JERRY V. MARLIN, M.D. F.A.C.S.  NEUROLOGICAL SURGERY

 

 

 

 


Jerry V. Marlin, M.D., P.A.


Neurological Surgery



8220 Walnut Hill, Suite 604



Dallas, Texas 75231



(214)363-2587



FAX (214)363-6996



Web Site: http:\\drjerrymarlin.com





PAIN AND SUFFERING





BIOETHICS







Physicians daily deal with patients who experience pain and are suffering from the effects of their disease, illness or injury. What is the best approach to treating your patients' painful condition? The first step in any approach is to develop a strong, caring patient-physician relationship. There is no singular approach that can be utilized. Each patient has individual and often multi-factorial problems that have to be dealt with. The length of time required for the treatment of a patient will depend on the disease state. However the duration of the painful effects of the disease, illness or injury may last longer than expected by either the patient or the physician. Hopefully, this lecture on pain management will improve our ability to care for patients who are in pain or are suffering.




Specifically I would like to address certain issues. The first would be to define "pain". The second is to look into the question of whether pain and suffering symptoms commonly are identified by healthcare providers and are effectively treated. Also, what are the effects of pain on the patient's health or their relationship to their family and friends? In addition, the question then arises of how can I best inform my patient about their painful condition? At this point, conferences on pain and suffering are important because our patients want relief from their pain. Society has also placed an increased emphasis on the relief of pain and suffering. Presbyterian Hospital of Dallas instituted a Bioethics survey. The survey has revealed a need to increase the awareness of the problems associated with the diagnosis and treatment of pain through education. Many recent ethical journal articles and lectures have discussed the lack of adequate pain relief provided by physicians. Pain control and management have become commonplace articles in newspapers. In The Wall Street Journal, August 1998, comments were made related to New York state's actions to help remove the red tape that doctors encounter when prescribing pain medication. In the article, a quote from the The Journal of American Medical Association, May 20, stating "Not to relieve pain optimally is tantamount to moral and legal malpractice." In New York state, the definition of an addict was changed. No longer is this "anyone who habitually using a narcotic drug". The definition changed to describe a person who "unlawfully uses a controlled substance". The New York state political system has responded to complex problems such as intractable pain, especially in those individuals who are severely ill.




Pain can be defined in many ways. Stedman's Medical Dictionary states that pain is "an unpleasant sensation associated with actual or potential tissue damage, and mediated by specific nerve fibers to the brain where its conscious appreciation may be modified by various factors." The Macmillan Dictionary states "unpleasant physical sensation resulting  





Page 2


PAIN AND SUFFERING


September 24, 1998


from or accompanying injury, illness or other physical disorder. A second definition is applied as "emotional distress or suffering; anxiety; grief." One author stated "Pain is a subjective experience. Most efforts to measure and understand it are woefully inadequate." Another stated "Human pain is a multidimensional experience".


The Bioethics survey results found that there were three major impediments for effective ethical decision-making for the critically ill and terminally ill patients. The first is fear of legal action. The second is poor communication with patients and their families. The third was a lack of knowledge of policies and procedures related to advanced directives and the law. With regards to end of life issues, the ethics survey pointed out the following. 50%percent of those surveyed believe that too little pain medication was prescribed when caring for a dying patient. However 90 % asserted that we can effectively manage pain in the terminally ill patient. 64% also responded that the terminally ill patient's spiritual needs are given inadequate attention. 43 % of those surveyed felt that financial pressures to not reduce the quality of care. When discussing the concerns of inadequate pain medication, the survey indicated that 29 % of physicians strongly agreed that clinicians give inadequate pain medication, most out of fear of hastening a patient's death. 46 % of nurses strongly agreed with this statement where 25 % of clergy and other individuals, such as social workers, agreed with this statement.


Hopefully at this point I have begun to increase your interest in pain management and treatment. If I have accomplished an increased awareness then indeed my task is nearly completed. However I would like to now define the three types of pain..


Acute pain is the immediate effect of a noxious stimuli causing the individual to search for the cause and eliminate the stimulus from their environment. Acute pain can be related to a new event or an exacerbation or a recurrence of a clinical condition with long intervals of intervening remission. Narcotics usually satisfactorily reduce or alleviate acute pain.



Chronic pain is defined differently. Chronic pain may be defined as a significant pain that persists more than a few weeks for which no treatment is readily available to eliminate the underlying problem. There are authors who use different time measurements before which chronic pain would be diagnosed. Overall, chronic pain may be caused by a malignant or a benign disease or illness. Chronic pain is not defined as a malignant pain or a benign pain.




Page 3


PAIN AND SUFFERING


September 24, 1998


Chronic pain still begins from tissue damage related to illness, injury or surgery. The persistence of the pain may be due to a lack of return of normal tissue function. Neuropathic pain from damaged nerve fibers or persistent muscle spasm are two examples of conditions in which there may be lack of return of normal tissue function. Overall, chronic pain outlasts its biological function. Pain is present to make the individual aware of a health problem, whether internally or externally applied. Chronic pain, indeed, can be due to benign conditions such as osteoarthritis or a herniated lumbar disc. This type of pain can cause significant impairment in an individual's normal daily activities or their ability to work or cause unhappiness. The psychiatric effects of chronic pain are difficult to diagnose and vary between individuals. Often, patients who have had a pre-pain excellent ability to adjust to life can still develop psychiatric problems. Those patients with a pre-existing psychiatric problem can exaggerate their pain or use their pain to their own benefit such as to direct attention to themselves in a conscious or in an unconscious manner.


The management of chronic pain begins with a complete history and physical examination. The physician needs to collect all objective clinical testing data. The physician tries to identify objective physical or mechanical factors which could respond to direct corrective treatment. Further management is directed toward rehabilitation of the individual with emphasis on returning the individual to an independent and active lifestyle. Those factors which interfere with rehabilitation are sought. A routine reassessment of the goals and the outcome of treatment remains imperative. The psychological and social impacts of the patient's pain require an assessment. This type of approach can take a considerable amount of time and effort by the physician. Time constraints and clinical information overload may affect the physician dealing with these patients.


How can a physician effectively organize the enormous quantity of information related to a patient with chronic pain. In my practice, these individuals have seen multiple physicians and have huge stacks of paper documents related to their evaluation. They also arrive with stacks of x-rays all taken in order to identify a structural lesion causing their pain. I find that the use of an electronic medical record is invaluable in organizing this information. I and my staff often have to play the role of a detective in calling physicians and hospitals, searching for more information and obtaining other reports that may have not been brought to me by the patient, for whatever reason. Once the information is complied, I can often sit down at the computer and re-evaluate my thoughts and impressions about the patients' condition.



Page 4


PAIN AND SUFFERING


September 24, 1998


Being able to instantly review all notes and lab tests and full radiological reports and the MRI or CT or X-ray images in an organized fashion at home or in the office has become invaluable. Especially when answering telephone calls from the referring physician or patient months later, having any and all data at my fingertip is a time saving tool. Being able to recall the patients' history has been an extremely useful method of maintaining and improving upon the patient-physician relationship.


Many of the biomedical tests that are performed are quite subjective because they involve human interpretation. Examples of specific examinations are those that are performed by therapists or physicians trying to determine the physical performance and capabilities of an individual. Physical performance testing such as strength testing, lifting capacity and spine range of motion can be affected by the motivation of the patient but as well as cognitive factors. Repeating tests at least twice on separate occasions increases the validity of these testing methods. Physical performance testing will also vary by age group and by pre-existing neurological deficits or fatigue or handicaps. Interpretation often varies considerably among examiners when they evaluate the nature, the extent and the importance of physical pathology. There is no single system available to rate the relative value of an x-ray compared to the physical exam in the office compared to the answers obtained on history taking. What value does a CBC or a urinalysis have in an individual with chronic back pain? What value should be placed on a post-myelogram CT scan image of an area of abnormality in the spinal column? Because of these factors, the quantification of biomedical testing results in chronic pain evaluation and the correlation with the patient's complaints or perception of pain is quite complicated. The interpretation of this enormous clinical data will vary among physicians who are specifically trained to deal with chronic pain.



The evaluation of a chronic pain patient's behavior over time may be quite useful. The question arises, where should this patient's behavior be viewed? At their home? In their workplace? In a doctor's office? In a physical therapist's clinic? When should the individual's behavior be viewed? When doctors are present or family members? Perhaps the patient's activity should be video taped during relaxation time or when they are working on the job. Should they be evaluated on and/or off medication? Who watches these individuals? Certainly office personnel or observers who are specifically trained would be best, but family members can also see and perceive, especially over the time, the effects of their behavior. Many insurance companies now send me video tapes of Workman's Compensation carrier related patients to determine whether this affects my clinical decisions and judgement of their functional capacity. Viewing patients with chronic pain from trigeminal neuralgia or headaches may not be useful.



Page 5


PAIN AND SUFFERING


September 24, 1998


Behavioral evaluation and video imaging may be helpful with a patient who suffers from arthritis or back pain. Their habits may be altered improving their conditions with such insight into their daily activities.


I find in my practice that pain scales are quite useful for me to help identify the patient's perception of pain. A Pain Intensity Number Scale from zero to ten has been useful. A Visual Analog Scale such as drawing on a 10 cm. thermometer with 1 cm increments may be useful after the patient fills in their level of pain. I have always wanted a verbal description scale. I ask the patient to use the same words on each exam such as "none, slight, moderate, severe or the worst pain possible." Physicians may use a Faces Pain Scale. This scale uses an artist's drawing of a painful appearing facial feature with a number reference of zero to six.. The patient can circle the drawing that fits most with their perception of pain. I use these scales as a reference guide to obtain information such as average daily pain or pain during a selected activity. I also find that they are useful to determine pain levels during or after specific treatments.


A third and distinct type of pain is cancer pain. Cancer pain, again, arises from tissue damage due to malignancy or the treatment of the malignancy. Chronic pain due to cancer generally means persistent, significant pain for six months. The same psychological factors that magnify chronic pain of a benign origin require evaluation assessment and management. Depression or regression such as to a child-like state, anxiety and intolerance to stress are often present. The use of narcotics, however, differs when treating patients with cancer pain than those individuals that have chronic pain of a benign origin. Narcotic doses are routinely increased in patients with cancer pain. An analgesic ladder approach is often referred to in pharmacology literature. Beginning with simple non-narcotic analgesics, then advance to or add N.S.A.I.D. then add adjuvant analgesics ( steroids, biphosphonates, local anesthetics ) and add or use narcotic analgesics. Recurring and continual tissue damage require adequate doses of analgesics.


However chronic pain and the use of narcotics need discussion. Tolerance can develop with the use of narcotics. Narcotics administered chronically can suppress the production of natural endorphins. Without this natural resource for pain control, the perception of pain will often intensity. Tolerance develops and less analgesia from the narcotic occurs. Soon a dependence on the medication and quick return of withdrawal symptoms are seen. When dependence and withdrawal symptoms occur, the pain perception intensifies. Depression results from chronic narcotic use frequently. Narcotics dull motivation and add a sense of fatigue or reduced energy levels in the patient.



Page 6


PAIN AND SUFFERING


September 24, 1998


This kind of impaired motivation and fatigue adversely affects their rehabilitation. Still, these individuals need narcotics. Morphine and opiates are useful because they act on specific MU receptor sites in the brain.


MU receptor sites are seen in several areas including the reticular formation, hypothalamus, medial-dorsal thalamic nuclei, septal nuclei, periaqueductal gray matter, amygdala, frontal lobes and corpus striatum. MU receptors are seen especially in the dorsal horns of the spinal cord and the substantia gelatinosa of the spinal cord as well as along the spinal thalamic and spinal reticular tracts. Morphine reduces the release of substance P from primary afferent nerve fibers. Morphine also reduces the response of dorsal horn neurons to painful stimuli. The MU receptors most likely are going to be looked at very closely in the upcoming years. Recent studies suggest that a single nucleotide polymorphism (or SNP) in the coding region of the MU receptor gene position 118 varies between races and individuals. The addictive effects of narcotics like heroin may be explained because of these coding differences. Beta endorphins may have a different pain relief potential than natural endorphins. This genetic alteration may help explain differences in the addictive potential between individuals. Morphine still remains an excellent drug for pain control. Morphine can be taken orally or given by intravenous or intramuscular injection. Long-acting oral morphine such as MS Contin may be best used on a continual basis instead of on a prn basis for chronic cancer pain management. Recent studies at M. D. Anderson Hospital in Houston suggests that topical Fentanyl or Duragesic gave the patient a better satisfaction with their pain treatment and a lower impact and frequency of side effects. The reduction of the gastrointestinal side effects was probably due to the method of absorption. The degree of pain relief and the ability to sleep adequately were not significantly different, however, between the oral and topical analgesics.


Overall, in chronic pain control, the physicians and the patients must interact together. The physician's role would be to provide adequate pain relief. The physician needs to provide insight into the source and causative factors of pain. Treatment needs to be through individual specific pain management programs. The patient needs knowledge and understanding of their pain through education. The physician needs to reassess the treatment recommended for pain control. The patient, however, needs to desire and participate actively in a strong patient-physician relationship. Honesty and open communication about their health condition remain paramount. The patient needs to show evidence that they are striving to improve. They need a prove a willingness to return to full social function. They need to show the physician that they are properly using their narcotic medication as prescribed. The patient needs to actively participate in their rehabilitation. 



Page 7


PAIN AND SUFFERING


September 24, 1998


As a neurosurgeon, I have been amazed by the huge increase in information related to the functional anatomy and physiology of pain. From the peripheral receptors to the cerebral cortex, pain pathways are organized to maintain the specific type and location of pain. These pathways are meant also to integrate all sensory afferent stimuli. The control of pain requires an understanding of the ascending and descending pathways and the interneuron circuitry and the neurochemical reactions at many levels in the pain pathways. Understanding chemicals such as substance P, somatostatin, endorphins and enkephalins and their modulation are becoming increasingly important. Stimulate a peripheral nerve-free ending or receptor and the nerve impulse is carried to the central nervous system by a nociceptive afferent fiber. There are mechanical nociceptors, thermal nociceptors, combined type mechanical thermal nociceptors and free nerve endings, all which have different thresholds for response to a noxious mechanical stimuli, chemical or heat. The deeper somatic tissues are often supplied by free nerve endings. Fibers are often interposed between muscle fibers and blood vessel walls as well as into fascia and tendons. Periosteal nociceptive receptor plexuses are found. In cancellous bone, A-delta and C- fibers surround the blood vessels. Chemical interactions cause activation of these free nerve endings or activation of the afferent sensory fiber system such as tissue release of KCl, bradykinen, prostaglandin and histamine and serotonin. Substance P release from nerve endings may also cause extreme stimulation and hyperalgesia. Visceral nociceptors, for example of the gastrointestinal tract or the heart, both mechanical and chemical, send impulses through A-delta and C-fibers along the sympathetic peripheral nerves and chain. The abdominal and thoracic visceral afferents perhaps compose only about 10 percent of the afferents found in a somatic nerve.


Overall, however, the nerve fibers will pass through the skin and somatic structures into peripheral nerve branches and then gather together into fascicles. The fascicle fibers will then pass into the dorsal root ganglia and then into the dorsal horn gray matter of spinal cord. There are studies that suggest that the dorsal root fibers are not the only pathways for nociceptors. There are unmyelinated ventral root fibers which are present which also have nociceptive afferent input. There are various types of nerve fibers present whose origins are from various structures such as muscle spindles or Golgi tendon organs or


those receptors for touch, pressure and vibratory sensation. These fibers vary in their size as well as are unmyelinated or myelinated which can affect their speed of transmission of information. Also the same A-delta and C-fibers can pass through cranial nerves V, VII, IX and X.  



Page 8


PAIN AND SUFFERING


September 24, 1998



As the unmyelinated fibers of the nerve root pass into the spinal cord, they often go to Lissauer's tract or lamina II, substantia gelatinosa, or lamina V, of the dorsal horn gray matter. In the past neuroscience developed a gate control theory of pain control. Indeed modulation between large fiber myelinated sensory afferents would inhibit pain impulses from smaller unmyelinated or C-fibers. This was thought to be due to inhibitory neurons with local ipsilateral interconnections within the substantia gelatinosa. However there is indeed a much more complex interneuron circuitry present. The neural transmitters that are present within lamina V will include somatostatin, cholecystokinin and substance P as well as enkephalin. Glutamate, substance P and calcitonin gene related peptide, vasoactive intestinal peptide and somatostatin are released into the extracellular space of a dorsal horn of the spinal cord by activation of C-fiber systems. Glutamate may produce a fast excitatory synaptic action where substance P may produce slower excitatory effects. Neuropeptides can be distributed down through axons to modulate or to cause neurogenic stimuli with peripheral soft tissue inflammation. Once the information is processed in the dorsal horn of the spinal cord then the afferent pathway extends along the lateral spinothalamic tract generally from Rexed lamina V but also some contributions from I, VI, VIII and IX. The lateral spinothalamic tract will divide into two collaterals, a lateral and a medial group. Collaterals are also noted to go to the brain stem, specifically the periaqueductal gray and reticular formation or the nucleus cuneiformis. The fiber system of the lateral spinothalamic tract will then synapse on the VPL thalamic nucleus in a distribution that is somatotopic corresponding to the small receptive fields in the body. This is an excitatory receptive field system. However there are also inhibitory fibers present which can inhibit these VPL spinothalamic neurons. Eventually the afferent stimuli will be relayed to the sensory cortex, SI and SII, of the parietal lobe of the brain. Perhaps the VPL nucleus is simply involved with the discriminative qualities of pain. If a lesion is made in the lateral thalamus, this causes contralateral burning sensations or paresthesias. Often an emotional response with autonomic reactions can be seen with this type of pain. The lateral thalamic lesion somehow diminishes the inhibitory influence of the medial thalamic nuclei. There is then a constant input to the cortex then which is interpreted as pain. The medial spinothalamic path fibers synapse on the medial thalamic nuclei. Then cortical projections become diffuse and without the somatotopic representation and project toward the limbic system. This may alter the normal behavior responses of an individual to painful stimuli.





Page 9


PAIN AND SUFFERING


September 24, 1998



There is also a descending pain control pathway. Generally, as expected, the descending pathway has an inhibitory influence on dorsal horn gray matter neurons. Opiate receptors are found in the medial thalamus and periaqueductal gray in the dorsal horn in the spinal cord. When you stimulate the periaqueductal gray, analgesia occurs and there is stimulation of fibers that project to the midline medulla, not to the spinal cord.


Neurons in the nucleus raphe magnus contain serotonin. This may be one reason that serotonergic medications play a role in pain control. Other areas of the brain stem such as the mesencephalon have fibers passing into the dorsal horn of the cord. Overall there are many different pathways affecting the spinal cord dorsal horn system. Interestingly, there are alpha adrenergic substrates that have been found in the locus caeruleus in the upper posterior pons which are released with electrical stimulation. These fiber systems tend to inhibit nociceptive cell stimulation in the dorsal horn.


What happens if we stimulate the somatosensory cortex of the parietal lobe? Pain can be reproduced. If you resect the postcentral gyrus, often 80% patients will have pain relief, but long-term relief does not occur. Indeed this is one example of how clinical applications for performing lesions in the central nervous system may not achieve a long-term benefit. In cancer patients, ablative lesions have a place in pain management, but overall the perception of pain will return. Most likely there are two systems present that help the cerebral cortex understand the sensory input. The neospinothalamic system probably has sensory discriminative input keeping the spatial and the temporal localization of a pain stimulus organized. Whereas the paleospinothalamic system including the dorsal horn gray neurons and brain stem reticular nuclei and hypothalamus with multisynaptic fibers from both intralaminar and medial thalamic nuclei have more to do with behavior reactions. These ingrained actions may be the result of evolutionary effects. Yet the limbic system and the reticular activating system probably have input into the motivational and affective behavior of the individual patient. Also information has to be processed such as previous experience with pain. The data integration of the frontal lobes and limbic systems will also use previous memory input to determine what action is taken when a pain stimulus is present. This cognitive evaluation of pain may be a separate functional system or a combination of both of these.



Page 10


PAIN AND SUFFERING


September 24, 1998

APPLICATIONS



Knowing where the specific Mu receptors are located allows the physician to rapidly reduce pain. Direct infusions of morphine into the areas around the spinal cord or the brain would theoretically have a quicker and more direct effect. Indeed there are more immediate effects of pain reduction, often quite dramatic, if morphine is placed into the brain or over the spinal cord. Epidural catheters or Ommaya reservoirs, which are inserted into the cerebral ventricles, are used for infusions of small dosages of morphine.


Carefully prescribed, the pain relief is not associated with the same degree of secondary sedation, respiratory depression and cognitive impairment as would occur with higher IV or PO morphine dosages to bring on the same level of pain relief. Therefore when patients are being treated for cancer, the physician needs to continue to identify the specific site of the painful stimuli and remove this insulting stimulus. The treatment of the original disease and source of pain still remain the most important goal.


In addition to the known causative factors of pain, the psychological impact of the chronic pain needs to be addressed. The goal overall would be to improve the patient's quality of life, especially in a patient with chronic pain, whether due to cancer or a benign disease. In such cases, a team approach may be needed with the help of psychologists and psychiatrists trained specifically in chronic pain management. Biofeedback, cognitive retraining techniques or music therapy can be beneficial pain management techniques.


When discussing the painful condition and treatment with the patient, the physician needs to anticipate the next effect of the disease or treatment on the patient. If this information can be fully explained to the patient, this will relieve their expected anxiety. The significance of anxiety cannot be overstated. Indeed the physician needs to discuss not only the ability of the treatment to relieve pain but whether controlling the disease or curing the disease process is expected. Indeed telling the patient that the goal would be to eliminate pain may not be appropriate in all cases and could cause significant problems for the patient who would otherwise expect complete pain relief. Physicians need to understand the expectations of the patient. Stress factors are then going to be present. Indeed those stress factors can be accentuating the painful effects of the disease.



Page 11


PAIN AND SUFFERING


September 24, 1998


Every day in my practice, people ask me straightforwardly "Does stress cause my pain?" They do feel stress is a significant factor and at times feel that stress is the only reason that they are in pain.


Specific diagnosis and specific treatment of the painful stimuli are important. Also being specific will help the radiologist as well to determine the best imaging test. Try to improve upon the speed of diagnosis and the diagnostic quality of the testing procedure, clinical information needs to be given to the radiologist on the expected findings. Precisely define the current illness of the individual patient. Identify all other associated clinical conditions which are going to be affecting the patient's health and well-being. In many cases there may be psychological co-existing problems such as depression, stress intolerance, inability to work or unhappiness.


If a physician can be very specific about the source of the pain then often diagnostic and therapeutic nerve blocks can be utilized to manage especially the neuralgic sources of pain. Clinical and neurological examinations can localize the specific nerve root or peripheral nerve branch causing the individual to hurt. When this source of acute pain is identified, this seems to bring a sense of relief to my patients. Especially in those patients with cancer pain or chronic pain from undiagnosed conditions, this unknown produces a significant suffering.


Lack of knowledge of the cause for their pain can quickly undermine the patient-physician relationship. Talk to the patient regarding their pain and reduce the anxiety related to all the unknown factors. The symptoms of their illness can be reduced with management of the anxiety produced by the unknown.


Regardless of the current illness, common, benign, painful conditions can co-exist in patients with cancer. Large disc herniations can be present in a patient with prostate cancer metastasis to the spine. Patient with known coronary artery disease can still have severe chest and arm pain related to a disc herniation in their neck, especially at the C6-7 level.


Determining specific methods of treatment need to be emphasized. Overall the general philosophy is to consider a nondestructive procedure or pharmacological techniques for chronic pain control first. If an individual only has a few weeks to live then an implanted or an externalized access for epidural or intraventricular narcotics should be strongly considered. If a three month or longer survival is expected then indeed an implanted spinal or intraventricular pump can be clinically effective and cost effective.


Page 12


PAIN AND SUFFERING


September 24, 1998

When the physician determines by clinical criteria and evaluation that the patient requires pain control or relief, then narcotic analgesics should be prescribed. With a good patient-physician relationship, the amount of narcotics and the proper use of narcotics can be quickly agreed upon. Nonsteroidal anti-inflammatory drugs can be quite valuable in reducing pain and inflammation. These can be effective to supplement and to reduce the need for narcotic analgesia. If depression is present, other antidepressant medications such as Effexor or Elavil should be added as indicated. Medications such as Neurontin or Tegretol may be quite useful, especially with neuropathic related pain. For patients undergoing surgery, nonsteroidal anti-inflammatory drugs and local anesthetics, especially applied during and after surgery, can increase the effectiveness of a narcotic analgesic afterwards. General anesthetics do not prevent the activation of nociceptors nor do they prevent hyperalgesia. Even after surgery, epidural continuous infusions of morphine or intermittent anesthetics can significantly improve the patient's comfort level. Their perception of pain after surgery or during labor and delivery can be improved dramatically. Surgeons realize that there is a significant clinical benefit measurable in terms of outcome Secondary co-morbidity aspect of an illness, especially after surgery, should be reduced. The patients will have an improved appetite, better sleep, quicker ambulation, a reduction of fatigue and an improved sense of well-being. Overall their healing should be enhanced.


However there are going to be those types of patients that need other treatments. Again, I have mentioned that selective peripheral nerve root blocks with deposition, for instance, of steroids and anesthetics can significantly reduce neuropathic pain. Non-pharmacologic strategies can be adjunctive treatments to improve upon the degree of pain perceived by the patient and often can be common sense approach to the care of the individual.


Examples include but are not limited to:


1. Heat and Cold Applications are commonly used superficial techniques for pain modulation. Care should be exercises when cold is applied to a limb affected by peripheral vascular disease or tissues receiving radiation therapy.


2. Massage, myofascial release techniques, and hands on physical therapy techniques can be quite beneficial when indicated.


3.Exercise is so important in order to strengthen weakened muscles along with stretching exercises for immobile joints, and cardiovascular conditioning and bring relief of fatigue.



Page 13


PAIN AND SUFFERING


September 24, 1998


4. Re-positioning of injured limbs, and reduction of pressure on tender areas or edematous tissue to prevent ischemia or pressure sores.


5. Immobilization of fracture sites or torn tissue may be required and comforting for the patient. Often simple bracing with corsets for low back pain temporarily can be beneficial. 6. T.E.N.S. Transcutaneous Electrical Nerve Stimulation with continuous low voltage electrical stimulation of large myelinated nerves may reduce pain transmission along afferent neural pathways.


7. Acupuncture and acupressure techniques can be useful especially if cultural barriers do not inhibit an open minded approach to pain management.


8. Cognitive training to return control back to the patient and teach them coping skills.


9. Pastoral Counseling and Support Groups are quite beneficial techniques especially for patients who so desperately need to talk to someone about their health condition.


10. Bed rest can be so helpful but in moderate amounts perhaps as in acute back pain for 2-3 days and then intermittently for 30 to 60 minutes throughout the day. Walking with an upright posture with isometric tightening of the abdominal and gluteal muscles after bed rest is significantly beneficial.


Spinal cord stimulation has been a very useful tool in the armamentarium of pain specialists and neurosurgeons. For neuropathic pain due to neuronal infiltration by tumor, spinal cord stimulation can be quite useful. In peripheral neuropathies or in unilateral radicular pain that is resistant to all treatments including surgery, spinal cord stimulation can be beneficial. The literature shows a reduction in the overall benefit with the passage of time. But these individuals, if they are improved, are significantly able to participate once again in normal daily activities. A temporary implantation of a dorsal column stimulator can often identify the patient who would benefit from the permanent placement of the device. These individual patients have to be carefully selected. The overall goal would be to reduce the transmission of afferent pain impulses to the cerebral cortex. Somatic pain, especially due to cancer, will respond better to intraspinal epidural narcotics than to a dorsal column stimulator. However there are certain types of disease processes such as carcinoma of the pancreas where celiac plexus blocks can be quite beneficial for the majority of individuals.





Page 14


PAIN AND SUFFERING


September 24, 1998


Patient Education


One of the first questions that is given to the patient from the family at home is simply "What did your doctor say about your problem?" There have been different studies about the relative ability of an individual to recall information. Perhaps 20 percent of information may be recalled when given to an individual verbally and 40 percent may be recalled when given to the patient in a formal written manner. Overall these patients often do not fully comprehend their illness. Later patients have difficulty trying to express to their family members what the physician told them. This lack of information and memory of the doctor's recommendations does not improve upon the patients' or families ability to participate actively in their treatment.


The patient may often ask themselves "Do I understand my condition?" At this point, patient educational pamphlets can help explain a health-related condition. Allowing the patient to have a specific diagnosis written down for them can be quite beneficial. Then the patient can read about their condition, but also when they access literature or text on the Internet, they may be able to then correlate or at least surf for information specific to their disease process.


The education of the patient regarding their condition and the expected outcomes of therapy is quite important. Patients do not understand by reading literature or accessing the Internet how this information applies to themselves. Indeed the patients' expected outcome is often different from the physicians' expected outcome. The time line to completion of treatment is not always the same for each patient, even with the same disease.


When the patient and physician return to talk with each other, there are internal questions they both ask of themselves. Do both the patient and the physician feel that there has been adequate treatment of the illness? Do both the patient and the physician feel that there have been adequate treatment and management of pain? Has healing been enhanced? Has the patient been well informed? Using the Internet may be one way to enhance the patient- physician relationship.



JERRY V. MARLIN M.D.


Copyright 2001 JERRY V. MARLIN M.D.
Last modified: 01/06/03