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>> Hello, and welcome to the Spinal Cord Injury forum.
I'm Stephen Burns, medical co-director
of the Northwest Regional Spinal Cord Injury System.
The forums, the video recordings,
and our online media content are made possible by a grant
from the National Institute on Disability
and Rehabilitation Research.
Tonight, we are pleased to have three individuals
from the Rehabilitation Institute
of Washington giving a presentation
on multidisciplinary management of pain in spinal cord injury.
Dr. Kathleen Burgess, physiatrist, Randy Hermans,
physical therapist, and Dr. James Moore, psychologist
and director
of the Rehabilitation Institute of Washington.
There'll be time for questions after the presentation.
Now, please welcome our first speaker, Dr. Kathleen Burgess.
[ Applause ]
>> Hello there.
Very nice to be here today.
This is a picture of where we work out--
work at, me and my colleagues.
We basically deal with injured workers,
people who have chronic pain.
They're almost all seen with a team approach
between this group, the therapist,
the psychologist, and a physician.
That's who we are.
Today, I'm gonna talk briefly about different kinds of pain,
acute pain, and then chronic pain, discuss briefly
about why chronic pain develops, talk about some
of the different kinds of pain in spinal cord injury,
and then some of the medications that they use
to treat it, and other treatments.
So first, what is pain and why do we have it?
Lots of people have tried to define it.
The best-- most well-known is by the International Association
for the Study of Pain, and they described pain as unpleasant,
sensory, and emotional experience associated
with actual or potential tissue damage.
And the reason why this is important is although it
includes sensory information
that means what my nervous system is telling me,
it also includes an emotional component,
and that's for everybody-- and I would say in all circumstances.
It also can be actual tissue damage.
But sometimes, people end up getting the pain sensation
and the pain signal even though no actual tissue damage has
happened or is no longer ongoing.
And then of course, the goal of pain is protection.
Best case scenario, your brain would
like to absorb the information about its environment,
make sure that it knows that it's safe,
there's nothing life threatening going on,
and then it has mechanisms to actually turn pain off.
And that would be its best case scenario.
So, the different kinds of pain--
one way to categorize pain is to [inaudible] it
between acute pain and chronic pain.
Cute pain-- acute pain is kind
of the standard pain that we think about.
You have an injury, but usually, it hasn't been very long,
you go in to see five doctors, and every doctor says, "Oh, yes.
This is a broken elbow.
This is tendinitis.
It has a very definable source of pain."
Typically, when the injury heals,
the pain your pain goes away.
You might need opioids, but usually,
that resolves in a couple of weeks.
This is the easy pain that isn't in any trouble.
Sometimes, pain becomes chronic, and the definition
of chronic pain is any pain that lasts beyond the normal.
You can see what a vague almost--
and [inaudible] use the word bogus,
but just a vague description of what it is.
Normally, we think about pain that's been going on for more
than three months, kind of gets itself lumped
into the chronic pain mode.
Frequently, you go into 10 different doctors, and now,
you might get 10 different answers.
One guy says it's this, the next person says it's that.
Frequently, when pain becomes chronic,
it no longer has a very specific source that's generating
the pain.
Frequently, chronic pain is difficult to understand
by physicians who don't deal with it a lot,
it's poorly understood by patients,
and it can be a very frustrating situation.
So when pain goes from acute to chronic, what's happening,
why does this happen, and this is really the million dollar
question, it's an area of intense research right now,
person who figures this out is, you know,
gonna be a millionaire.
But in general, we think that its abnormal changes
to two different parts of our nervous system;
the sensory nervous system that's bringing in information,
and then the motor system that has to do with moving your body.
So normally, when there's an injury, there is damage--
either mechanical pressure to a tissue, chemicals from the body
that were released due to the injury that injured a nerve.
The nerve takes this information, and it's gonna go
to the spinal cord, and the spinal cord connects
with another nerve, and then it goes up to the brain.
In the brain it's altered by a variety of different parts
of your brain, and then ultimately, it will land up here
in the top part of your brain where you recognize it as pain.
When pain is brand new and acute, these chemicals
that are released from the tissue,
they make the nerve fire faster, fires more frequently,
and it's easier for it to fire.
So when you touch it lightly, for example,
if you have a big swollen finger, you know,
that just to touch it lightly, now,
it's gonna send this big pain signal, 'cause that nerve,
it's all revved up, it's more easily stimulated.
There are some cells in the spinal cord
that are helper cells to these big nerves, and sometimes,
they contribute to the ongoing information.
They give out amino acids that are excitatory,
they give out chemicals that make it inflamed, and again,
it helps the nerve send this signal that it's injured.
Initially, this is great information for the body.
It means that you won't move your joint as much,
you'll protect it, you'll take some rest, and hopefully,
that will promote healing.
Somehow, however, when the system gets going,
it forgets to turn itself off, and these nerves
that come all the way out to your skin, they are revved up,
and they will keep going more easily.
In addition, in the spinal cord, when pain has been ongoing
for a long time, that can also have its own changes.
Sometimes, the area in the spinal cord
that is receiving the signal, it will sort of span out.
And now, areas that were next to the injury come in, and they end
up connecting with these nerves
that carry the pain signal to the brain.
And this explains why sometimes, with chronic pain,
the person's pain spreads, maybe started at their foot, and now,
it's in their ankle and their leg,
even though they never had a new injury.
In addition, nerves that normally carry the soft touch
or just light touch signal, they come in, and now,
they start to either act as if they are pain nerves or connect
with other parts of the nervous system
that then connect with pain signals.
And then things that normally wouldn't be painful,
like the light touch of your sheet, the wind blowing by you,
now, those signals come in, they're connected to signals
that carry the signal of brain-- of pain to your brain,
even though we know that that wasn't really a sensation
that normally would injure somebody or cause pain.
That's called wind up, that's also called chronic pain,
there's a lot of research into this area.
Again, in principle, it all started
to protect the nervous system.
In practice, it's not really clear why it sort of gets stuck
in this ongoing situation.
In between these peripheral nerves that get inflamed
and the spinal cord, there certainly can be a situation
with chronic pain where the pain signal is now being perpetuated
by changes in the nervous system,
and it's no longer connected to an injury out in the periphery.
In addition, at the very top of your brain, you have a map
of your body, and in principle,
it's sort of the same for everybody.
If I pinch somebody's thumb really hard, when we look at it
with a special kind of MRI, the same part
of my brain is gonna light up that's connected to my thumb.
Recently, they have found that this part
of the brain actually changes with time
and can change with injury.
For example, people who do Braille and use a lot of stuff
with their thumb, the part that corresponds
to their thumb might get bigger than other people's area.
In addition, sometimes, when there's pain,
the area might expand and be bigger
than it would have normally.
Sometimes, when there's amputation or lack of sensation,
areas nearby sort of come in and take up the space that used
to be taken up by the other body part.
And then finally-- and you might know more about this,
Dr. Burns-- but I was reading that they did one study
in people with spinal cord injuries, and they saw
that people who didn't have any sensation did have this
phenomenon where areas nearby would sort of scoot
in to the part of the brain that was missing,
or lacking from the periphery.
>> But then, people who had pain,
it was more likely to happen.
So they're not quite sure how they're gonna use this
information to help treat pain, but it certainly is something
that they have discovered, illustrating
that pain has turned out to be way more complex
than anyone ever thought.
The whole acute pain when I have an injury,
when that's over, my pain is gone.
We know that that happens sometimes.
But complex pain really is participated in by a lot
of different areas in your brain that change with time.
Additionally, we know that when the pain signal goes
up to your brain, it sort of takes a side trip, and it'll go
through multiple parts of the brain where memory
and emotion are stored that changes the pain signal
and then alters it before it gets up to the top part
of your brain where you can sense it.
So again, just speaks to the complexity of pain.
In the motor system, the part that's contributed
to by the muscles and activity,
we know that pain can impact the way people move.
Sometimes, when there is pain, it can make people not want
to move, whether that's subconscious or not.
Sometimes, this impact on the way
that we move can make people have abnormal movement patterns.
The easiest one to think about is a limp, then initially,
people start limping in an attempt
to decrease the amount of pain they have.
However, we know then
when people develop abnormal body patterns, that in
and of itself can contribute to pain.
We know that fear and anxiety also affects movement
and how people move.
And then we know with time, even just like when I walk,
I don't have to think about walking.
It's almost a subconscious pattern.
Not using a limb that's painful can almost become a subconscious
thing, and people can learn how not to use something.
We believe that that's to be detrimental 'cause we know
that all joints were meant to move.
So what happens in a spinal cord injury?
Spinal cord injury, a high frequency of pain, sometimes,
it's due to injury to their spinal cord, sometimes,
it's due to muscles and tendons.
A small minority have pain that's so bad, they're unable
to do most activities.
Lots of different kinds of pain after spinal cord injury.
Similar to dividing it between acute and chronic,
I'm gonna change it to pain that comes from your nervous system
and then not nervous system pain.
We call this not nervous system pain, nociceptive pain,
and that comes from injury to muscles, to tendons,
could be a burn, this can be acute or chronic,
and then we tend to define neuropathic pain,
which you might have heard described as pain that comes
from an injury to the spinal cord or the big nerve roots.
After spinal cord injury, this can occur year, or-- sorry--
months or years later.
Now, people have tried to classify what kind
of pain happens after spinal cord injury.
And in principle, this is so than when we focus treatments
and we see if things are working, we will know
if it worked because everybody's sort
of had the same kind of pain.
In reality, we know that this is a great thing to try,
that frequently, pain does not always fit
into such easy category.
But in general, this is one way to classify pain
after spinal cord injury.
Nociceptive pain, meaning pain in muscles and tendons,
or something happening in your guts, and then pain that's due
to the spinal cord injury, either at the level
of the injury or below, or there's other kinds of injuries
that happened to nerves.
Different kinds of musculoskeletal pain
after spinal cord injury, certainly, early on,
it can be from spine fracture of from the injury itself.
Shoulder injuries can develop
when people are using a wheelchair a lot
or doing transfers.
Muscle spasms, sometimes arthritis,
things that people may have gotten even had they not had a
spinal cord injury.
Low back pain is a very common one.
Overuse injuries, again, related to movements
that your shoulder would not normally be doing,
[inaudible] fitting wheelchair, improper transfers,
and then disuse or contractures.
And again, this gets back
to when our brain has given us a signal that something hurts,
and initially, it wants us to stop using it,
and that's great initially.
When pain becomes chronic, usually,
that mechanism is not as helpful.
When people don't use a joint, an elbow or a shoulder,
a hip or an ankle, if you don't range it all the time,
it will get stuck there, and somebody
who has never been injured, it will get stuck
after certain period of time.
People who are injured, it gets stuck faster.
So just a reminder that, you know,
no matter what somebody's condition is,
to gently range the joints everyday is an important part
because the contractures can end up being painful.
Pain at-- in the musculoskeletal system,
it could be above your injury, it could be below.
Frequently, it is related to movement.
Sometimes, you-- this is easier to find because it's tender.
You can push on it and find it.
They might do an x-ray and MRI and come
up with more of a diagnosis.
And if it's up here where people still have sensation,
frequently, that's more easy to define exactly
where it is and how it feels.
People can also get pain after spinal cord injury
from inside their guts, having to do with their bladder,
urinary retention, urinary tract infection, the kidney stone,
constipation, appendicitis, just like people
without spinal cord injuries might have, stomach ulcers.
These kinds of pain, they might not present similar
to an un-spinal cord injured person.
And this is where, just like other parts of your care,
you'll have to remind people, you might have
to remind the physician to think about these things,
because sometimes, a kidney stone isn't gonna present
as back pain.
It might present as increased spasticity in your legs,
or increased leg or back pain that doesn't seem
to be related to the gut.
Neuropathic pain that comes
after spinal cord injury, how does it happen?
Loss of blood flow to the spinal cord, mechanical traction
on the spinal cord, sometimes, people can develop a syrinx.
Does everybody here know what a syrinx is?
Okay. So in the middle of your spinal cord,
you have a very tiny canal that's running--
that has fluid in there.
Sometime after spinal cord-- as the spinal cord is recovering,
there might be-- that might start to expand
as it collects with fluid.
Sometimes, that doesn't mean anything, sometimes,
it can push on your spinal cord
and then give you more weakness or pain.
And so, a syrinx that comes up can be a new finding,
and that might be associated with pain after, you know,
years after there's spinal cord injury.
And then of course, the kind of bone pushing
on your spinal cord would contribute to neuropathic pain.
What does neuropathic pain feel like?
Anybody here with neuropathic pain wanna say what it
feels like?
Okay. Below the level of an injury,
it's frequently described as burning, tingling, numb,
it might be aching, this can be on both sides,
this might happen months or years after the injury,
and it might be associated with something called allodynia,
where you just touch your leg lightly,
and that's a painful sensation.
At the level of the injury, it can be on both sides.
It can be the situation
where normal sensations are more painful, and it can also occur
that things that are normally painful are even much
more painful.
Sometimes, at the level of injury,
it might be that just one side of the spinal cord
or the nerve root coming out as injured, that might feel
like pain that comes in a band around your body.
It might be radicular, meaning that it goes
down your leg or down your arm.
When it's radicular, although we call that neuropathic,
it has a very specific pattern, and again, this can occur weeks
or months after the injury.
Couple kinds of neuropathic pain or nerve injury pain
that can happen after spinal cord injury, but more sort
of related to life; diabetes, central poststroke pain,
and then compression of a nerve.
The most common one is carpal tunnel in the wrist, also,
ulnar nerve at the elbow, either from resting your elbow down
or this kind of movement.
Sometimes people can develop something called tarsal tunnel
in-- syndrome in the foot.
Lots of medications are used for the treatment of pain
after spinal cord injury.
I could separate them out to the ones that we normally use
for musculoskeletal pain and the ones
that we normally use for neuropathic pain.
>> We could also think about this as medications for things
that are acute and new, and medications
for things that are chronic.
What we do, working with injured workers and with patients
who had pain for a very long time, this categorization sort
of uses its usefulness, because frequently,
you have to try a lot of different medications in order
to get some assistance.
So different ones, everybody knows about anti-inflammatories,
acetaminophen, antiseizure medications
such as gabapentin that's called Neurontin
and pregabalin called Lyrica.
This can be very effective for numbness and tingling,
can also really help with sleep, and we know that any sort
of sleep irritation
or disruption can contribute to people's pain.
So, people with chronic pain frequently have a physician
that will put them on getting their sleep normalized.
Other medications include muscle relaxants, like cyclobenzaprine,
methocarbamol, I forgot to add ones like baclofen
and tizanidine, used more for spasticity.
Sometimes, those can also use--
be used for sort of muscle pain or for sleep.
Antidepressants, such Cymbalta and amitriptyline.
Now, opioid medications, like Vicodin, Percocet,
Lortab, are called opioids.
They are frequently used after spinal cord injury,
and they're frequently used for all kinds of--
they're not so frequently used after spinal cord injury,
but they can be used for all kinds of--
different kinds of pain.
This has some particular side effects,
including decreasing people's respiration,
causing constipation,
maybe making somebody have a low blood pressure.
For these reasons, they might not be used quite frequently
in people with spinal cord injuries.
Are they helpful?
You know, sometimes, they are.
Frequently, they are best after a brand new injury.
When things become chronic,
these definitely lose their effectiveness.
Now, we've seen two-- what I as tell you about the brain map--
the biomap in your brain, the people who take chronic opioid,
sometimes, that can change that map as well,
it can change the environment in you spinal cord, and in general,
for things that are chronic, there's becoming a trend away
from using opioids for pain.
Other kinds of medications can be used for pain
after spinal cord injury that are into the spinal cord,
such as lidocaine, ketamine, baclofen,
clonidine, and morphine.
These kinds of pain procedures are not a 100 percent useful,
and they'll typically come at very end of a long set
of other things that had been tried.
Other kinds of treatments for pain, deep brain simulation,
transcortical stimulation, spinal cord stimulators, again,
it would be great if they worked 100 percent in all people.
They don't.
They have some side effects, and typically, are used more
for more disabling pain.
Other treatments for pain include exercise, massage,
acupuncture, and psychological interventions, again,
probably not one study that showed one
of these was great for everybody.
When pain becomes chronic, people really have to try a lot
of different kinds of things to figure
out what might work for them.
The psychological interventions are critical.
As I mentioned earlier, all brain--
all pain signals come through the brain and are modified
by the part of our brain where memory and emotion are stored.
All pain has psychological component to it.
And so, when people's pain becomes chronic,
just like you would look at surgery, injections,
medications, different kinds of treatments,
psychological aspects to pain should always be included.
So in summary, people
who sustain spinal cord injury may experience pain syndromes
that are typical to other people that are not related
to their injury, they might have syndromes related
to their injury, and some of these might present differently
and need really, a trained person to think about them
so that they don't go overlooked-- get overlooked.
Once pain becomes chronic, it really is difficult
to treat for everybody.
Multiple medications are usually tried,
alternative treatments are tried, this is a very hot topic
of research too, with the new brain scans that they have,
they are really learning a lot about all the different parts
of the brain that are contributing to pain.
As I'm sure you've heard from other physicians
and care providers, really, even chronic pain, is it's a time
for you to remember that you are the expert regarding
your condition.
You might have to educate other people on it.
Don't even underestimate the rules of general health,
eating right, getting enough exercise, getting enough sleep,
trying to manage the stress in your life
so that it's not contributing to a revved up nervous system
that then contributes to pain.
Always try to include time for psychological care,
identifying the sources of stress--
I think Jim is gonna talk more about this--
having a social circle, having activities that like to do,
believe or not, it seems minimal,
but all of those really can contribute to controlling pain.
>> So our next speaker will be Randy Hermans,
a physical therapist with the Rehabilitation Institute
of Washington.
>> Thanks.
It's a pleasure to talk to you today.
I'm a physical therapist, and so, I tend to work
in a context of exercise.
But what I enjoy most about working with folks
with chronic pain is that it really does take a
team approach.
So if you leave here with some actions items today,
just be aware that if you're dealing with chronic pain,
that-- I mean, looking to get some help,
you really need a team approach of people to help you with that,
and you need a physician kinda covering the aspects
that Dr. Burgess covered.
You really should have some contact
with a skilled therapist, whether it's a PT or an OT,
helping you with your movement, but also keep in mind,
chronic pain aspects of movements,
which I'm gonna talk about,
and in getting the psychological support in the areas
that Dr. Moore is gonna talk about.
Last of good information
about exercise being an important aspect
of managing chronic pain in the general population, but also,
a couple of good-- cases of literature talking
about exercise helping spinal cord individuals as well.
And so, couple of things you noted here are--
[inaudible] resistant exercises should be basically different
types of strength training,
and then a home exercise program involving some flexibility
and basic strengthening exercises.
So I'd like to talk briefly about different types
of exercise and how you might use that to approach one aspect
of managing chronic pain.
Lots of different types of exercise--
and I tend to break them down into some different groups.
One would be relaxation and flexibility types of exercise.
Generally, at the beginning of the-- when you're first injured,
you have intimate association with both physical therapist
and occupational therapist, and primarily, [inaudible] teaching
to move safely and care for yourself.
Once you've attained those goals,
maybe you have less interaction with those folks.
But if you're dealing with the pain problem, it might be time
to reconnect with someone or establish a relationship
with someone that can help you really set
up an appropriate exercise in a context of managing pain
and asking about some relaxation and flexibility exercises.
In our clinic, we do about stretching, certainly,
a full body stretching program every day.
This not only helps to keep the muscles in the joint slimmer,
but from essential nervous system sensitivity
that Dr. Burgess was talking about, where normal things start
to create that pain, it seems like repetition of normal things
on a daily basis seems to kind of help address that wind
up situation, where as you do things,
they're initially uncomfortable but are safe and normal.
If you do them repeatedly, [inaudible] the body begins
to pay less attention to them.
And that's one aspect of managing your chronic pain.
We do things, in addition to regular exercise,
such as just basic yoga activities, tai chi,
there are lot of different avenues of relaxation
of flexibility activities out there for you
that will appeal to your interest.
So talk to your therapist, or if you don't have a therapist,
since you're working with them, maybe reestablish contact
with someone that your physician can recommend to you
and have them evaluate your relaxation,
your flexibility program.
Benefits of these activities include reduced pain, of course,
decreasing muscle tension, and perhaps,
dealing with some spasticity, certainly, decreasing stress,
and perhaps, improving sleep, basic diaphragmatic breathing,
the importance aspect of relaxation, whether you do that,
you know, through a relaxation tape or some sort of yoga style.
Normalizing range of motion in all the joints is important
for the next part of what I'm talking about,
which is maintaining appropriate posture
and appropriate stabilization.
Stabilization, or good posture, or body mechanic,
just basically refers to using your body in the environment
where it's the strongest in wheelchair users,
we're certainly talking about the shoulder,
but also the trunk and the head.
All joints in the body, whether it be a finger or wrist or neck,
have a position where there's the least amount of stress
across the joints, and where the muscles that control
that joint are the most effective.
>> And since many things in life take us out of those positions,
we wanna do exercises and activities
that really help us reestablish those positions,
so that as we go through our normal day to day activities,
our body knows how to maintain those positions.
So for wheelchair users, it's particularly important
to have good stability around the shoulder girdles,
these would be scapular styles of exercises, certainly,
exercises for the rotator cuff, exercises for the elbow
and wrist, and [inaudible] little bit individual on,
you know, what are the best exercises based
on their presentation, based
on how long they may be using the wheelchair,
based on what their lifestyle activities are,
based on what type of wheelchair they are in.
So this is the time where you really wanna get an
individualized program, and you know, again, look at--
meeting with a therapist that is kinda skilled
in helping you device that,
and then just maintain a regular posture
and stabilization exercise as part
of your normal daily routine.
Strength training is also important component of dealing
with chronic pain, not only to strengthen and allow you
to do the things that you wanna do, but also for, again,
looking at this kind of wind up phenomenon
where in our population groups, simple activities,
and maybe even like, vacuuming or cooking, which of course,
aren't injuring the body, become often times extremely painful,
and that can be a little-- can be significantly disabling.
But those things don't have to be things that you avoid.
They can be things that you can back-- get back to.
You just need the strength to be able to do that.
And so, a regular repetitive strengthening program not only
will help give you the strength to be able
to do those normal activities that you wanna do, but then,
repetitively and consistently overtime, can also help deal
with the-- more of that central nervous system sensitivity
where the spinal cord and the brain are sending pain signals
even in the presence of normal stimuli.
So these benefits are including--
improved posture and biomechanics
which are important, improved functional capacity level,
which is extremely important for self care,
strengthening can improve lean body mass and help
with your metabolism, and then also,
decreasing your risk for injury.
So in wheelchair user, an injury to the rotator cuff or the neck
and shoulder can be a significant impact
on your function.
And so, thinking about just getting that area strong as--
as stable as you can would be extremely important.
And let's not forget cardiovascular exercise.
So cardiovascular or aerobic exercise,
using large muscle groups in repetitive fashion at low level
to try to ultimately elevate the heart rate to a level
that generally [inaudible] for about 20 minutes to release some
of those natural endorphins in the brain that can help
with mood, can help with sleep, can help with pain management,
as well as a variety of aspects of health, and certainly,
spinal cord individuals from most folks are gonna be build
to find something that is available in this arena.
And this is where a skilled therapist could also recommend
something for either a piece of equipment or a location
where we might be able to pursue that.
And again, [inaudible] role and benefits
from cardiovascular exercise, helping a chronic muscle pain,
dealing with depression and sleep,
and decreasing overall risks of injury and disease.
So I guess if I had a take home message for you today in regards
to exercise, recognizing that we're not just exercising for,
you know, basic flexibility and strength, but in the context
of managing chronic pain, we are also exercising
to desensitize the whole system to movement,
so that your everyday normal activities become less painful,
and that your body ultimately is stronger and more able to take
on the challenges that you need to on a daily basis.
And really, the best person to do that would be a PT or OT,
perhaps someone that you worked with in the past.
And if you haven't, you know,
reassessed your exercise program recently,
now might be the time to do that.
Okay. So I'd really encouraged you to do that.
That would be my take home message for everybody today.
>> So our final speaker will be Dr. James Moore.
He is a psychologist and the director
of the Rehabilitation Institute of Washington.
>> Thanks, Steve.
It's a pleasure to be here with all of you.
Thanks for coming.
The-- I don't know if you can read it very well,
but the subtitle of my talk is
"Making the best of a bad situation."
And I think unfortunately, most of the people that I see
in my practice have had serious injuries, and they have had pain
for long periods of time, and not everyone--
in fact, very few people completely overcome their
pain problems.
So the reality is I think you have to live
with a certain degree of pain.
And my job in working with individuals
who have chronic pain is to really help people make the best
of a bad situation, to manage the pain
so that you don't become depressed,
that you are not grouching and irritable,
that you don't stop moving entirely,
so that you don't let the situation interfere
with your relationships with others, to try to cope with it
in a way that allows you to have a good quality of life.
This is a drawing by Rene Descartes from early 1600's,
and this shows his depiction
of the nerve pathway carrying pain signals to the brain.
And Descartes thought that it was almost
like a mechanical connection between the point of an injury
and the brain processing those signals.
And it was almost like pulling on a rope and ringing a bell.
It was automatic and that the amount
of pain you had was supposed to be in direct proportion
to the degree of injury that you suffered.
And he actually felt that the--
he separated the brain from the mind and said
that cognitive processes, emotional factors,
psychosocial factors, had absolutely nothing to do
with the experience of pain,
that it was simply a mechanical process.
And this kinda lead to the classic medical model that was
in existence probably for the next 350 years.
It's only been the last 30 or 40 years
that we've become much more aware of the fact
that psychological process, emotions, thought processes,
have a huge influence
on how much pain people experience from a given injury.
There is very little correlation between the severity
of an injury and how much pain it causes.
So pain, as Dr. Burgess said, is a very complex process,
very difficult to understand, but clearly,
it's not just direct pathway.
She already gave you one of these definitions.
I was wanting to make the point that we now perceive pain
to be both-- it is unpleasant sensation, but it's combined
with both physical and emotional components,
and the brain does not always process all the pain signals
that you receive.
So people who have chronic pain, they have injuries 100 percent
of the time, but they may go through periods of time
when they don't hurt at all,
or when their pain is only 50 percent
of what it is some other times.
And then there are times when it is much worse.
And those changes in pain are influenced by lots
of psychological processes.
Again, the difference between acute pain
and chronic pain has already been discussed.
The basic point I wanna make is
that acute pain is influenced mostly by the injury itself,
the tissue damage that people experience.
Chronic pain is much more influenced
by all those other psychological factors.
This is a nice heuristic model that's been
around for a long time--
actually, I think developed initially at the University
of Washington-- to kind of help people understand the different
components of a chronic pain problem.
So everything begins with an injury or tissue damage,
and typically, when you have an injury, there is pain sensation
that resolves from it, but not always.
You might have an injury and-- a minor injury anyway--
and be so distracted by something that you are doing
that you don't notice it at the time.
People in horrific accidents might be so overwhelmed
by the danger and the people with them
and determining whether they are safe,
that they don't realized they fractured a bone until,
you know, an hour later when the emergency has passed.
So you don't necessarily always have pain
in direct proportion to the tissue damage.
When you do have the pain experience,
especially a chronic pain experience,
we all have thought processes about that pain.
So you all have a complex set of ideas and beliefs
about your pain, whether your pain is caused
by some undiagnosed medical condition,
whether your pain is something that is going
to greatly impact your life, whether your pain is something
that is treatable, whether your pain is something
that other people believe you have, whether other people care,
whether your doctors, really,
they're trying their best to treat your pain.
So you have lots of ideas about your pain.
And how you think about pain can influence
on how you respond emotionally.
So people that have very pessimistic, negative,
hopeless outlooks are much more likely to become depressed.
People who believed that people don't really care,
they are not interested, they are not trying very hard
to be helpful, may become angry.
So how you process the pain and people's response
to it influences your emotional reaction to it,
which is very important, 'cause negative emotions, anger, fear,
depression, all feed back in to--
make the pain experienced even worse.
>> And then there's a behavioral response to pain.
We call that pain behavior.
And initially, pain behavior is something that you do
to avoid hurting more.
So people start to move in a guarded fashion,
they avoid activities that might aggravate their pain,
they move in a way that, you know, somehow protects them.
But those behaviors can become habitual, you start doing them
without thinking about them, and even after you've healed,
you may still engage in behaviors--
and some of those could cause secondary pain problems
and make the whole situation worse.
How you respond behaviorally
to pain also has a huge influence on other people.
So if you're behaving in an irritable way because you hurt,
that can have a huge impact on the people you care about,
in your family and in your social environment.
If you become quiet and withdrawn, again,
that has an impact on other people
and on your relationships with them.
So, it's very important to recognize what you're thinking,
how you're emotionally suffering,
how your behavior has changed, and it's also important
to recognize how your behavior is influencing people
around you, because it's very easy
to make other people miserable when you're miserable,
and it can lead to lots of difficulties in relationships
that you don't want to have happened.
So, part of my job as a psychologist,
working with people with chronic pain,
is to help them remain sensitive to other people.
You know, when you hurt, there's a natural tendency to focus
on how miserable you are, and you kinda forget
about other people sometimes, and that they may be suffering
in a somewhat different way, and that you have
to remain sensitive to others.
Otherwise, relationships can suffer.
So I have two goals as a psychologist working with people
who have chronic pain.
One is to control the pain as much as possible,
so one way of doing that is to use distraction.
And so, you know, one distraction technique could be
to count backwards from a million by sevens.
But-- that might work.
It will occupy your focus of attention.
But it's not a very enjoyable thing to do.
So you know, my view of distraction is to have as busy
and active life is possible, to have things that you do
on a daily basis that keep you focused and interested,
and stimulated so that you have less time to focus on pain.
When people have injuries, they're physically limited
in what they can do and they're hurting, there's a tendency
to wanna stay home and not do anything.
But then, you have a whole lot more time to focus on pain,
and pain can be worse.
It's important to control fear and other negative emotions.
The reality is if you have a fear
that you're gonna aggravate pain,
your focus of attention is gonna be on the area that hurts.
Your brain will actually process pain signals much more readily
when there's fear associated with that pain problem.
Depression is certainly associated with increased pain,
same with is true with anger.
Relaxation techniques are very helpful.
You can certainly reduce the pain caused
by muscle tension by using relaxation.
There's often a distraction component mixed
in with relaxation, and then modifying beliefs
and expectations.
And one of the ways of doing that is to use techniques
such as self-hypnosis to try
to give yourself more positive expectations about your ability
to manage pain or to lead an active lifestyle
in spite of pain.
In the University of Washington system, you have a richness
of really good rehabilitation psychologists
who have expertise in this area.
So that's the treatment that is readily available
in the Seattle area.
The other part of my job, and maybe the one that occupies most
of the time, is actually trying
to help people prevent the unnecessary negative
consequences of pain.
So obviously, you're not gonna be thrilled and happy
when you hurt, but I think you can also avoid severe
depression, you know,
severe anger problems, and that's important.
And so, my job is to help people not let pain complicate their
life any more than necessary.
This is just a slide that gives you the current prevalence
of all kinds of different mood disorders in the United States,
and this is in a population of people
without pain versus with pain.
These are not spinal cord injured individuals.
But as you can see, the prevalence
of emotional disorder is two to three times greater
when someone has a pain problem.
So pain really does cause emotional difficulties
for people.
This-- the prevalence of chronic pain and the prevalence
of major depression for people with back
and neck pain is 15.7 percent, a similar figure for individuals
with chronic pain and spinal cord injury has been
around 30 percent.
But I think it's important to recognize that it really-- how--
whether or not someone gets depressed
and how depressed is influenced by how much the pain
or the injury influences the quality of your life.
So the people that we work with in the pain management program,
almost all of them are not working,
they have suffered severe financial losses,
quality of life has changed significantly,
and the prevalence of depression is closer
to 45 percent in that group.
So kinda-- you know, when you've suffered more changes,
you're gonna have more emotional distress associated with it.
So one way of managing depression is
to change how you think about situations.
So when someone has-- you know, this is a simple model
of cognitive restructuring.
And those of you who have had any psychological treatment,
you've probably seen something like this.
But activating events can include situations
of having chronic pain.
That can be an activating event.
How you think about that chronic pain can influence how it
affects you emotionally, how it affects your behavior pattern,
and to some extent, some physiological changes.
So if you think that pain is a sign
of something dangerous going on in your body,
then you might stop moving.
So that's a behavioral change that can then lead to kind
of worse conditioning and the loss of function, and certainly,
loss of ability to enjoy life.
So a part of the process of managing emotions is
to become more aware of how you're thinking
about what's going on in your life,
and to see if there's a more rational way
or a more optimistic way of evaluating that situation
so that you can minimize some
of the negative emotional consequences.
Changing behavior is also very important.
So when someone becomes depressed, there's a tendency
to view everything in a negative way.
And so, the person who is depressed doesn't feel
like doing anything, they don't think they're gonna enjoy
themselves, they don't wanna get together with friends
because it's too much trouble,
they wouldn't have any good time anyway.
And so, they tend to kind of view everything
in a negative way, then they stop doing things.
And it's important to self-manage depression
to maintain an active lifestyle which should include exercise,
involvement in social activities,
doing something productive, and it could be washing the dishes.
I mean, 'cause after you wash the dishes, it feels good
to have a clean kitchen.
And so, doing something productive is important.
Doing something that's rewarding to you
or that you just take pleasure or enjoyment from,
and having some fun, having, you know, the ability to laugh.
So you have-- people who are depressed often have
to force themselves to get out and do some
of these things 'cause they don't feel like doing them.
So you really have to make yourself do it.
And then problem solving is another important strategy
to manage depression.
The reality is, most people, I think, are depressed not
because of a biochemical abnormality in the brain,
but they're depressed because their life isn't what they
wanted to be.
They're not doing the things that they wanna do,
their marriage isn't quite as positive as they would like it
to be, their relationships aren't as good,
they're not doing anything fun and interesting.
And so, I think you have to do some problem solving
so that the quality of your life is closer
to what you would like it to be.
And that's probably the best solution for depression.
So sometimes, getting out and socializing more,
calling up a friend, trying to do something
to make your relationship with your partner more positive,
and little by little, you can create a better life
for yourself, and depression will automatically diminish.
So, a couple of cautions about treatment for depression, the--
kind of the standard of care.
If someone is depressed, they see their doctor,
you'll get a prescription for an antidepressant medication.
And this is a bill of goods that we've been sold.
It may not be completely accurate.
So it's clear, the research coming out now is
that antidepressant medications are probably far less effective
than we used to think they were, especially for mild
and moderate cases of depression.
So they're not the cure-all that some
of the pharmaceutical companies would like us to believe.
>> So it's important that you don't rely just
on an antidepressant if you're feeling depressed.
You wanna still make the behavioral changes
and the cognitive changes
that will help you get rid of that depression.
And then another question is if you're gonna get counseling,
psychotherapy, there isn't--
psychotherapy is not all the same.
And so, the therapies that are demonstrated to be effective
for treating depression is cognitive behavioral therapy,
which is a process
of systematically changing your thoughts, looking at things
in a different way, and changing your behaviors.
And that's helpful.
Interpersonal therapy is a type of therapy that's mostly focused
on improving problems in your relationship, solving problems.
And that's shown to be effective.
Support of counseling, which is I think what most people get
when they see a councilor, may not be very effective.
If you're going and you're talking to somebody
and they are listening in a supportive way
and being encouraging, that may not be enough
to actually overcome a significant depression.
So usually, good therapy involves, you know,
learning something, trying out new skills,
completing homework assignments, doing something
that involves you changing your thought processes
and your behaviors.
If you're avoidance is a big topic
in the chronic pain field--
[inaudible] avoidance simply means
that when people are afraid that moving or engaging
in activity will cause more pain or cause an injury,
they tend to avoid being active.
And this is a factor that's as common in individuals
with spinal cord injuries as in other types of chronic pain.
And so, there are, you know, what are referred
to as catastrophic thoughts.
So when you think that moving in this way is going
to cause some horrible problem, you know, that's a thought
that will create pain related fear, and that fear is going
to cause you to avoid movement or activity
that you think is gonna make you worse.
But if you do that too much, then you lose fitness,
you lose conditioning, you might end up not being out and about
as much, so you're gonna be more isolated, and that can lead
to depression in a whole downward spiral.
So it's important to maintain a good level of activity
and to know what is safe to do, certainly don't do things
that are dangerous, but I think sometimes people don't know
what's safe and what isn't.
And sometimes, one of your providers can help you recognize
what is possible.
Anxiety and fear are normal.
We all have them.
And normal anxiety and fear are caused
by a realistic expectation that something bad is gonna happen.
Pathological or abnormal fear and anxiety are caused
by over-predicting the probability
that something bad will happen.
So when people have fear-avoidance beliefs regarding
pain, sometimes, people over predict, you know,
the possibility of something bad happening if they move
in this way or they do this.
So one way to overcome this excessive pain related fear is
by the cognitive structuring--
cognitive restructuring that I talked about for depression.
So trying to identify what are the thoughts
and beliefs you have about moving and what that will do
to you, and to try to rethink that so you're looking at it
as objectively as possible.
The best way to overcome fear is exposure, facing the thing
that you're afraid of.
So if you're afraid of dogs, you have to be around dogs
to overcome that fear.
If someone is afraid of movement, you have to move.
You have to actually engage in activities.
Somebody can tell you it's safe, but until you do it
and nothing horrible happens, you know, you'll--
it will be hard to overcome your fear.
So gradually, you know, approaching an activity,
so starting out with a little bit of something.
So if you wanna-- if your goal is to, you know, spend 3 hours
out cruising around, you start out with 2 minutes or 3 minutes
or 4 minutes-- you know, you gradually try to build
up your endurance and your ability to do something.
And you do it at a pace where you can last the length of time
that you want to, and make sure
that you use the correct technique for doing things.
But people can become much more active than they think they can.
Most of us hold ourselves back because we're kind
of afraid we can't do something.
And so, often people can accomplish much more
than they realize.
This is an example--
this picture is a gentleman named Mark Wellman
who has paraplegia.
But he climbed up there.
So he's a rock climber.
And on the website, there's lots of pictures
of him scaling the sheer rock face.
So he probably started with a little bit of that activity
and worked his way up to it.
And then it's important to pay attention to your relationships.
So again, when people hurt the--
you know, you wanna be left alone, most people,
when they feel sick, they wanna be left alone.
They don't wanna talk to anybody.
But if you got pain all the time, there's a tendency
that you will withdraw, and that can drive people away from you,
and you'll lose an important part of your life by doing that.
If you're grouchy and grumpy and irritable because you hurt,
you might, again, lose a lot of relationships,
you can very quickly drive people away from you.
So I think it's important you, again, maintain that sensitivity
to the people around you so that you don't make them miserable,
because you need people in your life.
It's important to be aware
that your pain behavior has effects on others.
People see you grimacing, they see you being quiet,
they see you acting grumpy, they see you not moving,
and that concerns other people, that bothers other people,
that distresses other people,
and that changes how they treat you.
And sometimes, relationships become unbalanced,
they're not quite the same, someone be--
can become a caretaker instead of a partner
when you don't really need that.
So it's important to be aware of what you're doing,
how it's affecting other people.
It's important not to make others guess what you want.
I think when people are around someone who is in pain,
they don't know whether they should say,
"How is your pain today?"
because your response might be, "Well, until you brought it up,
you know, it was fine.
But now that you brought my attention to it, it hurts."
Of course, if you don't ask, then they'll say,
"Well, they don't care.
They don't even ask."
So don't make people guess what you want.
You know, it's easier on the other person if you tell them
that you like to be asked how you're feeling,
or if you like to be asked if you need help with something.
If you don't wanna be asked, then it's okay
to tell them that, and people are generally happy to respond
to you the way you want.
But you know, they can't read your mind.
They don't know what it is.
So you want them to be sensitive to you, I think at some point,
that you be sensitive to others.
When people see someone in pain
or someone struggling physically, they feel obligated
to do something to help you, and sometimes,
there isn't anything they can do to help you,
and then they feel guilty.
And so, people around you
who see you suffering sometimes feel pretty miserable,
'cause their-- they feel helpless.
They feel like there is nothing they can do.
Telling them there's nothing that they need
to do let's them off the hook,
or telling them how they can help will then give them
some direction.
And you want others to be sensitive to you--
and again, this is the same issue.
It's important to speak up and tell them and let them know
who you are and what you want and what you need
and how you expect to be treated,
so that you have good communication
in your relationships and people aren't always guessing
who wants what comes or not.
Okay. I think that's my last slide.
Thank you.
[ Applause ]
>> Yeah. The question was, well,
we all work together in the same place.
So we talk to each other all the time.
The question was, what if you have one provider here
and another one across town, and how do you handle that so
that there is kind of some cohesion in treatment.
And I think asking people to talk to each other.
I mean, so I've had patients asked me,
would I mind calling their primary care doctor,
or would I mind calling their other mental health counselor.
And so, I think getting them to communicate and send notes back
and forth to each other, and maybe even have a conference,
a telephone conference, so that everybody is
on the same page and working together.
You know, we strongly believe
that a team approach is the way to go.
So you wanna try to create a team as much as you can.
Any other thoughts?
>> Yeah. Coming from a therapy perspective, you know,
as a therapist, the first thing I wanna know is that, you know,
this is not a medical issue that needs to be addressed either
with medicine or surgery or some sort
of intervention out of my domain.
So as you work with a-- either your PT or your OT,
that's the first thing that they're gonna want to know.
>> And so, a call from a physician or a discussion
with the physician is really important for me.
So when I'm working with someone, I know that the things
that I'm offering for them and suggesting to them
and helping them with,
really are safe 'cause that's what I'm telling you,
and really are appropriate.
And in that context, that can help me help someone that's
having difficulty, or--
particularly the pain problem, move forward.
It's much easier for me to get someone to work through pain
and discomfort when I know that yes, that's--
they've been full evaluated medically,
and this is really a pain problem, and not, you know,
saying something unstable medically.
So I think if you're following my suggestion of making contact
with a therapist or just kind of brush up on your exercise plan,
the first thing you're gonna wanna know is
that you're medically stable and ready
to participate in those activities.
>> Yeah. You know, we have doctors,
that's how we're trained, we're all trained in a team.
Even in my private practice,
I frequently call the physical therapist,
I frequently call other people.
It's part of what I do as a physician.
The family physician or other physicians might take a little
bit of [inaudible], you might really have to tell them,
you know, this is really important to me,
because they might not be used to it.
But most therapists-- you know, when I call a therapist,
I've never had a therapist say, "No, I don't have time,
don't call me in the future."
Therapists are clearly already in the mood
to be sort of a team project.
So I think most of the time, if you let your needs known,
you kinda get what you want.
And if it is not a rehab doctor,
you might have to help them along.
So we know that opioids change the chemical [inaudible]
of the spinal cord, they change the map in the brain,
has this been shown in other classes in medication.
And I know that-- well, do you know?
>> I'm not aware of it yet.
>> Okay. You know, we did know
that there's a less norepinephrine
in the spinal cord fluid if people have chronic pain,
but they haven't really connected
that to changing the chemical structure the way
that opioids have been found to do.
The-- as I mentioned earlier, the brain has--
nervous system has ways to shut the pain signal off
in the spinal cord and-- coming down from the brain.
For some reason, opioids, they tend to inhibit this ability
to shut the pain signal off.
And I don't know the other medications have been found
to do that.
>> I have a question for the group.
How many people have an established exercise program
that they do every day?
Okay. That's not enough.
[ Laughter ]
>> That needs to be everybody, okay?
I assume--
[ Simultaneous Talking ]
>> 'Cause you're interested in managing your chronic pain,
and exercise is a huge part of that.
How many people have regular contact with a PT or an OT
that helps them with their movement [inaudible]?
Not enough.
Everybody got a take home message for me today?
Okay. Look in that address book, talk to friends,
talk to your physician and get in contact with someone.
It doesn't-- I could teach someone a good home exercise
program that would really go long ways
to not only addressing musculoskeletal components
of things that I would see,
and wheelchair users have really specific musculoskeletal needs,
but also, to help people address chronic pain, I could--
it wouldn't take many visits, 2, 3,
4 visits to really help someone establish a very good home
exercise program that they could do every day that would,
you know, not only go a long way towards supporting just general
health and functional activity, but towards managing pain.
So maybe if we ever come back, I'll get everybody
to raise their hand when I ask that question.
>> So her question was a son who is 27 months
after a spinal cord injury and his pain is like T2
to T6, where is his injury?
[ Inaudible Remark ]
>> Okay. So that's kind of around his--
[ Inaudible Remark ]
>> Yeah. So you know, if we spent some sort of--
time sort of trying to characterize it, you know,
it's chronic, it seems to be maybe more neuropathic related
to spinal cord injury, and again, what you have
to have is a physician who is willing
to try a variety of medications.
But sometimes they don't work.
And to never under estimate the importance of psychology
and good sleep habits in trying to decrease your fear,
because sometimes in the end,
that's gonna be all that you have left.
And the person who figures out chronic pain,
is gonna be millionaire.
The person who can figure out why the spinal cord
and the nervous system didn't shut off like it's supposed to,
that's a hot air of topics, and we wish we could figure it out.
>> Just some small thing to add to that is for most
of the patients that I see, their pain isn't gonna go away,
and that's one of the first messages we give people.
So then what, right?
So that's what we're dealing with, the then what.
So how do you manage the fact
that that pain is not gonna go away
and still have a good quality of life,
and it takes a team approach to help the person, but you know,
the person has to do some activities
on what to do with that.
[ Pause ]
>> The question was how long should you try anticonvulsants,
gabapentin, et cetera, just give him a chance to work.
>> That's right.
So you know, most people would say several weeks.
Clearly, 1 or 2 days is not gonna be enough.
And with gabapentin, every doctor is different.
I do it at night, start at night and slowly increase it.
Once you get up to about 900, 1200 milligrams at night
at one dose, in my experience, if you haven't seen anything,
nothing is happening, it's not gonna work, you know.
You know, other doctors take it all the way up to the max,
you know, 3600, maybe 4000 milligrams and try it up there
for a while before you come down.
So I'd say weeks.
It's not gonna be days.
And you wanna make sure-- like I said, that you're sort
of directing your care and you're thinking about what is it
that I hope to get from this; sleep aid, numbness
and tingling, benefits, maybe a mood benefit, because some
of that stuff, or all of it, the physician has no way
of knowing whether or not it was effective.
So completely different than a blood pressure medicine,
where you come in-- and I do all the monitoring, and I check it,
and I'm gonna decide whether this is working.
All of these medications for pain, really,
it's up to the patient.
The patient has to be able to say whether
or not it was helping.
How about you Dr. Burns?
Is that weeks or months for that--
>> Yeah. I think a trial of six
to eight weeks is probably plenty
on that sort of medication.
I wouldn't expect somebody would have a response
if they had it already at that point
and were already up to a maximal dose.
And people respond differently, some people respond better
to one medicine than another in the same class,
but I think it's very important
to assess the response someone has had and decide,
is it worth it, what sort
of side effects are we experiencing, keeping in mind
that side effects can be additive.
Some patients are on four or five different medicines
that are sedating to affect their bladder function,
to affect their spasticity, to affect their pain.
There's some preliminary research coming
out showing some major effects on cognition
from gabapentin and-- that needs to be--
that research needs to be extended a bit to say,
but it's something we really need to be cautious about.
We need to pull medications back for really not seeing a benefit,
instead of just adding a second and third and fourth one.
>> Questions about marijuana.
Sometimes, when patients ask about this, I'd like to say,
you know, my education about marijuana
in medical school was almost zero.
It's not something that I use or know any colleagues who do.
And so I don't-- I think Jim has [inaudible]
[ Inaudible Remark ]
[Laughter]
[ Inaudible Remark ]
>> Well, I think there's really not a whole lot of data
on how effective marijuana is.
There certainly is some research showing that it may impact one
of the opioid receptors, and certainly,
I hear [inaudible] reports all the time from patients
that it's the one thing that helps them
and probably not nearly as harmful as many
of the medications on the market that are being prescribed.
You know, it's illegal, but there--
it's not being enforced, at least in Seattle.
Smoking it is probably not the healthiest way
to ingest the drug, but people can consume it otherwise.
So you know, it's a judgment call I think, and I see more
and more patients using it, and I think we'll know more
in another ten years about how effective it could be.
>> One other quick thing about the marijuana and how
in chronic pain setting, we sort of tend to limp it in.
In addition, you know-- similar to opioids
which are great antianxiety medications, sometimes,
people can get into a situation where they have chronic pain,
where they become relatively dependent on their opioids
for their antianxiety effect.
And frequently, it's not something that's really
conscious to them.
And what happens frequently, because pain and anxiety is
so interrelated to a pain, is that people--
what we're ending up treating is really an untreated anxiety
problem, and it's getting treated with opioids,
or perhaps with marijuana.
And as a physician, that's what my concern would be,
is that we would get into a situation
where really what I'm treating is an anxiety problem
with the medication that's not the best anxiety treatment.
>> And so, that would be another sort of slippery slope for me,
recommending marijuana, which is a great antianxiety medicine
for patient who has chronic pain,
'cause that could be an issue.
[ Inaudible Remark ]
>> Yeah. So methadone is a long acting opioid.
The longer acting ones tend to give people less of a buzz
and sort of less addictive if you will.
However, when it comes to chronic pain,
the jury is still a little bit out on the advantage
of long acting opioids for chronic pain up until,
you know-- even last five years,
it's been the main say of treatment.
Now, there's more and more evidence
that ongoing chronic opioids actually can make people's
pain worse.
It can make it spread.
So methadone is a good choice
when you're picking a long acting one,
less sort of addictive.
The trend is now away from long acting opioids.
Other names would be Opana, MS Contin, Oxycontin,
all of those are long acting opioids.
And there is some evidence that for some people,
if you switch it up, one does happen to work better
than another, or sometimes, if somebody's been on one
for a long time, they switch it to a different one.
>> Its important to recognize that with the opioids though,
you-- within a short period of time, you develop a tolerance
to their effects, and then you have to increase the dose
to continue to get the same pain relief.
And people can end up with--
I mean, we've seen patients taking 2000 milligrams
of Oxycontin a day.
Horrible pain, you know,
they are totally tolerant to the medicine.
So I think it's not a medicine that ever is terribly effective.
We have tapered for chronic pain.
We've tapered literally thousands of people off
of opioids, and if you ask them how was your pain now
that your off it, they say,
"It's still there, but its not worst.
I feel so much better.
I mean, my mind is better, I'm not so moody
and grouchy, and I sleep better."
So generally, people feel better without it.
There's more recent evidence
that it creates Opioid-induced hyperalgesia,
so it actually makes pain worse, and that can be done
with modest doses, for as little as four weeks,
you can actually create a worse problem.
So I think it's not a great treatment
for pain that becomes chronic.
>> Other good medications that sort
of hit several things are the tricyclic antidepressants,
Amitriptyline, Nortriptyline, Desipramine, they help us sleep,
help with the pain, sometimes,
help with mood even though you're not really treating that.
Cymbalta is the new one.
That one's kind of hit or miss.
I've had a lot of people who've had like,
a lot of pain relief on it.
You know, their pain is just gone.
Other people, not really doing as much.
But normally, I start with Neurontin.
>> There are certainly, evidence that depression is greater
in people who are unemployed than people
who are employed, setting pain aside.
Certainly, it's my experience-- and I think there's some data
that supports this as well,
is that the more pain impacts your life.
So if you're not able to work, if you suffer a financial lose
because of [inaudible] the social interaction
and the work environment and the personal satisfaction
from doing it, that that's a factor that's gonna add
to depression.
So I think not working is a big factor.
>> I mean, I had to agree, you know, where I am at RIW,
it's almost exclusively injured worker.
So now, I don't have the injured non-workers seeing
so much of that.
But certainly, among injured workers, it does seem
that once people stop working, really,
everything can tend to implode.
[ Inaudible Remark ]
>> Yeah, I would say definitely.
[ Inaudible Remark ]
>> It's a distraction.
Once you have a financial control and power, now,
you don't have so much worry.
Frequently-- although people say-- like I just said,
someone today who said they can't turn their neck
when they're looking in the car.
But when they go to work, they're talking to people,
they're bending and reaching, that's way more therapy
than you'd ever get in two hours a week at PT.
So a lot of activity, socializing,
there's just almost no end to the list
of why getting back into life is better.
And when it changes your pain,
when psychological things change your pain, it's real pain,
the brain lights up on the MRI just like pain that's brand new
from an acute musculoskeletal when it's contributed
to by psychological factors.
So it's all real.
It's never imaginary.
>> Just to add to that.
It doesn't necessarily have to be work.
I mean, I think doing voluntary activity,
it's valuable having some social interaction or a hobby
that you love, or a craft activity that you like doing.
I mean, I think it's important to have something that you do
that gives your life meaning and ideally gets you out
or around other people.
>> So in the interest of time, I'd like to wrap
up the formal question and answer session right now,
thank everyone for some excellent questions,
and thank our three speakers tonight.
[ Applause]
[ Silence ]