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August 4, 2008

That Achy-Breaky Feeling
By Kim M. Norton
For The Record
Vol. 20 No. 16 P. 30

As baby boomers enter their “golden years,” the medical community has developed a renewed focus on determining the cause of pain, encouraging movement, and offering relief.

When it comes to pain, baby boomers are a unique population. No other generation has pushed themselves harder or demanded more from their bodies. And when dealing with pain, boomers often feel that every ailment can be alleviated, becoming dissatisfied with any other result. With more than 20% of baby boomers turning 60 by 2011, pain management has become a priority for patients and physicians across the country.

“The boomers are the first generation to stay active on an aging frame longer,” says Nicholas A. DiNubile, MD, an orthopaedic surgeon in Havertown, Pa., specializing in sports medicine and the author of FrameWork — Your 7-Step Program for Healthy Muscles, Bones, and Joints. “They have beaten their bodies harder unnecessarily and, with people living longer, they are going to be experiencing more pain. But since the boomers know that to a certain extent they can control their ‘age clock’ with diet and exercise, they are not showing any signs of slowing down.”

The boomer population may believe it’s no more prone to pain than any other population, but this is the generation that grew up with the “no pain, no gain” mantra, says DiNubile. “The boomers are also less accepting of ailments and pain and will go to any length to fix it to the point where there is little regard for healthcare consumption,” he says. In seeking to alleviate their pain, boomers are turning to both traditional and nontraditional therapies for solutions.

Regardless of age or whether the pain is acute or chronic, patients are all looking for one thing: relief. To what degree they’ll go to relieve the discomfort varies based on the amount of pain they are in to begin with, their pain threshold, and their expectations regarding pain management.

Finding a Cause
When assessing a patient for pain, primary care physicians carry the burden of finding the source and treating it accordingly or referring the patient to an appropriate specialist. However, this may be easier said than done.

The source of pain could be an old sports injury or a neurological disorder such as fibromyalgia. Or it could be less concrete in origin, perhaps stemming from a psychological or emotional issue causing stress in the body, explains Eugene R. Viscusi, MD, director of acute pain management in the department of anesthesiology at Philadelphia’s Thomas Jefferson University.

“The [primary care physician] should determine the underlying cause of the pain through a thorough workup before referring the patient on for further treatment,” says Viscusi. Depending on the cause, there are myriad approaches that can be taken. If the pain stems from a nonneurological episode such as a twisted ankle, nonsteroidal medication or weak opioids may be sufficient. For more complicated pain, a specialist or orthopedic surgeon may be the next stop.

According to the American Chronic Pain Association, “Pain is a silent epidemic in the United States. An estimated 50 million Americans live with chronic pain caused by disease, disorder, or accident. An additional 25 million people suffer acute pain resulting from surgery or accident. Approximately two thirds of these individuals in pain have been living with this pain for more than five years.”

Acute pain due to inflammation, trauma, or surgery is generally short lived and can be easily managed with both traditional and nontraditional methods. Anxiety and emotional distress are common with acute pain but, as the pain dissipates, so does its emotional aspects. Chronic pain, however, persists over a long period of time, is generally resistant to medical treatments, and is often accompanied by depression, loss of range of motion, and muscle atrophy. Common types of chronic pain include arthritis, lower back pain, joint and/or muscle pain, and fibromyalgia.

When dealing with chronic pain, professionals agree that movement is absolutely necessary to prevent muscle atrophy, although maintaining function and managing pain could be considered polar opposites. “What limits those with chronic pain is the fear of movement. They anticipate pain and associate pain with more harm, which is untrue,” says Peter Sanzio, PT, CSCS, a licensed physical therapist and clinical applications specialist with Performance Health Technologies in Trenton, N.J.

Movement can cause pain, but when patients realize that it causes no additional discomfort, they tend to want to go further and achieve more range of motion. Products such as Performance Health Technologies’ Core: Tx are designed to provide goal-oriented precision feedback, which encourages the patient to increase their range of motion, says Sanzio. “Chronic pain sufferers have so much to gain from moving, and there is nothing worse then seeing a patient who refuses to move and their body starts to atrophy, which can contribute to chronic pain,” he adds.

“When dealing with certain pain conditions, ‘pain free’ can be a realistic goal, depending on the primary cause,” says David N. Maine, MD, director of the Center for Interventional Pain Medicine at Mercy Medical Center in Baltimore. Each patient requires an individual treatment plan that depends on the primary etiology and treatment goals.

Management may be complex, while at other times it’s pretty straightforward, Maine adds. “For instance, in a patient with chronic pain because of spinal disease, sometimes medications are effective or an epidural or nerve injection could be beneficial and provide lasting results, while in other patients, spine surgery or surgically implanting a pain-modulating device may be more beneficial,” he explains.

Whatever the treatment regimen, it is important to understand what the patient wants to achieve. For someone whose pain is always a 10 on a scale of 1 to 10, success may be defined as reaching a pain level of 6. Likewise, another patient with acute pain may expect to return to a 0, says Maine.

When embarking on a pain treatment regimen, basic coping skills, attitude, belief in success, and modification of diet and exercise are all important components to a well-rounded plan.

Psychology of Pain
The type of pain and how the patient copes with it will dictate how pain is managed. “Belief in the treatment is an important component to the success of the treatment,” says Robert J. Gatchel, PhD, chairman of the psychology department at the University of Texas at Arlington.

“To illustrate this point, numerous studies have found that, when administered correctly, placebos can be more effective on pain when the placebo is given under the high expectation of success,” says Gatchel. Mind and body must be considered together when treating or understanding pain, he adds.

Effective ways of dealing with pain from a psychological point of view can include distraction, hypnosis, stress management, use of coping skills, and biofeedback. “When combined with physical methods such as medication or nontraditional therapies like acupuncture, physical success can be seen,” Gatchel says.

Coping skills can be a valuable weapon in the battle against pain as patients begin to view their situation from a different perspective. “When the pain is acute due to an injury, understanding that the pain is temporary and dealing with it as such can and will improve overall function of the affected area,” says Gatchel. If the pain is due to a prior injury, recalling those experiences can be helpful in knowing that the pain will end.

In addition to memory, patients are encouraged to slow down and pace themselves, focus on dealing with the pain rather than dwelling on it, and avoid limiting the use of the affected area out of fear of causing more damage, he adds.

Whether suffering from acute or chronic pain, patients can benefit by maintaining a nutritious diet, getting an adequate amount of exercise, and exploring modalities such as massage, chiropractics, acupuncture, or trigger point needling (TPN). Although considered somewhat less mainstream, acupuncture and TPN have helped patients with acute and chronic pain.

“Acupuncture can be a stand-alone therapy or one used in conjunction with another treatment plan such as physical therapy or massage,” explains Sung Kim, LAc, an acupuncturist with Sequoyah Acupuncture in Oakland, Calif. “It works by inserting extremely thin and sterile needles into the surface of the skin, which help regulate pain in the body by affecting the central nervous system by releasing endorphins.”

The needles are inserted in the top layers of the skin along certain channels of the body to help alleviate pain or other conditions. Although it is unclear how acupuncture works, the National Institutes of Health recognizes its benefits. “I believe in and support acupuncture as a treatment modality because it can relieve significant pain. If the patient believes it can work, he is more likely to achieve relief than if he did not believe the therapy would work,” says Maine.

While acupuncture can be used for several conditions, including infertility, eczema, and psoriasis, TPN is used strictly for pain relief and can be a particularly nice alternative for patients with muscle pain. It differs from acupuncture in a number of ways. “First, there are specific acupuncture points on the body that acupuncturists generally use to offer their patients relief. With TPN, I can treat virtually the entire body. Second, to practice TPN, you must be a medical doctor because the treatments involve injecting needles deep into muscle tissue, and to do this, you must know the body and where the organs, nerves, and arteries are to avoid puncturing them accidentally,” says David H. Kim, MD, of Pain Management Solutions in Moorestown, N.J.

“Although TPN works best when treating muscular pain, it can still be beneficial for patients with pain from nerve damage, arthritis, fibromyalgia, migraines, and surgery. It is a low-risk therapy that provides good results,” Kim adds. Whether treating pain at the surface with acupuncture or deep in the muscles with TPN, both therapies are designed to alleviate pain and increase mobility and range of motion.

It’s important to note that no two patients present with the same pain, and no two treatment regimens will look alike. Whether a baby boomer, a retiree, or a young adult, experts recommend that patients be evaluated thoroughly, both mind and body, before a treatment plan is instituted.

— Kim M. Norton is a New Jersey-based freelance writer specializing in healthcare related topics for various trade and consumer publications. She can be contacted at kim_norton1@hotmail.com.

The Future of Pain Management
The pipeline of new solutions for managing postoperative pain is bustling with new technology. Here’s a glimpse of what’s around the corner.

Iontophoretic Delivery System
Traditional intravenous, patient-controlled analgesics are labor intensive and require a significant amount of time to load the drug and program the pump. The fentanyl iontophoretic transdermal system will be less labor intensive, eliminate the pump, and reduce dosing and medication errors through a preloaded, transdermal patch. “The whole concept behind the iontophoretic delivery system is that it is a novel way of delivering fentanyl in a transdermal system that sticks to the upper arm and is controlled by the patient with a double click,” explains Eugene R. Viscusi, MD, director of acute pain management in the department of anesthesiology at Philadelphia’s Thomas Jefferson University.

The same lockout controls are in place with the delivery system, which needs to be replaced every 24 hours. The preprogrammed device is limited in that it cannot be customized for the atypical patient, says Viscusi, adding that the system should be available for clinical use soon.

Peripherally Acting, Mu-Opioid Receptor Antagonists
Two recently approved drugs—methylnaltrexone (Relistor) and alvimopan (Entereg)—will likely change the equation for opioid use and delivery. “Opioids are good for pain management, but known side effects include constipation and slow return of bowel function,” Viscusi says.

Methylnaltrexone is a treatment drug that corrects opioid-induced constipation, while alvimopan is a preventive treatment administered preoperatively and postoperatively to speed the return of bowel function. “Both of these drugs antagonize the opioid receptor in the GI [gastrointestinal] system to block the effects of the opioid. Look for both of these drugs in fall 2008,” Viscusi says.

Further down the pipeline is an intravenous acetaminophen for patients who are unable to swallow pills or can’t swallow due to paralysis or being in a coma. The drug is not yet in the application process, but it has been approved in Europe, and about 180 million doses have been administered so far, says Viscusi.

The last and possibly most interesting drug is transient receptor potential vanilloid 1 (TRPV1), whose model compound is none other than purified capsaicin from chili peppers. “TRPV1 agonists deactivate the channels of the C-fibers, the pain pathway for pain transmission. In a couple of studies, it was found that a single application of the drug prior to closing the surgical wound produced prolonged pain relief,” says Viscusi. Although it did not give complete relief, TRPV1 significantly reduced patients’ reliance on other pain medication following surgery, he says.


How Physicians Can Help Patients Cope With Pain
• Don’t dwell on the pain’s physical symptoms.

• Focus on ability, not disability.

• Recognize the patients’ pain and encourage them to speak freely about it and its control over their lives. Do not make judgments.

• Encourage relaxation exercises to ease the tension that increases pain and redirect attention away from the pain and suffering.

• Demonstrate mild stretching exercises and encourage patients to do them daily if appropriate.

• Set realistic goals and evaluate them often. This can help patients realize that their desires can be achieved, one step at a time.

— Source: American Association of Chronic Pain