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Chronic Pain Can Steal Sleep


Work and Pleasure



If you've ever pulled a muscle, burned your hand or smacked your head, you've felt it sometimes for days. It's pain, and as bad as it feels, it's actually good for you. Acute pain is nature's way of telling you you've been injured and alerting you to be careful not to make it worse. Eventually the injured tissue heals and the acute pain goes away.

Now imagine feeling pain all the time. Chronic pain continuous pain lasting longer than six months affects an estimated 30 to 50 million Americans. It can result from injuries that never fully healed, unsuccessful surgeries, lower back problems, systemic conditions like arthritis and fibromyalgia, or a variety of diseases. Chronic pain interferes with work, restricts everyday activities, and can even take the joy out of life.

Until recently, chronic pain was not viewed in isolation but was thought of as a symptom of something else. Today it's recognized as a separate condition similar to a disease, and unlike acute pain, it's not a function of a healthy nervous system. Pain management has become a fast-growing medical subspecialty and a focus of research.

Multidisciplinary Approach

At the Medical College of Wisconsin and Froedtert Hospital, some four dozen physicians and other medical professionals treat adults and children who experience chronic pain. One of those specialists, Martin D. Hoffman, MD, believes a multidisciplinary approach often results in the best outcomes.

A typical pain team might include a physiatrist, anesthesiologist, psychologist, nurse, and a physical therapist or occupational therapist, says Dr. Hoffman, whose specialty is physiatry. Dr. Hoffman served as a Professor in the Medical College of Wisconsin Department of Physical Medicine and Rehabilitation.

Often, he says, a variety of approaches may be necessary to give patients relief from chronic pain. Persistent low-back pain, for instance, might be alleviated through procedures like trigger point injections, sacroiliac joint injections, epidural steroid injections or facet injections. Those procedures do carry some slight, but serious, risks, he says, and they are best left to a physician skilled in performing the procedure and qualified to intervene if an emergency should develop during the procedure.

Because many chronic pain sufferers become stressed or depressed, psychologists can intervene with techniques such as stress reduction or biofeedback. Physical therapists and occupational therapists can help patients feel more comfortable, and teach them ways to perform everyday tasks without aggravating their pain. Therapists might also suggest stretching and strengthening exercises.

Phychiatrists like Dr. Hoffman often recommend a course of treatment in conjunction with the referring physician and other team members. The physiatrist may also recommend medications and perform appropriate procedures while keeping the referring physician informed about the patient's progress and prognosis.

Treat Pain Early

When chronic pain does not arise from an underlying condition or disease, Dr. Hoffman says, it can develop as a result of delayed treatment for acute pain. The problem occurs, he says, when what should have been a simple musculoskeletal injury is not treated up front. Patients and, in some cases, their physicians believe the injury will heal and the pain will disappear in time. In fact, any pain that persists for weeks does require intervention.

In recent years, pain specialists have found that drugs originally approved for one use may also be effective in easing chronic pain. One that Dr. Hoffman has prescribed is Neurontin (generic name: gabapentin), an antiseizure medication. There's plenty of science to support the use of Neurontin for carefully selected patients with chronic pain, he says. He and other pain specialists might also prescribe a low-dose antidepressant like Elavil (amitriptyline) to promote sounder sleep, as well as other antidepressants and anti-anxiety drugs to counter depression in some patients.

Sleep deprivation is often associated with long-term pain, notes Dr. Hoffman. Patients who don't sleep well can develop more diffuse symptoms, and then depression, and it becomes challenging to overcome that cycle.

Narcotics Generally Not Appropriate

Dr. Hoffman discourages patients from long-term use of opioid (narcotic) drugs like codeine and Vicodin (hydrocodone). They're not appropriate or effective for chronic pain, and they do increase dependence, he warns. His view is supported by the National Institute on Drug Abuse (NIDA), which warns that opioids are among the most commonly abused and misused class of prescription drugs, along with some depressants used to treat anxiety and sleep disorders, plus certain stimulants.

Opioids may interact with other drugs and are only safe to use with other drugs under a physician's supervision, the NIDA website says. Typically, they should not be used with substances such as alcohol, antihistamines, barbiturates or benzodiazepines. These drugs slow down breathing, and their combined effects could risk life-threatening respiratory depression.

Chronic use of opioids can result in tolerance to the drugs so that higher doses must be taken to obtain the same initial effects, the NIDA site continues, adding: Long-term use also can lead to physical dependence the body adapts to the presence of the drug, and withdrawal symptoms occur if use is reduced abruptly. Symptoms of withdrawal can include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goosebumps and involuntary leg movements.

Benefits of Exercise

Dr. Hoffman is a strong advocate, however, of exercise as a natural pain reliever. In a research study he conducted a few years ago at his laboratory at the VA Medical Center in Milwaukee, he found that after riding an exercise bike for 25 minutes, eight patients with long-term back pain felt significantly less pain than they felt before they began the exercise. He presented his findings at the May 2000 meeting of the American College of Sports Medicine.

Although he could not definitively say what caused the reduction in pain perception, Dr. Hoffman said it involved the whole body, not just sore backs. "The exercise was done with the legs, and we found the pain alteration to affect a stimulus to the finger, so it's pretty safe to say it's a systemic effect. Therefore, we expect the site of any chronic pain to be affected to some degree as well. If people would exercise a little bit they would likely get some relief from their pain," says Dr. Hoffman.

If you have chronic pain but don't have access to an exercise bike, you can still exercise for pain relief, says Dr. Hoffman. "For the average person with chronic pain, the advice I would give is if they can walk, and they have a place to do it, that would be ideal. If they don't live in an area where it's safe to walk or they don't like getting out in the cold or don't have a shopping mall or a treadmill, one of the indoor exercise devices would be an alternative," he says. And, he adds, it's important to exercise at a moderately high intensity level to realize pain-relieving benefits.

Dr. Hoffman realizes that people with spinal-nerve damage might not be able to use a regular upright exercise bike. However, he notes, they might find a recumbent bike or a stair-stepping machine more tolerable. The best remedy for chronic pain? The same answer as for any other disease, he says. Prevention.

Barbara Abel
HealthLink Contributing Writer