A recent report from the Institute of Medicine described in an article in the Journal of the American Medical Association has discussed the magnitude of the prevalence of pain in the US. The article states that about 100 million Americans suffer from chronic pain. This is pain that lasts weeks or months; Not bumps and bruises that resolve quickly.
The data used to determine this number is based on a number of techniques to review medical information and was assembled at least in part by the National Center for Health Statistics. If you have chronic pain, you are not alone. These numbers are also consistent with research from the World Health Organization that estimates that 37% of the population in developed countries has chronic pain.
The prevalence estimates of adults for selected pain conditions were also listed in the report. Moderate pain affected 10% of the population, or 21.3 million people. Another 11% had severe pain, effecting about 22.5 million. Joint pain affects about 33% of the population. Arthritis of all types affects 25% of the population. Functional disability affects 12% of the population. The authors also noted that the study did not include children, military personnel, people in prison, and those in long-term care facilities.
The report mainly concentrates on the fact that there is a huge number of people who deal with chronic pain on a daily basis. However, we do not have good information of the impact of pain on employment, disability, functional abilities and the direct and indirect costs. In general, there is minimal information available on the cost of pain, in terms of medical expenditures and secondary costs to society.
The report makes a strong recommendation for a national, population-level prevention and management strategy. A public health approach to pain management is necessary, including prevention, care, education and research. It also recognized the serious problems associated with opioid use and diversion, and the need to develop a better approach to pain care that is beyond the use of such addictive medication.
As noted in this article, reducing the effects of pain and its associated morbidities with regards to the quality of life will require a cultural transformation. Chronic pain itself may need to be considered as disease. The extent of this disease affects about 4 out of every 10 adults in developed nations worldwide. Patients and healthcare providers need to recognize the problem and develop improved treatment and management solutions for the complex condition.
Chronic back pain is extremely common in America. About 10 percent of the population has chronic low back pain. In general, 85 percent of the population will suffer from back pain at some point in there lives. In any one year, about 70 percent of the population will seek care for back pain. The economic cost of back pain in the United States is about $200 billion annually. New treatments that could reduce the cost and improve the outcome of back pain, especially pain generated from the discs, is of major interest to patients and healthcare providers.
A recent study published in Pain Physician studied two patients with discogenic low back pain. The authors took stem cells harvested from umbilical cord blood and transplanted them into discs of patients with low back pain. The patients have been followed for two years, and they have had significant improvements in pain and function. They also have had no complications. The patients treated had to fit a slim criteria: No other significant illness, no failure of more conservative care, and only a single disc in the lumbar area that had a tear and caused pain during a discogram. At two years from transplant the discs was returning to a more normalized state. In other words, the stem cells regenerated the normal internal structure and healed the disc.
Stem Cell Study
This study is definitely preliminary, since only two patients participated, but the concept is promising for the future. If we can help the body heal itself and return to normal function, it would be a preferred method to medication that diminishes symptoms or surgery which changes structure and function in the body. The process of harvesting stem cells is complex, and keeping them healthy and from being killed or causing problems once injected are significant long term problems. We also do not know exactly which discs may be helped and at what stage of injury stem cells may be of most benefit. We only know the stem cells have the potential to be a solution in certain situations. Years of further research are necessary to determine how this treatment may work.
The message to take from this research is that there is hope for the future. Scientists and doctors are trying new ideas and some are working. For a certain class of those suffering from back pain related to disc issues, there may be ways in the future to restore the discs back to health with stem cells. That said, the best solution as always is to take care of your body, get regular exercise, and work on building strength in the muscles in the area. There is no free ride with a magical solution. We still need to maintain our health and not overly stress or injure our backs. These solutions are only for limited cases, not for fully herniated discs or those with multiple disc problems.
A new study out of Norway suggests that children of parents who have chronic musculoskeletal pain have a higher risk for developing similar pain. The study started in 1984 and used health surveys to determine if age, sex or other factors contributed to musculoskeletal pain. The findings suggest that children of parents with pain had a 20-40 percent increased risk of developing similar pain. Specific genetic variables and environmental factors were not isolated, but the important conclusion is there is a relationship between parents with pain and a subsequent occurrence in their children.
As a practitioner in pain, this study has several implications. Pain and the subsequent behaviors often do run in families. Parents can easily model behavior such that children learn the same strategies in coping with adverse events. The behaviors learned are sometimes good, but also can be maladaptive. If parents tend to complain and do not take responsibility for their actions, children often show the same behavior. Genetics also play a role, and psychological problems such as depression, which has a high correlation to pain, also has a high genetic component. Many diseases correlated to pain like rheumatoid arthritis and some aspects of osteoarthritis have genetic components.
Parents often have an influence on good and bad health habits in their children, such as diet, exercise or if the child becomes a smoker. A lack of exercise often contributes to pain and increased incident of injuries due to a lack of muscle condition. Obesity is positively linked to chronic pain, and the eating habits of parents are often taught to their children and they are at an increased risk of becoming obese. Smoking is also positively linked to pain, and parents who smoke often have children who smoke.
Whether the link between parents and children and both having pain is due to genetic or environmental factors is unclear. Both genetic and environmental factors likely play a role, but to what extent is unknown. Some pain is probably genetic, but a lot of pain could be a result of negative learned health behaviors. The long and short of it is, make healthy choices for yourself and for your children.
Every action has risks and benefits. In the medical world, every medication has risks, and sometimes the risk of doing nothing is worse than treating the issue. This is especially true in many medical conditions such as hypertension or diabetes. The same goes for pain medicine. There are risks and benefits for everything that is done, but there are also many alternatives to treat any particular problem. Choosing the right treatment plan is an individualized decision between the patient and the physician.
Interventional pain treatment has risks and benefits, and there are well known complications from most procedures. The main risks are fairly clear, but there are four complications that arise more often than others. They are:
- Infection. Whenever the skin is broken, this is a possibility, and is prevented usually by cleansing the skin with alcohol or special antibacterial soap.
- Bleeding. Most procedures are done with a fairly small needle. If a patient is not on a blood thinner or does not have a bleeding disorder, this complication is uncommon.
- Allergic reaction. This is rare, but if it does occur, it can be treated.
- Damage to another critical structure with the interventional equipment. This can usually be avoided by taking routine precautions and by having a skilled physician preform the procedure.
Recently, a study was done recording complications from many of the common injection type procedures preformed by pain physicians. Almost 20,000 procedures were done, and the rate of anything abnormal was found to be less than two percent. The most common minor problem was a vasovagal reaction (Feeling like one is going to faint). The next most common issue was an increase in pain, which resulted in the procedure being stopped prior to completion. Other notable problems included one serious allergic reaction (1 in 20,000), and 10 dural punctures (1 in 2000). There were no major complications resulting in any serious injury or permanent neurologic damage.
Treating pain is a complex problem. For every problem, there are often multiple options and pathways to improvement. Sometimes, the pain physician may suggest an interventional procedure to help one improve function and decrease pain. As noted above, the risks of most of these procedures are extremely small. The most common issues are feeling faint or light headed and having increased pain during the procedure and temporary increased symptoms. An experienced interventionalist will make the procedure beneficial and minimize risk to the patient.
Thermaine is a relatively new drug that is being used to treat chronic pain, typically in individuals suffering from low back pain. Theramine is a proprietary formulation of neurotransmitters, amino acids, antioxidants, neuromodulators, anti-inflammatory and immunomodulatory peptides, whey protein, and adenosinsine antagonists.
It is a trademarked formulation of compounds and considered a food supplement. It was designed to be used to treat a variety of pain syndromes, including acute and chronic pain. Each ingredient in the capsule was determined based on its ability to modulate an aspect of the sensory processes involved with pain signals. It is meant to moderate the effects of inflammation on the pain response. All of the ingredients that make up the compound have been approved by the Food and Drug Administration.
A recent article in the American Journal of Therapeutics suggested that Theramine was more effective than low dose ibuprofen for chronic low back pain. It was found to effective in decreasing both pain and inflammation in chronic low back pain sufferers. Part of the theory about why this supplement is helpful because it is thought that the chemicals present help restore certain compounds that are depleted or not present in individuals suffering form chronic pain.
It’s effectiveness means that the product is not cheap. A simple online search reveals that a one month supply costs over $300. If one has money to spare, it may be a safe consideration. It appears to be safe, with reasonable science behind its development. For a greater look into Theramine and its inner workings, check out this website.
Recently, the Star Tribune published an article on professional athletes playing through pain. The article discussed whether the Vikings quarterback, Teddy Bridgewater, was not tough enough since he and the team elected not to play him against the Packers, four days after he suffered an ankle strain. The article also discussed how other athletes never missed a game due to injury. Furthermore, it basically said , if you are going to be a professional athlete, you need to play through pain.
Stupidity is playing while you are acutely injured to tell others you are tough. Pain is the way the body tells a person that they have an acute injury. Tissue damage stimulates the sensory fibers and initiates the body’s response to injury. Inflammation occurs, and then blood flow to the area increases in order too bring cells to clear the damage and initiate the healing process. Continuing to stress damaged tissue will usually only weaken the area or cause further injury. In an acute pain injury, protecting the region from further damage reduces the pain and allows quicker and more complete healing. The culture of toughness would be considered just stupidity from a medical viewpoint.
Professional athletes tend to have short careers in sports due to the fact that they tend to overstress areas of the body, causing permanent damage and reducing their abilities. Tiger Woods now is on the down side of his career due to back and leg injuries. Most football players do not play long into their 30’s due to injury. The NFL now has major lawsuits regarding concussion and head trauma. Many professional athletes have severely degenerated joints, back and neck issues from repetitive trauma, and now have chronic pain issues.
Acute pain is the signal from the body that there is tissue damage. Treating acute pain is doing the right stuff medically to allow the injury to properly heal. Chronic pain is not due to acute tissue damage and inflammation, but is an abnormal response to signals from previously healed damage. Rest is great for an acute injury but not for chronic pain. Activity can take your mind off the pain, release endorphins to act as natural pain relievers, and help build strength in affected areas. Activity in areas of chronic pain will decrease the pain in most cases. Working through chronic pain is tough, but it actually decreases pain signals and improves function.
Many people who have pain complain of tight muscle spasms, knots or bands in or near the pain’s location. If a person has neck or low back pain, they often feel like the muscles in their neck and back are extremely stiff and tender. This occurs because the muscles near the pained region tighten up in an effort to limit movement in that area. Just like a cast protects your broken ankle, your body attempts to shield itself from more pain. Acutely, this serves a purpose to protect a structure from moving when injured. Chronically, this is a maladaptive response. Movement maintains blood flow, strength and flexibility.
People with chronic pain often notice they have lost flexibility and find that muscles in the painful area tight and tender. Patients often want a pill to treat the muscle tightness; a quick solution. Tight muscles hurt when one tries to be active and reduce our ability to move smoothly. In response to the demand, doctors often prescribe muscle relaxers; medications that are supposed to reduce muscle tightness. There are many drugs that affect muscle tightness, but most are good only in acute situations, and for a very short time. For chronic muscle issues, most of the medications are minimally effective.
The medications that are most often used for chronic muscle spasms are drugs which also diminish pain signals in some way. Benzodiazepines (like valium, Ativan, and Xanax) act on the central nervous system to reduce signal transmission and enhance the compound GABA that influences pain sensation. Unfortunately, these compounds are highly addictive and lose effectiveness quickly. They are most helpful in acute situations only. Baclofen and tizanidine are also centrally acting, and they prevent muscles from tightening up and decrease pain signals. These two are not addictive, but only work for some patients and each can have its own serious side effects. Flexeril (cyclobenzaprine) originally was developed to be an antidepressant, but its central acting turned out to relax muscles, however, it’s very sedating, inducing deep sleep and is best used only at night. There are multiple other medications also available, but few are helpful except for acute injury type pain.
Muscle tightness and spasms in chronic situations are best treated without medications. The best treatment is stretching and strengthening the muscles and area. It seems counter-intuitive to exercise sore muscles, but this is the most effective management. Physical therapy is excellent to learn the appropriate exercises. Massage and chiropractic adjustment can also be useful. However on a long-term basis, it is up to the individual to do the exercises, daily stretching and strengthening. If you have chronic pain issues, the best treatment is to do the work and over time the pain will get better. There are no shortcuts when doing the maintenance to stay healthy.