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Hurdles on the Road to Recovery

Hurdles on the Road to Recovery

October 29, 2018

Chronic pain is challenging to treat and all possible avenues that can be of help should be utilized. Following are some common misconception that can become a hurdle on the road to recovery of the patient. I felt it’s important that I write on this as I encounter these issues in my daily practice. Unknowingly one can create hurdles in his / her progress and these can be easily addressed by education and effective communication. If you have any similar concerns please feel free to contact me for advice.

I have divided them into different categories-

  • Pain Related
  • Medication Related
  • Interventions Related
  • Psychology / physiotherapy Related

Pain Related

I have pain so there must be some ongoing damage in my body

While pain is a protective response and brings to our attention a number of medical issues, longstanding (chronic) pain does not equate to ongoing damage. Longstanding pain can change the way nerves carry sensation to the brain leaving a memory imprint in the nerves. This imprint persists even if the cause of pain is removed and this can explain the persisting pain. There are numerous other mechanisms involved and I can help you understand the ones relevant to your problem. If there are any other concerns like infection then relevant investigations can help to rule these out.

I have had many investigations and treatments and still no one is able to help me

Investigations such as MRI, CT scans are able to tell us what is different from expected/ normal. Unfortunately, they cannot directly confirm the pain source as all of us are unique and every deviation from normal does not cause pain. For example if we do MRI scan of spine of random fit people a significant number of them will show abnormalities, but these individuals may not have any pain. Hence it is important to interpret MRI finding in relation to patient’s history and examination findings.

Sometimes injections are used as an aid in diagnosing the pain source. Let’s assume that you have back pain and we suspect that it is due to arthritis of joints in your back. Now there are many joints in the back and a number of them may have arthritic changes. If I numb the nerve that carries pain from one of these joints and your pain goes away then this will help narrow down the likely source of your pain. These diagnostic injections can help plan the further course of treatment.

Medication Related

I do not want to take any pain killers as they have side effects and may damage my kidneys

Whilst no medicine or intervention is free from possible side effects, the risks are minimised by carefully selecting the right medications at the right dose. A number of factors have a bearing on the medications prescribed and please inform the doctor of

  • Your other medical conditions
  • Medications you are using
  • Medications you have used in the past and the reason for discontinuing
  • Any allergies

Each one of us is unique and pain being a personal experience requires nothing less than a tailor-made therapy. If a medicine has caused side effects or not helped someone it does not mean that your response will be the same. A number of sources such as internet, family members, neighbours, books, media etc. play a role in shaping our opinions. It’s important not to generalise from the experiences of others. Even if one experience side effects, majority of them are transient and are resolved with the discontinuation of the medications. If you have any doubts about the medications you have been prescribed you should not hesitate in clarifying with the prescribing doctor.

The issues encountered in the developing countries are unique. On one hand we have patients who are inappropriately concerned about all painkillers causing damage to kidney or other body organs and on the other hand we have patients who misuse medications and are more liable to suffer from such complications. These issues can be addressed by education and good communication.

My pain is better when I take medicines but it comes back when I stop the medicines. What does this signify?

If a pain has persisted for years, getting rid of it completely, can be challenging. Chronic pain is frequently accompanied by weakening of muscles, altered biomechanics, low mood, anxiety, poor sleep and other stresses. It is unlikely that all of these can be addressed by a short course of a magic pill. Most problems in today’s world have a lifestyle component. For example, if you are overweight and have arthritic knee pain then any magic pill or injection is unlikely to provide a long lasting solution. It will require weight management to reduce the load on the knees, exercises to strengthen the muscles along with pain killers and other interventions depending on the severity of arthritis. Life style modifications, self management are an integral component of chronic pain management. While pills no doubt have a role, one cannot rely on them alone.

Chronic pain needs to be treated as a disease and not as a symptom of a disease. Like diabetes and high blood pressure your pain medications will need to be adjusted as your symptoms change. If permanent cure is not possible then I will help you achieve best possible control of symptoms and educate you about the do’s and don’ts.

If I take medicines regularly they will stop working

Tolerance to medicines means the same dose of medicine becoming less effective with repeated use. This is a well know scientific fact and does not mean that medicines will stop working. It can be easily overcome by

  • Rotating to a different medicine of the same class (as with opioids) or
  • Discontinuing the medicine for some time or
  • Using medicines which work by different mechanisms.

Some medicines may need a dose reduction prior to stopping to prevent withdrawal symptoms and this is best done under doctors supervision. This should not become a reason for refusing painkillers.

I will become addicted to pain medicines

Deciding whether or not to use certain medications is dependent on the risk benefit ratio. If the likely benefits outweigh the risks then closely supervised trial of medications while accepting certain side effects or risks is a reasonable option. The risks can be further reduced if you comply with your doctors instructions and attend regular follow up appointments. Addiction is more likely with certain classes of drugs such as sedatives, opioids. In a motivated person, sedatives can be reduced by using relaxation techniques and sleep hygiene practices. Without sounding like I am trying to promote opioid therapy, I feel that carefully supervised opioid therapy, in low doses , can have beneficial effects in certain subgroup of patients. Screening for risk of addiction prior to starting the medicine can help to further reduce the risk .

While the western world may be struggling with opioid abuse epidemic, in the developing nations we see another subgroup of patients who do not want to use painkillers like morphine despite having terminal illness because of the associated taboo. Many believe that it is something for use only in the last days of life. A significant proportion of these patients will however happily agree to use a stronger opioid patch. It’s sad to see patients nearing the end of live refusing to use painkillers and suffering because of the prevalent misconceptions.

Injection Related

Spinal Injections are dangerous

Technology and our understanding of medical issues has advanced significantly in recent times. Using x ray, ultrasound or CT guidance not only helps reduce the risks but also helps to ensure accurate delivery of the medication at the intended site. Risk profile of carefully performed spinal injections by appropriately trained specialists is negligible. Technological advancements such as radiofrequency treatment and in the field of regenerative medicine have opened multiple new avenues.

Steroids used in the injections are dangerous

Every medication has possible side effects and so do steroids. Regularly used oral steroids have a markedly different side effect profile when compared to the one off use as in spinal injections. Majority of side effects seen with oral steroids are rarely seen with one off spinal injections Facial swelling, significant weight gain, thinning of skin, infections etc. Some studies have found that patients on oral steroids are five times more likely to have side effects. To reduce the chances of side effects further I limit the dose and the number of times one can have these injections in a specific time.

I do not want to take injections/ painkillers as I will not know how the disease is progressing if I mask the pain

Pain is a crude indicator of disease and cannot be relied on for monitoring disease progression. Persisting pain apart from prolonging your suffering can have other detrimental effects on your body. If your doctor feels that a close vigil needs to be maintained on your disease then he/she will request for appropriate investigations to monitor the progression. This should not become a reason for suffering.

Physiotherapy and Psychology Related

Physiotherapy is not good for me as I get increased pain with physiotherapy

I will try and answer this with the help of an example- let’s assume I run a marathon tomorrow. I am bound to experience pain and stiffness afterwards because that is not a usual physical activity for me. I will do better if I gradually training myself over a period of time , slowly increasing my running distance before running the marathon. Similarly if you have had limited activity for some time there is a good chance that your muscles have become deconditioned and need to be retrained gradually to undertake the desired level of activity. The goal or the level of activity may vary from person to person (e.g. marathon or just walking to the nearby market ) but what is important is to understand is that most people get more pain if they do more activity than what their body can handle. It does not mean that physiotherapy is not for you. Physiotherapy is essential component of your recovery. The key is to start low and go slow. Which means maintain a certain minimal level of activity irrespective of your pain levels and gradually built up on it giving your body enough time to get accustomed to the new activity levels. A good physiotherapist will gauge your capacity accurately and breakdown bigger goals into smaller achievable steps to keep you motivated.

Psychology input means I do not have genuine pain and it is all in my head

Mind plays a huge role in how we deal and react to ongoing issues and this is where psychology can help. Understandably low mood, anxiety, stress, relationship or work strains are frequent partners of chronic pain. These play a big role in magnifying the perceived pain and correcting these alone can lead to improvement in perceived pain. Besides addressing these factors psychology experts can help you realistically analyse your rational and irrational fears and arm you with coping and pain management strategies to deal with episodes of exacerbation. Sometimes joint sessions with other family members help in dealing with issues more comprehensively.

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