oct 24; 55 (8): 1167-71.

 

Information:

www.paincommunity.org

EDNF conference 2013 Dr. Chopra:

http://ehlers-danlos.com/2013-annual-conference-files/Chopra_Chronic_pain_and_EDS_Final_1slideS.pdf

EDNF conference 2014 Dr. Pocinki:

http://ehlers-danlos.com/2014-annual-conference-files/Alan%20Pocinki.pdf

EDNF conference 2015 Dr. Chopra:

http://ehlers-danlos.com/2015-annual-conference-files/Chopra.pdf

Dr. Tennant article about hormone therapy:

http://www.practicalpainmanagement.com/treatments/hormone-therapy/testosterone-replacement-female-chronic-pain-patients

http://www.practicalpainmanagement.com/treatments/hormone-therapy/hormone-testing-replacement-pain-patients-made-simple

http://www.practicalpainmanagement.com/treatments/hormone-therapy/hormone-therapies-newest-advance-pain-care