Tag Archives: Pain Management

Dr. C’s Journal: Pain Without Treatable Cause

Pain is useful to survival, and therefore is evolutionarily conserved. There is a very rare syndrome with the congenital inability to experience pain that Is caused by mutations in the SCN9A gene, which codes for a sodium channel (Nav 1.7). Research on this channel has apparently produced some advances in pain medication, but not as much as expected.

Individuals with insensitivity to pain have many accidental injuries which can cause blindness, mutilations of the extremities, and other severe problems. Lack of ability to feel pain is serious handicap.

Pain is generally a useful red flag that warns us to stop the painful activity, or guides us into the doctors office; about half of all medical visits involve pain of some sort.

Considered as a symptom, pain helps guide the physician into the proper diagnosis and treatment. Normally the pain stops when the condition that produced it is corrected. Pain sometimes outlives it’s usefulness, however, and becomes a major problem on his own. The most obvious condition is “phantom limb pain”. Most people who have had an amputation will continue to experience pain in the extremity that is no longer present.

Back pain that has no valid surgical treatment will sometimes drive individuals to surgeons who will operate on them unsuccessfully. A second opinion, preferably by a medical doctor like a neurologist, is always a good idea with back pain without sciatica, numbness, or other localizing symptom to tell the doctor where to operate.

Neuropathic pain is another conundrum. I know of an individual who was bitten on the foot by a dog, and continued to have severe foot pain for many years after the original injury healed.

All pain is interpreted in the brain, and continuing circles of central nerve activation is the leading theory of phantom limb and neuropathic pain. Pain is not objectively measurable; there is no meter that you can attach to the patient and find how much pain they are actually having. The doctor must assume that the patient has the pain they are describing, and ask the patient to rate it on a 0 to 10 scale, describe its severity, time course, quality, and any factors that will make it better or worse. Most often this produces an avenue to treatment, but sometimes not.

A few decades ago, busy doctors would label the pain that they could not diagnose as “psychological”, and dismiss the patient to suffer in silence. Much of the pain, however, was very real to the patients, who joined in patient advocacy groups and produced a political backlash which induced doctors to overtreat the pain, often with opioids.

The over-prescribing  doctors, and unscrupulous drug companies led to the flooding of the market with opioid medication, leading to the opioid crisis that is now being addressed. There is difficulty in making scientific progress on an adversary that cannot be measured properly.

Some doctors, usually anesthesiologists, specialize in treating the chronic, severe pain that standard medical practice has been unable to diagnose or alleviate.

They may use nerve blocks, antidepressants and combinations of different pain medication. Judicious propofol has been used also not only for chronic undiagnosed pain, but also depression.

My wife had a pain problem which responded to a combination of two simple medications, motrin and acetaminophen. The suggested overall approach is to get the best medical care available to diagnose the cause of the pain, and ask for a pain management referral if a solution is not found.

More information can be found in the appended Wikipedia article.

—Dr. C.

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Opioids: Postsurgical Pain Management (Mayo Clinic)

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Dr. C’s Journal: Rib Fractures & Cracks

Broken ribs are fairly common, and if you’ve ever had one, you don’t want another. A rib fracture causes lots of pain, which is worse when you take a deep breath, press on the area, or twist your body.

The pain on taking a deep breath creates a catch 22, because taking a deep breath every few minutes is a good idea, if not essential to keep your lungs open and functioning, yet you don’t want to do it because it hurts a lot.

A rib fracture is usually caused buy a direct trauma to the chest from a fall, automobile accident, or sport.

Repetitive minor injury can also cause rib fractures. This can occur when you escalate your exercise to rapidly and stress a bone, like in the foot, or when you have a chronic cough that’s violent and continuous, which could cause a stress rib fracture.

Interestingly, children age 10-12 can stress their chests enough with a heavy backpack to cause a problem where are the ribs meet the breastbone, called the costochondral junction.

Any severe chest pain raises concern for heart disease, and the fact that it is worsened by pressure on a certain area, or by taking a deep breath can be reassuring. The doctor should be contacted depending on the severity of the pain and how certain you are it is related to trauma.

Of course, if the pain in the middle of the chest, feels like pressure or radiates, You would be foolish not to go to emergency room. The treatment for a rib fracture no longer includes taping the chest, but rather continuing to take occasional deep breaths and use medication if needed for pain.

Of course you need a doctor’s diagnosis in order to continue doing this. If the Fracture was due to a fall, you should definitely educate yourself on how to avoid falls in the future. In July 2020, I posted an article on falls that you could access by typing “falls” into the question box.

There are a variety of things you can do to prevent falling: remove clutter in the house, strengthen your muscles, check your eyesight, hearing, proprioception, and balance. There are even programs for teaching the elderly HOW to fall.

Please refer to the mayo clinic article on broken ribs for more detail.

—Dr. C.

Mayo Clinic Article

Intensive Care Views: ‘Pain & Airway Management’

Pain Management in the Intensive Care Unit.

Institution: Department of Anesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin & Massachusetts General Hospital, Harvard Medical School, Boston