US News and World Report: Pain Management

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Posted by Ted ( on June 06, 2000 at 18:04:53:

Nothing specifically on CHs here though.

Cover Story 6/12/00

Conquering pain

Treatments for body and mind break a cycle of agony

By Josh Fischman

A Wisconsin rarity, bright April sunshine, beams through the windows of a large room at Milwaukee's Columbia Hospital. The rays catch milk crates filled with weights, sets of dumbbells, a treadmill, gym mats spread on low tables, and other trappings of a makeshift gym. On one of the mats, Bill Mains, 49, is learning how to get into bed.

"Not that way," says Steve Olson, a physical therapist, as Mains swings his legs up and then flops down on his back. "You're going to twist yourself up." Mains, trim in a maroon sweat suit and a neat gray beard, looks puzzled; he has been getting into bed this way for decades. "You want to move your hips, torso, and shoulders as one unit," Olson says. "Sit on the side of the mat, then lower down sideways until your shoulder touches and then swing your legs up. That way you won't twist your spine."

The last instruction resonates. Mains slipped on the ice while walking three years ago and landed on his back. "At first I tried to ignore the pain, kind of bull my way through," he says. "But it feels like someone is drilling into my spine. And they're using a large drill." Despite painkillers, he started snapping at his wife and eight children. The pain spread to his legs and grew worse. "At times the nerves in my legs feel like they're on fire, with flames running up and down. All the things I liked to do–canoeing, bowling, even gardening–I couldn't do anymore." He couldn't even climb the steps of the Lutheran church where he serves as the minister. His pain would come in the night, stealing sleep. Flaring. Firing. Minute by unending minute. It is hard to imagine this type of agony.

No hope? Unless, that is, you're one of 50 million Americans who live with chronic pain: body-wrenching jolts from arthritis, back injuries, headaches, cancer, and nerve problems that no one can pin down and which never go away. In April, a Gallup survey reported that Americans with severe or moderate pain typically have lived with it for a year and a half. Many of these people see no hope for relief.

They're wrong. At Columbia, and many other clinics, therapists are now attacking these stubborn cases with a variety of weapons: not just painkillers but relaxation techniques, physical therapy, psychotherapy, and drugs originally developed to treat epilepsy and depression. Doctors tend to treat chronic pain by dousing it with drugs, mainly painkillers such as Vicodin, Demerol, and morphine, or the new generation of anti-inflammatory medicines such as Celebrex. Sometimes surgeons block the pain-carrying nerves. Often this works, especially for short-term pain. But often the pain comes back.

The reason: New research shows that chronic pain is a vicious band looped between mind and body, where agony creates stress and stress magnifies pain, over and over and over again. "The pain becomes part of a cycle. Our job is to break into that cycle wherever we can, and so we use a lot of things, not just a needle with Demerol," says psychologist John Galbraith, who directs Columbia's pain clinic and is treating Mains. (Three years ago, Galbraith also treated this reporter when he was suffering from shooting leg pains.)

These programs–which treat people as outpatients for several weeks–give new options to patients who have been through countless doctors' visits, multiple surgeries, and a gamut of drugs. They still use drugs, but they also offer evaluations and help for newer pain victims who want to stop the problem before it grows worse (box, Page 64). The approach looks like a winner in a comparison between 3,000 patients who enrolled in pain clinics and other patients who had just one type of treatment, such as drugs or surgery. At the March meeting of the Midwest Pain Society, psychologist Dennis Turk reported that fewer than 17 percent of the clinic patients were rehospitalized within a year, while 40 percent of the single-therapy patients were. Of patients who were on opioid drugs, 78 percent of single-therapy patients were still on them a year later, but just 33 percent of the clinic patients were. "Remember these are the hard cases, the ones who've tried almost everything else first," says Turk, a pain specialist at the University of Washington in Seattle. "We're usually the court of last resort."

More such venues are opening. Some clinics are at community hospitals like Columbia; others are part of renowned facilities such as the Rehabilitation Institute of Chicago. Seventy-nine pain clinics were listed by the Commission on Accreditation of Rehabilitation Facilities in 1987. Today there are 200.

The treatments can cost as much as $25,000, and not all insurance plans cover them. Patients who hope for quick relief may be disappointed. "I see a lot of patients who go to these places and drop out," says David Stein, an anesthesiologist who has a pain practice in Milwaukee. "They don't stay because they're in too much pain." But others, such as cancer patient Alice Schaefer of Fox Lake, Ill., hang tough. "When my pain was bad, it was the end of the world," says the 76-year-old, who spent four weeks at the rehabilitation institute after radiation treatments damaged her nerves. "I felt as if I had tried everything, seen every top doctor. Nothing worked." That was last October. Today there's still pain, but Schaefer has learned to keep it in check. She has even gone back to an old hobby, windsurfing. "What I've learned to do is 'step over' my pain."

That sounds like New Age mumbo jumbo, admits neurologist Norman Harden, who directs the pain clinic at Chicago's rehabilitation institute. But it's not, he insists. "We've learned that chronic pain has many dimensions, physical, psychological, and social, and if we treat some of them, the whole situation usually will get better." Helping patients recognize that their pain doesn't signal danger to their bodies can go a long way toward ending their pain-tension cycle.

Chronic pain is different from what you feel when you cut your finger with a kitchen knife. That cut sends signals racing up nerves in your arm, through your spinal cord, and then to your brain, where they sound a loud alarm: "Body damage!" The brain responds with a command to tense muscles that jerk your arm back. It also triggers the release of your body's own painkillers, called endorphins.

With chronic pain, that same alarm is triggered over and over, sometimes by an ongoing disease like arthritis. At other times it continues long after the original injury has healed, perhaps because of damaged nerves. Either way, the endless alarm "sets off some really horrible things, because your body just isn't set up to handle long-term pain," says Galbraith. Constantly tensed muscles, for instance, make nerve endings more sensitive, leading to more pain and, not surprisingly, more muscle tension. You begin to hold your body in guarded positions that favor the hurt areas but stress new muscles, spreading the pain. As you become less active, muscles get weaker. You get depressed. Low moods magnify pain sensations. After a while, pain nerves seem to "cross wires" with nerves that transmit gentler sensations, so even a light touch is agony. These vicious loops of pain keep circling around your body, growing tighter with every passing month and year.

Breaking the cycle. Bill Mains enrolled in Columbia's program to break out of the loops. About 10 people, gathered around a conference table at Columbia, are going to try to help. One, rehabilitation physician James Lincer, summarizes Mains's plight: the fall on the ice, an operation two months later to remove a torn disk, anesthetic injected near the spine to numb the nerves–known as an epidural block–the next year and another one the year after that. "Each time the pain returned," Lincer notes.

Galbraith weighs in from the psychological side, giving the results of a lengthy personality test, which reveals depression and exhaustion. Olson, the physical therapist, reports that Mains has a lot of stiffness around his waist and hips.

Someone opens the door and Mains, who has been waiting outside, walks in. "How's it going?" Galbraith asks. "OK. But the gossip from the other patients at lunch tells me it will get a lot harder in the next few weeks," Mains answers.

"True," says Galbraith, smiling. After some chit-chat, the group maps out a strategy for dealing with Mains's pain: physical therapy to correct an imbalance in his posture; occupational therapy to teach him how to lift things using his legs instead of his back; biofeedback to train him to relax. Mains agrees to try drugs, including antidepressants and one called Neurontin. It was developed for epilepsy, but it also dampens the nervous system's alarmed response to pain.

Over the next three weeks, Mains will follow a routine that takes him from therapy to therapy for eight hours a day. A packed schedule has benefits of its own, says Chicago's Harden. "You have to remember these are depressed, discouraged people, and a lot of them have become virtual shut-ins. So we give them a place to go, appointments to keep for a full day, and they're not just sitting at home thinking about how much they hurt."

The routine also gives the therapists a chance to see people like Mains daily, check their progress and make adjustments. "I'll hear from the physical therapist that a patient is having trouble stretching," says Steve Rice, a biofeedback therapist at Chicago. "So we work on releasing those muscles."

Relax. Relaxing on command is not easy, but it's crucial to breaking the link between pain and tension. Rice begins by showing patients the contrast between a tensed and relaxed muscle. A patient tenses muscles in his feet and then tries to relax them to highlight the difference, then does the same thing for other muscles. Next, the therapist hooks sensors to the skin over muscles to measure their tension. A biofeedback machine lets the patient see on a screen or hear from a tone how tense or loose muscles are getting. The goal is to relax without a machine.

The sense that patients' bodies are within their command is a big boost. Rick Rogowski, 31, a human-resource specialist in Chicago, woke up six years ago with what felt like a sprained neck. The pain worsened as he strained other muscles by tilting his head to the side, and he felt excruciating spasms every time he tried to hold his head erect. After three weeks in the Chicago program, he notes, he can feel the spasms coming on–"they don't sneak up and surprise me"–and uses progressive muscle relaxation to ward them off.

Physical therapy–strengthening and conditioning long-inactive bodies–tends to be much harder on patients than relaxation-oriented biofeedback. "Remember, we're dealing with people who've guarded themselves against pain by not moving," says Scott Fishman, chief of the division of pain medicine at the University of California-Davis Medical Center. But exercise releases pain-killing endorphins and makes the body more resilient.

Tinameri Turner is in Week 3 of the program at Columbia and Year 15 in her battle against fibromyalgia–muscle pain across her body with several exquisitely tender "trigger points." Every day her therapist has her stretch and do some very light lifting. "I dread physical therapy. I don't mind the stretching stuff. I mean, certainly it hurts, but it's a good hurt. But the strengthening stuff that they're trying to have me do is just so difficult," she says. Sam Marjanov, age 46, another pain patient, goes through a daily struggle with 10-pound weights.

Occupational therapy teaches patients how to perform daily tasks without reinjury. For Rachel Galarza, it means playing with putty. Last summer the 39-year-old woman threw out her back and had disk surgery. But the back spasms continued and she began to develop headaches, eventually landing at Columbia. "When I got here, I was wondering: 'Why am I rolling out putty? It's my back that hurts.' " But rolling putty strengthens the fingers and wrists. When Galarza has to carry a package, she can bear more weight on those body parts, rather than taking the weight on her torso and straining her back.

Mind and body. Rogowski is learning how to manage the emotional strain in individual counseling sessions. "I'm really realizing that when I came here, I was going through this cycle of frustration and incredible anger. I was frustrated with my doctors, and at home I just wanted my wife to leave me alone." Counseling has helped him come to terms with his pain. "I don't know if it can be cured, but I know I can learn how to manage it." For Jackie Gorecki, who walked gingerly into Columbia two years ago after being rammed by a forklift in a warehouse, help came from the other patients. "At first I didn't want to be one of them. It seemed incredibly unfair; I was only 20 and should have been out having fun. But I needed to hear what they had to say and learn how they coped."

Because pain is both a mind and body affliction, drugs help manage it, too, even drugs that aren't aimed at pain. Neurontin, the antiseizure drug Mains is taking, is one example. Galbraith also likes to use Klonopin, a drug from the same family as Valium, because it reduces anxiety. Antidepressants like Prozac remove depression's magnifying glass from the pain symptoms. Local injections of opioids into muscle trigger points can stop the chronic pain cycle as well.

But which drugs to use remains a source of some controversy in the pain-management field. Harden, for instance, doesn't like his patients to take anything in the Valium family. Patients can build up tolerances, and he worries that the drugs can interfere with the concentration needed to learn other pain-management skills. As for painkillers like Vicodin or other narcotics, forget it. "They're too hard to manage and create dependency." Russell Portenoy, who chairs the pain-medicine department at Beth Israel Medical Center in New York City, disagrees. "Opioids get a bad rap," he says, citing one study of 36 patients with back pain lasting several months. Those on opioids had less pain and less distress than the nonopioid group. About 94 percent were responsible in their drug use–they stayed within their prescriptions. After six months, 86 percent had no withdrawal symptoms when taken off the drugs.

"Right now I'm taking care of an executive who's been in chronic pain for 20 years," says Portenoy. "She's had a hip replacement, sciatica, and arthritis in her fingers. She was just very, very miserable. And I put her on methadone." The drug, which has a slight molecular difference from morphine, is a powerful painkiller without the addictive potential of its cousin. "Now she sleeps better, her mood is much better." The key is not prescribing addictive drugs to patients with addiction-prone personalities, he says, and using the drugs with the support of a multidisciplinary program, not by themselves.

Still, a multitherapy approach is no guarantee of success, whether drugs are used or not, say some experts. "The patient's care can become fragmented," says Fishman. He worries that patients are pulled in different directions by different specialists and physicians. Patients can get confused and drop out if they can't turn to a single doctor for advice.

The high cost of a multidisciplinary treatment can prevent some pain sufferers from seeking help in the first place. Columbia, for instance, costs about $25,000 for the full six-week course. Some insurers will cover the cost if they know the program; Wisconsin's Blue Cross/Blue Shield, for example, covers treatment at Columbia.

For a growing number of patients, those dollars are buying a real reduction in human suffering. Bill Mains is back at work and using relaxation techniques to keep the cycle of pain, stress, and more pain under control. "Flare-ups are still scary," he says. "I had one my first day back. But now I have techniques that help me work through them. I think I'm finally understanding this is a lifestyle change." And Rick Rogowski? Neck straightened, he's on his way back to work, too. His occupational therapist says, without a hint of irony, that he has a real good head on his shoulders.

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