Do You Know That?
- almost every adult has experienced one or more brief episodes of musculo-skeletal pain associated with injury or excessive physical activity
- approximately 3.5 million Canadians experience musculo-skeletal pain
- more than 30% of the Canadian working population is experiencing some form of pain symptom

Have you ever sprained your ankle?
Burned your hand?

Then you know that pain is a message that tells us something is wrong with our body. The pain gives us a clue (and sometimes a solution) about how to deal with that problem. We put ice on our ankle and limit our walking for a few days- we put an ointment on the burn and keep it immobile until we can gradually move our fingers and wrist.
This type of pain is ACUTE- it has a quick onset and resolves within a short period of time.

Has anyone ever told you that they ‘know exactly how you feel’ when you are in pain?
Have they also suggested that they know ‘how you can get rid of
your pain’ ? (because something worked for them)

The fact is that no one knows exactly how to solve your pain problem. There are many reasons for people to be in pain and not all pain symptoms can be treated or managed the same way.

When pain has been a symptom for more than 12 weeks, it is referred to as CHRONIC or PERSISTENT.

This type of pain often does not seem to have a rhyme or reason. No matter what we do—it is still there. Resting or exercising for long periods of time seem to make little difference. In fact, sometimes it just gets worse.!!

You may have been told it is non-malignant soft tissue pain. The good news is your health professional has told you the pain is not dangerous….the bad news is that you still do not know how to control the pain and get on with your life.

 

What is Pain?
The International Association for the Study of Pain accepted a definition of ‘pain’ which was developed by Drs. Harold Merskey and Nicholas Bogduk. Pain is defined as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’.
That means that this experience is subjective—and it belongs to only you!
It also means that your body may or may not be injured or have a disease but it ‘feels’ as if it has been damaged in some way.
This definition of pain also suggests that the pain may also have some ‘emotional’ effect on you.
Pain is therefore strictly a message- a sensation that something is wrong or feels that it may be wrong with your body.

What is wrong?
The task ahead is to figure out what is wrong and what you can do about it. We experience different types of pain sensations because there are many bony and soft tissues in the body that have different pain receptors. These receptors are in muscles, ligaments, tendons, nerves and blood vessels.They can also be in the periosteum (tissue surrounding bone) and in our internal (visceral) organs.
Cancer pain sensations may behave differently.
The pain sensations experienced are ‘different’ because receptors respond to many factors- including movement, pressure, light or deep touch, temperature or barometric pressure.
The physiotherapists at The Downtown Clinic have treated patients with cancer (malignant) pain. However, the majority of Clinic patients are those experiencing chronic non-malignant pain.

What are you Feeling?
Because chronic pain is ‘always there’, it is easy to become overwhelmed and anxious about constantly being uncomfortable.
When you experience pain, ask yourself, what it ‘feels like’.
Try and separate the physical words (throbbing, burning, aching, stabbing, pins and needles) from the ‘emotional’ words (aggravated, angry, frightened, stressed out, frustrated).

What can you do?
Try and focus on something that will CHANGE the unpleasant (noxious) sensation.
If my arm hurts when I try and pick up a plate, can I slow down and think about what part of my arm hurts?
How high do I have to lift the arm before it starts to hurt?
Where does it hurt?
I may be able to soon figure out whether it is the movement of my arm or the weight of the dish that is increasing the pain.

Where Can I get Help?
It is well recognized in the medical literature today that in order to be effective, pain programs must be multi-disciplinary in nature. That means that no one health professional has all the answers to your problems.
It also means that, in order to make progress - you will have to become the most important member of your health care team.

There are few facilities in this Canada that can offer one site pain management programs. Even then, participation may involve long days away from your ‘routine’ and even overnight stays.

The physiotherapy staff at The Downtown Clinic has been helping people in pain for many years. They are experienced in being able to assist you find the community health care team that you need.

After an initial physiotherapy and counselling assessment, they will take the time to review their findings with you, make treatment recommendations, ensuring that you are involved in the process.
Health care services may then be co-ordinated with occupational therapists, psychologists, registered massage therapists and fitness personnel (not a complete list!)

The physiotherapist will also maintain a close working relationship with your family doctor, ensuring that appropriate medical investigations and assessments are carried out when necessary.

So—What Does Pain Management really mean?
Learning to control the different pain sensations you are experiencing to ensure they do not flare (or get out of hand) will allow you to improve your functional activities (and quality of life!).

Since pain is a 24/7 problem, applying pain management principles on a 24/7 schedule, is also important.

Current information on the physiology, anatomy and chemistry of pain will allow your physiotherapist to recommend thermal (hot/cold) and electrotherapeutic modalities for you to use throughout the day (and night). Using these modalities may allow you to better control the amount of pain medication you are taking.

Your physiotherapist may also recommend the application of hot or cold packs and try different pillows and supports with you. It is important that you become ‘as comfortable as possible‘.

Dampening (controlling, reducing the intensity) of the pain, will allow you to then concentrate on building strength and endurance in your muscles- so that you can return you to an improved level of function.

PAIN VS. SUFFERING
What is the distinction between pain and suffering? Aren’t they inevitably intertwined? Not necessarily. Julian Kalmar, www.thehappinessformula.com describes how a back injury which kept him supine for years, challenged him in a way that eventually changed and enriched his life. He provides a story that beautifully illustrates that pain need not always be connected to suffering

THE THREE LEGGED DOG
Once as we drove to the store, a three-legged dog limped by trying to keep up with two other dogs. As a six-year-old I became terribly sad for the poor dog.
When the master asked what was wrong, I told him. He said, “Oh, don’t worry about him, he’s perfectly happy. Don’t you see his wagging tail and happy smile?”
“Yes,” I said, “but he’s lost a leg. I feel so sorry for him.”
“Julian, that dog was probably hit by a car and was in terrible pain. A vet amputated his leg to save his life,” said the master. I felt a lump in my throat and started tearing up.
“Julian, if that dog felt sorry for himself, he’d be in hiding somewhere with his tail down. Look at him. He’s playing with his friends, tail in the air, sniffing things, and exploring. He’s too involved to care about his missing leg.” People mope around for months if they lose a leg. They keep thinking about all the things they can’t do. They ‘suffer’ more pain by keeping it going in their minds.”
“So that dog is smarter than most people. He’s doing what he’s always done, and he probably doesn’t even think about his leg.”
“Pain can’t be avoided sometimes, but suffering is a choice. We suffer when we dwell on pain. So always try to be like that dog: Focus on what you can do and do it.

But- When am I going to be able to do all the things I did before I started having all this pain?
Once you have developed improved control of your pain symptoms, you are better able to understand what is happening, and (are not so fearful or worried), you are now ready for the next step. EXERCISE!!

Your physiotherapist will work with you to develop an exercise program that will allow you to improve your range of motion as well strength while not ‘flaring’ your pain.

It is sometimes a slow and frustrating process (2 repetitions forward and 1 back).
However, because your body is now more ‘comfortable’ you will notice gradual improvement in both your ability to exercise and in your general activity level.

The Downtown Clinic holds weekly pool classes at Chelsey Park Health Club on Oxford Street. The shallow, warm water is a good medium to learn how to move sore or stiff joints and muscles. Patients can also use the whirlpool and sauna and progress their exercise program into the gym.
Many patients also become ‘members’ of a facility like Chelsey Park, to work on their program several times a week.

Achieving good strength and endurance is important for pain control.
Each exercise program is individualized and designed to meet the needs and the lifestyle of you- the patient.
Some people prefer to exercise at home, others may want to use a community fitness club or attend a Pilates studio.
Your physiotherapist will help you find both the suitable exercise program and the venue you enjoy.

When happens when I am discharged from Physiotherapy?
As you continue to make improvement, you will be seen by your physiotherapist less often.
But your therapist will constantly re-assess and review your progress- and your concerns. S/he will ensure that you have both the tools (exercise program, home devices) and contact with any health or fitness personnel that you need (registered massage therapist, personal trainer) to assist you in moving forward.

However, you are always able to make an appointment with your physiotherapist- any time you wish.
The philosophy of The Downtown Clinic is to ensure that you ‘are able to maintain your well-being throughout your life’.

Some people find that regular or occasional visits with their physiotherapist allow them to maintain this ‘well-being’.

Remember you do not need a medical referral to see a physiotherapist!

Web Links
Canadian Institute for the Relief of Pain & Disability www.cirpd.org
Canadian Pain Coalition www.canadianpaincoalition.ca
Chronic Pain Association of Canada (CPAC) www.chronicpaincanada.com
Canadian RSD (Reflex Sympathetic Dystrophy) Network www.canadianrsd.com
Endometriosis Support Network
(Fibromyalia) FM Network
Arthritis Society
Purdue Pharma (educational site) www.paincare.ca

ELECTRO-THERAPEUTIC Modalities

Because our body can ‘conduct electricity’, different types of electrical current have been used by physiotherapists for many years to treat acute and chronic pain conditions.

Electrical modalities used in physiotherapy clinics are safe and have first been designed and developed in research labs and investigated in clinical trials.

These non-invasive (no skin is broken), drug-free devices are used to modulate (settle down) pain symptoms. Generally the current in these machines increases the blood circulation, speeding up tissue healing (oxygen and other nutrients are carried to the injured site).
Different currents will also stimulate the production of hormones and neuro-transmitters (chemicals from different areas of the brain). Research has shown that serotonin, cortisol and endorphin levels are often increased after use of these modalities.

The overall effect is often a period of reduced pain, muscle relaxation and better joint movement.

Each type of modality will work on the nervous system a little differently. Your physiotherapist will discuss with you, the type of current that may be most beneficial for your pain problem.

All electrotherapeutic modalities have a few contra-indications- like pregnancy and pace makers. This will be discussed with you before any treatment is started.

Many of these devices are now portable, and designed for patients to use on their own. After a trial in the Clinic, you may be encouraged to use them at home to assist you in developing the 24/7 pain management schedule.

Interferential Current Therapy (IFC)
Interferential Currents

IFC can be used on both spinal (neck, upper and lower back) as well as peripheral (shoulder, elbow, knee, and hip) joints.
Four (4) electrodes are applied to the area to be treated. There are 2 settings that are used on the IFC, each for 20 minutes.
This type of current tends to penetrate quite deep into the tissues and has been helpful in for deep joint or muscle pain.
The treatment has been described by patients as ‘relaxing’ and having a ‘pins and needles sensation’…like an electrical massage

 

 

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS):
This high frequency and low intensity current is based on the Gate-Control Theory. Electrodes are placed on specific acupuncture points, on areas crossing the spinal cord (neck, mid or low back). Stimulation of this area, ‘closes the gate’ (in the spinal cord) and does not allow the pain (noxious) information to go to the brain.
TENS machines can be worn during the day- and afford some people good relief of symptoms so that they can stay at work and/ or manage their chores at home.
It can be safely worn for many hours a day.

ACU-HEALTH-TENS:
This portable hand-held battery device is a TENS unit with a pointer application. It allows the patient to stimulate acupuncture points ‘electrically’.
It is a very useful modality to help control head, neck and jaw pain. Stimulation of classical Chinese acupuncture points will also assist in relaxation and better control of pain sites that are often challenging to treat (endometriosis, repetitive strain injury).

For more information on TENS and IFC
www.spine-health.com

SYNAPTIC -2000
This machine works on the basis of what is called SEA technology. Synaptic Electronic Activation. It is a blend of continuous wide-band treatment frequencies of 400-40,000 Hertz and high intensity current output of up to about 57 milliamps. The resultant ‘treatment pattern’ has been described as pleasant and efficacious for most patients and usually affords a period of anaesthesia after treatment. The patient usually uses the machine while sitting. By controlling a hand-held ‘plunger’, the patient can gradually increase the intensity of current until such time as he/she ‘can no longer go any higher. Because of the high frequencies achieved synaptic can often stimulate and dampen pain receptors that are otherwise difficult to fin/touch.
Scientific studies are showing promising results in synaptic assisting with the control of difficult chronic pain conditions, including degenerative disc disease, whiplash and fibromyalgia. Some limited trials have been used with cancer patients.
www.synapticusa.com

CODETRON:
Codetron is a low frequency and high intensity current based on acupuncture-endorphin theory.
Seven electrodes are applied to various acupuncture points, specifically chosen for the condition to be treated.
The Codetron often produces a nice ‘chi’ effect without causing any burning or cutting sensations.
Treatment sessions are usually ½ hour in length,
Patients often experience an initial fatigue but reduced pain. Continiued use often allows the patient to feel like they have ‘more energy’, improves sleep patterns allows better pain control.
Codetron has been used in clinical trials showing good effects on the management of severe chronic pain conditions, including cancer.
www.receptrx.com
www.ncbi.nlm.nih.gov/pubmed/1353654

 

THERAPEUTIC ULTRA-SOUND:
The sound head of this machine produces sound waves in a frequency of 1-3 MHz. Ultra-sound gel is used on the skin to reduce friction and conducts the sound waves from the machine into the skin. During the treatment, the sound head is constantly moved, allowing penetration of the sound waves deep into the tissue. There is often a mild heating effect post treatment.

 

 

Talking to Your Doctor or Health Provider about Pain
Remember – the experience of pain is subjective and belongs to only you!

So when you go and see your doctor and talk about pain, you are giving him/her very little information, with which to help you.

If you have gone through child-birth, had a tooth ache or the flue, had surgery for any reason, then you know that we experience different types of pain sensations- for different reasons.

It is important for your doctor to help you differentiate between those very specific reasons for your pain - and what is referred to as non-malignant pain.
This ‘other’ type of pain is called non-malignant (and not benign) because although the good news is that it is not caused by a serious problem such as cancer, the bad news is that it is definitely having a significant effect on your ‘quality of life’…. i.e. your ability to do what you want to do, including sleep!

When you are describing pain which is (probably) caused by muscle and ligament sprains, bone or joint pain or even pain caused by nerves or blood vessels, help will be received faster if you can be more specific about what you are feeling….
A few suggestions!

Do NOT (only) use the word PAIN when you are talking to your doctor.
DESCRIBE what you are feeling- aching, stabbing, shooting, heaviness, weakness, pins and needles, numbing, cramping, and burning.
Then try and explain when this type of PAIN gets worse- i.e. the ache in my right shoulder is worse when I am throwing a ball (when the arm is above shoulder level)
i.e. the cramping in my left foot is worse after I have walked for 15 minutes.

Can you now try and figure out what will CHANGE the pain?
i.e. when my arm is supported on a pillow or table, I have less pain in my right shoulder
i.e. when I stretch my calf muscles, the cramping in my foot eases a little

Working with your doctor to figure out the reasons for your ‘non-malignant pain’ – may be less frustrating if you can start to talk to each other this way.

Medication for Pain Management:

It is important to continue to remind yourself that NOT ALL PAIN SENSATIONS ARE THE SAME. It goes without saying therefore that YOU CANNOT TREAT ALL TYPES OF PAIN WITH THE SAME TYPE OF MEDICATION.

It is estimated that approximately 30% of the Canadian population have daily chronic (more than 3 months) pain. Obviously, many people work with and function with their pain relatively well. Only a small percentage of people will be disabled by pain.

Although physiotherapists rely primarily on conservative methods to treat and manage pain (heat, ice, water, electrotherapy, exercises, massage, spinal mobilizations), the additional use of appropriate pain medication may be essential for good treatment results.

Drug therapy has changed greatly in the last decade. Pain research scientists have been able to find the reasons for ‘different’ types of pain sensations (bone, nerve, blood vessels, muscles); and the pharmacologists have been able to develop medication that will ‘target’ the specific sites in the brain and spinal cord , (where this medication is metabolized or used) .
So medication may be for pain only, others for the inflammatory process associated with pain, others to correct the chemical imbalances in the brain caused by disruptive sleep, others for depression and anxiety symptoms which often accompany the pain.

Some people tolerate certain medications better than others and side effects have to be carefully monitored. It may be that dosages of medication need to be modified or a total change in a type of medication is needed if there are too many adverse effects.

Many people are frightened about the use of narcotics for effective pain relief. Narcotic options, including the use of opiodes and canniboids, may be the most effective pain medication for certain types of pain conditions.
When you are in ‘pain’, your brain literally does not produce your ‘usual or normal pain medication’ (which have specific sites on your brain). Appropriate use of medications, will attach to these sites , reducing the chance that you will get ‘addicted’ to this type of medication.
Your doctor is able to screen and monitor you carefully; titrating (incrementally increasing) the amount of medication that has the best effect for you.

The following is an excerpt from an article printed in the London Free Press on November 28, 2007 entitled Oxy-contin provides important benefits, written by Dr. Patricia Morley-Forster and Dr. Harold Merskey

“ Oxy-Contin is one of the leading long-acting opiods (narcotics) for people with severe intractable pain. Three percent of the general population experience intense burning pain from damage to the nervous system caused by diabetes, stroke, herniated discs, and severe pain from arthritis and muscular-skeletal disease. All medications have risks and benefits. The harm that they can cause has to be weighed against the good that they can do. The risk/benefit ration for Oxy-Contin and several opiods favours the medication and does not favour or precipitate withdrawal or undue restriction of any such drugs”.

www.emedicinehealth.com/pain-medications/page5_em.htm

 

Whiplash / Neck Injuries
The term whiplash is usually used to describe trauma to the neck caused in a motor vehicle accident (car, bus, motorcycle).

Whiplash however is a very general term that only describes the movement pattern of the neck. This movement ‘beyond its normal range’ often causes stretching or tearing of the soft tissues in the neck region.

A ‘whiplash’ injury can therefore be caused by a fall –such as from a bicycle, horse, or down the stairs. It can also be caused by head-banging, from shaken baby syndrome or even when on those ‘spinny’ rides at an amusement part.

Neck injuries caused in MVAs have been also called hyper-extension / flexion injuries and more currently are referred to as acceleration-deceleration injuries (stop-start). Because there are many factors influencing the extent of the injury and because no two people are exactly the same, the initial examination is very important.
Symptoms and treatment willbe influenced by knowing which direction the person was hit, where they were sitting in the vehicle, what type of impact was sustained as well as the injured person’ immediate symptoms (? was it pain, or headaches, or back pain or nothing at all)

Whiplash patients usually present with some type of pain in the neck and shoulder blade region. The pain may travel down the arms and cause some weakness and/ or pins and needles.
Associated symptoms may include headaches, balance disturbances, visual problems, hearing loss, tinnitus (ringing in the ears), jaw pain (tempero-mandibular joint dysfunction and swallowing difficulties).

The exact cause of whiplash and its associated symptoms is not often clear. Mild injuries (sprain or strain) may result from overstretching of the ligaments in the neck (the main culprit we think is the anterior longitudinal ligament).

More severe injuries may be resultant from muscle or ligament tears or even fractures in the cervical vertebrae.

Unfortunately, a small percentage of patients die as a result of severe neck trauma. At autopsy, tears and breaks that have been missed- even with MRI imaging can be seen. So don’t tough it out ---go and get appropriate treatment!

It is not uncommon for the patient not to feel very much discomfort for a day or 2 after the accident. They may then notice that they have difficulty lifting their head off the pillow!

A whiplash may be only 1 of the types of injuries sustained in an MVA.The force of the impact travels down the spine, and seat-belts, head restraints and air bags may save you- but also the ty. Associated injuries often include those to the chest, upper or lower back pain, as well as injuries to the arms and legs

Early management of whiplash-type injuries is important for good recovery. Understanding what you can do to settle the acute symptoms and learning how to modify your activities will help you get better faster.
It is important to tell your doctor that you have been involved in a car accident. He/she may want to have x-rays or other investigations done to rule out any fractures.

You do not need a medical referral to see a physiotherapist- and you can begin your recovery program immediately!

www.uihealthcare.com/topics/medicaldepartments/orthopaedics/whiplash/index.html

http://backandneck.about.com/od/bodymechanics/a/whiplash.htm

www.ninds.nih.gov/disorders/whiplash/whiplash.htm

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