by Paige Bourne, DPT
Imagine your doctor walks into the room and asks you to describe your pain. The first words that come to mind are stabbing, exhausting, burning, nagging, and unbearable; all words that are frequently used to describe chronic pain. You have seen multiple physicians, had imaging completed, and tried physical therapy for a few weeks but always left appointments feeling worse. All of your testing has come back negative, and your medical team is unsure as to why you are continuing to have pain. These experiences would be challenging to any adult in chronic pain. Now, imagine you are a teenager or parent trying to navigate this situation.
Traditionally, the treatment of chronic pain has included medications, injections, and physical therapy. Each of these interventions may be appropriate. However, individuals affected by chronic pain often find themselves continuing to be limited by pain if treated with these interventions alone or individually. Many pain management programs are now recognizing the importance of a multidisciplinary approach to chronic pain management with a focus on patient education and improving function.
Chronic Pain in Children and Adolescents
What is the first image that comes to mind when you hear chronic pain? A middle-aged man with low back pain from an injury years ago? A woman with neck pain lasting months after a minor car accident? Probably not a teenager who is unable to bear weight through her right leg after a gymnastics injury a year ago or a 10-year-old with ongoing abdominal pain after a stomach virus last winter. In a pediatric chronic pain clinic, these are two fairly common referrals. Other diagnoses that are frequently seen include:
• Chronic and ongoing pain as a result of surgery or injury
• Complex regional pain syndrome (CRPS)
• Functional neurological symptom disorder (conversion disorder)
• Amplified musculoskeletal pain syndrome (AMPS)
• Hypermobility/Ehlers-Danlos syndrome (EDS)
• Chronic abdominal pain
• Chronic headaches/migraines
• Chronic fatigue syndrome
• Postural orthostatic tachycardia syndrome (POTS)
Individuals who are referred to a pain management clinic have often seen many providers who have ruled out a variety of diagnoses and injuries. It is important to recognize the long and often frustrating journey that has led a patient and his or her family to seek out help from a pain management clinic. As therapists, in order to best meet our patient’s needs, we must be well-versed in understanding the most up-to-date information about chronic pain.
Understanding Chronic Pain
Treating patients who are affected by chronic pain first requires medical providers to change their thoughts and knowledge about pain itself. Traditionally, pain is understood as a sign of injury or damage. It is more helpful to consider pain as an alarm system of the body. Pain signals are sent from the body to the brain as an indication of potential danger. It is then the brain’s responsibility to determine whether the perceived danger is real and, if so, what actions to take to keep you safe.
In this model, it is important to acknowledge the impact of external and internal influences on pain. These influential factors can include your location, who you are with, your beliefs about pain, and your prior experiences with pain. For example, a knee injury that occurs in a championship game is likely to be less painful than if the same injury occurred at work. Likewise, a parent involved in a car accident may not realize the degree of their own injuries until they have been able to check on their child’s safety. In each case, the context of the injury influences the individual’s pain intensity. The athlete is able to continue playing due to the importance of the game, and the parent’s brain prioritizes their child’s safety over their own.
In chronic pain, the danger signals essentially misfire. Things that would not normally cause pain, such as water from the shower or the compression of a sock/shoe, send signals to the brain that there is a threat to your body. When you consider pain in this way, it is easier to understand that a sock is not causing damage or injury and therefore the pain is a result of an overactive alarm system that needs to be rewired to function at a more appropriate level.
For clarification, this is not to say that chronic pain is “in your head,” because that is an inaccurate phrase heard frequently by individuals who are affected by chronic pain. It is, however, empowering to acknowledge that individuals are able to take control of some of the internal and external factors that influence pain. The members of a well-versed team of pain management providers are able to help patients address these factors.
A Multidisciplinary Approach
Pain is a multifaceted experience, and to truly address all aspects of pain the treating team should include a variety of providers working together. The providers may include a pain management physician, a physical or occupational therapist, a cognitive behavioral therapist, a psychiatrist, and a social worker. Each discipline is present to provide its specialized skills to help the patient return to functioning.
The role of physicians in a pain management programs varies from patient to patient. Some patients require further testing to rule out diagnoses other than chronic pain. Other patients will require injections, completed under sedation in the pediatric population, or medication management. Psychiatrists may also be involved in the patient’s care in order to help the patient manage the anxiety and depression that often accompany chronic pain. The goal of this clinic is to provide narcotic-free pain management to help children and adolescents return to functioning with their peers.
Physical and occupational therapies are also focused on functioning. Oftentimes patients with chronic pain have become used to a sedentary lifestyle. When movement is painful, it is difficult to find the motivation to move. Traditionally, we are taught to rest an injury in order to prevent further damage, but when pain signals continue long after an injury is healed, rest reinforces the brain’s perception that pain is indicative of danger. Physical and occupational therapists help to gradually increase a patient’s activity level and “retrain” the brain that movement is healthy and safe.
Mental health services are a critical component of pain management. The way we think about pain affects how we experience pain and therefore how we are able to overcome it to return to functioning. If you believe your pain is caused by a dangerous injury and it will never end, it is more difficult to improve. Patients work with a cognitive behavioral therapist to learn pain-coping skills, challenge long-held beliefs about pain, improve sleep, and help reintegrate into normal activities. A social worker may also be present to assist family members in navigating the complex world of chronic pain. It is often frustrating for parents to hear that there is no “quick fix” to addressing their child’s pain and, depending on a family’s location, it may be very difficult for parents to find the recommended care locally. Social workers can assist in overcoming these barriers.
Goals: Decreasing Pain or Increasing Function?
Frequently, by the time a family can locate a pediatric pain management program, the child who is affected by chronic pain has already begun to miss school or has transitioned to home and hospital schooling. The child perhaps is no longer socializing with friends or is unable to sleep at night due to pain. It is our natural instinct to rest and avoid activity when we are injured or in pain. However in the case of chronic pain, decreased activity levels reinforce the brain’s perception that the body is injured. This becomes a cycle. We don’t move when we are in pain but the human body is designed for movement, and deconditioning often leads to more discomfort and pain upon trying to return to a more active lifestyle.
In traditional therapies, goals may focus on decreasing pain and healing the tissues that are damaged or dysfunctional. However, in the case of chronic pain, the tissues are likely healed already. Therefore, it is important to address the decreased functioning and participation that patients with chronic pain experience. Goals typically revolve around gradual increases in activity and function. Small goals such as walking to the mailbox daily may grow to larger goals of walking for five minutes continuously. Over time, as patients increase their functional level, they may also experience a decrease in pain as they retrain their nervous system to perceive activity as normal and safe.
As healthcare providers, our training often teaches us to focus on specific impairments and dysfunctional body structures, and address the diagnoses we find through special tests and imaging. But where does that leave us and our patients when these assessment techniques are not enough? The most effective place to begin shifting the conversation in the right direction is with our patients and with other healthcare providers. Ensuring that we are understanding the most-up-to-date literature in pain science and being able to provide education in a patient-friendly manner ensures that our professions and our patients continue to move forward. RM
Paige Bourne, DPT, is a physical therapist in the Multidisciplinary Pain Rehabilitation Clinic and the International Center for Spinal Cord Injury at Kennedy Krieger Institute, Baltimore. She received her Doctorate of Physical Therapy from Emory University in 2013. She works in Kennedy Krieger’s outpatient therapy program treating individuals of all ages affected by pathologies of the spinal cord and pediatric patients experiencing chronic pain. For more information, contact [email protected].
Topicals Offer a Safer Route to Pain Relief
Affordable and easy to use, topical analgesics can provide temporary pain relief without the danger of prescription medicationsby Frank Long, MS, Editorial Director
Pain relievers that can be used without harmful side effects are taking center stage in the healthcare market as consumers grow increasingly alarmed about the potential for addiction and organ damage that accompany the use of some pain medications. Topical analgesics may offer a solution that can help some pain sufferers sidestep those problems; especially those affected by chronic pain symptoms associated with osteoarthritis.
Effective for Superficial Joints
Pain sufferers who look to topical analgesics as a tool to help manage symptoms will find two forms of these products available: prescription strength and over-the-counter products. Each type offers the desirable benefits of non-addictive and affordable pain relief that can be applied locally.
Prescription topicals are the more potent of the two types and can provide pain relief comparable to prescription oral analgesics while creating minimal adverse systemic effects.1 The literature surrounding the effectiveness of topicals in pain relief is mixed, so to investigate the efficacy of prescription topicals researchers conducted a review of the literature published in English-language journals.1 That review found strong evidence for topical analgesics formulated with diclofenac—a nonsteroidal anti-inflammatory drug (NSAID)—and topical ibuprofen in treating chronic joint-related conditions associated with osteoarthritis.1
Other evidence that points to the benefit that topical pain relievers can provide for chronic pain is outlined in a report from Harvard Medical School.2 In that report Rosalyn Nguyen, MD, notes that topical pain relievers can be effective in helping to relieve pain among superficial joints such as the feet, ankles, knees, elbows, and hands—areas where the source of pain is close to the surface.2 “In those areas the medication can penetrate closer to the joint,” Nguyen says.2
The possibilities of non-addicting and affordable relief are not the only benefits topical analgesics offer. Another advantage is that they are delivered and absorbed locally to treat pain symptoms. For topicals formulated with NSAIDs, this means the body does not become flooded with an additional medication. This may be especially important among individuals for whom NSAIDs cause stomach upset.
While topical NSAIDs offer distinct advantages over their orally-taken counterparts, some topicals still may be problematic for people who have a history of gastrointestinal bleeding. For this population, Nguyen notes, a topical NSAID would carry less risk than an oral formulation but she would still be reluctant to use an NSAID topical for a person whose medical history makes the drug risky to use.1
As an alternative to avoid the unwanted effects of stomach irritation and gastrointestinal bleeding, some patients may find effective temporary pain relief from non-prescription topical analgesics.
Counterirritants and Capsaicin
The market for non-prescription topical analgesics has many options that include products formulated with natural ingredients such as menthol, eucalyptus, and camphor oil that provide the sensation of hot or cold to mask pain symptoms.2,3 These products are easy to use and easy to access.
Many over-the-counter topicals include capsaicin in their formulas; a natural and odor-free ingredient that causes depolarization of the neurons and a temporary warming or burning sensation.3,4 Topical capsaicin has been found effective in treating the symptoms of osteoarthritis, but an uptick in local adverse effects has also been associated with its use.5 The pain-relieving mechanism of capsaicin works to overload the pain sensors in the area of skin where the topical is applied. Capsaicin shares similar pain-reducing benefits with counterirritants but is contraindicated for individuals who are allergic to hot peppers.2
The Arthritis Foundation notes that many studies have shown capsaicin to effectively decrease pain caused by osteoarthritis as well as rheumatoid arthritis and fibromyalgia.6 The effectiveness of capsaicin was also tested in a double-blind trial based at Case Western Reserve University, which found that after four weeks of treatment members of the osteoarthritis study sample had mean pain reductions of 33%.7 The authors of the study concluded that “…capsaicin cream is a safe and effective treatment for arthritis.”7
A cure for osteoarthritis has yet to materialize.8 Efforts to find an effective treatment for the condition continue to move ahead and include exciting research such as the development of stem cells that could become cartilage and be used to repair localized joint defects. In the here and now, however, there are strategies for managing the pain symptoms associated with this chronic disease that can provide relief without elevating the risk for adverse systemic effects. Topical analgesics can be part of those strategies and be used as a tool to help the 27 million Americans living with osteoarthritis manage their symptoms independently and improve their quality of life. RM
1. Argoff CE. Topical analgesics in the management of acute and chronic pain. Mayo Clin Proc. 2013;88(2):195-205.
2. Harvard Men’s Health Watch. Get rub-on relief for arthritis joint pain. Harvard Health Publishing. Available at https://www.health.harvard.edu/pain/get-rub-on-relief-for-arthritis-joint-pain. Accessed September 26, 2019.
3. Carey E. A Guide to the Best Pain Relief Creams for Arthritis. Healthline. Available at https://www.healthline.com/health/arthritis/creams. Accessed September 26, 2019.
4. Anand P, Bley K. Topical capsaicin for pain management: Therapeutic potential and mechanisms of action of the new high‐concentration capsaicin 8% patch. Br J Anaesth. 2011;107:490–502.
5. John M Eisenberg Center for Clinical Decisions and Communications Science. Analgesics for Osteoarthritis. 2012 Feb 15. In: Comparative Effectiveness Review Summary Guides for Clinicians [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2007. Available from: https://www.ncbi.nlm.nih.gov/books/NBK91428/
6. Arthritis Foundation. Supplement Guide: Capsaicin. Available at https://www.arthritis.org/living-with-arthritis/treatments/natural/supplements-herbs/guide/capsaicin.php. Accessed September 26, 2019.
7. Deal CL, Schnitzer TJ, Lipstein E, Siebold JR, Stevens RM, et al. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Thera. 1991;13(3):383–95.
8. Arthritis National Research Foundation. New Breakthrough Osteoarthritis Molecule. August 10, 2017. Available at https://curearthritis.org/breakthrough-osteoarthritis-molecule/. Accessed September 26, 2019.