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Pain Management
Controlling Pain Helps Speed Your Rehabilitation
WHat Exactly Is Pain? The International Association for the Study of Pain defines it as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”1 Pain is complex; it includes an emotional component that affects thinking and behavior, as well as a physical component that limits movement and function.
Each person experiences pain differently, so your pain may differ significantly from that of someone with a similar injury. Determining how your pain is produced and experienced will guide the choices for the best treatment approaches for you. A multidisciplinary approach is best. This can include drugs; application of heat and cold; the use of ultrasound; cognitive and behavioral therapies; complementary medicine (acupuncture, cannabis, meditation, hypnosis, biofeedback, yoga, massage); exercise; devices such as transcutaneous electrical nerve stimulation (TENS); epidural electrical stimulation; and intrathecal drug delivery (injecting medications directly into the spinal canal that surrounds the spinal cord). I recommend combining therapies that provide synergistic pain relief with minimal side effects. Avoid narcotics, if possible (or work with your doctor to wean yourself off them as soon as possible), because they are highly addictive and can have harmful long-term effects on your ability to perform rehabilitation and return to work.
The nature of your pain (sharp versus dull, or burning versus freezing, for example) is not nearly as important as the frequency and duration. I have felt some kind of pain every day for the last eleven years, which means my pain is chronic. On a scale of 0 to 10, it varies from a 1 to an 8, depending on a multitude of factors, including stress, medications, exercise, urinary tract infections, among others. As you no doubt already know, pain will sap your energy, limit your sleep, make you irritable and prone to anger, and limit your rehabilitation, so I’ve found ways to address mine. My tactics have evolved over the years, and what works for me may not suit you, but “grinning and bearing it” is really not an option. That’s no way to live your life, which is why effective treatment of pain is a necessity. As you begin your pain management journey, don’t expect any single treatment to completely eliminate your pain; keep in mind that pain management is successful even if it only reduces the severity of pain. But this shift can make an enormous difference!
My Pain Journey
My own battle with pain began in the hospital, right after my accident. Even though I was paralyzed, I felt pain everywhere, coming in waves that overwhelmed my ability to think. It’s likely that the pain was caused by the surgery I had undergone, combined with the pain of being intubated. Mercifully, the doctors had ordered an excellent painkiller, Dilaudid (hydromorphone), a derivative of morphine. Within a minute of receiving it, I would be transported to a state of bliss; I felt like I was floating in space and was completely without pain. Unfortunately, Dilaudid could not be my long-term pain medicine because it’s almost always given intravenously, it’s highly addictive, and it causes constipation.
One hundred and twelve days later, when I was discharged from Kessler Rehabilitation Center to return for further inpatient rehabilitation in Rochester, my pain medicine of choice had become Vicodin, another opiate (specifically, a combination of hydrocodone and acetaminophen). Before I got into the van, I took two Vicodin. I needed another four hours later; the roads were bumpy, which made my shoulders hurt terribly. But as my wife pulled into the admissions bay at Strong Memorial Hospital, I was flooded with emotion to finally be home, back in my city (and at my hospital). Filled with elation, I promised myself I would never take opiate drugs again. Those drugs had addressed my pain well, but the side effects (fuzzy mind, constipation) were not things I wanted to live with for the long term.
I wasn’t able to keep that promise to myself, at least not immediately; it was still too early in my recovery. After every physical therapy session, the pain in my shoulders was so great that nonsteroidal anti-inflammatory drugs (NSAIDs) were not sufficient to reduce it. Instead, I was given a fentanyl patch, which was adjusted by slowly increasing the dose until it brought my pain level down to a 1. Over the next month, my pain became more localized, in my right upper chest and biceps. This was both musculoskeletal and neuropathic pain. The musculoskeletal pain was caused by ambulating with my platform walker, which required me to support myself with my forearms. The neuropathic pain was a burning sensation when I touched my skin. So I began using a topical patch that released lidocaine (Lidoderm) locally to numb the pain.
By the time I left Strong Memorial Hospital’s rehab unit on October 7, 2009 (four months after my accident), my pain medications included:
• Duragesic (fentanyl patch) for generalized severe pain
• Lyrica (pregabalin), 150 mg, three times per day for neuropathic pain
• Lidoderm (lidocaine) patches, a fast-acting local anesthetic
• Flector (diclofenac) patches, an anti-inflammatory pain reliever for musculoskeletal pain
• Zanaflex (tizanidine), a muscle relaxant that decreases tightness and spasticity everywhere, thereby decreasing pain
That’s quite a list of powerful drugs, but they made it possible for me to work hard on my physical and occupational therapies, to be with my loved ones without being distracted by debilitating pain, and to be able to concentrate, think, and, eventually, return to work.
Acute versus Chronic Pain
Pain can be characterized as acute or chronic. You may frequently experience both. Acute pain, like the pain you feel when you burn yourself on the stove, are stung by a bee, or break a bone, is a physiologic response that alerts you to the injury. This involuntary reaction is part of our survival mechanism. While the pain of a broken bone is more intense and lasts longer than that of a bee sting, the pain diminishes and then disappears within a pretty predictable time frame in both situations—two days for a bee sting, and two months to a year for a broken bone. Chronic pain, in contrast, lasts beyond a “typical” time frame and is frequently part of a complex biopsychosocial situation in which emotions, environment, and social interactions play significant roles in generating pain.
Nociceptive versus Neuropathic Pain
Pain can be divided into two categories based on the process by which it arises. Nociceptive pain comes from damaged tissue and nerve fibers, such as that caused by cutting your hand while using a knife. It feels burning, stabbing, or throbbing, and usually gets significantly better within hours to days. In contrast, neuropathic pain comes from damage to the nervous system itself. Specifically, the peripheral and central nervous system (called the somatosensory system) are damaged by nerve trauma or nerve diseases. Neuropathic pain also differs from nociceptive pain because it is more likely to be chronic, with months to years without improvement. It can cause you to feel abnormal nerve sensations called dysesthesias and paresthesias, which are usually felt in the arms, hands, legs, or feet. Paresthesia and dysesthesia differ in severity. Paresthesia is more sensation than pain, a tingling or pins-and-needles feeling. Dysesthesia is usually painful; it frequently causes a burning sensation, and it’s not explained by an obvious injury to a limb but may be “created” centrally in your brain. Finally, allodynia is hypersensitivity—it describes pain from a stimulus, such as light touch, that is not normally painful.
Neuropathic pain is especially common after ANI. It’s the kind of pain that’s “all in your head,” because it really is self-created, at least in part. Consequently, the nature of the pain sensation, the situations that cause the pain, and what makes it better or worse are unique to each individual. Neuropathic pain can originate from anywhere in the body where there are nerves: in the sensory nerves in your skin, nerves in your spine, and nerves in the brain itself. The most widely known example of neuropathic pain is phantom limb pain, which is when you feel pain from a limb that is no longer present. In this case, damage to the nerves of that limb causes a reorganization (a kind of neuroplasticity) of the transmission, modulation, and perception of pain by the brain.
Spasticity
Spasticity is a side effect of paralysis that increases muscle tone (tightness). It’s caused when there is damage to the parts of the brain or spinal cord that control voluntary movements, and the symptoms range from stiffness to uncontrolled spasms. Spasticity can cause severe pain, or it may have no effect on your daily life. My spasticity causes my right upper arm to tighten progressively over the course of the day, causing increased pain. It can make one of my legs get stuck behind the other when I try to walk. Spasticity can limit your range of motion, and thereby your independence. It also increases with other health problems, such as constipation or urinary tract infections.
Paying attention to spasticity is important. There are several effective drugs for spasticity, including baclofen, tizanidine, and clonazepam. They all have side effects, so try several to find the one that works best for you. Regular stretching to maintain flexibility and using hot packs or a vibrating massage device can reduce spasticity significantly. If you have severe spasticity, especially with pain, talk to your doctor about the option of having a small pump implanted that infuses baclofen directly into your spinal canal. Since the pump contains a lower dosage than oral medication, the side effects are minimized.
Pain Treatment and Management
Controlling your pain is essential to your recovery. Don’t tough it out. Managing your pain with prescription and over-the-counter drugs, as well as non-drug therapies, will help you tamp down pain so that you can work on your rehabilitation. Your goal, as you try different treatments, is to find approaches that reduce your pain with few or no side effects and few or no interactions with other drugs. As you will learn, there’s usually no single drug that possesses all these properties.
You should also seek to optimize treatment of other conditions that might sensitize your perception of pain. Treatment of high blood pressure, heart failure, diabetes, and other medical problems should be handled before you start drug treatment for pain. This is particularly true if you have muscle spasticity and increased tightness (tone); treatments to reduce muscle tightness (such as baclofen and tizanidine) will dramatically lessen the need for pain treatment.
Drug Therapies
Drugs can be an essential part of pain management as you embark on rehabilitation, but long-term use of drugs should be avoided as much as possible, because all drugs have side effects that may become harmful over time, and different drugs may interact with each other to create new side effects. Drugs should always be used in conjunction with nonpharmacologic approaches, which we’ll explore later in this chapter. For many patients, using combinations of drugs that target different metabolic and nerve pathways can result in improved pain relief and fewer side effects, because this allows for lower doses of each drug. Combination therapy is often necessary because fewer than half of individuals with neuropathic pain respond to a single drug.2
Medications should be administered through the most effective and comfortable route, allowing you the maximum amount of control. Pain relievers for moderate to severe pain should be taken on a fixed dose and scheduled around the clock and not on an “as needed” basis. This approach will allow for more consistent pain relief, since you don’t have to play catch-up after a previous dose has worn off.
For neuropathic pain, the most common drugs are ones also used to treat other conditions.3 These can be medicines that prevent depression (tricyclic antidepressants such as amitriptyline or nortriptyline), because they decrease activation of brain areas that process pain. Chronic pain can cause depression, and vice versa, setting in place a vicious cycle. Drugs that prevent seizures (anti-epileptics, such as gabapentin or pregabalin) are also effective for pain relief, because they calm hyperactive nerves. Serotonin norepinephrine uptake inhibitors (SNRIs such as venlafaxine (Effexor) and duloxetine (Cymbalta) have been used as initial treatment because of fewer side effects than tricyclic antidepressants. Opioids are third-line drugs due to the risk of dependency, addiction, and overdose.
The pharmacologic approach to nociceptive pain primarily involves nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil), diclofenac (Voltaren), and naproxen (Aleve, Naprosyn).
Cannabis and cannabinoids: Cannabis (marijuana) has been used for thousands of years to treat pain and enjoy a state of relaxation. There are two widely available species (types) of cannabis: Indica and Sativa. There’s a common misunderstanding that Sativa energizes you and Indica relaxes you. But the truth is that almost all cannabis comes from hybrids of these two species, because hybrid plants grow larger and faster, and they’re more resistant to disease. The cannabis plant contains cannabinoids, which are compounds that bind to specific receptors in the brain, spinal cord, and other organs. The best-known cannabinoid is tetrahydrocannabinol (THC), which is responsible for most of the psychoactive effects, including relaxation, euphoria, and hunger. The other important cannabinoid is cannabidiol (CBD).
To understand the use of cannabis for treatment of pain, we must first start with definitions of the preparations that are available for use. “Medical marijuana” is dried material from the cannabis plant, consisting of THC, CBD, and other cannabinoids. Medical marijuana can be purchased from dispensaries in a variety of preparations. Some dispensaries sell medical marijuana that has been grown under conditions (type of seeds, hydroponics versus soil, UV light versus sunlight versus special colors) that increase the amount of CBD relative to THC. It’s not sold in pharmacies, because it’s not legal at the federal level, only on a state-by-state basis, and it’s not currently available for insurance coverage. However, when properly cultivated and analyzed for relative concentrations of CBD and THC, the medical marijuana sold in the dispensaries may be safer than marijuana purchased in “retail settings.”
The FDA has approved one cannabis-derived drug product: Epidiolex (CBD), and three synthetic cannabis-related drug products: Marinol (dronabinol), Syndros (dronabinol), and Cesamet (nabilone).4 These approved drugs are available with a prescription from a licensed health care provider (usually with special training for Schedule I drugs, which include cannabis). These cannabinoids are FDA-approved for the treatment of pediatric epilepsies, chemotherapy-induced nausea and vomiting, and extreme weight-loss conditions, like AIDS. All other medical conditions will be “off-label,” and therefore not covered by insurance.
The data in the medical literature on the use of cannabis for chronic pain treatment is equivocal but overall negative. But many of the studies did not use well-defined cannabis preparations. The best studies used the FDA-approved cannabinoids (dronabinol and nabilone), which lack THC and therefore have fewer euphoric effects and almost no physical effects. A survey of ninety-one publications that used CBD showed no benefit compared to placebo for chronic pain.5 More than half of the people studied had neuropathic pain; they also showed no benefit. However, there was a large increase in harmful effects related to mental, physical, and emotional function among study participants who received CBD. A 2017 meta-analysis of twenty-seven studies examining the effectiveness of cannabis in treating chronic pain found only weak evidence that cannabis alleviated neuropathic pain, and no evidence suggesting that cannabis was useful in other types of pain.6 Overall, the careful randomized studies of cannabis-based medicine (herbal cannabis, plant-derived or synthetic THC, THC/CBD nasal spray) in chronic neuropathic pain show that the potential benefit may be less than their potential harm.
There are two factors, in my opinion, that affect the efficacy of cannabis-derived products as treatment for neuropathic pain. The first is the method of ingestion, and the second is the relative amount of THC versus CBD. There are several small randomized trials that show short-term benefit for smoked7 or vaporized cannabis8 in patients with neuropathic pain. Unfortunately, these small studies did not report the amount of THC versus CBD, and there were side effects that caused about 20 percent of the patients to stop their use.
If you choose to include cannabis as part of your pain relief regimen, it’s important to use medical cannabis distributed by a pharmacy or dispensary, because cannabis grown for recreational use isn’t suitable for medical use. It’s not FDA-approved, nor is its composition and potency regulated, so it’s not possible to predict its efficacy and side effects from one purchase to the next. It’s also important to note that when you smoke cannabis for medical use, you will be exposed to all the dangers associated with smoking cigarettes, including the possibility that the cannabis may contain contaminants, which can damage your lungs. It also has the potential to become addictive, causing increased tolerance and withdrawal symptoms that make it difficult to stop. Furthermore, the physiologic effects of smoked or vaped THC may negatively affect your ability to function in work or school.
Therefore, medical marijuana should only be used when other treatments for neuropathic pain have not helped. If this applies to you, work with your doctor and dispensary pharmacist to find the dosage, relative amounts of THC versus other cannabinoids in the preparation, and the type of delivery (oil by mouth, edible, or topical) of medical cannabis that are effective and safe for you. Note that dispensaries do not sell preparations that can be smoked or vaped.
Lidocaine infusion: Lidocaine is often used for local anesthesia, to numb the nerves that cause nociceptive pain, before surgical (often dental) procedures. But several studies have shown that it can also be useful in treating chronic neuropathic pain. In outpatient settings, doses of 3 to 5 mg/kg administered over 30 to 60 minutes can relieve neuropathic pain in the short term, with sustained benefit of several months in about 40 percent of patients.9
Topical therapies: There are three widely available drugs you can use on your skin for local pain relief without systemic side effects. All three use a gel pad in which the drug slowly passes from the gel into your skin providing 8 to 12 hours of pain relief. The lidocaine (Lidoderm) patch is most effective in treating allodynia. The diclofenac (Flector) patch is the most common of several NSAIDs that exist in patch form. While it is best used for acute muscle and joint pain, it has also been useful in patients with neuropathic pain that is caused by inflammation such as complex regional pain syndrome (CRPS). Capsaicin is a compound derived from chili peppers that is thought to decrease pain by inhibiting pain-sensing nerves in the skin. It is most commonly used in creams, which must be applied every 6 to 8 hours for several weeks to achieve maximum benefit. I found it useful for my right chest pain, but after a couple of months of use, I developed burning and a red allergic rash (this occurs in about 40 percent of patients), so I had to stop using it.
Decreasing Your Dosage
Over time and as appropriate, you should try to decrease your drug intake. Why? Because taking as few drugs as possible means decreasing unwanted side effects, which will improve your quality of life. Here are my guidelines to help you get there:
• Only make changes to your medications based on consultation with your doctor. That person can be your primary care physician, your physiatrist, or another pain specialist. In most situations, it’s up to you to initiate a decrease in medications. If you don’t say anything, your doctor will think that everything is OK. In response to your request, they will likely try to decrease your dose by 50 percent over the course of three months. If you’re fortunate, you will eventually find that you’re able to completely stop taking a medicine or that you can take it at a greatly reduced dose.
• Begin with the medicine that is causing the most side effects, especially those that affect your thinking, bowels, libido, sleep, or energy.
• Stop medications that work through the same mechanism. For example, oxycontin and fentanyl are both opiates, so you should not be taking them at the same time. Sometimes, two doctors will start you on different medications for the same problem, especially if your list of prescribed drugs is not updated. This can easily occur when your doctor is not using an electronic medical record (EMR), or their EMR is different from the next doctor that you see. Make sure that you bring a current list with you to your appointment, and that your doctor reviews your medication list. Use drugs that are synergistic; one drug should enhance the actions of another.
• Keep in mind that drug titration (slowly increasing or decreasing the dose of a medication until you find the right balance between positive effects and negative side effects) is part of achieving pain relief. It can take a while to arrive at the correct combination of drugs and doses, so don’t lose faith if it sometimes feels like you’re taking two steps forward and one step back.
In the eleven years since my injury, I’ve been able to wean off a lot of drugs or have greatly decreased the dosage. I found that a combination of exercise and massage—and paying attention to actions that caused muscle pain—allowed me to gradually discontinue my fentanyl patch in three months. Within six months, I was able to achieve pain control using Lyrica, Flector, and Tylenol instead. Drug titration is an ongoing process—so don’t get discouraged if it takes a while to figure out what works best for you.
Behavioral Approaches to Pain Management
When developing a pain management routine, don’t limit yourself to just medication. Be open to nonpharmaceutical approaches to reduce pain, such as exercise, acupuncture, massage, meditation, and yoga (see chapter 8 for more information). I found these therapies beneficial during my rehab and continue to use them to this day. As you consider these options, keep in mind that the skills and techniques of therapists can vary widely. If the first one you try doesn’t help, that doesn’t mean that the technique is not useful; it could be that therapist isn’t suited to your needs.
Exercise
Exercise can be one of the most helpful therapies for pain. It works by stimulating the modulating nerves that inhibit transmission of pain and by raising the threshold for pain. Exercise also requires concentration, which can distract you from pain. The benefits are mental as well as physical, because your brain releases endorphins (the “runner’s high”) that make you feel good. Talk with your therapists about an exercise routine that will improve your cardiovascular fitness. This increases blood supply, improving your endurance so that muscle fatigue and pain occur only after extended use. The increase in strength makes it less likely that you will sustain an overuse injury, which would cause nociceptive pain that can trigger neuropathic pain. I try to do some form of cardiovascular exercise, usually stationary cycling, for forty-five minutes every day. I also perform more focused occupational or physical therapy, or weightlifting, for thirty minutes every other day. I’ve found that using my entire body for exercise helps decrease the localized pain in my right arm.
Cognitive behavioral therapy (CBT) uses your own thought processes to help you gain control over your pain.10 It works in two ways: First, it activates the modulating pathways that descend from the brain to inhibit transmission of pain; and second, it teaches you how to control your pain rather than be controlled by it. CBT techniques include relaxation, physical exercise, imagery, desensitization exercises, and goal setting, to train yourself to develop the ability to handle pain. Training yourself to separate your emotions from your pain allows you to work through it and thereby function better. Used in conjunction with other pain-relief therapies, CBT can be an important component of your long-term pain management program. (For more on CBT, see page 22.)
Relaxation techniques can help diminish chronic pain by inhibiting pain transmission from the brain. These techniques include meditation (see page 79), learned deep relaxation, guided imagery, self-hypnosis, and mindfulness. In each of these approaches, you learn how to focus your mind and prevent intruding thoughts and external stimuli from distracting you. These approaches work by decreasing sympathetic nervous system (SNS) activity (the fight-or-flight axis). Among them, meditation and mindfulness can be very helpful, but you may need to work with your therapy team to find the ones that feel most comfortable for you. These techniques are noninvasive, do not require drugs, and can be performed at home. Personally, I use a combination of yoga breathing, self-hypnosis, and meditation.
Thermotherapy, Ultrasound, Hydrotherapy, and Cryotherapy
Thermotherapy is heat therapy used to improve blood flow to muscles that have become painful due to overuse. Too much activity (as can easily occur with paralyzed muscles during exercise) builds up lactic acid, which is painful. Heat opens the blood vessels to the affected area and speeds removal of the lactic acid. Muscle spasms can also respond to heat, particularly if they form a knot, like a charley horse. There are many ways to use therapeutic heat. Moist heat and a heavy material that keeps it in place seem to be the best from my personal experience, as does a warm shower or hot bath. Heating pads work well, as do the more expensive heated massage pads that can be purchased from specialty stores. One warning: When applying heat to body parts with diminished sensation, make sure to have someone else check the temperature or place it against a part of your body that senses temperature well, like your face, so that you don’t experience a burn.
Ultrasound is a noninvasive way to obtain images of internal organs such as the bladder, heart, and kidney. But it can also be used to provide relief from both pain and muscle spasms, by heating deep tissues with sound waves, which penetrate farther than topical heat, to warm tendons, ligaments, and fascia. Phonophoresis is the use of ultrasound to deliver topically applied pain-relieving drugs to the tissues. I recommend trying ultrasound first, because there is much debate over whether phonophoresis is any better than high-frequency ultrasound alone. If you don’t notice improvement after three treatments, ultrasound is unlikely to be helpful for you. This may be because the inflamed tissue is too deep for the ultrasound to penetrate or that the problem is not inflammation.
Hydrotherapy is like a whirlpool bath, which involves placing the painful limb in swirling warm water for fifteen to thirty minutes. It works similarly to ultrasound treatment in terms of warming the affected limb. I found it very useful for my feet, which are hard to treat with ultrasound.
Cryotherapy, the application of cold, can be effective at decreasing nerve and muscle pain. Cold slows the speed of nerve transmission, making it harder for pain signals to reach the brain. It also decreases muscle spasms, which contribute significantly to pain perception. And, if exercise has damaged muscle, cold will decrease the inflammation. For best results, apply cold every one to two hours, for twenty minutes at a time. I like to use flexible ice packs with Velcro tabs that hold them in place.
Massage, Acupuncture, Trigger Point Therapy, Myofascial Release, and Other Therapies
These therapies can be very useful when used in conjunction with other methods of pain control.11 All four techniques treat sites where muscles, nerves, and myofascia combine to form small knots, also called trigger points. These sites are frequently associated with increased spasticity and tone that pinch off the blood supply and cause pain. The myofascia, a thick layer of fibrous material that surrounds muscle bundles, normally stretches like a rubber band, allowing nerves and blood vessels to slide between the bundles. After injury or prolonged immobilization, the fascia can stiffen and become inflamed, making it less flexible. This change can “trap” the nerves, further irritating them and causing pain with movement. The fascia also has sensory receptors that can transmit pain. In rare situations, injections of lidocaine and steroids may be helpful. A number of therapists incorporate the concept of trigger points and myofascial disease into a therapeutic massage modality (see more in chapter 8). The long-term benefits of myofascial release remain to be proven, so it should not be a primary therapy for pain management.
• Acupuncture: Some acupuncturists treat local pain by using needles to target dysfunctional muscles and joints, but many use a broader concept of organ and tissue health that can’t be manipulated by stimulating specific points. The broader approach focuses on increasing your qi (vital energy—pronounced “chee”) and making sure it is symmetrical as it flows through your body. Once your qi is increased and symmetrical, specific problems should resolve over time.
• Meditation: Meditation is among the most useful approaches to pain treatment. It’s easy to learn, completely safe with no side effects, easy to practice, and it prevents chronic pain from promoting harmful neuroplasticity such as complex regional pain syndrome (CRPS; see page 83). Meditation quiets the mind by focusing your thoughts intently on a word, thought, object, or movement. The more you practice meditation, the better you become.
• Self-hypnosis: A lot of people think they cannot be hypnotized, let alone self-hypnotized, but the truth is that almost everyone can. The power of hypnosis is that you use suggestions that isolate the pain in a way that reduces its intensity. Similar to meditation, it is easy to learn and can be used throughout your life.
• Biofeedback: Biofeedback involves providing a person with physiologic information while performing a movement or functional task. It’s useful to learn to control what is usually an involuntary process. It can be used to prevent simultaneous activation of two muscles that normally oppose each other when making a movement. For example, my injury caused me to contract both my biceps and triceps muscles when I tried to bring a fork to my mouth, when only the biceps should be active. I learned how to stop using the triceps by observing the activity of the muscles with electrodes that generated lines of force on a screen, in a technique called electromyographic (EMG) feedback. This decreased the work of my biceps so that it was less likely to be painful due to overuse.
• Yoga: Through its three main components (postures, breathing, and meditation), yoga can improve your physical health (fitness, balance, flexibility, and strength), mental health (by reducing stress and anxiety), and overall quality of life. The ability to achieve the postures is less important than the focus it requires to perform them—even if your attempt doesn’t look pretty!
• Massage: Massage decreases pain both directly and indirectly. While there are different approaches to therapeutic massage, the basics include muscle compression and stroking. Compression stimulates circulation, which helps promote muscle relaxation. Stroking (long slow movements along the muscles) enhances relaxation. For me, massage has the best effect on my back, since my spinal erectors (the muscles that hold you upright and rotate the back) become tight from my sitting all day in a wheelchair.
Devices
Transcutaneous electrical nerve stimulation (TENS) uses brief electrical pulses to stimulate nerve excitation which, over time, diminishes the transmission of pain.12 A typical battery-operated TENS unit (Figure 12) is connected to the skin using four electrodes.
Figure 12. TENS unit
The unit can deliver electrical signals of different pulse width, frequency and intensity. For pain, TENS is usually set to a high frequency (>50 Hz = 50 times per minute) with an intensity below muscle contraction. The location of the electrodes can also be adjusted to achieve maximal pain relief.
Invasive Therapies
The three most common invasive approaches are injections of lidocaine to induce nerve block, spinal cord electrical stimulation (SCS), and intrathecal drug delivery (IDD), also known as the “pain pump.”13 Local injection of lidocaine and corticosteroids to decrease inflammation is effective for short-term pain relief only. SCS and IDD are longer-term approaches with high success rates. SCS is based on the concept that stimulating touch or vibration nerves can decrease input from pain nerves. The SCS device consists of several parts (Figure 13A): stimulating electrodes implanted in the epidural space of the spinal cord, wires that connect the electrodes to a generator, an electrical signal generator implanted in the lower abdominal area, and a remote control that you use to alter the intensity of stimulation. An X-ray of an SCS device is shown in Figure 13B. Each black rectangle is a small electrode placed under the vertebrae that represent the dermatomes from which pain arises. SCS is effective in at least 50 percent of patients, measured by a two-point reduction in pain on the ten-point scale and a decrease in pain medication dosage.
A newer technology is dorsal root ganglia (DRG) stimulation. The DRG are collections of sensory nerve cell bodies within the epidural space. In the DRG, sensory signals from a specific area of the body communicate with the nerve roots to enable spatial location of pain. Therefore, stimulation of the DRG provides therapy to a specific area that may be difficult to treat with SCS, including the hand, chest, abdomen, foot, knee, or groin. It is also easier to program, fewer patients have discomfort due to paresthesia, and there is less variation due to position. Future advances in technology (see chapter 19) are likely to make this approach more effective.
Figure 13: Spinal cord stimulation
For IDD, a pump steadily infuses drugs into the space surrounding the spinal cord, which then flow up to the brain through the cerebrospinal fluid. There is a 70 to 90 percent success rate among patients who undergo this procedure, usually because higher doses of pain medications can be given without systemic effects.14 At present, the FDA has approved morphine, baclofen, and ziconotide for IDD.
Common Pain Syndromes and Treatments
Central Pain Syndrome. Central pain syndrome may be the most problematic type of pain experienced after injury.15 It’s caused by damage to the nervous system, which causes increased sensitivity to pain generated in the brain (rather than the spinal cord or peripheral nerves). After stroke or TBI, it most frequently occurs in the face, and after SCI it may occur anywhere, although it most commonly appears at the level of the injury. Central pain can be constant or periodic. It is frequently described as pins and needles, shooting or jabbing, or burning. Symptoms include increased pain (sometimes, even a non-painful stimulus, such as bending my arm, will cause me pain). Treatment may be difficult, because drugs must cross the blood-brain barrier and the specific receptor pathways remain unknown. The three classes of drugs used are carbamazepine (for seizures), nortriptyline (for depression), and gabapentin (for neuropathic pain).
Complex Regional Pain Syndrome (CRPS). CRPS is a chronic systemic disease characterized by pain, edema (swelling), and changes in skin appearance.16 The cause is unknown but likely involves inflammation, nerve damage, abnormalities in the autonomic nervous system, and increased activity of the central nervous system. Because ANI patients have these exact problems, episodes of CRPS occur in more than half of them; and many will develop it more than once. I’ve had it three times over seven years in my right arm, the limb most significantly impaired by my injury. To improve CRPS and achieve long-lasting results, you’ll need to take a multidisciplinary approach, starting by meeting with your physiatrist. Pain reduction is the first priority. Your doctor will be able to present you with a wide variety of therapies and suggest how to use them in combination for the best effects. For example, heat treatment and transcutaneous electrical nerve stimulation (TENS) are both effective at pain management, and may be helpful for you. Edema is best treated with a combination of elevation, massage (especially lymphatic drainage), and compression. Your doctor will also likely recommend cardiovascular exercise—which, for me, is the most effective treatment.
Your routine should include both active range of motion (ROM) exercises within the pain-free range to regain function, along with stress loading and traction. Stress loading involves applying weight to the affected limb frequently during the day. I usually lean on my right forearm on top of my wheelchair’s arm for five to ten minutes every hour. Traction requires a weight and a pulley. The simplest setup is to have the pulley hanging on the top of a closed door, with a ring for you to hold on one side of the pulley and a weight on the other side. Holding on to the ring for five to ten minutes three or four times daily strengthens the bones and muscles in your arm. Over time, you increase the weight as you improve. I find this traction exercise less useful than other exercises, because most devices use a water-filled bag as the weight (I worry about leaking), finding the right door is not easy (it needs clearance on top), and it can be uncomfortable. Mirror box therapy (see Figure 8; page 47) can be a useful addition to exercise therapy in addressing CRPS. Several drugs can be used to treat CRPS, including antidepressants; anti-inflammatories, such as corticosteroids and NSAIDs; gabapentin and pregabalin; and opioids. The goal should be short-term use. I’ve found corticosteroids to be most effective, starting with 60 mg/day and a slow tapering off over two weeks.
Keep Going!
Reducing your pain in ways that allow you to enjoy time with family and friends and help you participate in physical, occupational, speech, and other therapies is an essential goal, not a luxury. Furthermore, if you are experiencing pain frequently, you may associate this pain with rehabilitation and thereby reduce your willingness to perform physical and occupational therapy. Make sure this subject is one you and your family raise with your health care team as soon as possible; your mental and physical recovery depend on it.
Everything You Need to Know
Pain is one of the most common consequences of ANI. Unaddressed, it damages your quality of life, and limits your ability to achieve your recovery and rehabilitation goals.
Successful pain management requires a multidisciplinary approach, active monitoring and adjustment of your pain medications, and a willingness to try pain relief techniques besides drugs, such as cognitive behavioral therapy, meditation, exercise, self-hypnosis, and more.
Early on, consult with a physiatrist or pain specialist who has expertise in regaining function while managing pain.
Your goal in pain management should be to find yourself relying less on drugs and more on other therapies as you recover physical strength, range of motion, and mental resilience.
Keep a journal of everything you do to address your pain, and keep the conversation going with your care team. Achieving successful pain management is an ongoing process.