PAIN MANAGEMENT FOR NECK AND BACK PAIN

Pain, especially intractable or chronic pain, used to be something many patients simply had to learn to “live” with. In recent years, however, researchers have learned a great deal about pain and its physiological and psychological basis, leading to treatments that can provide complete or partial pain relief.

Untreated pain can interfere with the healing process by affecting the immune system and leading to other undesirable results. In cases of back pain, discomfort can impede the rehabilitation process by interfering with exercise and increasing the risk of psychological distress.

Patient reports of continuing pain in the absence of a definitive pathology have all too often been dismissed by health professionals who traditionally expected to find an organic cause for pain. Even in the absence of such a cause, however, chronic back pain can lead to neurological feedback processes that only serve to worsen the pain and make it more difficult to treat.

Pain is inherently subjective, and a greater awareness of the need for taking pain seriously is growing among the health community as well as the public at large. This is particularly true for chronic neck and back pain sufferers. While the great majority of cases are self-limiting and resolve on their own, the risk of recurrence and development of chronic disease is significant. Chronic back pain tends to be very difficult to treat, especially in cases involving failed back surgery or neuropathic pain (“nerve pain”).

These considerations have led to a proliferation of services available to patients seeking both medical and alternative treatment for neck and back pain. Pain management is rapidly becoming the preferred approach in many professional communities.

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What is pain management?

Pain management, also known as pain medicine , draws on many disciplines in science and the healing arts to systematically study pain, its prevention, evaluation, diagnosis and treatment, as well as the rehabilitation of painful disorders. The pain may be the result of an injury, surgical intervention, cancer or other particular cause, or may constitute the primary problem, as in neuropathic pain and headache.

In spine and musculoskeletal cases, pain management is usually distinguished from surgical treatment, and is employed as an alternative to surgery as part of an aggressive conservative care program, or after surgery to cope with residual or recalcitrant pain. Pain management and the techniques it uses also help to identify the source of neck and back pain, determine the areas to be addressed surgically, and rehabilitate the patient after surgery.

Pain management uses a wide variety of techniques to address pain and painful disorders. The scientific basis for these approaches varies from those that are completely without experimental support to those whose effectiveness has been well demonstrated in clinical trials. In view of the diverse uses and methods of pain management and pain medicine, an overview of this fast-developing field is needed. This article highlights certain aspects of this diverse area.

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Pain management techniques

Clinical research is continually being conducted to help determine which therapies are the most effective in treating back pain and neck pain. Consult your physician if you have questions about a specific program. Most of the clinically substantiated practices that have evolved in the conservative treatment of back pain are now incorporated in pain management programs designed to address pain in a systematic way. In addition, there are many methods that were not developed, or had not gained wide acceptance, until recently.

There is currently no universally accepted classification of pain management techniques. In general, these can be grouped in terms of their invasiveness. Some, such as physical therapy, are not invasive at all and do not inherently involve the use of medications. Others, such as pain medications, are purely pharmacologic in nature, while still others involve invasive techniques such as injections. Some techniques fall into two or more groups, such as injections, which invasively introduce medications into the body.

We can classify the most widely used techniques in terms of the degree of intervention they involve:

• Noninvasive non-drug
• Non-invasive pharmacologic
• Invasive

Noninvasive non-drug techniques

There is an immense variety of noninvasive non-drug techniques available for treating back and neck pain. A few of the most widely accepted in comprehensive pain management programs are the following:

• Exercise —physical exertion with the aim of training or improvement. Includes the McKenzie method, water therapy, flexion exercises, aerobic routines, and many others. May involve active, passive, and resistive elements. Exercise is necessary for proper cardiovascular health, disc nutrition, and musculoskeletal health.
  
• Manual techniques —manipulation of affected areas by means of chiropractic adjustments, osteopathy, massage therapy and other techniques. Some evidence for the effectiveness of certain techniques is available.
  
• Physical therapy —combined use of manual therapy, exercise training and other methods under medical supervision. Physical therapy offers well-known benefits for back pain sufferers, but programs vary widely in the selection of techniques used.
  
• Behavioral modification —use of behavioral methods to optimize patient responses to pain and painful stimuli. Cognitive therapy involves teaching the patient to alleviate pain by means of relaxation techniques, coping techniques, and other methods. Biofeedback involves the gradual alteration of neuromuscular signals for symptomatic improvement.
  
• Cutaneous stimulation —superficial heating or cooling of skin. These methods include cold packs and hot packs, and should be used in conjunction with exercise.
  
• Electrotherapy —the most commonly known form of electrotherapy is transcutaneous electrical nerve stimulation (TENS). TENS therapy attempts to reduce pain by means of a low-voltage electric stimulation that interacts with the sensory nervous system. Randomized controlled trials have yielded mixed results regarding the efficacy of TENS.

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Noninvasive pharmacologic techniques

Pain relievers and related drugs are used at every stage of the medical treatment of back pain, from the initial onset of acute pain to facilitation of rehabilitation, treatment of chronic back pain and alleviation of pain in cases of failed back surgery. The most common are:

• Analgesics —includes acetaminophen. Long-term use involves risk of renal damage.
  
• Nonsteroidal anti-inflammatory agents (NSAIDs) —includes aspirin, ibuprofen, naproxen, and the new COX-2 inhibitors.
  
• Muscle relaxants —used to treat muscle spasms due to pain and protective mechanisms.
  
• Narcotic medications —most appropriate for acute or post-operative pain. Since use of narcotics entails risk of habituation or addiction if not properly supervised, they are not often used for chronic conditions.
  
• Antidepressants and anticonvulsants —used to treat neuropathic (“nerve”) pain.

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Invasive techniques

Invasive techniques in pain management involve invasion of instruments and devices into the body. However, pain management should be distinguished from surgery, which involves a greater degree of surgical insult and permanent alteration of tissue than other invasive techniques.

A multitude of invasive therapies have been used to treat neck and back pain. Some of the most popular include:

• Injections —direct delivery of steroids or anesthetic to nerve, joint or epidural space. Injections into the facet, peripheral nerve, “trigger point” and other locations are also known as “blocks”. These may provide relief of pain (often temporary) and can be used to confirm diagnosis. Epidural injections provide temporary relief for severe back pain.
  
• Prolotherapy —injection of solution to stimulate blood circulation and ligament repair at affected site. The effectiveness of this technique is not known.
  
• Surgically implanted electrotherapy devices —implantable spinal cord stimulators (SCS) and implantable peripheral nerve stimulators. Clinical data offers inconclusive findings on the effectiveness of SCS.
  
• Implantable opioid infusion pumps —surgically implanted pumps that deliver opioid agents directly to affected nerve. The appropriateness and effectiveness of these devices for treating chronic back pain is controversial.
  
• Radiofrequency radioablation —deadening of painful nerve via heat produced by a specialized device. The efficacy of this treatment is mixed.

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Pain management specialists

Health professionals in many fields have completed specialized training in pain management. Currently, there is no single field of medicine or health care that represents the preferred approach to pain management. Indeed, the premise of pain management is that a highly multidisciplinary approach is essential.

Pain management specialists are most commonly found in the following disciplines:

• Anesthesiology
• Physiatry (also called Physical medicine and rehabilitation)
• Interventional radiology
• Neurology
• Physical therapy
• Osteopathy
• Primary care medicine

Specialists in psychology, psychiatry, behavioral science and other areas may also play an important role in a comprehensive pain management program.

Several respected professional societies offer certifications, training and other credentialing in pain management or pain medicine. Some of these organizations include: American Academy of Pain Management, American Academy of Pain Medicine, American Board of Pain Medicine, and the American Pain Society.

Most pain management specialists are seen by referral from a physician. If you feel it is appropriate, consult your physician for information about a pain management program. Pain management specialists are most often called upon to treat severe back pain, challenging chronic pain, and patients with failed back surgery syndrome.

Patients should keep in mind that there are many varieties of pain management programs to explore. This process can be confusing or frustrating at times, but the important point is to work proactively with your health professionals and not to give up if one initially encounters an unsatisfactory result. While this can be a significant challenge for patients enduring pain, once you find an approach that you are comfortable with your condition should improve.

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