Pain Management

Question: What are some ways to manage pain?

Answer: From http://www.orthop.washington.edu. Written for people with arthritis, but a lot of it is applicable equally to RSI. There are a number of other relevant articles at the same site, e.g., on stress management, exercise programs, ways to accomplish ordinary activities without pain, etc.
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Pain Management
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In general, pain is your body’s alarm system. It tells you something is wrong. When part of your body is injured or damaged, nerves in that area release chemical signals. Other nerves act like tiny telephone wires and send these signals to your brain where they are recognized as pain. Pain “tells” you that you need to do something. For example, if you touch a hot stove, the pain signal makes you pull away your hand to prevent further injury. This type of pain is useful because it is your body’s way of protecting you from further injury.
Long-lasting pain, for example the pain of arthritis, is a bit different. While it is also an alarm that tells you something is wrong, it often isn’t sufficiently relieved when you treat it. Controlling this type of pain is important since it can disrupt your life.
The methods used to control short-term (Acute) pain, such as strong painkillers, are not useful for controlling the long-lasting (chronic) pain of arthritis. Other methods, such as those listed in this program, can help.
Arthritis pain is caused by:
* inflammation, the process that causes the redness and swelling in your joints
* damage to joint tissues caused by the disease process or from wear and tear
* muscle strain caused by overworked muscles attempting to protect your joints from painful movements
* fatigue caused by the disease process, which can make your pain seem worse and harder to handle
The Pain Cycle
Along with physical changes, the emotional ups and downs of arthritis can also add to your pain. If you feel depressed and stressed, your pain may seem worse. You can get caught in a cycle of pain, depression, and stress that makes everything seem harder to handle.
To understand how people experience pain, it is important to understand two facts:
* Everyone reacts to and manages pain differently.
* How you deal with pain can affect how you feel your pain.
People react differently to pain for many reasons:
Emotional and social reasons: Your fears about pain, previous experiences with pain, and your attitude about your condition can affect how you react to pain and how much pain you feel. Your cultural and religious background, and the way people around you react to pain may also affect how you react to pain.
Physical reasons: The sensitivity of your nervous system and the severity of your arthritis determine how your body reacts chemically to pain. These factors also determine whether your nerves will send or block a pain signal.
Despite these differences, you can learn to better manage your pain. Many people with arthritis have discovered that with will power, skill, and practice, it is possible to take the pain in stride.
There are many ways to help control pain. Some pain control methods focus on emotional and social factors. Other methods focus on physical factors. Using a combination of methods is often the best way to control your pain.
Pain Signals
Many scientists think pain control methods help reduce pain by blocking pain signals. The signals are sent through a complex system of nerves in the brain and spinal cord. There are many things that can block these signals and thus prevent the pain message from reaching your brain.
What makes your pain feel worse?
* stress
* dwelling on pain
* fatigue
What blocks pain signals?
* heat or cold treatments
* physical therapy
* positive attitude
* exercise
* relaxation
* some medicines
* Massage
What Blocks Pain Signals?
Pain signals are blocked by chemicals made by the brain, called endorphins. There are several things that can cause the brain to produce endorphins. These include “natural” controls, such as your own thoughts and emotions or “outside” controls, such as medicines. Here are some examples.
Natural controls: A father, driving with his children, is hurt in a car accident. The father is so worried about his children that he doesn’t feel the pain from his own broken arm. The concern for his children somehow blocked the pain signal and kept the pain from affecting him.
Outside controls: Certain medicines, such as morphine, imitate the body’s endorphins and block the pain signal. Other pain control methods, such as heat and cold treatments, physical therapy, exercise, relaxation, and massage can stimulate the body to release its own endorphins or to block the pain signal in other ways.
There are many things you can do to help control your arthritis pain. The goals of these methods are to control pain by:
* learning new ways to reduce pain
* taking as few pain medicines as possible
* changing pain habits that disrupt your normal lifestyle
* increasing your physical and social activity so you can return to an active life, as much as possible
The methods listed here will work differently for different people. So, some methods may work for you, but some may not. Some methods are things you can do for yourself. Others require help from your doctor or other health professionals. Talk to your doctor about these methods. With a little practice, you will find the right ones for you.
Taking Control
Your mind plays an important role in how you feel pain and in how you respond to illness. People with arthritis often feel helpless and depressed about their condition. With these feelings, come decreased activity, poor self-esteem, and increased pain. So, building a sense of control by adjusting your thoughts and actions is an important part of pain management.
Below, are some ways you can take control of your thoughts and actions to help control your pain. Thinking differently may not get rid of your pain entirely, but having a more positive attitude can help. Many of these methods are easier said than done. But with practice and patience, you can master them, too.
Keep a positive attitude: Having arthritis and the pain that goes with it can lead to a life built around pain and sickness. One way to reduce your pain is to build your life around wellness, not pain or sickness. Live what is called a “wellness lifestyle.” This means to think positive thoughts, keep a sense of humor, eat a balanced diet, exercise every day, and enjoy activities with others. It also means following your treatment plan, taking your medication properly, and practicing relaxation. Many people with arthritis are already doing these things and feel good about themselves. Arthritis can limit you, but it doesn’t have to control your life. Talk to your doctor, nurse, or therapist about how you can make your life more healthy. Get involved in a favorite activity or hobby. Remind yourself of what you can do rather than what you can’t do. You’ll feel better and your pain will not seem as severe.
Don’t dwell on your pain: How often do you think about your pain. The amount of time you spend focusing on it has a great deal to do with how much discomfort you feel. People who dwell on their pain usually say their pain is worse than those people who don’t dwell on it. One way to take your mind off the pain is to focus on someone or something else. Everyone has the ability to be distracted. The more you focus your attention on something outside of your body, the less you will be aware of physical discomfort. For example, get involved in an activity or hobby you enjoy, develop a new interest, or get involved with helping others. If you can’t help but think about the pain, try to think about it differently. Think of the pain as your body’s message to do something different.
Change your pain habits: It’s easy to slip into the habit of drinking alcohol or taking more medicines to escape your pain. If you answer “yes” to any of the questions below, you may need to find new ways to handle your pain.
* Do you drink alcohol several times a day?
* Do you use up pain medication faster than you used to?
* Do you spend all day in bed?
* Do you talk about pain or arthritis much of the time?
Changing your pain habits will help you feel better. One way to make a change is to do something positive in place of the old habit and to reward yourself. Discuss these habits with your doctor, nurse or other health care workers who specialize in pain management. Ask them to help you find new ways to cope with your pain.
Create a pain management plan: You can make a chart of your own pain control methods. This will help you keep track of which methods you have used, and which ones work best for you. Make a chart like the one located at the back of this program. Adapt it often. Post it where you can refer to it often, such as on your refrigerator or medicine cabinet.
Heat and Cold Treatments
Using either heat or cold treatments can reduce the stiffness and pain of arthritis. Cold packs numb the sore area. They are especially good for severe joint pain and swelling caused by a flare (a period during which disease symptoms return or become worse). Heat treatments relax your muscles. You can use dry heat methods, such as a heating pad or heat lamp, or moist heat methods, such as a bath or hydrocollator pack.
Here are more ways you can use heat or cold treatments.
Heat
* Soak in a warm bath, shower, Jacuzzi, or whirlpool.
* Place a heating pad on the painful area. Don’t sleep with the heating pad on, because you might burn yourself.
* Use an electric blanket or mattress pad. Turn it up before you rise, to combat morning stiffness.
* Use flannel sheets. They feel warmer against your skin.
* Use a hot water bottle wrapped in a towel to keep your feet, back, or hands warm.
* Before getting dressed, warm your clothes by placing them on top of the dryer for a few minutes.
* Place hot packs on the painful area. These are filled bags that are heated in water and covered with a towel. Be careful not to let the pack get too hot.
* Dip your hands in a paraffin bath. This is a mixture of melted paraffin and mineral oil. The warm coating soothes stiff, painful fingers. Ask your doctor or therapist about this method.
* Use a combination of heat and cold. This is called a contrast bath. Soak your hand or foot in warm water, then cold water, then warm water again.
Cold
* Place a cold pack or ice bag on the painful area. You can buy these at the drug store or you can make one by wrapping a towel around a bag of frozen vegetables.
Before using:
* Your skin should be dry and healthy.
* Protect the skin over any bone that is close to the surface of your skin. Place extra padding over the area to prevent burning or freezing your skin.
After Using:
* Check the area for any swelling or discoloration.
* Carefully dry the area.
* Gently move your joint to reduce stiffness.
* Allow your skin to return to normal temperature before using another treatment.
Use Heat or Cold Safely!
Do:
* Use either heat or cold for only 15-20 minutes at a time. Let your skin return to its normal temperature before using another application.
* Always put a towel between your skin and any type of pack.
* Always follow the advice of your physical therapist or doctor carefully when using these methods, specially heat.
* Check your skin before and after using heat or cold.
* Use milder temperatures for a child’s skin, because it is more sensitive than an adult’s skin.
Don’t:
* Do not use either heat or cold if you have open cuts or sores.
* Do not use cold packs if you have poor circulation or vasculitis.
* Do not use heat that is too hot or cold that is too cold. It is normal for your skin to appear pink after using a hot or cold pack. If an area appears dark red or spotty red and white, there may be some skin damage. Blisters also appear if the pack was too hot or too cold.
* Do not use creams, heat rubs, or lotions on your skin while using a hot or cold treatment.
* Do not make your bath or shower water too hot. This may cause dizziness or fatigue.
* Do not use an electrical device unless it is UL approved.
Exercise
Another key to coping with pain is to follow an exercise program designed by your doctor or physical therapist. Your program should include special range-of-motion exercises to help keep your joints movable. It should also include general fitness exercise, such as swimming or walking. These help keep your heart, lungs, bones and muscles strong. Exercise also helps relieve stiffness and gives you an improved sense of well-being. Here are some tips to help you exercise properly:
* If you have a flare, do only gentle range-of-motion exercises.
* Start with just a few exercises and slowly add more.
* Listen to your body. If it hurts too much or if you begin to have too much pain, stop the exercise. Ask your doctor or therapist to help you learn the difference between normal exercise discomfort and too much exercise pain.
* Ask your local Arthritis Foundation office about joining a supervised, warm water or land exercise program. Many people find exercising with a group is fun as well as healthy!
* For more information about exercise, read Exercise and Your Arthritis, available from your local Arthritis Foundation office.
Using Your Joints Wisely and Saving Your Energy
Using your joints wisely means doing everyday tasks in ways that reduce the stress on painful joints. Saving your energy means “listening” to your body for signals that it needs to rest. It also means learning to pace yourself so you don’t become too tired. Here are a few guidelines for using your joints wisely and for saving your energy:
* Be aware of your body positions. Avoid activities that involve a tight grip or that put too much pressure on your fingers. Use self-help devices, such as jar openers, reach extenders, zipper pulls, and buttoning aids. These aids put less stress on your joints and make difficult tasks easier.
* Use your largest and strongest joints and muscles. For example, use a shoulder bag to carry items. This protects painful elbow, wrist, or finger joints. When you lift or carry objects, spread the weight of the object over many joints. This prevents you from placing too much stress on one joint.
* Avoid holding one position for a long time. Move or change positions often. Keeping joints in the same position adds to joint stiffness and pain.
* Balance rest with activity. Learn to understand your body’s signals that you’re getting tired. Take breaks when you need them. Don’t wait for the physical signals of pain before you rest. Plan your schedule to alternate activity with rest – even when you are feeling well!
* Respect pain. If you have pain that lasts for two hours or more after completing an activity or exercise, then you’ve done too much. Next time, do a little less or go about it in a way that takes less effort.
* Simplify your work. Plan ahead, organize, and create short cuts. Use labor-saving devices, such as an electric can opener or electric garage door opener, that require less energy on your part and place less stress on your joints.
* Ask for help when you need it. Family and friends would rather help you than have you become too tired or ill from doing too much.
* Read Using Your Points Wisely, available from your local Arthritis Foundation office.
Splints
If a joint is very swollen and painful, your doctor or therapist may suggest you use a splint to rest the joint. This helps reduce swelling and pain. Your doctor may recommend that you wear the splint during certain activities, all day, or only at night. This depends on how severe the swelling or pain is.
Sleep
Getting a good night’s sleep restores your energy, so you can better cope with the pain. It also rests your joints, to reduce the pain and swelling. Only you know how much sleep your body needs, so get into the habit of listening to your body. If you feel tired and ache after lunch every day, for example, take a brief nap. This can help restore your energy and spirits. If you have trouble sleeping at night, try relaxing quietly in the afternoon rather than taking a nap. Here are some other tips to help you sleep better:
* take a warm bath before going to bed
* listen to soothing music or a relaxation tape
* spend some quiet time by yourself before you go to bed
* read
Do not take sleeping pills unless your doctor recommends them.
Massage and Topical Lotions
Massage increases blood flow and brings warmth to the sore area. You can massage your own muscles or you can ask your doctor to recommend a professional who is trained to give massages. If you have arthritis in your shoulders, elbows, wrists or fingers, you may not be able to give yourself a massage. When giving yourself a massage, use lotion or oil to help your hands glide over your skin. Menthol gels also provide a comforting tingle that can further ease the painful area.

Topical “deep-heating” rubs may contain medicines that block the sensation of pain. Or, they may increase blood flow in the skin where they are applied, and distract attention from the painful muscle or joint. Usually, these ointments do not penetrate very deeply into the skin. Therefore, claims that the active ingredients go directly to the joints and relieve pain are not true.
Tips for Safe Massage
* When doing self-massage, stop if you have any pain.
* Don’t massage a joint that is very swollen or painful.
* If you use a menthol gel for massage, always remove it before using a heat treatment-otherwise you might burn yourself.
* If you have a professional massage, make sure the massage therapist has sufficient knowledge about arthritis.
Relaxation
People who are in pain experience both physical and emotional stress. Pain and stress both have similar effects on the body. Muscles become tight and breathing becomes fast and shallow. Heart rate and blood pressure go up. Relaxing can help you reverse these effects. It gives you a sense of control and well-being, and makes it easier to manage pain. Relaxation is more than just sitting back, reading, or watching TV. It involves learning ways to calm and control your body and mind. Relaxation does not come easily, especially if you are in pain. It takes practice. The best time to use relaxation skills to manage your pain is before the pain becomes too intense. There is no best way to learn how to relax. Everyone responds differently to different techniques. Try some of the methods below until you find some that work for you.
Guided imagery uses your mind to focus on pleasant images. First, begin by breathing slowly and deeply. Think of yourself in a place where you feel comfortable, safe, and relaxed. This may be a favourite vacation spot, or a porch swing in your own backyard. Create all the details -the colors, sounds, smells, and how it feels. These images take your mind away from pain and focuses it on something more pleasant.
Prayer is very relaxing and comforting for some people. You may want to make a tape recording of a soothing inspirational message.
Hypnosis is a form of deep relaxation in which your attention is focused internally-away from the usual thoughts and anxieties. You’ll need to work with a professional trained in hypnosis, who has been referred by your doctor. Some psychologists, counselors, or social workers who are trained in hypnosis may be able to teach you how to safely hypnotize yourself.
Suggestions for positive change seem to be more easily accepted while a person is quiet and relaxed. Most people who find hypnosis helpful in relieving pain, report it as soothing and enjoyable as well.
Biofeedback uses sensitive electrical equipment to help you be more aware of your body’s reaction to stress and pain, and to learn how to control your body’s physical reactions. The equipment monitors your heart rate, blood pressure, skin temperature or muscle tension. These body signals are shown on a screen or gauge so you can see how your body is reacting.
Biofeedback helps you learn how you feel when your muscles are tense or relaxed. If you do a relaxation technique while using the equipment, you can learn to control some of your body’s responses to pain. One advantage to biofeedback is that it shows you that you have the ability to relax.
Relaxation audio tapes help guide you through the relaxation process. These tapes provide directions for relaxation, so you don’t have to concentrate on remembering the instructions. Many professional tapes are available for purchase. You might also want to make your own tape of your favourite relaxation routine.
Tips for Relaxing
* Pick a quiet place and time. Take at least 10 minutes for yourself with no noise from TV, radio or other people. Use soft music to muffle other noises.
* Sit or lay in a comfortable position with your head supported and your eyes closed.
* Take a deep breath. Feel your stomach move in and out with each slow, deep breath.
* Continue to breathe deeply and slowly, focusing on just your breathing.
* Try thinking about words such as “peace” or “calm.”
* Don’t worry about whether you reach a deep level of relaxation. Allow the relaxation to go at its own pace.
* Other thoughts will come into your mind. Don’t try to chase them away, but just quietly go back to your breathing. Concentrate on relaxing and staying calm.
* Do not practice right after a meal. If you fall asleep, don’t worry. Next time, try to stay awake the entire time.
* Set aside time regularly to practice! Then, relaxation will become easier.
Some people find it very difficult to relax. They feel they don’t have time to practice it, or they don’t believe it will help them. Others feel embarrassed for taking the time. With a little practice, most people get some relief from relaxation.
Transcutaneous Electrical Nerve Stimulation (TENS)
TENS helps reduce pain for some people with arthritis. It is a small device that uses mild electric pulses to stimulate the nerves in the painful area. This blocks the pain message in several ways. To use a TENS machine, electrodes are taped on the skin near the painful area. These electrodes are connected by wire to a small, battery-operated stimulator. TENS doesn’t hurt, but it may cause some tingling. Usually it feels like vibration or tapping. TENS works for some people, but not for others. Talk to your doctor or therapist about whether TENS might help you.
Support Groups
Sharing your feelings and experiences with a group can make living with arthritis easier. The basic goal of a support group is to give you a way to share and learn about arthritis. A group also helps you to feel understood, and can give you new ideas to help cope with problems. It can also help you feel good about yourself because you’ll be helping others in the group. Groups may be run by professionals or they may be self-help groups led by people with arthritis. Some groups focus on pain control. Others have no certain topic but work with people who have different types of problems. Contact your local Arthritis Foundation office or ask your doctor about local groups for people with arthritis or people with pain. Sometimes you can help yourself with the help of others like you.
Counseling
Any major disturbance in your life- such as illness or chronic pain-may make you feel anxious, depressed, angry, or even hopeless. Many people become depressed when they have severe pain. Some people feel so bad they cannot sleep or eat. In these cases, therapy or counseling may help.
Some people are afraid to admit they need help. They believe that others will think they are crazy if they talk to a professional about their problems. But it’s smart to get help when you need it. If you have the symptoms of depression-poor sleep, changes in appetite, crying, sad thoughts-talk with your doctor.
Some psychologists or counselors are specially trained to work with the emotional side of chronic health problems like arthritis. These people can also teach you how to manage stress. Pain is stressful. If you have increased stress, you may feel more pain. So, learning to manage stress can also help you manage your pain. There are many people who can help you manage your arthritis pain.
Your Health Care Team
This is your first place to turn for help. The team includes your doctor and a nurse. It may also include an occupational therapist or a physical therapist, a social worker, counselor, psychologist, and a pharmacist. Talk to the members of the team about ways to cope with pain. They may be able to help you find services in your area. Don’t be afraid to suggest to your doctor a pain management idea of your own, or one from this program. You know yourself and your pain better than anyone.
Pain Clinics
Pain clinics specialize in treating pain. They may be located in a hospital or may operate independently. Some clinics treat all types of pain. Others specialize in treating certain types of pain. And some clinics specialize in certain types of treatments. The clinics can’t cure your health condition, but they may help you to learn better pain management skills. Ask your doctor about pain clinics in your area.
Pain can be the hardest part of having arthritis. But there are many things you can do to help control it. Don’t give up if the first methods you try don’t work. Try other methods. You can often get the greatest pain relief by using a combination of methods. Researchers are looking into ways to control pain. They are finding ways to block pain at the site of the injury. They are also finding new ways to harness the body’s natural pain relief system. Contact your local Arthritis Foundation office for more information about arthritis and pain. The following programs and booklets may be useful.
Programs
* Arthritis Self-Help Course: a six-week program that teaches you about arthritis and self-care skills, such as relaxation.
* Arthritis Foundation YMCA Aquatic Program: recreational exercise classes conducted in warm water.
You may be interested in some related topics:
* Exercise and Your Arthritis
* Joint efforts
* Diet and arthritis
* Managing fatigue
* Managing pain
* Managing stress
* Sex and arthritis
* Arthritis “remedies”
* Guide to Medications: How to Use Them Wisely
* Taking Charge: Learning to Live with Arthritis
* Using Your Joints Wisely
Adapted from the pamphlet originally prepared for the Arthritis Foundation by Robert L. Swezey, MD, FACP, FACR, and Beth A. Ziebell, PhD. This material is protected by copyright.


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