Chronic Pain: Integrative Treatments

Nontraditional techniques, coupled with trusted drug therapies, are lifting the spirits of chronic pain sufferers.

From the WebMD Archives

For decades, Mary Sienkiewicz, now 42, could barely get out of bed in the morning because of the severe lower back pain that radiated down her legs. This past summer, however, she was able to Rollerblade through her hometown of Schererville, Ind.

Sienkiewicz's pain, which she describes as a "deep aching and weakness with pulsating and throbbing," began after a car accident in 1986. "I lost my 20s and 30s because of this pain. If I ever did anything active, I suffered for three to four days afterward," says the financial planner, who recently returned to work after years of disability.

She didn't take the pain lying down. Since the accident, she had undergone two surgeries to repair the herniated disc in her back and tried just about every type of medication and therapy out there. Nothing made a difference for long.

All that changed when Sienkiewicz entered a four-week "boot camp" for people in chronic pain at the Rehabilitation Institute of Chicago (RIC), one of the nation's first multidisciplinary pain clinics.

"It was extremely intense," she recalls. With sessions Monday through Friday from 8 a.m. to 4:30 p.m., the program is composed of aerobic exercise to help boost the body's natural painkillers, called endorphins; individualized physical therapy; biofeedback lessons; psychological counseling to help the patient accept and function better with pain; and medication to treat some of the underlying tissue problems and other issues, including pain-related depression and sleeping difficulties.

"My pain went down from a level of seven or eight --- if not a 10 or higher --- to a one or a two," she says. "It's not a quick fix, and if you stop practicing what you learned, the pain will return," she cautions, but that knowledge gave Sienkiewicz the incentive to continue with her individualized program.

Integrative Approach to Chronic Pain

Clinics and programs with a multidisciplinary, or comprehensive, approach to pain management are becoming more popular as people reject the traditional pill-and-surgery model of treating pain because, like Sienkiewicz, they find it's not always effective.

In a 2004 survey, conducted on behalf of the American Chronic Pain Association, 72% of people with chronic pain said they had had pain for more than three years --- including 34% who had had it for more than 10 years. Nearly half said their pain was not under control. Such uncontrolled pain has ripple effects on jobs, relationships, and the ability to lead a normal life.

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"There is no way to be pain-free unless you get comprehensive care. You just can't, say, inject pain away. It doesn't work," says B. Todd Sitzman, MD, MPH, director of advanced pain therapy at Forrest General Cancer Center in Hattiesburg, Miss. "Pain can be well-managed when the whole focus of treatment is on function. We want to get the patient as active and independent as possible."

Steven Stanos, DO, medical director of the RIC Chronic Pain Care Center and Sienkiewicz's doctor, agrees. "The multidisciplinary approach toward treating pain is definitely a trend. The public is more aware of it because of all the problems we have had with pain medications recently."

Stanos is referring to the recent headlines about Vioxx, a painkiller Merck voluntarily withdrew from the market in September 2004 after research linked it to an increased risk of heart attack. A similar drug, Bextra, was later taken off the market. Since then, all anti-inflammatory painkillers have been under scrutiny.

And this multidisciplinary trend has legs. "Baby boomers are aging at a rapid pace ... and [this group] will not put up with pain," says Mary Pat Aardrup, executive director of the National Pain Foundation in Englewood, Colo. "We are going to see some big changes in the pain field in terms of how to have a functional life within the confines of what you are experiencing."

Treating the Person, Not Just the Pain

Like diabetes, chronic pain is a condition that needs to be managed on many fronts, says Dennis Turk, MD, the John and Emma Bonica professor of anesthesiology and pain research at the University of Washington School of Medicine in Seattle and president of the American Pain Society. "When we treat diabetes, we use insulin, but we now know that all people with diabetes also need to watch their diet and exercise, in addition to the use of insulin therapy [and other diabetes medications]. The same [multidisciplinary approach] is true with pain," he says.

Turk explains how-and why. "From a biomedical standpoint, we [tackle] the tissue source of the pain with medication or surgery. From a psychological standpoint, a significant number [of patients] have related depression and anxiety. From the social side, people with chronic pain may engage in bad behaviors that can make things worse.

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"We need to find ways to treat the person, not just the pain," he says.

Treatment should also include coping and pain-management skills. "When you have chronic pain, you think that anything you do will hurt you further --- so you become a recluse," Sienkiewicz says. "The program enabled me to see that I won't hurt myself if I become active again."

Managing pain is often a family affair, says Stanos. "Pain psychologists work with the family, who want to help but go about it the wrong way. As a result, the patient gets lazy and passive because they know their family members will do it for them."

Some programs such as RIC's also include a recreational therapist. "A therapist takes them out and into the community," explains Stanos, "to use techniques learned in boot camp to get back to the activities they once loved. The problem in chronic-pain patients is that they are not coping well ... but learning to live better with the pain can decrease the ongoing use of medications."

"That's the best thing the clinic did for me," Sienkiewicz says. "I tried to fix the pain and get rid of it, as opposed to accept it and learn how to live with it."

Biofeedback, Deep Breathing, and More

Many of these programs use biofeedback and deep-breathing techniques. Biofeedback measures bodily functions, such as breathing, heart rate, and muscle tension. Patients learn to train their minds to control these functions. When first learning biofeedback, patients have sensors attached to their bodies and to a monitoring device that provides instant feedback about their pain. A biofeedback therapist then teaches them physical and mental exercises to help control that function.

The results are displayed on the monitor so that patients can see what works to relieve their pain. "People in chronic pain have elevated levels of stress, and we teach them to control their anxiety and reduce tension with a deep-breathing technique," Stanos says.

Patients in pain can learn much the same method at Stanford University's Pain Management Center, where they undergo cutting-edge functional magnetic resonance imaging (fMRI) scans to visualize pain in the brain by mapping blood flow. Then doctors feed signals back to the person, showing him or her how pain can intensify with stress and, conversely, improve with distraction techniques such as music or deep breathing.

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Acupuncture is on the treatment roster of some major pain clinics, such as The Cleveland Clinic's Pain Management Center, which has acupuncturists like Timothy Rhudy, MS, Lac, on staff. "Clinics would never have non-MDs and acupuncturists in the past," he says.

According to Rhudy and other practitioners of acupuncture, this treatment uses needles to correct energy-flow imbalances in the body's qi, or energy patterns flowing through the body. Diseases, including chronic pain, occur when there are disruptions in this flow, they say.

But acupuncture is "no quick fix. It's part of an integrated approach," Rhudy says. "Acupuncture can sometimes jump-start a patient to get them to make changes in their own life, whether trying tai chi or yoga, or finding other ways of staying active and keeping the body flexible and working the muscles to keep pain at bay." In most cases, acupuncture requires multiple treatments over several weeks.

In a study of 570 people with knee osteoarthritis, those who received acupuncture in addition to anti-inflammatory pain relievers significantly improved knee function and had decreased pain compared with people who only took medication. This study appears in the Dec. 21, 2004, issue of the Annals of Internal Medicine.

Gain on Pain

"We are starting to realize pain is not the enemy, but an important warning system on the body's part," says Jacob Teitelbaum, MD, medical director of the Annapolis Center for Effective CFS/Fibromyalgia Therapies in Maryland and the author of Pain Free 1-2-3! A Proven Program to Get You Pain Free NOW.

"Pain tells us if something needs attention, but we normally ignore it and try to mask it with medication. Pain is trying to get our attention just like the oil light on the dashboard."

According to Teitelbaum, pain management involves better nutrition and a focus on sleep, as well as addressing potential hormonal deficiencies that may make pain worse. In a National Sleep Foundation poll taken in 2000, 20% of American adults reported that pain or physical discomfort disrupted their sleep a few nights a week or more.

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The bottom line is that "chronic pain should not be a passive disease," Sitzman says. "You have to fight it and find what works for you."

Just like Mary Sienkiewicz did. "The clinic gave me a toolbox. It taught me how to accept this disease, and how I can learn to live and work with it," she says.

WebMD Magazine - Feature Reviewed by Michael W. Smith, MD on June 01, 2006

Sources

Sources: Mary Sienkiewicz, finacial planner, Schererville, Ind; B. Todd Sitzman, MD, MPH the Director of Advanced Pain Therapy at Forrest General Cancer Center in Hattiesburg, MS, Steven Stanos, D0, the medical director of the Chronic Pain Care Center at the Rehabilitation Institute of Chicago, Mary Pat Aardrup, executive director of the Englewood, Colo-based National Pain Foundation, Dennis Turk, MD, the John and Emma Bonica Professor of Anesthesiology and Pain Research at the University of Washington School of Medicine in Seattle and the president of the American Pain Society and Jacob Teitelbaum, MD, the medical director of the Annapolis Center For Effective CFS/Fibromyalgia (FMS) Therapies in Maryland and the author of Pain Free 1-2-3! A Proven Program to Get You Pain Free NOW.

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