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Chronic pain—or pain that persists longer than three to six months and does not improve with standard treatments such as ibuprofen, hot or cold packs, or physical therapy—affects an estimated 50.2 million people in the United States. It’s a complex health issue, comprising nuanced psychological, physiological, and behavioral elements that often lead to the condition to often go undiagnosed, misunderstood, and over-looked, according to local specialists.
“As an interventional pain clinic, we are on your side to get your pain to a zero or as low as we can,” says Dr. Andrew Will, pain medicine physician at Twin Cities Pain Clinic. “Sometimes, a certain amount of pain unfortunately is still accepted. We don’t have the solution for everything. But I would say that portion of the pie is becoming smaller and smaller. We are realizing that there are solutions to many of these things that we didn’t realize before.”
As medical advancements make the identification of pain generators easier and as treatment options evolve, patients are better able to manage their chronic pain conditions and live more comfortable lives.
BACK AND NECK PAIN
Some of the most common types of chronic pain that specialists treat involve the back and neck, from scoliosis to spinal stenosis, degenerative disk diseases, herniated and ruptured disks, and osteoporosis. Here are a few of the treatments doctors are providing to bring relief to patients.
Nerve Blocks
Nerve blocks, or neural blockades, are simple procedures that involve the injection of local anesthetics, sometimes combined with a steroid, around inflamed or damaged nerve tissue to block pain from specific areas. They are generally used for short-term relief, such as an epidural in labor and delivery or regional anesthetic blocks for surgery. Selective nerve blocks can help pain specialists determine the location of a specific pain generator, which can help them deliver pain relief to a targeted area.
“Interestingly, at my first pain clinic 30 years ago, I would do a few procedures a day, and they were blind epidurals and nerve blocks—no image guidance whatsoever,” says Dr. David Schultz, pain medicine physician at Nura Pain Clinic. “And now, I do higher volumes of procedures in a day, and each one is precision image guided. It’s done to diagnose or treat, or sometimes both. The science of pain management has become extremely sophisticated and requires pain specialist physicians to devote their full-time attention to keep up.”
Spinal Cord Stimulation
Spinal cord stimulation is an adaptation of an already effective treatment primarily for arthritis pain relief: transcutaneous electrical nerve stimulation (TENS), a system that delivers a soothing, buzzy electrical current externally using electrodes to target nerves that may cause pain.
Spinal cord stimulation uses an implantable neuromodulation device to send electrical signals to targeted areas of the spinal cord. The best part is: You don’t feel a thing.
“We’re able now to exploit mechanisms that activate inhibitory pathways that can effectively suppress pain without relying on this kind of weird, and sometimes not terribly pleasant, buzzy sensation,” says Dr. Louis Saeger, pain medicine physician at Premier Spine and Pain Clinics.
Targeted Spinal Drug Delivery
Though the targeted spinal pain pump hasn’t evolved much since the 1980s, Schultz affirms it’s still an effective treatment for chronic pain that fails to respond to anything else. “I consider it the best method for the worst pain,” he says.
Pain pumps provide relief by delivering opioid medications and local anesthetics directly to the fluid surrounding the spinal cord through a programmable pump. This effectively targets problem pain areas without the use of oral pain medications, which may contribute to the overuse of opioids and the ongoing opioid epidemic.
Radiofrequency Ablation
Radiofrequency ablation is a procedure where a nerve is disabled using the heat generated from alternating electrical currents, preventing transmission of pain signals from that nerve back to the brain. The procedure was traditionally used to treat facet joint pain in the neck and back, but recent advancements have expanded the use to target knee or hip joints when other treatments haven’t worked.
The Intracept Procedure, a form of radiofrequency ablation that was developed in 2018, enables physicians to target the basivertebral nerve to treat chronic lower back pain. This was a region that experts had never implicated in chronic pain before. In the procedure, a physician inserts a radiofrequency probe into the center of the vertebrae at the “trunk” of the basivertebral nerve. The probe applies heat to coagulate the nerve, making it unable to transmit pain signals.
ARTHRITIS AND JOINT PAIN
According to the Centers for Disease Control and Prevention, at least 24 percent of all adults (or around 58 million people) are currently diagnosed with arthritis, and it’s one of the leading causes of work disability. Treatment for arthritis can include over-the-counter painkillers, physical therapy, steroids, and electric stimulation to nerve cells using the TENS system. Most recently, pain practitioners have found that radiofrequency ablation is also an effective treatment for chronic arthritic pain.
Saeger says he frequently sees patients with sacroiliac joint pain—a literal pain in the butt that can be extremely disabling for patients. But with a minimally invasive fusion surgery of that joint, patients can achieve more function and mobility with less associated pain.
CHRONIC HEADACHES AND MIGRAINES
“Migraines” can often be a misnomer for any type of chronic headache or head pain, but the cause isn’t always the same for every patient. So the first step of treating headaches, or migraines, is to determine the cause of pain.
“Many people come in, and they call it a migraine because they use that term for anything that’s a bad headache,” Saeger says. “That’s a common thing.”
There are dozens of types of headaches, and some can be treated with over-the-counter medications. Migraines are often treated with a class of medications called triptans, and in February, a new drug called atogepant was approved by the FDA as the first and only oral CGRP receptor antagonist specifically developed for the preventative treatment of migraine.
But if a headache persists longer than three months, you should consider seeing a pain specialist who can more accurately get to the root of your headaches. Saeger says he often sees people who were diagnosed with headaches or migraines, when the source of their pain is actually in their cervical spine—a common symptom of a whiplash injury. Treatment—or preventative pain techniques—can include Botox and peripheral nerve stimulation.
I HAVE CHRONIC PAIN. HOW DO I GET FORMALLY DIAGNOSED AND TREATED?
“The philosophy is to start with the simpler intervention and to work through until you find [the solution],” says Dr. Andrew Will of Twin Cities Pain Clinic. “I know it can be frustrating for patients to go through so many steps, but the reason you always find the solution in the last place you looked is because you stopped looking.” Here’s how specialists assess chronic pain.
1. Physical examination
A comprehensive physical examination for chronic pain assesses areas of the body to determine what the pain generator may be. A practitioner looks for tender spots on the spine, joints, neck, or other areas of concern.
2. Pain diagrams
A pain diagram is a 2D depiction of the human body that includes the front and back halves of the human body, inviting individuals to mark areas of concern from their own bodies onto the drawn human figure. It includes marks for numbness; pins and needles; and burning; stabbing; and aching pains. Patients are asked to identify areas of concern using a 0–to–10 pain scale.
3. Imaging
Thorough imaging is used to see inside the human body to detect issues that may not be clear to the human eye. Pain specialists may use a CT, MRI, or fMRI scan or a traditional X-ray to detect irregularities (such as scoliosis, disk degeneration, spinal stenosis, and other injury) that may be chronic pain generators.
4. Treatment
- Medication
- Steroids
- Facet joint injection
- Nerve block
- Transcutaneous electrical nerve stimulation (TENS)
- Ablation treatment
- Spinal cord stimulation
- Targeted spinal drug delivery
- Interacept Procedure
5. Pain counseling
Many pain clinics also offer pain counseling or comprehensive pain workshops to help address chronic pain issues. For example, Nura Pain Clinic offers a psychology-based workshop that helps patients learn and practice skills to manage pain, improve coping mechanisms and promote emotional well-being, and improve physical function.
FIBROMYALGIA AND COMPLEX CHRONIC PAIN SYNDROMES
Some conditions don’t have a clear pain generator, and that’s when pain management becomes more challenging. When it comes to conditions such as fibromyalgia, patients have complicated pain that is not well understood, sometimes leading primary care providers to overlook their conditions, diagnose them with anxiety, or write them off as hypochondriacs.
“Some patients have a physical pain problem that is poorly understood by medical science,” says Schultz, “while other patients have pain behaviors driven primarily by psychological issues. It’s an important question that physicians must address: ‘Is my patient’s pain behavior driven physically or psychologically, or are both physical and psychological issues involved?’”
If a physiological pain generator can’t be detected, then the focus shifts from the pain generator to the pain itself, and how to get to the root of the pain without entirely knowing the root of the problem.
“Often, in complex chronic pain, there is no single answer,” says Schultz. “Instead, there are multiple answers that each help a little bit, and together they make the quality of life much better.”
The best pain clinics use a comprehensive approach to pain management—combining psychology, physiology, and the latest technologies—to address all aspects of pain. While a person may have pain without a clear pain generator, it’s important not to write off their conditions as purely mental health issues. But mental health can also play a role in some patients’ pain experience.
Schultz gives the example of a patient with schizophrenia who developed nerve pain after several spinal surgeries. After implanting the patient with a spinal cord stimulator in an effort to ease their pain—something he would do for other patients with similar neuropathic pain—the patient began to believe that the implant was causing the pain.
“Patients with serious mental illness may also have severe physical pain, and they deserve treatment like anyone else,” Schultz says, “but psychiatric illness can sometimes make pain treatment more complicated.”
“Often, in complex chronic pain, there is no single answer. Instead, there are multiple answers that each help a little bit, and together they make the quality of life much better.” —Dr. David Schultz, Nura Pain Clinic
NERVE PAIN AND NEUROPATHY
Diabetic peripheral neuropathy is an extremely debilitating condition that causes shooting and burning pain in the feet, legs, and arms as a result of damage to peripheral nerves. But people with diabetes aren’t the only ones who can have neuropathy. One common condition that local pain specialists see is idiopathic sensory-motor polyneuropathy.
Previously, the painful condition was treated with medications that weren’t terribly effective. But last summer, Nevro announced its FDA-approved 10 kHz high-frequency spinal cord stimulation therapy for chronic pain associated with painful diabetic neuropathy. The high frequency of the stimulation allows the nerves responsible for transmitting pain to be inhibited by waveforms and frequencies of stimulation that you can’t feel. The technology provides a type of treatment that people with diabetes have never seen before.
“It’s amazing, really, what’s going on in the last few years in neurophysiological research,” Saeger says, “and translating this into advances, clinically, that have very substantially improved our ability with neural stimulation techniques to treat chronic pain syndromes much more effectively, much more pleasantly, and to treat categories…that no one had ever treated before.”
This article was originally published in the September 2022 issue of Mpls.St.Paul Magazine.