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Old 06-22-2005, 05:01 AM   #1
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Question Treatment for acute pain to prevent it from turning into chronic pain?

I was watching part of a TV program about chronic pain (I missed much of the program), and the Doctor said that it is very important to immediately treat pain agressively at its onset (to break the cycle of pain) so that the pain doesn't become chronic. He said that even if an injury is healed, a person can continue to have chronic pain. He spoke about phantom pain.

What I want to know is, what treatments should be used at the onset of pain (from an injury, etc.) to prevent the pain from becoming chronic? Is there any "formula" for preventing acute pain from turning into chronic pain?

I injured my forefoot in November 2003, and it wasn't until 2 weeks after my injury and being unable to walk that a doctor finally prescribed physical therapy. I was never prescribed any pain meds when I was in excruciating pain when I first injured my foot. I was only prescribed NSAIDS which did not, and still do not, help with the pain. To make a long story short, a doctor caused more injury to my foot by injecting cortisone into the top of my foot. The fat pad on the ball of my foot is atrophied as a result of cortisone. I am still in pain as of this day with nerve & bone pain. Perhaps that doc hit a nerve in my foot when he inserted the needle.

I am wondering if anything could have been done early on to prevent the acute pain from turning into chronic pain. I know it doesn't help that I've lost fat padding on the ball of my foot so that I'm practically walking on bone, so I can't say that my foot is 100% healed because there is something wrong with it in that there is fat pad atrophy and possible nerve damage.

I've never had any pain in my life that turned into a chronic pain before. I am still trying to learn how to live with this pain.

 
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Old 06-22-2005, 10:39 PM   #2
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Re: Treatment for acute pain to prevent it from turning into chronic pain?

Sealover, I think that is a question we would all like answered. However, I think that every case is different. You mentioned that is was two weeks before you started getting some treatment for your foot. I believe (my opinion) that getting treatment as soon as possible MAY help to prevent it from being a chronic problem. However, a lot of pain problems don't show up right away. For example, just in one calendar year so far, I have had 4 surgeries, two of them being on my back and one on my neck. In the back and neck surgeries that I had, was from something that happened a long time ago, but it did not show up for a while. It all depends on what part of the body is affected. By the time I really started feeling pain and went to the doctor, it was too late. I had nerve damage, discs out of place, etc. So now I have chronic pain and am told it will be for life.

I have heard stories where a Dr failed to diagnose a problem also, and it goes undertreated and the problem ends up being a chronic pain problem. So I'm not sure if we could ever answer that question. Of course some people have Cancer and other "Chronic" pain problems that may or may not be helped with early treatment. I would like to believe that someone with cancer who had early treatment would be healed. However, I have had many family members and some friends that go to the Dr for a neck ache and end up finding out they have cancer everywhere. As for myself, I think If I would have went to the Dr sooner, I may have not had as many problems. But I really had no reason too. I didn't feel the pain until it was too late.

I think its a good question, just not sure if there is an answer, at least not for everyone.

 
Old 06-24-2005, 05:14 AM   #3
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Re: Treatment for acute pain to prevent it from turning into chronic pain?

If you are looking for a cookie cutter solution, my answer is there isn't one yet. We do know through surgical trials & observation that certain things reduce the development of some kinds of pain (wind up style pain -- allodynia, hyperalgesia), we also know a fair amount about interventions which aid in healing injuries better. (Its been shown that in wrist surgery if you treat the pain more aggressively the wrist heals *sooner* and more completely.)

The problem with the question is that pain has so many causes, and there are so many different kinds of pain. Mechanical pain will generally subside when you get the mechanical problem fixed, nerve problems generally seem to be unfixable at this point, cell death pain is atrocious and honestly I don't think there is a single shoe for this either. Which brings me to what we really do know: All of the types of pain I've talked about can lead to the development of hyperalgesia, and allodynia - and take on a life of their own completely independant from the injury itself. That type of pain I think we can stop or at least greatly reduce the incidence - the problem is our entire health care system & drug regulation system has to change to do it. Agressive treatment of pain is the last intervention tried, and from the studies I've seen it should probably be the first.

In surgical trials: (Knee surgery & wrist surgery) Pretreating with NMDA antagonist (Ketamine, dextromethorphan) and a COX-2 inhibitor greatly reduce the development of allodynia & hyperalgesia and lead to better outcomes. Positive outcomes are further increased by adding a long acting pain med around the clock, breakthrough meds, and liberal doses of tylenol (90%+ reductions!). Contunuing NMDA antagonist after surgery helps some, but no where near as much as pretreating.

NMDA antagonist can retard pain WU/Allodynia/Hyperalgesia that has already built up, but other than case reports of a few people able to tolerate them long term they do not appear to reverse the damage. Thus far, nothing has been found to do that.

Work is being done on seeing if local anaesthesia can help reduce complications from surgery and injuries, and it is promising though not quite as effective as the NMDA+the kitchen sink approach.

Its my opinion, and I'm far from alone in it - that everything you do to reduce the pain after an injury helps. Managed pain is clearly better than unmanaged pain, but its unethical to conduct trials to measure outcomes and inflict the type of injuries on people that are likely to lead to allodynia, WU, and hyperalgesia (and of course deny half of them any kind of pain care)-- so you wont find trials saying it, you do find some observational evidence for this though, and some fo the best occurs in wartime. It wouldn't be that hard to look at quite honestly, denying pain care is pretty routine at many clinics - so finding that half of the group is easy, finding the people who have had really good pain care is far harder, and it is always subjective (How do you measure really good pain care for instance - is your sample really representative?), observational studies tend to get a lot less weight.

The best I can tell you is, in the poor tortured animals we have done these things to, they have a rather nasty chemical cascade that happens, show nerve damage & brain damage from it that can be seen, demonstrated, and repeated and verified by others. These observations closely match the subjective ones and all of the objective ones we had been able to observe in humans. That doesn't mean it doesn't have naysayers, but the evidence supporting the chemical cascade is very strong, and the evidence supporting intervention to prevent is is also pretty strong even if its unethical to do the direct to direct comparisons in humans.

What I think you are really asking is, will you always be in pain, and I think the answer is possibly. If they correct the physical problem - the padding on your feet (assuming this is possible to do, I don't know much about this kind of problem) that would greatly help, but you say you still have some kind of nerve damage and that is far harder to deal with, and most of what has been tried really doesn't work. It can be managed, but it probably isn't possible to reverse it. In terms of allodynia & hyperalgeisa, if you didn't develop them already, there is a fair chance you wont. Keeping the pain managed is a very good idea to prevent that, but not everyone ends up with that problem. If the pain starts to radiate at all though, you probably need more aggressive management.
Pain that radiates tends to spread, its a bad sign.

There does appear to be a window where these things develop, and where there appears to be an option to prevent their development. But they aren't the only kinds of pain, they are just types of pain that don't appear to heal when the injury does, and its a minority of people that it happens to, and at present if the problem is truly preventable the health care system we have is failing these people, and even if the techniques are discovered to eliminate every case (not just from surgical proceedures) it will still likely continue to fail those patients because of the regulatory climate around it.

 
Old 06-25-2005, 12:02 AM   #4
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Re: Treatment for acute pain to prevent it from turning into chronic pain?

Thank you for the replies! Very helpful information.

 
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