Chronic Pain Management
After a patient presents with complaints of Chronic pain. One
needs to first find out the diagnosis. Is there a neuropathy,
neuromuscular pain or is the process central. Then one needs to
focus on the treatment of the particular disease process. If the
cause of the neuropathy is immune mediated then proper treatment by
current guidelines of this condition should take place. The most
common cause of pain is Myofacial pain. Which is easily treated .
Treatment Options
When treating pain with medications there are three general
categories of drug treatments:
Neuropathic & Psychiatric Medications
Neuropathic pain is associated with damage to the nerve. Often this
type of pain is associated with symptoms of burning or increased
sensitivity over the painful area. Neuropathic pain is best treated
by either antidepressants (e.g. Elavil, Paxil, Zoloft) or by
antiepileptics (e.g. Dilantin, Tegretol). The antidepressant
medications also have beneficial effects of improved mood, decreased
anxiety, and improved sleep cycle. These medications are not
addictive, and when appropriately managed have few side effects.
Pain Medications
Pain medications are separated into several categories:
Local pain relief.
Local anesthetics like Emla cream can be used over the
painful area.
- Acetaminophen (Tylenol)
Tylenol is used to treat pain, but it does not have the
anti-inflammatory effects of the NSAIDs listed below. Often,
however, in cases of chronic pain there is no inflammation at
the site of the pain, and thus Tylenol may be an appropriate
treatment choice. Tylenol is a safe medication when used
appropriately, but can be very dangerous when used
inappropriately. The risk of liver or kidney damage is
significant when more than the recommended dose of Tylenol is
used.
- NSAIDs
These are the nonsteroidal anti-inflammatory drugs (NSAIDs). The
NSAIDs (e.g. Motrin, Aleve, etc.) are most beneficial in cases
of acute pain, or flare-ups in patients with chronic pain. In
general these should not be used on a daily basis for the
treatment of chronic pain. When used on a daily basis for a
period of several years, there is a risk of damage to the
kidneys that can be significant. Furthermore, there are well
known risk of ulcer formation with NSAIDs. While the newer,
so-called COX-2 inhibitors (Celebrex, Vioxx), were designed to
avoid this complication, caution should still be used if there
is a risk of ulcers or GI bleeding.
- Narcotics : These medications are to be used in acute
conditions and for prn use only. Immune suppression is the
biggest problem for the patient in any long term use. This can
be measured by checking the IgG and IgG sub class levels. Immune
suppression leads to worsening of cancer, worsening of
autoimmune disease and may give rise to multiple infections.
Symptoms of chronic fatigue and mental cloudiness are reported
by all patients. For those who recommend these on a daily basis
they are Ignorant of the above facts. There is no need to take
pain medication if you are pain free. Men tend to have more Mu
receptors thus they often need drugs which can act on this
receptor. While women have more Kappa receptors and they benefit
from Kappa agonist and antagonist. There is no need for
chronic administration of Narcotics.
Treatment of painful conditions. For treatment of pain a
correct diagnosis of the specfic condition is needed. Chronic pain
is a term not a diagnosis.
Myofacial pain: Need to find out the perpetuating
factors
•Sudden trauma (muscles, ligaments, tendons, bursae,
discs )
•Repetitive motions; Excessive exercise; Muscle strain due to over
activity
•Systemic conditions (eg, gall bladder inflammation, heart attack,
appendicitis, stomach ulcers)
• Poor posture
and body mechanics, Lack of activity
•Nutritional deficiencies (B6 - B12 and mineral deficiency)
•Hormonal changes (eg, trigger point development during PMS or
menopause)
•Stress and Depression.Impaired
sleep . Exposure to chemicals.
•Chilling of the body (eg, sitting under an air conditioning duct;
sleeping in front of an air conditioner)
Treatment of the perpetuating factor will take care of future
development of this pain. In an acute attack the best treatment
remains the Trigger point injection. Immediate pain relief is seen.
We have seen this in chronic cancer patients. One elderly gentleman
who had severe metastases in his spine with pain did not want
narcotics. They would cause him to be drowsy. So he was
treated by one single simple lidocaine injection with complete
pain relief. Seen the same effect in Herpes Zoster pain.
Trigger points can also be inactivated by stretching , cooling
and heating. Simple massage also helps them. In selecting the proper
modality it worth to consider some facts. If the patient is elderly,
fragile and weak and live far from a rehab facility they will be
poor candidates for massage treatments. Do not give trigger points
in any patient who is standing up. This may cause them to pass out
and result in a injury. Young women are more likely to pass out.
Severe pain and inability to stretch is a indication for a T.P.
injection. Children do well with Florimethane spray.
C.I.D.P.
Any patient suffering from a painful neuropathy , autonomic
neuropathy with involvement of sweating or burning sensations has to
be evaluated for CIDP. As this is a treatable immune neuropathy. If
this is treated with narcotics this can make the condition worse.
Other neuropathic pains secondary to Herpes Zoster, AIDS,
Hepatitis -C, Lymes, Syphilis are also a immune mediated
neuropathy and should be treated like CIDP.
We do not recommend sympathectomy or other invasive procedures
which destroy nerve roots or spinal tracts. In time remyelination
will take place or the nervous system will re route the messages
through surviving fibers and this will negate the effects of these
surgeries.
Antidepressants: Low-dose antidepressants (e.g., tricyclic
antidepressants) may be prescribed for patients to take at bedtime,
to help relieve symptoms.30 Remember
stimulating antidepressants should not be used only sedating
antidepressants like amitrptiline should be used. Caution is
to be exercised in using these for CIDP or neuropathy patients as
these conditions will worsen by using these drugs. These drugs cause
a neuropathy.
Pain in
malignant disorders is either Myofacial or neuropathic.
Reflex
Sympathetic dystrophy, Complex regional pain syndrome need to be
evaluated for CIDP or nutritional neuropathies.
Acute Back pain.
Usually resolves within two weeks. Is usually Myofacial.
Fibromyalgia. Is a chronic pain disorder and will respond to various
immune antiinflammatory meds.
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Rheumatoid arthritis...
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What are autoimmune
diseases
Autoimmunity plays a role in more than 80 diseases. Following are
brief descriptions of some of the many diseases in which
autoimmunity may be involved
Following is a list of Autoimmune Diseases.
They are all caused by the immune system attacking
different organs of our body. Since all these diseases have the
same mechanism of action thus their treatment is essentially the
same. They are treated with IVIG, steroids, plasmapheresis or
other cytotoxic and immunosuppressive treatments. In our E-Book
you will find the antibiotic protocols.
AUTOIMMUNE acute disseminated
encephalomyelitis (ADEM) A flu followed by seizures and
coma, causing inflammation of the brain.(encephalitis). It is a
autoimmune disease.
Autoimmune Alzheimers: A memory disorder caused by autoimmune disease.
Autoimmune alopecia areata--A disorder in
which the immune system attacks the hair follicles, causing loss of
hair on the scalp, face, and other parts of the body.
Autoimmune ankylosing spondylitis--A
rheumatic disease that causes inflamed joints in the spine and
sacroiliac (the joints that connect the spine and the pelvis) and,
in some people, inflamed eyes and heart valves.
Autoimmune aneurysms and
their treatment with steroids
Autoimmune arthritis--A general term for more than 100 different diseases
that affect the joints. Many forms of arthritis and related
conditions are believed to have an autoimmune component.
Autoimmune autism
or Autistic disorder Also know know as a specific entity as PANDAS.
(Childhood psychiatric disorders)
Autoimmune hemolytic anemia--A condition in which immune system
proteins attack the red blood cells, resulting in fewer of these
oxygen-transporting cells.
Autoimmune hepatitis--A disease in
which the body's immune system attacks liver cells, causing
inflammation. If not stopped, inflammation can lead to cirrhosis
(scarring and hardening) of the liver and eventually liver failure.
Autoimmune Oophoritis
Premature Ovarian Failure causing infertility.
Autoimmune Behçet's disease--A condition
characterized by sores in the mouth and on the genitals and by
inflammation in parts of the eye. In some people, the disease also
results in inflammation of the joints, digestive tract, brain, and
spinal cord.
Autoimmune
Bullous
Pemphigoid
Skin lesions
Autoimmune Cardiomyopathy A very simple
treatment for end stage cardiac failure
Autoimmune Crohn's disease--An inflammatory disease of the small intestine
or colon that causes diarrhea, cramps, and excessive weight loss.
Autoimmune Chronic Fatigue Syndrome In
this condition you feel tired all the time.
Autoimmune Dermatomyositis--A rare autoimmune disease that causes patchy
red rashes around the knuckles, eyes, and other parts of the body
along with chronic inflammation of the muscles. It may occur along
with other autoimmune diseases such as rheumatoid arthritis or
systemic lupus erythematosus.
Autoimmune Diabetes mellitus, type 1--A condition in which the immune
system destroys insulin-producing cells of the pancreas, making it
impossible for the body to use glucose (blood sugar) for energy.
Type 1 diabetes usually occurs in children and young adults.
Autoimmune Epilepsy
Autoimmune In epilepsy either you pass out, forget, get
angry or have uncontrolled movements of the body.
Autoimmune Kawasaki's
Disease A disease affecting the skin and heart in
children.
Autoimmune Glomerulonephritis--Inflammation of the kidney's tiny filtering
units, which in severe cases can lead to kidney failure.
Autoimmune Graves' disease--An autoimmune disease of the thyroid gland that
results in the overproduction of thyroid hormone. This causes such
symptoms as nervousness, heat intolerance, heart palpitations, and
unexplained weight loss.
Autoimmune Goodpasture's syndrome
A autoimmune disease affecting the Lungs and Kidneys.
Autoimmune Guillain-Barré syndrome--A disorder in which the body's immune
system attacks part of the nervous system, leading to numb, weak
limbs and, in severe cases, paralysis.
Autoimmune Inflammatory bowel disease--The general name for diseases that
cause inflammation in the intestine, the most common of which are
ulcerative colitis and Crohn's disease.
Autoimmune Lupus nephritis--Damaging inflammation of the kidneys that can
occur in people with lupus. If not controlled, it may lead to total
kidney failure.
Autoimmune Multiple sclerosis--A disease in which the immune system attacks
the protective coating called myelin around the nerves. The damage
affects the brain and/or spinal cord and interferes with the nerve
pathways, causing muscular weakness, loss of coordination, and
visual and speech problems.
Autoimmune Myasthenia gravis--A disease in which the immune system attacks
the nerves and muscles in the neck, causing weakness and problems
with seeing, chewing, and/or talking.
Autoimmune Myocarditis--Inflamed and degenerating muscle tissue of the
heart that can cause chest pain and shortness of breath. This can
lead to congestive heart failure.
Autoimmune Parkinson diseases.
Parkinson which causes slowness and a flexed posture with tremors is
a autoimmune diseases.
Autoimmune PANDAS Pediatrics autoimmune
neuropsychiatry disorders
Autoimmune Pemphigus/pemphigoid--An autoimmune disease of the skin
characterized by itching and blisters. (Excellent Article modified
by cidpusa)
Autoimmune Pernicious anemia--A deficiency of the oxygen-carrying red blood
cells that often occurs in people with autoimmune diseases of the
thyroid gland.
Autoimmune Polyarteritis nodosa--An autoimmune disease that causes
inflammation of the small and medium-sized arteries. This leads to
problems in the muscles, joints, intestines, nerves, kidney, and
skin.
Autoimmune Polymyositis--A rare autoimmune disease characterized by
inflamed and tender muscles throughout the body, particularly those
of the shoulder and hip girdles.
Autoimmune Primary biliary cirrhosis--A disease that slowly destroys the
bile ducts in the liver. When the ducts are damaged, bile (a
substance that helps digest fat) builds up in the liver and damages
liver tissue.
Autoimmune Psoriasis--A chronic skin disease that occurs when cells in the
outer layer of the skin reproduce faster than normal and pile up on
the skin's surface. This results in scaling and inflammation. An
estimated 10 to 30 percent of people with psoriasis develop an
associated arthritis called psoriatic arthritis.
Autoimmune Rheumatic fever--A disease that can occur following untreated
streptococcus (strep) infection. It most often affects children,
causing painful, inflamed joints and, in some cases, permanent
damage to heart valves.
Autoimmune Rheumatoid arthritis--A disease in which the immune system is
believed to attack the linings of the joints. This results in joint
pain, stiffness, swelling, and destruction.
Autoimmune Sarcoidosis--A disease characterized by granulomas (small
growths of blood vessels, cells, and connective tissue) that can
lead to problems in the skin, lungs, eyes, joints, and muscles.
AUTOIMMUNE Scleroderma--An autoimmune disease characterized by abnormal
growth of connective tissue in the skin and blood vessels. In more
severe forms, connective tissue can build up in the kidneys, lungs,
heart, and gastrointestinal tract, leading in some cases to organ
failure.
Autoimmune sjögren's syndrome--A condition in which the immune system
targets the body's moisture-producing glands, leading to dryness of
the eyes, mouth, and other body tissues.
Autoimmune Systemic lupus erythematosus--An autoimmune disease, primarily
of young women, that can affect many parts of the body, including
the joints, skin, kidneys, heart, lungs, blood vessels, and brain.
Autoimmune Thyroiditis--An inflammation of the thyroid gland that causes
the gland to become underactive. This results in symptoms such as
fatigue, weakness, weight gain, cold intolerance, and muscle aches.
Autoimmune Ulcerative colitis--A disease that causes ulcers in the top
layers of the lining of the large intestine. This leads to abdominal
pain and diarrhea.
Autoimmune Uveitis--The inflammation of structures of the inner eye,
including the iris (the colored tissue that holds the lens of the
eye) and the choroid plexus (a network of blood vessels around the
eyeball). Uveitis occurs with some rheumatic diseases, including
ankylosing spondylitis and juvenile rheumatoid arthritis.
Autoimmune Vitiligo--A disorder in which the immune system destroys
pigment-making cells called melanocytes. This results in white
patches of skin on different parts of the body.
Autoimmune Wegener's granulomatosis--An autoimmune disease that damages the
small and medium-sized blood vessels throughout the body, resulting
in disease in the lungs, upper respiratory tract, and kidneys
Autoimmune Wilsons Disease.
Liver disease with slow movements, tremor,
More on autoimmune diseases.
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