Category: Painful Conditions

Research shows virtually everyone who undergoes an amputation of an extremity will describe some measure of phantom limb sensation. These are sensory illusions giving the person a sense that the missing limb is still present. The underlying cause of this disorder is not known. However, doctors suspect it may be linked to parts of the central nervous system that retain the memory of the limb before it was amputated. In many cases, the experience is not particularly troublesome and over time the sensation fades. For other patients, the phantom limb sensations become a source of severe pain that can persist for months or years. People who suffered a sudden traumatic amputation or those who have complications following a surgical amputation, are more likely to suffer from this syndrome. The intensity and quality of phantom limb pain are not the same for everybody. The patient may indicate they feel a lengthening or shortening of the phantom limb and its pain.

Diagnosis

Doctors often find during a physical examination of a patient with phantom limb pain that the stump is tender and there is deterioration of tissue around the wound at the tip of the stump. Patients with phantom limb pain may have neuromas or abnormal clusters of nerve cells at the ends of the nerves that have been cut during the amputation. Patients with significant stump pain may respond to diagnostic and therapeutic nerve blocks or injections of anesthetic medication around the painful structures. Phantom limb pain may also respond to nerve blocks used diagnostically to help reduce the irritability of the nerves that lead from the spine to the painful limb.

Treatment

The treatment of phantom limb pain should focus on correcting underlying predisposing conditions, including the development of neuromas or painful bone spurs in the stump. Some of the effects of phantom limb pain can be alleviated with the use of oral medications, which help reduce pain from nerves. The patients are usually started on a low dose and gradually given larger doses to provide the best overall results. Traditional pain medications and non-steroidal anti-inflammatory agents have a limited use when prescribed in conjunction with other therapies. Nerve block treatments can be extremely valuable for stump pain and phantom limb pain. Injections of anesthetics with anti-inflammatory medications around the painful areas of stump neuromas can provide long-term relief in selected patients. Epidural injections or sympathetic blocks containing anesthetics, sometimes in conjunction with anti-inflammatory or pain medications, can be used in the treatment of phantom limb pain. These injections are usually performed near the spine where the nerves originate. These injections are usually given in a short series over several weeks until the symptoms subside or a plateau is reached. Research shows treatment of stump pain occurring immediately after the amputation can be effective in preventing the development of long-term phantom limb pain. This treatment is often performed through a continuous epidural infusion, through a catheter placed either before or immediately after surgery. Earlier placement seems to be more effective. For some patients surgery is considered in order to remove the painful neuromas at the tip of the stump or to revise the scar at the end of the stump. Rehabilitation efforts to desensitize the painful area, including physical therapy methods, are sometimes utilized.

For patients who have severe pain affecting their ability to perform daily life activities, a combination of physical therapy and behavioral therapy can be utilized. Patients may be asked to complete broad examinations to help determine physical and mental statuses in order to determine what type of behavior modification will be most helpful. Most often patients will find counseling, biofeedback and relaxation techniques the most beneficial.

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Temporomandibular joint disorder (TMJ) is defined by an aching in the chewing muscles of the jaw. It is often associated with limitations in the ability to move the jaw as well as with clicking or popping sounds in the jaw. The pain generally occurs around the temporomandibular joint in the jaw, the sides of the face and head, the back of the head and the neck and shoulders. The pain is usually described as intermittent, dull and aching, but can sometimes be constant. The pain is often made worse by chewing hard food or by yawning. Symptoms can continue for years. Some patients feel their jaw does not move correctly when opening or closing the mouth. Their teeth may not meet when the mouth is closed as well.

Diagnosis

Careful examination of the mouth and dental structures is usually undertaken as a first step. Additionally, careful examination of the muscular structures at the sides and back of the head, neck and shoulders helps to determine the extent of the problem. X-rays of the temporomandibular joint are sometimes used. MRI examinations can give additional detail and show if there is displacement of the disk or arthritis in the temporomandibular joint itself. Other diseases including rheumatoid arthritis, inflammation of the arteries at the sides of the head, infections and tumors can also cause these symptoms. Appropriate tests for these diseases are undertaken as necessary.

Treatment

Treatment of temporomandibular joint dysfunction (TMJ) often involves a team of specialists for best results. Dental specialists help with splints applied in the mouth. Injections of anesthetic medications around the muscles over the joint can be helpful in reducing the pain from TMJ dysfunction. Nerve block treatments to help reduce pain in regions of the head, neck and shoulders related to this disorder are also helpful in long-term treatment. Physical therapy methods to reduce muscle irritability in the jaw as well as in the neck and shoulders are also useful treatments for TMJ dysfunction. The utilization of biofeedback training and relaxation therapy in conjunction with these other measures can provide additional relief in selected patients.

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Carpal tunnel syndrome is a disorder affecting the middle nerve of the wrist. This nerve is important because it helps operate our hand and supplies sensation to the skin of the hand. This nerve can get pinched where it passes over the bones of the wrist and underneath a strong ligament through an area called the carpal tunnel. The tunnel and surrounding tissues can get inflamed from repetitive use. This inflammation causes the tissues to swell, which puts pressure on the nerve and results in nerve damage. This compression of the median nerve is called carpal tunnel syndrome. Carpal tunnel syndrome is common in people who use their hands for repetitive activity, such as meat packers, computer keyboard operators, mechanics, carpenters and hairdressers. It is associated with diabetes, pregnancy and rheumatoid arthritis.

Diagnosis

The symptoms of carpal tunnel are numbness, pain and tingling in the hand, which is confined to the thumb, index finder and middle finger. This pain can occasionally shoot up the arm as far as the shoulder. The patient may also complain of weakness in the hand and decreased grip strength. There are certain physical signs the doctor will look for when he examines the patient with possible carpal tunnel syndrome.  These are called Tinels and Phalens. During both of these tests, the doctor will stress the median nerve by either tapping it or bending the hand. He will look for increased symptoms and pain. The diagnosis can be confirmed with a nerve conduction study, in which the electrical potential of the nerve is recorded with a fine needle. The neurologist will look for a decreased velocity of conduction in the median nerve. If this is present, the diagnosis is confirmed.

Treatment

The mainstay of treatment with carpal tunnel syndrome is to avoid the activities causing the disorder. In addition, splints are prescribed to keep the hand and wrist straight, especially during sleep because the middle nerve is compressed when we bend our wrist. Many of us bend our wrists unconsciously at night while we sleep especially when we grasp a pillow. That is why it is so important to wear the splint at night. Injections of anti-inflammatory drugs into the middle nerve can help as well. If it is impossible to change our daily activities or if carpal tunnel syndrome does not respond to injections and splinting, surgery becomes an option. During surgery, the doctor will splint the ligaments that are binding the nerves. This is called a carpal tunnel release, which is done as an outpatient procedure under local anesthetic. The patient can be back home within a few hours. Carpal tunnel syndrome can be readily treated if it is diagnosed early. The results of treatment are usually good. It is important to work closely with your doctor when managing carpal tunnel syndrome.

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Constipation is defined as: Difficulty passing stool Incomplete passing of stool Infrequent passing of stool

Causes of constipation may include:

• Chronic use of medications
• Chronic use of enemas
• Diagnostic procedures
• Emotional stature Neuromuscular impairment
• Gastrointestinal lesions
• Immobility
• Inactivity
• Lack of privacy for personal habits
• Less than adequate intake of bulk
• Medication side effects
• Musculoskeletal impairment
• Obstructive lesions
• Pain on defecation
• Pregnancy
• Weak abdominal musculature fibers

Constipation in pain management is common as many patients receive opioids to manage their chronic pain. Opioids decrease the motility of the gastrointestinal tract, thereby delaying the passage of the stool. Tolerance does not develop to constipation as it does to the other side effects of opiates.

Diagnosis

Patients with constipation complain of:

• Abdominal pain
• Appetite impairment
• Abdominal pressure
• Back pain
• Feelings of fullness
• Hard formed stool
• Headache
• Inability to defecate
• Nausea
• Pain with defecation

Along with attaining the patient’s history, the health care provider can further determine constipation by noting the lack of bowel sounds, palpating the rectal mass, and palpating the abdomen for a mass. If the problem has been noted and addressed for a couple of days without resolve, the physician may order an abdominal x-ray to view the blockage and the cause of the blockage if visible.

Treatment

Constipation can be treated with a liberal diet of fruits, vegetables, and plenty of water.         These tend to increase the hydration in the stool allowing it to move more readily through the system. Exercise helps the colon to initiate movement to move the stool through the system. Stool softening medications may be recommended and/or prescribed by the physician.

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Spinal stenosis is defined as the narrowing of the spinal column around the spinal cord or nerve roots. The spinal column is composed of a number of structures. The most delicate of these is the nerves that make up the spinal cord and branch out into nerve roots. These nerves are protected by a combination of bones, disks and ligaments. The bones have a number of joints, called the facet joints, at every level of the spine. Studies show that spinal stenosis occurs when degenerative arthritis of these facet joints leads to calcium deposits on the interior spinal ligaments. When this is coupled with a bulging disk, the result can lead to compression of a nerve root, which then causes pain and irritation. Patients may limp as a result of the pain and the reduced blood flow to the nerves. Patients may notice these symptoms occur after they walk a short distance. Resting may help relieve the symptoms. Patients will also find themselves leaning forward or flexing the lower spine to help relieve irritation of the affected nerves. Sitting for a time may also help relieve the pain. Research shows that the pain from spinal stenosis can mimic pain brought about by other spinal disorders. For most patients the condition develops slowly over time. It is quite rare for the condition to be brought about by a single incident.

Diagnosis

Doctors will often find during a physical examination that a patient with spinal stenosis will have an abnormal gait pattern. There is usually tenderness over the affected portions of the spine, with restrictions in range of motion at the waist. Doctors will often utilize X-rays, such as a CT scan, to better study the joints and bony structures in the spine. For patients who may be facing surgery, a MRI or myelogram is sometimes used to better study the nerve structures within the spine.

Treatment

Nerve block treatments or injections of anesthetic medication with anti- inflammatory medications can be quite helpful in treating the pain. These are epidural injections and are usually given in a series of three treatments over a two to three week period. If the epidural injections are not helpful, the doctors may use a nerve block designed to reduce irritation from the joints of the back that can be contributing to the symptoms. The use of oral nonsteroidal anti-inflammatory medications in conjunction with pain medications may be useful as well.

Doctors may prescribe physical therapy exercises that will initially address flexibility and proceed to strength training exercises for the surrounding muscles in order to provide support for the affected parts of the spine. For some patients with spinal stenosis, surgery is a last resort to relieve pressure on the effected nerves in the spine. This is usually reserved for patients with neurologic weakness in the affected extremities.

Behavioral interventions, including biofeedback and muscle relaxation training, in conjunction with counseling are used for patients with recurring pain when all other methods fail.  The goal is to develop coping mechanisms to live more productively with the residual pain.

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