What do you do when the pain is so bad that it affects your ability to live a happy and productive life? Verne Maree talks with representatives of the new, holistic approach to pain management.
A six-month bout of chronic tennis elbow that was only relieved with a judicious shot of corticosteroids into the joint got me thinking. Firstly, how debilitating such a relatively minor injury can be, and secondly, how the pain threatened my quality of life.
My path was the usual one: a visit to an orthopaedic surgeon I know and trust for the shot itself, followed by six weeks of physiotherapy and daily exercises at home. But, as I’ve since discovered, I could have gone straight to a specialist pain management physician like Dr Darren Phua of Novena Pain Management Centre.
He explains that pain management as a sub-specialty of anaesthesiology emerged internationally around 10 years ago, and in Singapore only five years ago or so.
“Its rise,” he says, “is a response to people’s desire to get relief from their pain without having to undergo expensive, risky surgical procedures.” Apart from helping those whose pain cannot be relieved by medication alone, he adds, it can often enable patients to reduce their medication and improve their quality of life.
Patients come to Dr Phua for chronic back and neck pain, cancer pain, chronic headaches and musculoskeletal pain. “Typically, our procedures are minimally invasive. They include epidural injections, spine and disc injections, sacroiliac joint injections, pulsed radiofrequency therapy, trigger point injections, sympathetic blocks and palliative procedures.”
Pain medications have adverse side effects, so there are clear benefits to reducing the need for them. Long-term use of anti-inflammatories, as he explains, is associated with gastric problems, kidney problems, and even strokes and heart attacks. Very strong medications such as narcotics can lead to tolerance, where you need more and more of the drug; or dependence, where you can’t function without the drug; or even addiction.
What is pain?
Pain has been defined as the unpleasant sensory or emotional experience associated with tissue injury, says Dr Phua. But it’s important to note that, according to the IASP (International Association for the Study of Pain), the injury doesn’t have to be current. Chronic pain can persist at the site of an old injury that has healed, usually due to nerves that haven’t healed properly and so keep on sending pain messages to the brain.
Worldwide, he says, we are seeing a growing awareness on the part of both patients and healthcare providers that pain needs to be dealt with. It is now regarded as one of the vital signs, like blood pressure, heart rate, respiration and so on. “The only difference is that it’s a subjective measure made by the patient, generally on a scale of 1 to 10.”
Is pain the enemy?
Not initially, according to Dr Nicholas Chua of Specialist Pain Center. In fact, pain is an essential function of the central nervous system, as it lets you know that something is wrong. Neuropathic pain, however, occurs when the nerves surrounding certain structures that were injured before do not recover.
“Pain that extends beyond a month is not good pain; and if still present after three months should generally be treated.”
He seems pleased when I tell him about my tennis elbow experience, where a corticosteroid injection together with physiotherapy worked to help me achieve a long-term solution.
“One of our objectives as pain physicians is not only to reduce the pain, but in cases like this to break the cycle of pain, to give you a gap so that you can actively engage in rehabilitative physical therapy that will provide a longer-term cure – like exercises you would be unable to do because of the pain.”
But this is one of the simpler kinds of cases, he hastens to add. Many of his patients are people who have suffered chronic pain for many years, pain that has been failed by all conventional therapies.
Spinal Cord Stimulation
For example, one of Dr Chua’s patients is a 40-year-old Caucasian woman who underwent back surgery in her teens and had suffered from back pain ever since. This woman had sought treatment in the UK, in Australia and in Europe. She’d been on high-dose opioids for quite some time, explains Dr Chua, and came to him a month ago for a pain episode so bad that no drug could help her.
“Known as FBSS, or failed back surgery syndrome, her condition is one that often starts to develop a couple of years after the surgery. Repeat surgery is often not indicated, because there is no structural instability.” Everything looks normal, but the pain persists – sometimes far worse than it was before the initial surgery.
“We trialled her on something fairly new on the market: spinal cord stimulation. It’s an electrical therapy delivered through a small device that is implanted where the epidural space is; it works by emitting a message to tell the back it is no longer in pain.”
This clever device is able to tell whether the patient is lying down, sitting up or on her side, and then adjust its signal appropriately.
“After a successful trial, the battery was implanted, and within two weeks her medication had been slashed by two thirds.”
Dr Chua recounts another wonderful story about a Malay patient of his, diabetic and an amputee, who had persistent ischaemic chest pain. Despite having had four stents implanted, he was still being admitted to hospital around 30 times a year because he was convinced he was having a heart attack. Though a fiercely independent individual, he had a difficult social history, too – he was divorced, unemployed and homeless.
Dr Chua diagnosed refractory angina pectoris, successfully trialled him on the spinal cord stimulator and managed to find a more affordable version of the device to implant.
“In the first year after that, he was admitted to hospital only three times. And when he came to see me a year later, he gave me his business card and told me that he now had a job as business development manager for the offshore shipping firm that he used to work for; he now had five supervisors reporting to him.”
“That blew my mind,” he admits. “I realised that, by sorting out this man’s pain, we had given him back his life.”
Pulsed RF Therapy
One of Dr Phua’s patients is an octogenarian, whose children brought him in. For two-and-a-half years, he’d been suffering from trigeminal neuralgia, a stabbing facial pain so severe that he couldn’t put his dentures in to eat.
Dr Phua used an important new therapy, pulsed radiofrequency (RF) – a non-invasive form of neuro-modulation that alters the pain impulses that go to the brain. After just one session, the patient achieved near-perfect relief. Two years later, he is still pain-free and no longer on medication.
Variable, subjective – but quantifiable
What influences our experience of pain? Not only do different people have different pain thresholds, but the same person can find a procedure quite bearable on one day, yet agonising on another. Every woman who waxes, for example, knows to have her Brazilian done in the middle of her cycle, when hormone levels are lower and skin less pain-sensitive.
Variations between people depend on a wide range of factors, including genetics: different races have different tolerances,” says Dr Chua. They depend on one’s state of health, too. If you have fibromyalgia, for example, you will be more sensitive to pain.
Dr Phua agrees. “Pain is a multi-faceted symptom that’s affected by a wide range of factors, including hormone levels.”
A clinically depressed patient, he says, is more likely to report higher pain scores. Not only is it hard to unlink a patient’s psychological profile from his or her pain response, he feels that it would be “terribly unwise” to try to deal with pain in isolation, “without factoring in any biological, psychological and social issues”.
Pain is very difficult to diagnose, admits Dr Chua.
“Clues in the diagnostic path are all we have to go on. I can’t see or feel a patient’s pain; only he or she can report it. If I did an MRI on you today,” he adds, “I’d probably find several areas of degeneration, though you may be completely pain-free.”
Because pain cannot currently be measured with anything like an electrical myographic test, EMG or nerve conduction study, he did his thesis on Quantitative Sensory Testing (QST), a non-invasive tool in diagnosing peripheral nervous system disorders.
“Pain medicine today is such an exciting field. And I’m hoping to be able through my thesis on QST to find more pieces of the puzzle.”
Poppies have been harvested for their opium at least since the third century AD, first by the Sumerians and the Babylonians. Ancient Egyptians used crude sedatives and analgesics for surgery, perhaps from the mandrake plant but also from poppies. And before opium was introduced to India and China, incense of cannabis was prescribed together with a nice glass of wine. Medieval England doctors used a potion called dwale, made from bile, opium, hemlock, bryony… and lettuce. We’ve come a long way.
In the mind?
Fewer doctors nowadays will dismiss your pain as being “all in the mind” when they’re incapable of pinpointing its cause, but this does still happen. And it occurs more often in Asia, admits Dr Phua, where stoicism is a prized virtue and the patient may be more likely to accept such a verdict.
On the other hand, as hypnotherapist Jonathan Garside-Atkinson of The Hypnosis Clinic reminds us, the mind can be very useful tool when it comes to dealing with pain. “While you can’t generally turn pain off,” he says, “you can change your perception of it.”
Hypnosis has a proven track record in helping patients with intractable pain to reduce their discomfort. It is also widely used in helping to reduce the pain associated with childbirth and even as an alternative to conventional anaesthetics used for surgery.
Interestingly, the levels of pain we experience can be directly affected by our expectations. Jonathan was able to effectively demonstrate this fact while teaching a course in Self-Hypnosis at London’s Imperial College.
Using a hypnotic suggestion that a person’s arm was free from pain, infection, bleeding, bruising, swelling and soreness, he says, “I was able (with their permission), to push a nappy pin through about two inches of flesh on their forearm. This resulted in no pain, and, even when the pin was removed, no bleeding.”
Now that’s food for thought.
Osteoarthritis Q&A with Dr Lim Yii Hong
What causes joint pain?
A few common causes are trauma, overload stress, tendonitis, ligamentous injuries, gout and infections. Arthritis is an inflammation of the joint, with any combination of the following five symptoms: warmth, swelling, pain, redness, or loss of function of the joint.
Can you describe the kind of pain that arthritis causes?
It can range from very mild ache, soreness or discomfort to very intense debilitating pain that prevents one from moving the joint at all. More common is pain that prevents us from moving properly. For example, a person with knee pain may still be able to walk or stand, but not very well.
Why are our knees so prone to osteoarthritis?
The knee joint is actually a fairly unstable, bony joint that requires many ligamentous structures and muscles to keep it stable, in place and functioning well. So, if any of these is not working well, osteoarthritis can set in over a period of time due to the increased stress on specific areas of the joint.
What is your approach to managing pain?
Everyone is unique, and there is no one-size-fits-all solution to managing pain. So it is important to understand the treatment modalities available and what would work best for your body and your condition. It is also important to get to the root cause of the pain and not just settle for temporary pain relief.
With knee osteoarthritis, for example, it is the stress on the knee joints that causes pain. Therefore, pain management modalities such as medication, hyaluronic acid injections or acupuncture, should always be paired with physical therapy to help rehabilitate the knee joint. Lifestyle changes may need to be made, too, for sustainable pain relief in the long run.
How have you helped someone to overcome knee pain?
I’ll give you an example: a 57-year-old woman whose chronic knee pain was affecting her mobility so much that she could only walk for 30 minutes at a time. Reluctant to consider the surgical options that other doctors had been recommending, she asked us about our non-surgical treatment modalities.
We diagnosed moderate knee osteoarthritis that was deteriorating due to weak muscle function. To delay its progression, we prescribed an unloading knee brace to reduce the pressure on her knee joint, the underlying cause of her discomfort. With this pain relief, she was able to embark on physiotherapy to improve her muscle function.
She continues to progress well, to the extent of being able to go off for an extensive overseas shopping holiday – within the first month of treatment!
Do you give nutritional advice?
It’s important to maintain a healthy BMI, so that excess body-weight is not adding stress to your knee joints. So we recommend following a balanced diet and avoiding energy-intensive processed foods that are poor in nutritional value. As a general rule of thumb, aim for 50 percent of your meals to consist of fruit and vegetables.
How can we try to avoid joint pain?
Keep active, keep moving, don’t sit for too long, exercise properly and progressively, and do things in moderation. Most of us are not made to run marathons, but none of us are made to sit on our buttocks for hours.
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