Jacob R. Caylor, MD, DABA, DABPM
Pain medicine has changed quite a bit over the last 20 years. We’re in a much more advanced space now, with new therapies becoming available every day. However, these new options create challenges for both the patient and the provider. Which therapy will best serve each unique case? As these therapies become more and more complex, how do doctors teach patients about the reasons why some choices are better than others? There are also patients who have received treatment but are unclear why certain decisions were made.
This blog is designed to educate our patients and to bridge the gap of knowledge between what our physicians and advanced practice providers now know and what patients may currently believe.
Along with this education comes the ability to advocate—for yourself as well as your family members—so when you’re faced with a decision, you can make the best decision.
Etiologies of Pain: Cause and Effect
Many people in pain management—patients and providers alike—believe in this paradigm:
A caused B, therefore fixing A will lead to the resolution of B
In this paradigm, A is generally some type of injury or event, and B is either pain or change in function. Maybe something has been twisted or overused. This then leads to feeling pain. But the assumption here is that the problem is one-dimensional and there’s nothing else that may be contributing to the problem.
By the time they reach us, most patients have tried some sort of other therapy. They may have tried home care, with rest, ice, or heat. They may have been evaluated by their primary care physician or a chiropractor. From there, they may have tried over-the-counter medications or therapy, but they’ve continued to experience pain or disability. After all of this, they’re sent to a spine or pain specialist in order to diagnose and treat the chronic pain.
The journey from the initial onset of the pain to a visit to PSA will often take about three to six months. Along the way, patients may learn to adapt to their pain and change the way they walk, sit, stand, lift, or do any number of other normal activities. Now, we’re not just talking about the initial injury or cause and the resulting pain, but all of the behaviors that have developed as a result.
Diagnosing the Problem
Pain medicine is a field. This means that those of us in the field don’t just focus on the treatment, we’re just as concerned with the diagnosis.
There are roughly 46 possible causes for lower back pain. In order to accurately diagnose—and therefore treat—any case, we have to look at the patient’s entire story: How did this story evolve? How does the patient describe the pain?
Along with the patient’s story, we conduct an examination and take a close look at the body: How does it move? How do the tendons and the musculature feel? Plus, we conduct studies like CT scans and MRIs.
From the story, examination, and study, we can begin to create a picture of the problem. But even then, with all of this work done, there may still be several causes for the pain. At this point, we may try different approaches to see how the pain responds—or doesn’t respond.
One approach is to try some form of injection, which patients often mistakenly call “shots.” Injections performed by a pain physician aren’t like flu shots, which are blindly injected into the muscle or skin.
Rather, these are diagnostic and therapeutic tools. They’re targeted injections that are specifically placed and contain two components: Local anesthetic and steroid.
With our findings as our guide, we may put a local anesthetic on a specific nerve. If the pain is reduced, we know we’ve found the source. But even if the pain isn’t reduced, we’ve still made progress in our search for the source and possible treatments of the pain.
With the steroid, we’re able to reduce inflammation, promote tissue healing, and allow the nerve to reboot.
The Pathway to Relief
Many patients wonder if their treatments will be effective and how long they’ll last. Unfortunately, there’s no way to predict the outcome of any treatment because every patient is different. While we do expect treatments to be effective and last for some time, the reality is that most pain journeys have their ups and downs.
In many ways, the pain journey is about breaking the pain cycle and peeling away the layers of pain. By the time a patient comes to our offices, three to six months after the pain was first discovered, there are so many other factors contributing to it, like altered biomechanics.
Similarly, when people talk about chronic pain in the back, the focus is mainly on the specific points in the back where the pain is felt. In reality, there’s much more to it and things like lymphatics, nerves, and muscles could also contribute to the problem.
As interventional pain physicians and diagnosticians, we feel it’s our responsibility to diagnose and treat what we believe is the primary source of your pain. We also feel it’s our responsibility to treat any additional sources of pain. By keeping you appraised of all of this information, we can teach our patients about what they’re experiencing and how we’re managing it.
This means that as you make your way through the pain journey, you can make educated decisions you feel confident about.