Medical treatment for pain and implications for massage application

Chapter Four Medical treatment for pain and implications for massage application



Chapter contents



Introduction


The diagnostic process


The A to Z of pain


Medical treatment


Medications for pain management


Treatment not using surgery or medication



Introduction


Those experiencing pain usually seek help from a family medical practitioner. If the problem is not relieved by standard treatments, the patient may then be referred to a specialist such as an internist or neurologist. Additional referrals may be made to psychologists.


The massage therapist needs to understand the diagnostic process and target of various treatments so that the massage application can support specific medical treatment. When therapeutic massage is used in conjunction with typical medical treatments such as medication, supplements or herbs, surgery, manipulation, physical therapy, etc. it is necessary to evaluate the massage application so that it is supportive of medical intervention as well as taking into account potential risks for massage associated with treatment.



The diagnostic process


The process of identifying the cause of the symptoms related to pain includes typical assessment procedures such as history taking, physical assessment, specific assessment (X-ray, blood tests, strength and stability testing, etc.), and interpretation of the information gathered.



History taking


A physician’s detailed question and answer session with a patient can often produce enough information for a diagnosis. Many types of pain have clear-cut symptoms which fall into an easily recognizable pattern. Most physicians will also obtain a full medical history from the patient, inquiring about past trauma or surgery, occupation related strain, lifestyle behaviors, sleep habits, levels of emotional and physical stress, and the use of medications, both prescribed and over the counter. Typical health history questions used to diagnose pain include:



• Were you injured and, if yes, what was the nature of the injury?


• Do you experience radiating pain and the presence of any symptoms that suggest nerve problems such as:


– weakness

– numbness

– tingling or loss of function

– difficulty breathing

– dizziness, nausea, or vomiting

• How often do you experience pain?


• Where is the pain?


• How long does the pain last?


• When did you first develop pain?


• What factors make you feel better (relieving) or worse (exacerbating)?



Physical examination




• Observation includes: posture, gait, facial expression, willingness to move for examination, and ease of movement.


• Physical tests and palpation:


– Neuromuscular testing to determine whether there are any injuries to the pain area. These tests typically involve moving the body both passively and actively, to assess for strength, range of motion, and any loss of sensation.

– Assessment of the blood vessels, feeling the pulses to assess for briskness of upstroke and fullness, and the presence of any abnormal sounds.

– Soft tissue will be palpated for tender area, signs of inflammation (heat and edema), tissue texture changes, differences in temperature and dryness or excessive moisture, tremor (shaking) and muscle twitches, and changes in muscle and motor tone.


Diagnostic imaging



Plain film radiography (X-rays)


Plain X-rays are still the primary means of looking for trauma to bones involving the cervical spine. They have the advantages of low cost, wide availability, and good anatomic resolution. X-rays do not give a good image of soft tissue structures (muscles and ligaments).



Computed tomography (CT scan)


This painless, noninvasive technique produces cross-sectional images of tissues. CT scans offer far better tissue contrast resolution when compared with plain X-rays and are excellent for displaying bony architecture, although soft tissues are seen less well.


They are useful in assessing for complex fractures and dislocations, disk protrusions and disease of the joints of the vertebrae, and spinal stenosis (a narrowing of the space containing the spinal cord). CT scans produce X-ray images of the brain that show structures or variations in the density of different types of tissue.



Magnetic resonating imaging (MRI)


MRI is a noninvasive, painless imaging technique used to obtain images of bone and soft tissue. It uses magnetic fields and is based on detecting the effect of a strong magnetic field on hydrogen atoms contained in water. MRI scans use magnetic fields and radio waves to produce an image that provides information about the structure and biochemistry of the brain.


MRI cannot be used for people with implanted or other metallic foreign bodies not firmly fixed to bone but is reportedly safe with prosthetic joints and internal fixation devices. It is often preferred over myelography for the assessment of disk disease because it is noninvasive. Its principal disadvantages include cost and lack of availability.



Myelography (spinal cord imaging)


A water soluble contrast dye is injected into the epidural space via lumbar puncture and allowed to flow to different levels of the spinal cord. Plain X-rays, or more commonly CT scan, are then performed, to indirectly visualize structures outlined by the dye.


This technique is very sensitive at detecting disk disease, disk herniation, nerve entrapment, spinal stenosis, and tumors of the spinal cord. Side effects of the procedure include headache, dizziness, nausea, vomiting, and seizures.



Diskography


This involves the injection of radio-opaque dye into the center of an intervertebral disk (nucleus pulposus), using radiographic guidance, and may be used to determine disk disruptions.



Blood tests


Blood tests may be ordered to screen for thyroid disease, anemia, or infections which might cause pain.


Hopefully the diagnostic process will identify the cause of the pain and guide the treatment process. The massage therapist would utilize the information gathered during diagnosis as well as gather similar information themselves as they develop and implement an appropriate massage intervention. There are a variety of pain conditions. However, pain does not always neatly fit into a specific diagnosis and sometimes there is no identifiable reason at all making the pain experience so difficult to treat with traditional health care measures.



Box 4.1 National Institute of Neurological Disorders and Stroke


The mission of the National Institute of Neurological Disorders and Stroke is to reduce the burden of neurological disease – a burden borne by every age group, by every segment of society, by people all over the world.



The A to Z of pain


Hundreds of pain syndromes or disorders make up the spectrum of pain. There are the most benign, fleeting sensations of pain, such as a pin prick. There is the pain of childbirth, the pain of a heart attack, and the pain that sometimes follows amputation of a limb. There is also pain accompanying cancer and the pain that follows severe trauma, such as that associated with head and spinal cord injuries. A sampling of common pain syndromes follows, listed alphabetically.


Amputation refers to loss of a body part. Care includes managing wound, postoperative, and phantom limb sensation or pain. Abnormal sensations can be felt from the amputated body part which is no longer part of the body. These unusual ‘phantom limb’ sensations can vary from feelings of size, position, movement to actual feelings of heat, cold, itching and, or touch. Stump pain is specific to its location: at or near the amputation site. Unlike phantom pain, it occurs in the body part that actually exists, in the stump that remains. Stump pain has been commonly described as sharp, burning, shock-like, or super-sensitive to the skin region. Stump pain results from nerve damage in the stump region. As nerves heal from injury or surgery they may form abnormally sensitive regions, called neuromas, which fire abnormally, resulting in pain and skin sensitivity.


Arachnoiditis is a condition in which one of the three membranes covering the brain and spinal cord, called the arachnoid membrane, becomes inflamed. A number of causes, including infection or trauma, can result in inflammation of this membrane. Arachnoiditis can produce disabling, progressive, and even permanent pain.


Arthritis affects millions who suffer from arthritic conditions such as osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and gout. These disorders are characterized by joint pain in the extremities. Many other inflammatory diseases affect the body’s soft tissues, including tendonitis and bursitis.


Back pain has become the high price paid by our modern lifestyle and is a startlingly common cause of disability for many Americans, including both active and inactive people. Back pain that spreads to the leg is called sciatica and is a very common condition (see below). Another common type of back pain is associated with the discs of the spine, the soft, spongy padding between the vertebrae (bones) that form the spine. Discs protect the spine by absorbing shock, but they tend to degenerate over time and may sometimes rupture. Spondylolisthesis is a back condition that occurs when one vertebra extends over another, causing pressure on nerves and therefore pain. Also, damage to nerve roots is a serious condition – called radiculopathy – that can be extremely painful. Treatment for a damaged disc includes drugs such as painkillers, muscle relaxants, and steroids; exercise or rest, depending on the patient’s condition; adequate support, such as a brace or better mattress; and physical therapy. In some cases, surgery may be required to remove the damaged portion of the disc and return it to its previous condition, especially when it is pressing a nerve root. Surgical procedures include discectomy, laminectomy, or spinal fusion.


Burn pain can be profound and poses an extreme challenge to the medical community. First-degree burns are the least severe; with third-degree burns, the skin is lost. Depending on the injury, pain accompanying burns can be excruciating, and even after the wound has healed patients may have chronic pain at the burn site. For more on central pain syndrome, see ‘Trauma’ below.


Cancer pain can accompany the growth of a tumor, the treatment of cancer, or chronic problems related to cancer’s permanent effects on the body. Fortunately, most cancer pain can be treated to help minimize discomfort and stress to the patient.


Headaches affect millions of Americans. The three most common types of chronic headache are migraines, cluster headaches, and tension headaches. Each comes with its own telltale brand of pain:



• Migraines are characterized by throbbing pain and sometimes by other symptoms, such as nausea and visual disturbances. Migraines are more frequent in women than men. Stress can trigger a migraine headache, and migraines can also put the sufferer at risk for stroke.


• Cluster headaches are characterized by excruciating, piercing pain on one side of the head; they occur more frequently in men than women.


• Tension headaches are often described as a tight band around the head.


Head and facial pain can be agonizing, whether it results from dental problems or from disorders such as cranial neuralgia, in which one of the nerves in the face, head, or neck is inflamed. Another condition, trigeminal neuralgia (also called tic douloureux), affects the largest of the cranial nerves, and is characterized by a stabbing, shooting pain.


Lyme disease can cause severe neurological problems and pain if untreated. Those with chronic pain syndromes associated with Lyme disease may develop a heightened activation of the pain pathways, sensitizing them not just to one type of pain, but to multiple types of pain. This means that otherwise mild symptoms might be perceived as abnormally intense, problematic, or distressing for a patient with a history of Lyme disease, or for those with other pre-existing pain conditions like fibromyalgia.


Muscle pain can range from an aching muscle, spasm, or strain to the severe spasticity that accompanies paralysis. Another disabling syndrome is fibromyalgia, a disorder characterized by fatigue, stiffness, joint tenderness, and widespread muscle pain. Polymyositis, dermatomyositis, and inclusion body myositis are painful disorders characterized by muscle inflammation. They may be caused by infection or autoimmune dysfunction and are sometimes associated with connective tissue disorders, such as lupus and rheumatoid arthritis.


Myofascial pain syndromes affect sensitive areas known as trigger points, located within the body’s muscles. Myofascial pain syndromes are sometimes misdiagnosed and can be debilitating. Fibromyalgia is a type of myofascial pain syndrome.


Neuropathic pain is a type of pain that can result from injury to nerves, either in the peripheral or central nervous system. Neuropathic pain can occur in any part of the body and is frequently described as a hot, burning sensation, which can be devastating to the affected individual. It can result from diseases that affect nerves (such as diabetes) or from trauma, or, because chemotherapy drugs can affect nerves, it can be a consequence of cancer treatment. Among the many neuropathic pain conditions are diabetic neuropathy (which results from nerve damage secondary to vascular problems that occur with diabetes); reflex sympathetic dystrophy syndrome, which can follow injury; phantom limb and post amputation pain, which can result from the surgical removal of a limb; postherpetic neuralgia, which can occur after an outbreak of shingles; and central pain syndrome, which can result from trauma to the brain or spinal cord.


Pelvic pain or chronic pelvic pain refers to pain in the pelvic region (located between the navel and hips), lasting 6 months or longer. Chronic pelvic pain can be a symptom of another disease, or it can be designated as a condition in its own right. Spasms or tension of the pelvic floor muscles can lead to recurring pelvic pain as can long-term infection and pelvic congestion caused by enlarged, varicose-type veins. The condition is more common in females but does occur in males.


Reflex sympathetic dystrophy syndrome, or RSDS, is accompanied by burning pain and hypersensitivity to temperature. Often triggered by trauma or nerve damage, RSDS causes the skin of the affected area to become characteristically shiny. In recent years, RSDS has come to be called complex regional pain syndrome (CRPS); in the past it was often called causalgia.


Repetitive stress injuries are muscular conditions that result from repeated motions performed in the course of normal work or other daily activities. They include:



• writer’s cramp, which affects musicians, writers, and others


• compression or entrapment neuropathies, including carpal tunnel syndrome, caused by chronic overextension of the wrist


• tendonitis or tenosynovitis, affecting one or more tendons.


Sciatica is a painful condition caused by pressure on the sciatic nerve, the main nerve that branches off the spinal cord and continues down into the thighs, legs, ankles, and feet. Sciatica is characterized by pain in the buttocks and can be caused by a number of factors. Exertion, obesity, and poor posture can all cause pressure on the sciatic nerve. One common cause of sciatica is a herniated disc.


Shingles and other painful disorders affect the skin. Pain is a common symptom of many skin disorders, even the most common rashes. One of the most vexing neurological disorders is shingles or herpes zoster, an infection that often causes agonizing pain resistant to treatment. Prompt treatment with antiviral agents is important to arrest the infection, which, if prolonged, can result in an associated condition known as postherpetic neuralgia. Other painful disorders affecting the skin include:



• vasculitis, or inflammation of blood vessels


• other infections, including herpes simplex


• skin tumors and cysts


• tumors associated with neurofibromatosis, a neurogenetic disorder.


Spinal stenosis refers to a narrowing of the canal surrounding the spinal cord. The condition occurs naturally with aging. Spinal stenosis causes weakness in the legs and leg pain usually felt while the person is standing up and often relieved by sitting down.


Sports injuries are common. Sprains, strains, bruises, dislocations, and fractures are all well known words in the language of sports. Pain is another. In extreme cases, sports injuries can take the form of costly and painful spinal cord and head injuries, which cause severe suffering and disability.


Surgical pain may require regional or general anesthesia during the procedure and medications to control discomfort following the operation. Control of pain associated with surgery includes presurgical preparation and careful monitoring of the patient during and after the procedure.


Temporomandibular disorders are conditions in which the temporomandibular joint (the jaw) is damaged and/or the muscles used for chewing and talking become stressed, causing pain. The condition may be the result of a number of factors, such as an injury to the jaw or joint misalignment, and may give rise to a variety of symptoms, most commonly pain in the jaw, face, and/or neck muscles. Physicians reach a diagnosis by listening to the patient’s description of the symptoms and by performing a simple examination of the facial muscles and the temporomandibular joint.


Trauma can occur after injuries in the home, at the workplace, during sports activities, or on the road. Any of these injuries can result in severe disability and pain. Some patients who have had an injury to the spinal cord experience intense pain ranging from tingling to burning and, commonly, both. Such patients are sensitive to hot and cold temperatures and touch. For these individuals, a touch can be perceived as intense burning, indicating abnormal signals relayed to and from the brain. This condition is called central pain syndrome or, if the damage is in the thalamus (the brain’s center for processing bodily sensations), thalamic pain syndrome. It affects as many as 100 000 Americans with multiple sclerosis, Parkinson’s disease, amputated limbs, spinal cord injuries, and stroke. Their pain is severe and is extremely difficult to treat effectively. A variety of medications, including analgesics, antidepressants, and anticonvulsants, and electrical stimulation, are options available to central pain patients.


Vascular disease or injuries – such as vasculitis or inflammation of blood vessels, coronary artery disease, and circulatory problems – all have the potential to cause pain. Vascular pain affects millions of Americans and occurs when communication between blood vessels and nerves is interrupted. Ruptures, spasms, constriction, or obstruction of blood vessels, as well as a condition called ischemia in which blood supply to organs, tissues, or limbs is cut off, can also result in pain.


Vulvodynia is chronic pain of the vulva – the external female genital organs. Women living with this condition report burning, stinging, irritation, and rawness in the vulva area that lasts for at least 3 months or more with no evidence of other possible causes such as infection, including sexually transmitted diseases, or skin problems. The pain associated with vulvodynia can occur all the time or just once in a while. It may or may not be promoted by touch. For many women, the pain is often triggered when pressure is applied to the vulva area, either when inserting a tampon, engaging in sexual activity, undergoing pelvic examination, wearing tight-fitting pants, or during exercise, especially bicycling or horseback riding.


NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by, or an official position of, the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient’s medical history.


All NINDS-prepared information is in the public domain and may be freely copied. Credit to the NINDS or the NIH is appreciated.


See: http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#102993084Pain



Medical treatment


The primary therapeutic outcomes from appropriate pain management therapy are as follows:



1. Relief of pain intensity and duration of pain complaint.


2. Prevention of the conversion of persistent pain to chronic pain.


3. Prevention of suffering and disability associated with pain.


4. Prevention of psychological and socioeconomic consequences associated with inadequate pain management.


5. Control of side effects associated with pain management.


6. Optimization of the ability to perform activities of daily living.


Acceptable outcomes include:



• pain at rest <3 on pain scale


• pain with movement <5 on pain scale


• ability to have at least 6 hours of sleep uninterrupted by pain


• ability to work at a hobby (e.g. crafts, play cards, gardening) for 1 hour.


Optimal outcomes include:



• minimizing physical and emotional suffering


• decreasing the disability caused by pain


• eliminating excessive reliance on medication or inappropriate medical resources


• accelerating return to a wide array of normal activities, including personal, family, and work.


Treatment for pain depends on the cause and on the individual needs of the person. Complete pain relief is not always possible; it is important for patients, physicians and other health professionals including massage therapists to work together to find the best treatment plan. Understanding the mechanisms of action of medical treatment, especially medication, helps the massage therapist make logical decisions about when massage may either support the outcome of treatment, and therefore reduce the medication dosage, or in some cases replace the medication. The health care system needs to take the treatment of pain seriously and be proactive and encompassing in pain management methods, conventional as well as alternative, within an integrated health care delivery system. The conventional health care practitioners need to learn about and respect the beneficial application of massage, and massage therapists need to learn about and integrate into the traditional (conventional) health care system. The management of pain is not an either/or process but instead a cooperative partnership among all (Box 4.2).



Box 4.2 Australian and New Zealand College of Anaesthetists ABN 82 055 042 852. Faculty of Pain Medicine: Statement on patients’ rights to pain management and associated responsibilities



1 Introduction

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Jun 19, 2016 | Posted by in PAIN MEDICINE | Comments Off on Medical treatment for pain and implications for massage application

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