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STOP PAINInflammation Relief for an Active Life
By VIJAY VAD Peter Occhiogrosso
HAY HOUSE, INC.Copyright © 2010 Vijay Vad
All right reserved.
Chapter OneWhat Is Pain?
Early one Sunday morning, I was just finishing breakfast when my emergency pager went off. It was a recent patient of mine, whom I'll call John. I had been working with John for several months on alleviating a chronic pain condition that he'd had for more than seven years. We had been able to minimize his pain levels with a regimen of proper diet, exercise, supplements, topical creams, and minimally invasive procedures. This morning, however, he was experiencing an especially disturbing "breakthrough pain," a condition that affects many chronic pain sufferers. Breakthrough pain comes on suddenly for short periods of time and can't be alleviated by the patient's normal pain management arsenal.
I have seen breakthrough pain due to bumps in the road of everyday life-factors that alter the mind-body relationship. Common culprits are extreme stress, or excessive flying, as the pressurized cabin in the plane can take a toll, or something as simple as catching a cold, which can trigger breakthrough pain by increasing overall inflammation in the body. It is common in cancer patients, but it also happens occasionally for the kinds of people I treat-those suffering mainlyfrom musculoskeletal pain, or MSK for short. Many researchers and physicians now prefer to use the term neuromusculoskeletal pain, because it accurately suggests that the nervous system is not only involved but also fundamentally altered by such pain, sometimes irreversibly. I'll follow their usage (although for simplicity I'll retain the traditional acronym MSK), because to understand how pain works, we have to assess the role played by the exceedingly complex human nervous system.
Indeed, most of the pain people suffer from, both in this country and in other parts of the world, involves the complex system of nerves (neuro), muscles and tendons (musculo), and bones, joints, and cartilage (skeletal). MSK pain, which covers a wide range of symptoms and causes, affects one in four adults worldwide and is the most common source of serious, long-term pain and physical disability. Chronic pain, often a result of unresolved MSK pain, is the cause for as many as 60 percent of people requiring early retirement or long-term sick leave. The costs associated with treating this form of pain in the United States alone reached a quarter of a trillion dollars during the years from 2003 to 2008. Excluding trauma, MSK conditions are responsible for roughly 25 percent of the total expense of illness in all developed nations. The monumental impact of MSK conditions is now recognized by the United Nations, the World Health Organization, the World Bank, and numerous governments throughout the world that support the Bone and Joint Decade 2000 to 2010. According to an influential paper released in 2008, this form of pain is "one of the most common reasons for self-medication and entry into the health care system."
My patient John may be just one small part of those statistics, but to me he represents the personal side of pain, because I saw just how big of a toll it took on his daily life. When I met John, he was at his wits' end, having all but given up hope of getting relief from what he experienced as "round the clock" pain. John runs several successful computer programming and Internet technology companies that require him to drive fairly long distances to work. When he first came to see me several years ago, the long drives were causing him considerable back pain. John is now in his mid-40s, but the initial source of his pain was an injury that occurred when he was just 14. While competing in a karate tournament, he threw a roundhouse kick, also called a "720" because it requires two full revolutions of the leg and body to deliver the blow. His opponent had fallen against the ropes to get out of the way, however, so there was nothing to stop John's leg and lower body from continuing to spin out of control. The whiplash left him a little sore, but he was able to finish the match. He didn't feel bad that day, but the pain soon intensified.
"I woke up the second day after the tournament," John said, "and I was absolutely screaming for my mother." At the hospital, he was given traction and sent home the following day. John felt essentially normal for the next 10 years, with only an occasional backache. He spent a decade laying tile and granite floors for a living, and even though he was on his knees most of the day, John felt little back pain, because his work forced him to maintain a strong body core and tight stomach. The problems developed after he stopped doing manual work and started his first computer job. He had been going to night school while laying tile, but once he began working at a computer station full time, he lost his core body tone, and after a few years his back pain started in earnest.
After examining John, I determined that he had a tear in the soft tissue in one of his spinal discs. When healthy, the discs separating the vertebrae in your spine are like jelly donuts: they have soft, gel-like centers surrounded by layers of fibrous tissues. Because of injury or aging, small tears can form in the outer layer of the disc (this is called an "annular tear"). When the gel-like center of the disc pushes through-like squeezing the jelly out of the donut-the result is a herniated disc. John had sustained a tear on the outside lining of a lumbar disc, located in the lower back. This caused inflammation of the nerve going down his left leg and resulted in severe back and leg pain.
The tear was most likely the result of that missed karate kick, and had gradually worsened over the years. John had seen a doctor in Florida who gave him an annual selective nerve root block (SNRB) injection, which is a special form of epidural injection commonly used for diagnosis and back pain management. The SNRB injections worked for a year or so, and John occasionally saw a chiropractor. But as his life became more sedentary and he put on more weight, the frequency of the injections went from once a year to every nine months, then six months, then three, and finally every two weeks. John was on what you might call a pain roller coaster.
CHRONIC vs. ACUTE PAIN
In a strange way, we in the West have developed a kind of split personality about pain. We may not like feeling it much, but we sometimes are taught that we should "suck it up" and bear it. I don't believe that's helpful, and in fact, just the opposite may be true. Some research has shown that pain and suffering can be extremely deleterious to our health, and not simply by making it hard for us to concentrate on work or family, or by reducing the quality of our lives. John C. Liebeskind, a renowned pain expert and a professor of psychology at UCLA, found that pain can even kill by delaying healing and causing cancer to spread.
Part of the misunderstanding about pain may come from the confusion between acute pain and chronic pain. Acute pain-say, from a severe burn or deep cut-may cause intense suffering, yet the pain is temporary. Just knowing that it will pass makes such pain more bearable. The pain incurred by a broken limb may be excruciating, but we can take solace in the day-by-day mending process and the gradual lessening of hurt and discomfort. Once the cast comes off, we usually feel relieved and whole again. In this case, complaining about the pain may indeed be counterproductive; we should do what we can to relieve the pain but focus primarily on healing its cause.
Chronic pain is often less intense than acute pain, but nonetheless can be far more debilitating. Thinking that there seems to be no end to this kind of pain makes it more difficult to bear on a psychological level. In this situation, it may be necessary to attack the painful symptoms as much as their cause. For one thing, the longer we suffer from a particular form of chronic pain, the lower our pain threshold becomes. This means that it takes less stimulation to initiate a feeling of intense pain. Just think of a bruised knee that you keep reinjuring. Merely pulling on a pair of pants can become a painful act, because the pain threshold has become so low. For that reason, we must be careful to treat acute pain quickly and effectively, so that it doesn't evolve into chronic pain. If the tear in his disc had been correctly identified and treated earlier, John would have saved himself a lot of suffering.
In this book, I will be talking about both acute and chronic pain, although I'll be spending more time on chronic pain for a number of reasons. After all, you can use many of the same treatments to reduce acute pain that I will be describing for chronic pain. And most acute pain can be treated effectively by conventional and/ or integrative modalities that are commonly available, including physical therapy, acupuncture, and chiropractic. Cuts, burns, stings, breaks, and sprains are considered "self-limiting," which means that as the painful stimulus lessens-you take your hand off the object that is too hot or cold, or your leg is placed in a cast and neutralized-the pain decreases markedly. Often even a severe pain in the low back or along the sciatic nerve in the leg will disappear as inexplicably as it occurred. (Some such pain may actually be cyclical, meaning that it will come and go.) Chronic pain, meanwhile, is both more complicated and more mysterious. It generally develops through a cumulative series of smaller changes we make to cope with acute neuromusculoskeletal pain. The chronic MSK conditions that most commonly require treatment include arthritis, back pain, and tendonitis. The incidence of chronic MSK pain is expected to increase substantially as levels of obesity continue to grow, not only in the developed world but in emerging nations as well. As our society ages and the baby boom generation enters their 60s, we can expect to see an exponential explosion in chronic MSK pain, so it really pays to know how it's caused and what we can do to stop it.
Chronic pain, which, as noted earlier, is defined as lasting more than six months, is most often caused by a failure to effectively treat some form of acute pain. Many of us have suffered acute pain at some point in our lives, whether from a bruised muscle, sprained ankle, broken bone, deep cut, or serious burn. But as long as the acute pain from those injuries is diagnosed and treated quickly and properly, we are generally able to avoid having it develop into chronic pain. Early intervention is the key-but not too early. Many conditions will heal themselves in six to eight weeks with modified activity and common sense treatments, such as ice, heat, soothing balms, and OTC medications. (See Appendix A for information on treating acute pain.) But after that time, if the injury hasn't healed and the pain dissipated, what are known as "pain pathways" are formed and lead to chronic pain.
Chronic pain can also be the result of an ongoing condition, such as arthritis, defined as the loss of cartilage-the shock absorbers in the joint-that can produce painful inflammation in the joints and limit range of motion. In other cases, it may be caused by an illness, such as a chronic Lyme disease infection, or even surgery that damages a nerve.
Chronic MSK pain, as with other chronic pain conditions, may be the result of a past injury, but it can also be due to the buildup of everyday stresses. A slipped or bulging disc as described above, for instance, may be the result of being overweight. But there may be other stresses on the disc, such as extended sitting, as with writers, artists, and office or factory workers, or driving. Truck drivers further compound the risk factor of driving long distances with lifting during loading and unloading.
Genetics and age also play prominent roles in chronic MSK pain. As we age, the gel within our spinal discs tends to dry out, making the spine less flexible and more prone to traumatic injury. And the relative strength of the protective outer layer of our discs is also conditioned to some extent by our genetic history in much the same way as some people are predisposed to cancer or diabetes. Being overweight can also increase the risk of our discs drying out.
And yet, chronic pain can sometimes be mysterious, its root cause hard to determine. There may be no evidence of disease or damage to tissues that doctors can directly link to pain. Or pain may remain after the original injury shows every indication of being healed-as was the case with John's karate injury and resulting acute back pain. John saw seven different doctors, including back and pain management specialists, orthopedic surgeons, osteopaths, and chiropractors, yet any relief he felt was always short term. "Nobody really seemed to spend any time to talk with me," he said. "It was like a mill. You were in there for 15 minutes and then you were out. You got a prescription and you were gone-and that drove me insane."
The prescriptions he got were for NSAIDs (non-steroidal anti-inflammatory drugs); nerve membrane stabilizers originally designed for seizure control; painkillers including opioids; and muscle relaxers. He was even given a complicated procedure called a nucleoplasty, which in his case wasn't called for. The problem was that the main source of his pain was the tear in the disc and not the bulge itself, which nucleoplasty is designed to treat. One specialist he saw even talked about replacing the damaged disks altogether.
When John finally came to see me, he was not only in pain but also feeling a great deal of frustration verging on despair. He told me that he was experiencing pain from the time he woke up in the morning until he went to sleep at night, and that the pain often disturbed his sleep as well. Even with all the treatments and medications he had gotten, he just wasn't getting significant relief. He could not sit for even five minutes-a hallmark clinical sign of a tear in the disc.
I decided to approach his situation from all directions. The weight he had put on and the prolonged sitting he endured during his years of sedentary work had added enormously to the initial problem of his injury. So I started John on a weight loss regimen of aerobic exercises, including swimming, treadmill walking, and yoga-based stretching exercises (See Appendix B for a selection of these stretching exercises) and an anti-inflammatory diet. I also advised him to make other lifestyle changes, such as cutting down on his commute and heating his back for 15 minutes at bedtime and in the morning and icing it after work. I told John that if he did all these things, he would see a significant improvement within six months. In a very short time, John went from missing two or three days of work per week because of his pain to being able to work five days a week.
To help him with the pain he felt while driving or flying long distances, I recommended a back brace designed to take pressure off the low back. The combination of using the brace for prolonged sitting, 45 minutes of daily walking and the weight-loss regimen was helping John start to break the pain cycle. I also gave him samples of an OTC patch and topical cream that managed to further reduce his pain during his daily commute and while at work.
It's not that John has no pain at all now. We are managing his pain in an ongoing way and keeping it at a minimum. I may still occasionally prescribe anti-inflammatories or pain meds, or suggest going to an osteopath, but only when absolutely necessary and only for short periods. I am usually able to get many patients to a pain-free stage pretty quickly, but others who have been seriously injured or have gone untreated for lengthy periods of time have to be willing to stay in it for the long haul. John knows that if he maintains the regimen he'll do all right most of the time. And that's a big change from the way he felt when all he experienced was pain. As he once put it, "When I'm in so much pain, I feel like I'm in the middle of a crowded room screaming and no one hears me. When you're in round-the-clock chronic pain, you feel lonely and isolated."
Knowing that there is a way out of pain and that people care about you is a major source of comfort at times like that. My job as a physician was not to treat him and his various scans as numbers in a generic protocol, but to customize his treatment plan, because pain is personal.
Excerpted from STOP PAIN by VIJAY VAD Peter Occhiogrosso Copyright © 2010 by Vijay Vad. Excerpted by permission.
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