Pain is the driving force that brings patients to see doctors. Patients often tolerate a certain amount of pain thinking “it will pass” or “it’s not that bad”. When the pain reaches a threshold point or the duration of pain isn’t lessening, the patient will finally make an appointment.
There is more than one type of pain. The routine type of pain we deal with in life is nociceptive pain. A sprained ankle, low back sprain or muscle injury are classic examples of nociceptive pain. Nociceptive pain can be very significant and requires health care support. Conservative care for nociceptive pain can range from bracing, casts, movement, rehabilitation, manipulation, soft tissue mobilization, acupuncture, nutritional support, or referrals to a pain management specialist for pain medication to ease the suffering during the healing phase.
Post-operative pain is commonly managed by pain medication from a pain management specialist or the surgeon. Pain can be co-managed with acupuncture, which can reduce pain and also reduce post-anesthesia nausea. Movement can also reduce pain. Some surgical procedures can have early, gentle post-operative motion of a joint. Equally gentle soft tissue mobilization can also reduce pain and muscle guarding or tightness. Psychology, or sports psychology may also useful to help a patient manage post-operative expectations of his/her return to sports or activities.
Neuropathic pain is different than nociceptive pain. Neuropathic pain is an inappropriate response by the nervous system. The nervous system generates pain that typically outlasts the healing phase. The pain is no longer coming from tissue that was damaged in the injury. The pain should have resolved, but in fact it has not stopped and is most likely increasing. This pain can be severe and debilitating. Patients often, but not always, have burning pain, extreme sensitivity to touch, worsening symptoms with exercise or movement, hypertonic muscles resulting in loss of range of motion, find pain medication offers little relief, may find migration of the pain to other parts of the limb or other parts of the body, and may become worse if the patient experiences any other pain. Many patients have found that their numerous doctors don’t believe their symptoms, level of pain, movement that worsens the pain, sensitivity to touch, flare-ups with therapy effort, or lack of response to pain medication. This pathology can be very frustrating to patients and doctors alike.
There are many forms of neuropathic pain and the published literature is divided in defining the categories and their inclusion criteria. One form is called complex regional pain syndrome (CRPS). There are three primary diagnostic guidelines that do not have a consensus. There are other papers that point out that the patients who have atypical CRPS cases don’t meet the diagnostic criteria and are then denied appropriate care. Other terms such as sympathetic maintained pain (SMP), sympathetic independent pain (SIP), and non CRPS neuropathic pain have evolved. The terminology of sympathetic maintained pain is being used more to avoid conflicts of academic debates over CRPS.
Some cases are quite complex and have neuropathic pain and nociceptive pain that overlap each other. In some cases, the nociceptive pain can continue to drive or maintain the neuropathic pain.
The doctors at the Soft Tissue Center have presented two papers and are writing a third paper that analyzed the presentation rate of patients who walked into our office who had neuropathic pain and didn’t know they had it. The presentation rate of neuropathic pain in new patients who walked in our clinic over a two-year period was 3%. These patients saw many physicians previously, as is typically the case for neuropathic pain patients. These patients require an extensive history to reveal all of the symptoms and failed attempts to resolve their pain. A referral to a chronic pain physician with a subspecialty in neuropathic pain confirmed the diagnosis with sympathetic blocks.
There is much to discuss regarding the management of neuropathic pain patients. The doctors at the Soft Tissue Center are well versed in the clinical diagnosis of neuropathic pain and excel at guiding patients through this management process.