Identifying and treating pain

EVERYONE experiences pain at one time or another. The difference is some experience it for a few weeks, while other may have to deal with it for months. In any situation, the most important thing is to understand the causes and treatments for the pain to avoid self-medication or misdiagnosis.

Pantai Hospital Kuala Lumpur consultant anaesthetist and pain management specialist Dr Gopinathan Raju says awareness of pain is still low, especially on the causes and treatments for chronic pain. If doctors fail to identify chronic pain, the patient will suffer without proper treatment.

Some patients prefer to seek over-the-counter drugs for their pain. Without proper prescription, long-term use of these drugs can lead to other health issues such as gastric and kidney failure.

He says there are two types of pain - acute and chronic. Acute pain lasts for few days or weeks while chronic pain lingers for more than three months. With proper treatment, those suffering from acute pain will be cured. Unfortunately, this is not the case for chronic pain.

Dr Gopinathan says treatment goals for chronic pain are mainly to reduce the pain to a tolerable level, improve the patient's quality of life, improve his physical movement and minimise the side effects of the drugs. Chronic pain patients have to live with the pain for the rest of their lives.

PAIN CYCLE

Patients with chronic pain will go through a pain cycle. The first is suffering from the pain, then feeling despair, loss of sleep and anxiety which could lead to low self-esteem and depression.

The Malaysian Association For The Study Of Pain has defined pain as a multifaceted sensory and emotional experience that is usually unpleasant. Depending on the cause of his condition, a patient may feel sensations which include pricking, pulling, aching, boring, cutting, drilling, freezing, pinching, pressing, pounding, smarting, throbbing, tingling, burning, cramping, piercing, stabbing and pins and needles.

Pain is often misunderstood due to the lack of specialists, says Dr Gopinathan. There are only a handful of pain specialists in the country and most of them are anaesthetists who have gone for further training in pain management.

"Understanding pain is not easy. A general practitioner looks at pain differently from pain specialists, who look into the patient's history, environment and lifestyle. You have to treat chronic pain. Unfortunately there are not many avenues for people to seek treatment here.

"When patients are referred to me, I need to rule out the other causes of the pain such as cancer, infection, neurological problems and soft fractures, especially in the elderly. I also need to know about their history. I investigate about their background - whether they are smokers or are stressed. This will help me determine where the pain comes from." 

My back hurts

MY BACK HURTS

The most common chronic pain is back pain which is harmless. Almost 70 per cent of back pain is due to muscles and ligaments spasm that can be treated with pain killers and anti inflammatory drugs. Medication can reduce between 30 and 40 per cent of pain. Physical therapy and exercise, and changing your mindset also help.

"Some patients are worried that they will be paralysed or die from back pain. I tell them to change their mindset and follow doctor's advice. Only five per cent of back pain needs serious treatment."

Management of pain is a multi-pronged approach that involves the participation of the pain specialist, physiotherapist, pharmacist, psychologist, dietitian and rehabilitation counsellors. Patients will undergo either pharmaceutical or non-pharmaceutical treatments or both.

"We will prescribe a combination of drugs for the pain. Patients go for physiotherapy and will undergo a graded exercise programme. Stretching muscles improves their flexibility and increases blood flow.

"Epidural injections relieve inflammation in the spine. They will ease the pain for six months. They are safer than surgery and done in a controlled condition. Surgery is the last option and only when the damage is too big such as a fracture to the spine or pressure on the spinal cord causing weaknesses to the muscle."

MANAGING PAIN

Pain which is not severe can be treated without medication. There are several steps to relieve the pain: • Doing simple exercises like walking, swimming or gardening. The exercise will reduce the stiffness of the muscle, increase strength and blood flow which will relieve pain and avoid stiffness of the joint and muscle. • Learn proper breathing techniques. Slow breathing helps ease pain. Yoga or tai qi helps with the breathing technique. • Stay positive by telling yourself that you will overcome pain. Tell yourself that everybody has good and bad days. Good days are when you don't have pain and you can do the things you want to do. On days that you are suffering from pain, avoid doing strenuous activities and do simple exercises. • Get a good night's sleep. • Distract yourself from pain. Find a hobby or do other things that will keep you busy. • Share with your friends about pain. • Do not blame yourself or others for pain.

Go for regular check-ups, avoid or stop smoking because it is one of the causes for chronic pain, exercise and eat healthily.

"If you are overweight, you have to lose weight. Being overweight can cause pain in the knee joints as well as other illnesses. Menopausal women need to make sure their bones are healthy."

What ails you

What ails you

1. Acute pain: Occurs as a result of injury to the body and generally disappears when the physical injury heals. Acute pain is linked to tissue injury. This includes:

• surgical pain
• muscles strain
• orthopedic type injuries
• labour and delivery

Symptoms:

• sharp
• burning
• cramping
• aching
• pressured

2. Chronic: Pain that lasts more than three months. The pain maybe multi-focal and vague. There may be no signs on x-rays or scans to indicate the source of the pain since some pain may be generated by tissue injury. Depression is common with chronic pain. Neuropathic chronic pain is caused by injury to the nerve. Symptoms include tingling, numbness or burning sensation. This type of pain is difficult to treat.

Common types of neuropathic pain include:

• Diabetic neuropathy - nerve damage as a result of high blood sugar.
• Post-herpetic neuralgia - pain from shingles after the blisters have healed.
• Peripheral vascular disease - pain in legs, usually during activity, from lack of blood supply to the extremities. The legs may be discoloured, cold and the skin may be shiny.

Symptoms:

• Painful itching.
• Strange sensation.
• Extreme sensitivity to normal touch and temperature.
• Burning
• Electric-like sensation.
• Painful numbness
• Pins and needles.

Non-neuropathic chronic pain - pain that is not caused by injury to the nerve which includes:

• Low back pain due to muscles, ligament, tendons, arthritis or damage disc.
• Osteoarthritis - arthritis resulting from wear and tear of the joints and with ageing.
• Rheumatoid arthritis - an autoimmune disorder resulting in pain, stiffness and inflammations of the joints.

Symptoms:

• Gnawing
• Pounding

3. There are many chronic pain syndromes that do not belong to neuropathic or non-neuropathic. These include:

• Fibromyalgia syndrome - diffuse body pain with tenderness in the muscles.
• Tension headache - pressure-type headache lasting days to weeks and often not severe.
• Migraine headache - episodic headache that persists for an hour to days with nausea and is often severe.
• Irritable bowel syndrome - abdominal pain with cramping, bloating and constipation often alternating with diarrhoea.
• Low back pain that is not related to disc injury and without a known cause.

Treatment

Specific treatment options need to be tailored to the individual patient. Consult healthcare professional to determine the right treatment.

Prevention techniques

• Regular exercise
• Maintain a healthy body weight
• Use safe techniques when lifting heavy objects.