Coping With

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					Coping With
Chronic Pain
Persistent pain is now being approached as a long-term illness such as diabetes
— one that’s managed rather than cured

42 CANADIAN HEALTH March/April 2008
                                       atricia Ruivo struggles to describe the chronic pain that constantly racks her body and
                                       shadows her attractive face. “It’s like being kicked by a horse,” she says — not just once,
                                       but over and over, day after day. Following a 2005 collision when a truck side-swiped
                                       her car, the 49-year-old mother of two teenagers in Oak Ridges, Ont., suffered multiple
                            injuries including a badly fractured pelvis, and spent seven months on crutches.
                               But long after the bones had knitted themselves back together, Patricia was left with an
                            aching sacroiliac in her lower back, burning ligaments in her legs and the all-over pain of
                            fibromyalgia in her muscles. “It feels as though things in my body shifted and didn’t go back

                            the same way, and in a lot of places my pain levels are still high,” she says. Her lower back and
                            upper thighs are the worst.
                               While Patricia may feel that she’s alone in dealing with her pain, she has, in fact, an
                            astonishing amount of company. An estimated six to seven million Canadians or one in three
                            people, suffer from moderate to severe daily chronic pain, says the Canadian Pain Society, a
                            Whitby, Ont.-based coalition of pain professionals from across the country. Persistent pain has

                                                                                     Pain by gender
                                                                                     Interestingly, some pain-producing conditions are
                                                                                     far more prevalent in one gender than the other,
                                                                                     which suggests a biological or hormonal component.
                                                                                     Women are more likely to have fibromyalgia, irritable
                                                                                     bowel syndrome, temporomandibular (jaw) and other
                                                                                     joint disorders, rheumatoid arthritis and migraine with
                                                                                     aura. Conditions more common in men include pain
                                                                                     from coronary heart disease, duodenal ulcer, pancreatic
                                                                                     disease, cluster headaches and ankylosing spondylitis,
                                                                                     a form of arthritis affecting the spinal and sacroiliac joints.
                                                                                     Most frustrating of all for patients and practitioners is
                                                                                     chronic pain that has no explanation at all.

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                                                              The new paradigm involves validation

                                                              of patients’ pain by health-care

                                                              professionals. “If patients say they

                                                              have pain, we believe they’ve got pain.

                                                              We start with that assumption and we

                                                              listen to their stories, 10 to 15 minutes

                                                              with no interruption — which is

                                                              quite refreshing for them”
                                                                            — Dr. Roger Shick, St. Paul’s Hospital, Vancouver

a hugely destructive effect on lifestyle, productivity and     strain injuries, shingles and pelvic conditions such as
mental health, as it can lead to anxiety and depression.       vulvodynia. Sometimes persistent pain results directly
One-half to two-thirds of people with chronic pain are         from physical injury — from a car accident or surgery,
unable, or less able, to exercise, walk, drive a car, enjoy    for example. In one-quarter of cases the pain is neuro-
normal sleep, perform household chores, attend social          pathic, believed to stem from a disturbance of the
activities or have sex because of their pain, according to     peripheral or central nervous system caused by trauma,
the International Association for the Study of Pain, a         inflammation, infection, metabolic disease or genetics.
Seattle-based group of pain professionals from more            Conditions producing neuropathic pain include diabetic
than 100 countries, including Canada. For a quarter of         neuropathy, multiple sclerosis, stroke, phantom limb
sufferers, their pain has led to strained or broken            pain, the bladder condition interstitial cystitis, vulvar
relationships with family and friends. And because             disorders and possibly fibromyalgia.
chronic pain is largely invisible, under-reported and             Neuropathic pain is particularly challenging to
under-treated, it creates an epidemic of silent suffering.     diagnose since often nothing shows up on an X-ray or
    While acute pain appears suddenly after an injury,         blood test. “The diagnosis of neuropathic pain may not
illness, surgery or other trauma and then subsides,            come to a physician’s mind unless he is on the lookout
chronic pain persists long after the injury. “Some say         for burning, stabbing or shooting pain, abnormally
the definition of chronic pain is pain that lasts six          sensitive areas of the body, or loss of sensation and/or
months, while others say three months,” notes                  strength,” says Gordon. “But once you think of it
neurologist Dr. Allan Gordon, director of the Wasser           and then diagnose it, there is a stepwise pathway of
Pain Management Centre at Toronto’s Mount Sinai                treatment to follow.”
Hospital. “I say it’s pain persisting at least a month
longer than the normal recovery period from an                 All in your head?
illness, injury or surgery.” But since many people try to      Pain is a tricky phenomenon because its measurement is
self-treat, ignore or “work through” their chronic pain,       almost completely subjective. In clinics, patients usually
by the time they get to a clinic such as the Wasser,           complete a questionnaire rating their pain on a scale
they may have been suffering for years or even decades.        of one to 10. If X-rays and MRIs fail to pinpoint an
It doesn’t help that at some of Canada’s more than             identifiable lesion, a patient can have difficulty getting
120 pain clinics wait times range anywhere from three          people to believe that he or she is truly in pain. “Docs
months to five years.                                          and family members say, ‘It’s all in your head,’ and the

    Many different conditions can produce chronic, non-        patient feels invalidated,” says psychiatrist Dr. Roger
cancer pain, including vertebral disc problems, repetitive     Shick, physician leader of the Pain Centre at St. Paul’s

44 CANADIAN HEALTH March/April 2008
The four stages of chronic pain
Neurologist, Dr. Allan Gordon, director of the Wasser Pain Management Centre in Toronto,
finds that people in chronic pain go through four stages. The first is Cure Me, Doctor! Here
patients expect that in a single consultation the physician will pinpoint the cause and prescribe
the cure. If that fails, they often move to stage two, or the Never-Ending Quest. They might
make the rounds of many different health-care specialties, including physiotherapy, chiropractic,
acupuncture, massage, exercise machines, stretch racks, injections, special diets, nutraceuticals,
vitamins and counselling, spending vast amounts of time and money. “It consumes them,
becoming a major focus of their lives,” Gordon says, adding that many get stuck in this phase.
   Some put their lives on hold until their pain is resolved, delaying travel, study or careers.
Others dangerously neglect different aspects of their health. In one tragic case, a Toronto woman
was so obsessed with finding and stopping the source of her widespread chronic pain — which
began in her early 30s at the site of a vertebra damaged by a misplaced epidural needle — that
she ignored the warning signs of advancing cardiac disease. She died suddenly of multiple heart
attacks at age 59.
   The third stage is the Silver Lining, in which patients start to look at what’s good in their
lives, such as family, work, hobbies or spirituality. The final stage is what Gordon calls Moving
On. This doesn’t mean expecting patients to suck it up and go home; it means helping them
manage their pain so it exists in the context of a balanced life.

Hospital in Vancouver. But that’s changing. The World          Treatment options
Health Organization now considers chronic pain to be           Because chronic pain is so complex and individual and
a disease in its own right and states that pain relief is      involves an intimate interaction between body and
a basic human right.                                           mind, there are many different approaches to treatment.
    The new paradigm involves positive validation of
patients’ pain by health-care professionals. “If patients      Medications Most sufferers have already tried over-
say they have pain, we believe they’ve got pain,” says         the-counter painkillers such as ibuprofen, acetylsalicylic
Shick. “We start with that assumption and we listen to         acid and acetaminophen, as well as topical lidocaine and
their stories, 10 to 15 minutes with no interruption —         capsaicin ointments. Many have moved on to prescription
which is quite refreshing for them.”                           analgesics containing morphine and codeine. Despite
    Pain is rarely “all in your head,” but it is always “all   concerns about possible addiction to opiates, problems
in your brain.” Pain is felt only when the brain receives      are rare when the patient is properly assessed for risk
a signal from sensory receptors located in the skin,           and the drugs are used correctly. Some antidepressants
blood vessels or tendons throughout the body. The pain         are useful against chronic pain, and there’s new interest
signal travels through sensory nerves up the spinal cord       in anti-seizure drugs to treat neuropathic pain and
to the thalamus in the brain and then to the cerebral          fibromyalgia. The exact mechanisms aren’t well
cortex, the part of the brain that processes thinking.         understood, but these drugs are thought to help stop
It’s believed that sometimes the pathway to the brain          damaged nerves from constantly firing pain signals.
becomes hyperactive and can’t switch off persistent pain       A study based at the Pain Centre at Montreal’s McGill
messages, and the brain overreacts. “It’s as if somebody       University Health Centre is investigating the safety
turned up the volume on the stereo and left it there,”         of using marijuana for chronic non-cancer pain.
says Shick. Or alternatively, the “Everything’s okay”
signal coming back from the brain gets blocked.                Physical therapies Benefits have been reported
    Continually peppered with pain messages, the spinal        from traditional treatments such as physiotherapy and
cord can become hypersensitive, and the pain takes on a        chiropractic, as well as non-traditional ones such as
life of its own. Even though the signals are confused, the     acupuncture and yoga, although these generally work
pain is agonizingly real. In such cases, many patients         better on acute pain than on chronic pain. Still, “I
suffer allodynia, pain from innocuous stimuli that             believe acupuncture can be effective,” says Gordon.
normally do not cause it, such as water from a shower,         “And so can yoga. I’ve seen it work.” But he advises
ordinary clothing or the gentle touch of a partner. They       caution regarding therapies that are untested, as these
may feel pain in an untouched part of the body.                can be “both expensive and unrewarding.”

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                                                                                  Shick’s clinic encourages

                                                                                  watching funny movies

                                                                                  and DVDs to promote

                                                                                  laughter. Laughter may

                                                                                  work by a combination

                                                                                  of distraction, raising

                                                                                  feel-good endorphins

                                                                                  and reducing stress

Blocks Injections of anaesthetic into or near a                  treatment, lack of evidence doesn’t necessarily mean
nerve can temporarily block pain signals. Injections             that a therapy doesn’t work.”
of botulinum toxin (Botox) into a muscle can decrease
pain for a period of months, although its effectiveness          Stress relief Since stress intensifies the perception
remains controversial. Also available are medial branch          of pain, relaxation and meditation can help decrease it.
(a branch of the nerve root) neurotomy, which cauter-
izes nerves, and spinal cord stimulation, which implants         Psychotherapy “All pain has a psychological
a tiny electrical device that interferes with pain signals.      component,” says Gordon. Individual and group
                                                                 counselling, behaviour modification, mindfulness-based
Alternatives There’s a plethora of alternative                   stress management and biofeedback can all contribute
treatments out there — from diets and supplements to             to managing pain. “A strong therapeutic alliance with a
lasers and magnets — although magnets were recently              treating practitioner is also important,” he adds.
judged to be ineffective by a large analysis of medical             In Vancouver, Shick’s clinic encourages watching
studies. One treatment receiving particular interest is          funny movies and DVDs to promote laughter. Laughter
low-energy photonic therapy (LEPT), which uses the               may work by a combination of distraction, raising
healing power of light. Several animal studies suggest           feel-good endorphins and reducing stress. “If you can
that this therapy can actually heal damaged nerves,              diminish depression and anxiety and encourage exercise
although evidence in humans is scant. The wife-husband           and laughing, as well as encourage people to pace
physicist team of Dr. Natasha Salansky and Dr. Norman            themselves and be assertive — and also tell them that
Salansky of the Millennium Health Institute in Concord,          they’re not nuts — all those things help,” says Shick.
Ont., have been using their patented version of LEPT                Patricia couldn’t agree more. In addition to an
to make pain lessen or vanish in hundreds of satisfied           acetaminophen-based prescription taken almost every
patients. LEPT, says Natasha Salansky, combines light            day, she gets pain relief from regular massages and from
rays from the healing range, including red and infrared,         the hydro-jets in a heated therapy pool. She’s reduced
to decrease inflammation, heal tissues and reduce pain.          her workload and now spends only about two days a
   As for scientific evidence of effectiveness, it’s difficult   week on her floral-design business. She’s also invested in
to do large clinical studies of LEPT, says Natasha               an extra-comfortable armchair, dining-room chair and
                                                                                                                              PETER GRIFFITH/MASTERFILE

Salansky, because funds aren’t readily available for             mattress, and is saving for a small outdoor whirlpool.
trials. About LEPT and other unproven therapies,                 Her bedroom has been redecorated so that on a bad day,
Shick says, “We don’t endorse them, but we also don’t            she has a beautiful oasis in which to rest.
condemn them. If it doesn’t hurt you, then okay.”                   Patricia’s advice? “Focus above the pain and pursue
Adds Gordon, “While I believe in evidence-based                  your joys.”

46 CANADIAN HEALTH March/April 2008

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