Pain Evaluation & Management
The basic concept of Fluidity of Paradigms is required for the understanding and treatment of Chronic Pain. By Definition, an injury results in an initial (1) Anatomical and/or Physiological Alteration. With injury comes the body's protective reactions, (2) Mechanical Splinting and general "Slowing Down" to rest and promote healing, (resulting in shortening of muscles and deconditioning). (3) A Learned Response, to prevent further injury to the organism (Cognitive/Psychological Response), then can compromise a complete return to pre-injury function.1. Anatomical:
The professional staff at Medical Rehabilitation Associates provides expert diagnostics and treatment. Electromyography (EMG) identifies neurological disorders such as carpal tunnel, diabetic neuropathy, and radiculopathy (herniated disc "pinching" nerve). MRA boast as having the largest number of Board Certified Electromyographers in New England. MRIs, x-rays, and laboratory studies, when obtained, are carefully reviewed with the patient.
Treatments approaches include: joint injections for arthritis and impingement syndromes, muscular injections such as trigger points, discograms which evaluate herniated discs, and epidural injections for pinched nerve pain of the low back.
The Hippocratic oath notes first a need to ease pain, then diagnose, and then treat. Our multidimensional physicians can combine traditional and complementary (acupuncture, herbal, and homeopathy) treatment.
Use of time-released narcotics is encouraged by the Academy of Pain Medicine and is frequently utilized when other treatments have failed. Other pharmaceuticals often prescribed include serotonin medications (with pain comes serotonin depletion, and poor sleep reduces serotonin production with resultant increased pain and a sense of helplessness and depression). Anticonvulsants (which decrease nerve irritability resulting in fewer painful nerve transmissions) and nonsteroidal anti-inflammatory medication, including the recently developed "COX-2" drugs, which can be used with diminished risk of developing intestinal and bleeding disorders, are often prescribed.
Other "High-Technology" treatments in which our physician team participates include intra-spinal implantation of neuro-electrical stimulators and pumps. Implanted devices with variable computer programs can now be programmed with telemetry. We provide services to the Neuro-Modulation Clinic at St. Mary's.
2. Mechanical Splinting and general "Slowing Down":
The body has tremendous regenerative qualities. The rehabilitation phase reconditions that which is nearly or totally healed. Imperfect healing (permanent anatomical problems which persist) will and can occur (amputation, permanent nerve or vascular injury, bone callous, loss of intervertebral disc space) and will require not only improving (1) range of motion, (2) strength, and (3) endurance, but also (4) adaptation with new techniques and adjustments.
A State of Wellness Requires a Proper Balance of Physical Activity and Rest. When this balance is upset in either direction, serious malfunctions are likely to occur. Whenever short, deconditioned muscle undergoes stretching, strengthening, and finally endurance training - Pain Occurs. This form of pain is known as "Delicious Pain" and can be misconstrued as damaging if a patient does not understand the rehabilitation model. Our physicians provide medical guidance to hospital inpatient and outpatient rehabilitative services. We also provide physical therapeutic services (athletic trainers and exercise physiologists) in most of our office locations.
Therapy should be active and not passive. Passive modalities (heat, ice, TENS, iontophoresis, vibration, biofeedback, traction, compression, massage, electrical stimulation, orthotics, and ultrasound) focus on edema control and relaxation of painful areas. Such therapeutic modalities can enhance quality of life by decreasing perceived pain scores. Passive modalities however only provide temporary improvement. With pain comes edema and shortening, weakening and decreased endurance of muscles. Modalities do not correct these problems. Although a patient may demonstrate decreased pain scores after modality treatment, pain returns if function (movement, strength, or endurance), is required at the painful site.
Passive modalities may be useful early in treatment or as an adjunct, but generally should be discouraged in favor of therapy that is functionally oriented and encourages patient independence. Just as the diabetic learns to drawn their own blood, (as a lab technician would), learns to identify appropriate insulin dosage (as a physician would), injects their own insulin (as a nurse would) and understands a low carbohydrate diet (as a dietician would), a patient with chronic pain can learn to function more independently and handle the various day-to-day aspects of managing their condition. With appropriate patient education and training, a healthy reduction of dependence on prolonged passive interventions can occur.
3. A Learned Response:
Following an injury, an emotional reaction will occur. An animal jumps (muscular response) after being kicked. It then sizes up the situation and either shruggingly shirks away into the shadows or gnarls its teeth to fight and bite back. Any injury requires emotional involvement for preservation of the individual and ultimately the species.
Emotions rarely remain isolated. Pain results in emotional stress and emotional stress results in increased blood flow and pressure, increased muscle tension, poor sleep, and further anxiety. Our Biobehavioral team offers integrated emotional support, stress reduction techniques, biofeedback, and group educational sessions with other clients.
Summary
Chronic pain often results in a major dramatic impact in ones life. Pain often becomes the center of the patient's life and activity. Our goal is to diagnose and treat the anatomical basis of pain and, at the same time, undo the "confounding" of symptoms by looking at the additional paradigms or rehabilitation and psychological stressors.