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What is a physiatrist?

  Physiatrists (fizz eye ah trists) practice physiatry, as pediatricians practice pediatrics.  Physiatry is short for Physical Medicine and Rehabilitation.  “Physical Medicine” includes physical treatments such as electrical, heat, cold, or traction modalities, and bracing or artificial body part (prosthetic) appliances.  “Rehabilitation” includes exercise, and task and/or mental training to minimize ongoing problems or re-injury.  For example, after a back injury, physical treatments may decrease pain and spasm, while rehab efforts may redevelop flexibility and strength, and supports and education may help modify a patient’s activities to decrease the chance of re-injury.

You say you’re a pain specialist.  Do you treat any kind of pain?

  I’m a physiatrist with a subspecialty in pain medicine.  I treat patients with sub-acute (lasting over a 2 or 3 weeks) to chronic (over 3 months) musculoskeletal or nerve pain problems, especially if the pain is stubborn, or compromising a patient’s lifestyle.  Typical problems would include back or neck pain, pain in the extremities, and headache.  For new chest or neck pain or distress, or new or severe headaches, you should instead call to 911.  However, if after appropriate initial care these or other pains persist, a pain specialist could be of assistance. 

How would you treat my back and hip pain?

  History, exam, and testing as needed help to establish a definitive or “working” diagnosis.  Initial treatment usually includes education about posture, and which activities to avoid.  Also, exercises to improve flexibility and strength.  Meds, electric stim, or other modalities may be tailored to the type of pain you have.  If the pain is severe, or fails to improve with conservative treatment, consider “CIA” – chiropractic, injections, or acupuncture.  I perform injections, but can send you to good doctors for the other two.  And, if appropriate, to surgical consultation (early if needed, but after initial care in other cases). 

What is nerve pain?

  Normal peripheral (not brain or spinal cord) nerves are sensitive only at nerve endings and the ganglia (groups) of nerve cell bodies.  After peripheral nerve injury, permanent changes in the “wiring” and chemistry in the nerve, the ganglia, and the receiving spinal cord and brain may occur.  This leads to burning or sharp nerve “neuropathic” pain, either continuously or with nerve irritation.  Later, other normal body regions supplied by these nerve regions may also become sensitive.  A finger injury can therefore lead to eventual shoulder blade soreness.  It’s like having a short circuit in the nerves.  For treatments, stay tuned. 

How do you treat nerve pain?

  We reviewed nerve (“neuropathic”) pain last week.  If you develop increasing burning or sharp pain and swelling after an injury or surgery, see a doctor early and ask about oral steroids, injections, or acupuncture.  Gabapentin–type meds for sharp pain, clonidine or tricyclic meds for burning, and anti-inflammatories are usually preferable to opioid meds like codeine, Vicodin-types, or Oxycontin-types for neuropathic pain.  Consider Injections, E-stim, or Acupuncture.  Maintain flexibility and strength in the involved body regions, or you could get permanent loss of strength or movement, and increased pain.  Pain counseling may also help.   

I had knee surgery.  Now there’s sharp pain and swelling from the knee down.  Did my surgeon blow it?

  Almost any traumatic event, if at the site of even a very small nerve, can partially injure that nerve, with subsequent neuropathic pain. Even a perfect surgery, or a needle puncture, or bashing your funny bone can traumatize a nerve, and start a nerve pain problem.  Some people are less lucky, in response to these insults, than others, for unknown reasons.  Onset of increasing swelling or burning or sharp pain can often be reversed with early oral steroids, or nerve blocks.  Get early help from your doctor or a pain specialist to try to stop the progression.  

What are narcotics? 

  “Narcotics” loosely describes medications that make you drowsy, confused, slow, and less responsive.  These include sleepers, or sedatives like barbiturates.  “Opioids” specifically describes opium derived naturally from the opium poppy flower, or its natural or synthetic brethren.  These include the short acting and thus more habit forming codeine, hydrocodone, and oxycodone.  Long acting opioids like long acting morphines or oxycodone pills, the fentanyl skin patch, or methadone pills are usually less habit forming.  Atypical opioids include Ultram (tramadol) or Stadol.  Opioids work better for pain that is not sharp or burning. 

How do I know if I’m becoming addicted to pain pills?  How long can I take the pills before I become addicted?

  People become ‘physically dependent’ on opioids (discussed last week) if they take them steadily, so that if the drug is suddenly stopped, changes in heart rate, sweats, and other body changes occur.  ‘Addiction’ refers instead to achieving not a bodily, but a psychological dependence which can be more long-lasting.  Few pain patients become addicted to opioid pain medication.  Some people are more prone to addiction, and different people may succumb to different types of addictions.  Addiction may unfortunately come quickly.  Fast-onset opioids like heroin, Percodan, and Vicodin-types are quicker to set the hook. 

Why are some opioid pain medication less habit forming than others?

  Short acting (and faster onset) Opioids like Vicodin, Percodan, or codeine may feel good emotionally, and some patients are probably taking them for more than just pain, and instead for dealing with stress, anxiety, or depression.  In contrast, the longer acting opioids discussed previously (like methadone or long acting morphine) comparatively don’t have the ‘rock and roll’ emotional release-effects.  If the short acting opioids help your pain, watch out, as you may be prone to addiction, and using the medication for the wrong reason.  If so, stress medication, or antidepressants plus counseling may be safer and more effective for you.

My neurologist took away my Fioricet and Vicodin, and now my migraine is even worse.  Why doesn’t he care about my pain?

  Fioricet is habit-forming, and not a modern treatment for chronic headache.  Vicodin and Fioricet may in the long run make headaches more frequent, long-lasting, and severe.  Some doctors suddenly withdraw headache medication to see how the symptoms level out after a few weeks, but I prefer a more gradual approach.  Sometimes stopping the medication for awhile may at least make it easier to diagnose the underlying headache, as tension headaches may improve after prolonged med stoppage.  If your headache is chronic, it may be more muscle tension than migraine anyway. 

What kind of headache do I have?

  It matters who you talk to, and when.  Ten years ago ‘vascular’ headache was a common diagnosis, but is now less in favor.  Physiatrists like me probably overestimate the neck as a source of pain referred to the head, but many neurologist-led headache conferences completely ignore the neck as a source of headaches.  Tension/stress/depressive headaches are prolonged and often on both sides, not associated with pre-headache or visual symptoms.  Clusters are one-sided, into the eye, kicked off by alcohol, make you a bit crazy, and are shorter in duration than migraines, during which you’re instead more likely to lay low, and avoid the light.

I told my doctor about my fibromyalgia, but now he thinks I’m nuts.  And he won’t treat it.  But it’s common and I know I’ve got it.  So why can’t I get help?

  Many doctors feel that the only people more crazy than fibromyalgia patients are the doctors who are willing to treat them.  I’m not an expert, but this seems a diagnosis with vague findings, without obvious tests documentation, and without specific treatments.  So treatment is difficult and thankless for both patient and doctor.  More specific methods of diagnosis and treatment will probably become available.  Remember, many multiple sclerosis patients were diagnosed with psychiatric problems before the final neurological diagnosis was made.  Still, fibromyalgia treatment is a huge uncontrolled internet industry, so be careful where you put your time and money.

Last week you made a cheap shot about my fibromyalgia.  So what specifically am I supposed to do about it?

  Sorry.  A practical approach to generalized (all over the body, not just in one region) muscle tension and pain looks for underlying joint or nerve problems that can be identified, and individually treated.  However, overall flexibility and gentle intermittent conditioning exercises must go on, after instruction by therapists or doctors, with creative additions and effort by the patient or the body will further decondition, tense up, and become more susceptible to re-injury.  Psychological education and exercises are good for a global approach, and diet and weight must improve, while smoking must stop.  Sound tough?  It’s mostly your hard effort, if you are to achieve success.

Will my pain ever go away?

  Persistent sharp or burning pain may not resolve, and may signify a malfunctioning nerve system.  It will likely improve somewhat with time and treatment.  If it stops, you’ll have an increased chance of re-occurrence compared to your pre-injury status.  Stretching and conditioning all tissues including muscle will usually eventually help, but must be done more gradually than for pain-free persons.  Passive treatments like pills, E-stim, massage, acupuncture, injections, and mobilization may make it easier to perform exercises, but on their own are of limited long-term benefit.

I got hurt at work, and my treatments are denied.  I still can’t work, my buddies think I’m faking it, and my wife doesn’t want me around the house.  What should I do?

  First, thank our governor.  Next, see if your doctor’s medical records adequately support the treatment desired.  Then call your adjustor to review the report.  If this fails, call the Division of Work Comp. information / assistance officer at (800) 736-7401, to review your options.  Above all, stay active.  Find appropriate modified work, with a new or old employer, even if a volunteer charity or service job.  Go to voc rehab for retraining if available.  Go to school on your own, to improve your English or computer skills, or for a specific goal.  The longer you couch it, the more likely you’ll end up disabled for life. 

What about Chiropractors?  And Acupuncture?  Are they quacks?  They sound less scary than your injections.

  I believe that chiropractic can help, especially in the early stages of reversible spine dysfunction.  I would not myself submit to aggressive manipulation on a continuing basis. I believe that chiropractic can help, especially in the early stages of reversible spine dysfunction.  I would not myself submit to aggressive manipulation on a continuing basis.  Chiropractors do more than just manipulate, though.  Acupuncture is based on non-Western philosophy, and is difficult for me to understand, but it seems to help more with conditions involving burning or sharp pain.  Both acupuncture needling and chiropractic manipulation are, like pills, injections, and surgery, passive treatment techniques that in general don’t build up your body and behavior to diminish further stress and injury.  We’ll cover more active treatments next week.

OK, after last week you said you’d talk about more active treatments for pain, instead of pills, injections, surgery, manipulation and acupuncture.

  Right.  Active efforts mean what you do for yourself, rather than just passively expecting someone else to solve your problems.  For example, losing weight, improving diet, and stopping smoking may help decrease stress and improve circulation and healing.  Avoiding aggravating postures or activities may prevent re-injury, as may safe stretching and conditioning exercises.  You may initially have to physically and mentally slow down to allow better preparation to do tasks more carefully.  Doctors don’t make as much money when teaching these concepts as they do performing passive treatments.  So research active treatments on your own, starting with our website.

Another pain doctor sent me to a pain psychologist.  Does he think my pain is in my head?

  Actually, your pain is in your head.  Sensation nerve fibers in your feet, for example, are stimulated and then send simple signals that trigger more complex signal relationships in the spinal cord, and then especially in the brain.  Complex brain nerve networks ignited by the outside stimulation coincide (in experiments) with the experience of pain.  Your own personal emotional history, and your current mental focus and mood will affect how much the pain disturbs your ability to function and concentrate on your life.  Therefore, counseling on how to live with the pain is often mandatory, to obtain your best performance. 

Why won’t my doctor give me more pain medicine?  She says I might get addicted.

  Different Doctors will have a variety of opinions on the type and quantity of appropriate pain medications, for a certain patient.  Doctor’s opinions have been influenced by their training, immediate friends and colleagues, and the problems they may have had with previous patients.  Tell your doctor about the problems in your life caused by the pain, and ask how he or she can help.  You can also get a second opinion with a pain specialist.  The amount of meds you get should depend on whether they help you to be more active and productive, not just on your sense of relief.   

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possible individualized pain treatment, for their particular problems."