Managing Chronic Pain: It Takes a Village

March 30, 2023

Chronic pain is a persistent and often debilitating condition that affects more than 50 million Americans. In fact, one in five doctor visits are related to pain, making it the leading cause of work loss and disability in this country.

Often caused by injury or illness, chronic pain can occur anywhere in the body. The defining feature is that it doesn’t go away. Even when the injury has healed or the underlying illness has been treated, the pain continues, frequently having a significant, negative impact on a person’s physical, psychological and social well-being.

The Purpose of Pain

“Pain is an essential part of the body’s protective mechanisms,” says Kutaiba Tabbaa, MD, Director of University Hospitals Parma Comprehensive Pain Center. “Acute pain is the immediate and temporary response to injury or disease. If something hurts, you stop doing it. If you break your arm, you splint it. If you have chest pain, you see a doctor to rule out or treat a heart attack. Pain helps us to survive.”

The difference between acute and chronic pain is that acute pain goes away once treated. Chronic pain, on the other hand, persists even after treatment or healing. “Chronic pain is pain that has outlived its usefulness. It no longer serves a purpose and has, in fact, become the disease itself.” say Dr. Tabbaa. “Chronic pain can be challenging to assess,” he adds. “It is often subjective, meaning it is difficult to measure, and diagnostic tests don’t always provide conclusive answers.”

The Brain Remembers

Every pain experience, acute or chronic, is registered in the brain. The brain processes the sensation, identifies it as pain and, ultimately, associates it with the events that led up to or caused the feelings of pain. The brain is rewired and the pain now becomes a memory – and like most memories, it can been recalled over and over again.

Because of the complex relationship between the brain, the nervous system and the body’s hormones, chronic pain requires a multidisciplinary treatment approach. It's not like having infection, where you take antibiotics and it’s gone. Chronic pain is complex and there isn’t one treatment or one pill that will cure it.

“Just like it takes a village to raise a child, it takes a village to care for a person with chronic pain,” says Dr. Tabbaa. “But the person has to be an active member of that village. They must participate in their treatment and be willing to get better. If they refuse to get out of bed and expect a pill to make them better, they will not progress. They must work with their team if they want to see improvement.”

A Whole-Person Approach to Treatment

“We are always looking at the whole person, including their personality and how their pain is affecting their life. Depending on each patient’s unique experience of pain, multiple types of care may occur simultaneously,” says Dr. Tabbaa. “In addition to the medical treatment we provide, many patients will also be referred for behavioral health services, chiropractic care and integrative therapies like acupuncture, massage and meditation. The whole idea of any treatment is to help them progress, so they can preserve their function and improve their life.”

The Treatment Ladder

The first step in treating a person with chronic pain is a comprehensive evaluation. During this initial appointment a complete medical history will be taken, making note of any injuries or illnesses that may be contributing to the pain and any medications they are currently taking.

Medications & Physical Therapy

The next step is almost always medical intervention. “I start by prescribing NSAIDs like ibuprofen combined with acetaminophen (Tylenol),” says Dr. Tabbaa. “When used together, they are very effective for most patients. I may also prescribe muscle relaxants and, sometimes, antidepressants to help patients feel better and more motivated.”

Opioids are rarely recommended, as studies have shown they work well for a year or so but then tolerance builds. “Patients on long-term opioid therapy become so sensitive to every ache and pain – their nervous systems are ‘soaked’ with this external opioid, depriving their own natural hormones the opportunity to fight the pain. In addition to needing more and more medication to control their pain, opioids can make the patient very sleepy and less active, contributing to weight gain which can make joint pain worse.”

In conjunction with medical therapy, physical therapy is almost always prescribed. “I often recommend aquatic (water) therapy,” says Dr Tabbaa. “Patients love it because they if they have back or knee problems, they can exercise in the pool with much less pain.”

Diagnostic Imaging & Minimally Invasive Procedures

If medications and physical therapy are not enough to manage chronic pain, the next step is usually a diagnostic MRI. “We want to see if a patient has a herniated disc, spinal stenosis, facet joint diseases or other underlying conditions that are contributing to their pain. Depending on the findings, there are many minimally invasive procedures, such as steroid injections or chiropractic adjustments, that improve the patient’s function so they can work on their recovery with less pain,” says Dr. Tabbaa.

Surgery

If a person is not improving with minimally invasive treatments, and a structural abnormality exists, corrective surgery might be an option. “We try to avoid surgery whenever possible, but if the person is experiencing weakness, loss of bowel/bladder function or other debilitating symptoms, it is a treatment option we will consider.”

Spinal Cord Stimulation

This therapy uses an implanted device that sends low-level electrical impulses directly to the spinal cord. The goal of this treatment is to block or modify the transmission of pain signals from the brain. It may be useful in treating many different types of chronic pain, especially back pain that continues after surgery.

Intrathecal Therapy

Often an option for people who have not responded to more conservative treatments, this therapy uses a surgically implanted device that delivers medication directly to the spine through a catheter. The patient has some control over the dosing and can administer the medication as needed for pain relief.

Neural Ablation

For people with chronic pain that hasn’t responded to other treatments, neural ablation may be a treatment option. For this procedure, a portion of nerve tissue is destroyed or removed to interrupt pain signals from the brain.

The Future of Pain Management

“I believe pain management as a medical discipline is still in its infancy,” says Dr. Tabbaa. “In the future, I expect we’ll see more research into the brain/body connection in people with chronic pain and how it affects the entire body rather than just the site of the original injury or disease. As our understanding grows, we hope to further develop and perfect our approach to the management of chronic pain.”