SERIES: CHRONIC MUSCULOSKELETAL PAIN, PART 3

TREATMENT TECHNIQUES AND TREATMENT IDEAS

Now that we have a better understanding of how pain occurs, we can talk about how to treat pain.

Treatments target pain at each of the 3 levels that we discussed (see Part 1 and 2):

1) peripheral pain receptors; 2) spinal nerves; and 3) the brain’s pain receptors.

1) Pain treatments for the peripheral nerves

The approach to prevent pain at the site of injury is to reduce the number of activated pain receptors.   The idea is to block “pain information” from being created.  Remember that small molecules (like Prostaglandin etc) get released after an injury (the release of all these molecules after an injury is a well known process called “Inflammation”).  There are a lot of medicines that block the release of these molecules: anti-inflammatories.  Motrin is one type medicine.  Motrin is part of a large class of anti-inflammatory drugs called NSAIDs (non-steroidal anti-inflammatories).  Aspirin also blocks inflammation.  These medicines all prevent the formation of small pro-inflammation molecules by inhibiting the COX gene.   

Steroids also block inflammation.  But steroids work through a different set of genes (ultimately blocking the inflammatory molecule: arachadonic acid).  

The technique for treating pain at the source, is by preventing “pain information” from being passed along the peripheral nerve.  This is done by medications like “Lidocaine”, which stop a "pain signal" dead in its tracks.  It doesnt just stop "pain signals", it stops all signals.  Just think how your lip feels after going to the dentists office.  Lidocaine is used for example when someone breaks their wrist and it needs to be "re-set" (straightened out, see talk).

2) Pain treatments for the spinal nerves.

Another approach for treatment is preventing the hand-off of “pain information” from the peripheral nerve to the spinal nerve. 

This is where opioids (like Morphine, Dilaudid, Perocet, Vicoden) take effect.  These dampen the signal passed along in the spinal nerves.  

Anti-depressants also dampen the pain signal within the spine.  The antidepressant medications increase levels of Serotonin, Norepinephrine, and Dopamine.  These are natural “feel good” molecules that are made by our body.  The idea is to increase the concentration of these molecules in our spine and brain, which overwhelms the "feel bad" pain signal.  They are essentially our body’s natural “narcotic pain medication”. 

Anti-Seizure”medications, particularly Gabapentin (Neurontin) and Pregabalin also work at this level. The idea is that our spinal nerves, which transmit pain to our brain, become hyperactive after getting overstimulated from the pain of surgery or a bad injury.  For some people (for reasons not understood) once our nerves are rocking-and-rolling, they don’t know how to calm down.  The same thing happens in the brains of people with a seizure disorder: they have hyperactive nerves.  Therefore, the idea is that anti-seizure medications will work in the same way on hyper-painful nerves.  Studies have shown that these medications are very effective, and can decrease chronic pain by up to 50% (particular those with back pain, or other nerve injury pains). 

Spinal cord stimulators (electoral stimulation) also interferes with the “pain information” transmitted within the spine. 

Tramadol is a commonly prescribed medication for chronic pain.  Its been shown to act both like an opioid (like morphine it actives the same Mu receptors in the spine), and it also acts like an antidepressant (it increases levels of serotonin and norephinephrine).  Tramadol is like a hybrid drug of different approaches for chronic pain. 

3) Controlling pain perception in our brain

Anti-depressants dampen the pain signal within brain as well as within the spine.  The antidepressant medications increase levels of Serotonin, Norepinephrine, and Dopamine in the brain too.  Remember that people with depression or anxiety disorders are at increased risk for developing chronic pain because it creates brain that’s more receptive to “pain information”.  Therefore, many doctors believe that treating someones mental state will reduce their brain’s sensitivity to pain.  Overall, the dose of medication that helps chronic pain is significantly less than that required to treat depression. 

It is also believed that there are many other techniques for training our brain to overcome (or at least reduce) chronic pain.  Psychotherapy, hypnosis, and relaxation techniques can decrease the perception of chronic pain, and also naturally increase some of our body’s natural pain relievers (like serotonin, and dopamine).

However, please note that the complex relationship between someones psychological state and chronic pain is only in the early stages of understanding and needs a lot more research. 

There are lots of other medications and pain treatment techniques.  Too many to cover in one blog.  If you have particular interest in one that is not mentioned here, contact us and we will try to post about it.