Treating Chronic Pain Patients

InFocus Issue 22, January 2022

Chronic pain is complex and can debilitate patients when all of its causes remain elusive. Australian certified Pain medicine physician and Rehabilitation physician Dr Ben Manion from Axxon Pain explains how understanding neuroplasticity and using swift and appropriate multimodal treatment by pain management specialists can greatly assist in the management of ‘Chronic Pain Patients’. 

People often wonder why we at Axxon pain chose our line of work. Our patients are lumped into one homogenous group called “Chronic Pain Patients” and generally are seen as those patients who are difficult to manage. The patients who are constantly requesting things from the doctor that make us uncomfortable. Those who want more tests and more medications. Those who don’t do well after a surgery, want to discuss the merits of CBD oil or a procedure someone is doing in America. They can make us feel as though they are drowning and we are unable or unwilling to help them.

Pain is perhaps the oldest symptom, but also one we are yet to fully understand. A firm diagnosis can be elusive, and the patient’s psychology, activity levels, employment and entire social framework are all impacted by the presence of pain. We as doctors devote resources to trying to identify a cause, so we can point to the abnormality on an Xray and say “That’s the reason you have pain”. When we are unable to find a plausible cause, everyone shares the frustration. Medicine remains quite mechanistic, and patients and doctors expect a logical answer to what seems like such a simple problem.

The Complexity of Pain

The difficulty is that pain is actually not simple. The left photo shows the shoe of builder in the 1995 British Medical Journal who put a nail through his foot. His pain was severe enough to trigger retrieval, sedation and IV opioids. Everyone, especially the builder, was surprised when the boot was cut off and his foot was found to be unharmed. The nail had slipped between his toes, and despite his real pain he had no real injury. There are other cases of people having serious tissue injury and being oblivious to it, such as the Chinese war veteran who discovered a 1.1-inch bullet lodged in his pelvis from a war 60 years ago, or the construction worker on the right photo with a 4-inch nail in his skull discovered incidentally on workup for a headache.

The Nature of Pain

Pain is essentially an experience, and relative to the wider context of who the individual is, and what is happening to them. Furthermore, it is an electrical problem as much as a structural one. As in any circuit, or car fuse box, the system may look pristine but refuses to work normally. The goal often shifts as they enter a pain management space from “What the hell is wrong with me” to “How do I fix this”.

As we learn more about persistent pain states, and as the opioid tap is gradually being turned off, we are recognizing there are a number of contributing factors to chronic pain. There may be genetic neurological vulnerabilities as well as psychological and early childhood ones. Sometimes a trigger such as a viral infection can be identified, other times it is a minor arthritis or a trauma as the perceived cause. It seems more and more there is a lock and key system at play, where some people will trip into a pain state with a trigger and others will not. Pain causes measurable alterations in the neuraxis, and although some psychological and behavioural modifications can help restore normality this is at heart a biochemical and electrical problem of the nervous system.

Understanding Neuroplasticity and Using Multimodal Therapy

Neuroplasticity is the key to resolving chronic pain. It is also one of the main reasons it progresses if unchecked. The nervous system loves adaptation, and the more it performs any particular task the better it gets at it. Pain is no exception, and once chronicity starts and biomechanical and psychosocial changes begin the snowball is well and truly rolling downhill.

To try and correct this we use typically multimodal therapy. The premise is to obtain relief from the neurological blizzard that pain causes, and then in this window of relief we attempt to restore function using rehabilitation techniques. Any underlying structural causes are reviewed, and if possible, treated directly. Contributing factors which can be improved, such as anxiety, are addressed. Medications are used, including inpatient infusions with ketamine or lignocaine.

It looks more and more as if the more effectively and rapidly this relief can be obtained, the better the chance of preventing chronicity. Newer techniques and systems such as radiofrequency neurotomy and spinal cord stimulation, when combined with existing therapies and good conservative management are the best way we have of doing this. Pain is at its heart not merely an uncomfortable sensation, it is a mayday call from a distressed nervous system. The faster and more definitively we can act upon it the greater our chances of saving the situation.

The advantage of treating the problem with neuromodulation devices (such as a spinal cord stimulator) is that there are no permanent structural changes. We are essentially treating an electrical problem using electrical methods, which avoids the disadvantages of most neurologically active medications. We anticipate 80% pain relief in the appropriate patient, which gives the patient and the wider healthcare team an excellent opportunity for active change using rehabilitation methods. The devices are usually removable, and have few side effects. Emerging technology in battery life and waveform generation is allowing an exciting glimpse into the future of pain management.

To state the obvious, pain is complex. It is an organic, evolving, multidimensional process which can be catastrophic to an individual and their wider social circle. Effective rapid intervention is the best way to try to limit the changes, and our best way to attempt to restore normality. Pain specialists are often underused, but are a valuable resource to assist in the control of all types of pain.

 

 

 

 

 

 

 

 

 

 

 

Original photos and sources:

1. British Medical Journal
Fisher JP, Hassan DT, O’Connor N. Minerva. BMJ. 1995; 310:70.

2. South China Morning Post
https://www.scmp.com/news/china/society/article/2167452/chinese-man-had-headache-and-doctors-found-nail-his-head

3. Dr Ben Manion in Theatre