Jonathan Aarons M.D.

Tired of Chronic Pain?

Pain Management in Burn Patients

pain relief in burn patient

Burn patients endure some of the most intense pain, not only during injury but in recovery as well. Damage to the receptors for pain in the skin occurs immediately. Nerve endings which are exposed but not injured also cause pain. There is an increased sensitivity to painful stimuli ( hyperalgesia) that occurs. There is also a secondary hyperalgesia in adjacent tissue that is not injured.

There are several types of pain that a burn patient experiences; Background pain which is constant, Procedural pain during operations and debridement, Post-operative pain after procedures. Opioids are the mainstay of pain control. Tolerance to these agents can occur due to prolonged use. Additionally, there is an entity called opioid induced hyperalgesia (OIH) that causes increased pain with increasing doses of narcotics.

Non-opioids such as non-steroidal anti-inflammatory agents (NSAIDS), acetaminophen and gabapentinoids (lyrica and gabapentin) can be used as adjunctive agents. They may decrease the dose of narcotics necessary to provide pain relief, limit tolerance and OIH.

Pain management in burn patients undergoing procedures can involve general anesthesia or other intravenous agents such as ketamine. IV propofol and remifentanil, two potent agents can be used as well. Topical and intravenous lidocaine has been reported to be useful in the treatment of pain in burn patients.

Non-pharmacologic techniques have been used in the management of pain in the burn patient as well. These include hypnosis, cognitive behavioral therapy, and distraction.

Managing the pain in burn patients is a challenging issue. Multi-modal therapy using all the techniques described above may be needed. Each modality has its benefits, side effects and risks. A thorough knowledge of all of these modalities is key to effective treatment.

The Treatment of Chronic Pain with Acupuncture

Acupuncture may be beneficial in the treatment of chronic pain. Acupuncture has been practiced for over 3000 years. The NIH produced a consensus statement in 1977 on acupuncture. It supported its efficacy for the treatment of pain and nausea and vomiting. A later 2012 finding by the NIH supported its use for neck and back pain, osteoarthritis and headache.

In acupuncture, disease is thought to originate from a disturbance in the balance of the flow of energy in the body or qi (pronounced chee). Acupuncture points can be stimulated to correct this imbalance. Needles are inserted along meridians in the body. Techniques include dry needling, electroacupuncture and heat stimulation. Acupuncture has been associated with the release of morphine like substances in the body ( endorphins).

In 2003, the WHO released a statement endorsing acupuncture for 28 conditions for which it has been studied and proven effective. Low back pain, knee osteoarthritis and headache are areas which seem to be helped by acupuncture.

Although usually safe, the treatment of chronic pain with acupuncture may have complications. These include disease transmission through the needle, nerve damage, pneumothorax, organ puncture, bleeding and infection among others.

In conclusion, the treatment of chronic pain with acupuncture is a useful adjunct to current therapy. Choosing a practitioner with adequate credentials, skill level and licensing is critical. Even though acupuncture may be useful in a variety of painful conditions, it is not a substitute for traditional medical evaluation and treatment. The addition of acupuncture for the treatment of chronic pain to any regimen should be discussed with your doctor or specialist.

Pain with Hypermobility Disorders

Pain with hypermobility disorders is a widely overlooked condition. Hypermobility disorders may be associated with a wide variety of chronic pain issues. These disorders include such entities as Erhlers-Danlos Syndrome (EDS) and other disorders of connective tissue. Joint hypermobility may occur in up to 2% of the general population and occurs more often in females, dancers, gymnasts and musicians. Patients may have widespread joint pain as well as extra-articular manifestations. Joint hypermobility may be identified using the Beighton score of 0-9, which is the only validated scoring system.

Additionally, patients with hypermobility disorders are at risk for recurrent injuries with minor trauma. These include dislocations, subluxations, tendon and ligamentous injuries and bursitis. Chronic pain with hypermobility disorders can occur in up to 30% of children and 80% of adults.

The chronic pain from hypermobility disorders can including joint aches (arthralgia) and muscular or myofascial pain. Back pain and headaches can occur. Osteoarthritis and osteoporosis occur more frequently than in the general population. Unusual painful conditions can develop such as CRPS, fibromyalgia, abdominal pain and neuropathic pain.

Other manifestations of hypermobility disorder including hyperelasticity of skin, easy brusing, cardiac autonomic dysfunction, chest pain, chronic fatigue, cognitive dysfunction and sleep disturbance. Anxiety among these patients can worsen the problem, leading to disability and depression.

Finally, pain management with chronic hypermobility disorders is multi-faceted. Pharmacologic therapy should be used along with physical therapy and psychological modalities. The baseline treatment includes acetaminophen and non-steroidal anti-inflammatory medications. Steroids should be avoided for chronic treatment. Anticonvulsants such as gabapentin and pregabalin can be tried. Skleltal muscle relaxants can treat the myofascial components. Anti-depressants can be used to treat the neuropathic pain. Opioids should be administered only after the above methods have failed. The risk of tolerance and substance abuse are significant. Cannabinoids are another option for treatment as well.

The Role of THC and Cannabis in Pain

THC or tetrahydrocannabinol is the active ingredient in Marijuana. Cannabinoids have demonstrated pain relieving effects in certain neuropathic pain conditions. The analgesic effects of these drugs are modest at best. Once ingested, THC binds to receptors in the brain and spinal cord called CB1 and CB2 and modulates the pain perception. These receptors are found within the central nervous system and the periphery. There are chemicals in the body which are called endocannabinoids which are naturally occurring and interact with these receptors as well. When THC compounds are administered to patients, they may increase pain tolerance and decrease pain sensitivity.

Cannabinoids have been used to treat many painful conditions, such as multiple sclerosis, HIV and headaches. Although these medications can be safe and effective, they have many side effects such as dizziness, euphoria and fatigue. The use of these medications carries the risk of misuse, dependency and mental health issues. One idea is to combine THC or cannabinoids with other pain relievers in order to decrease the effective dose of each and use their synergistic effects to treat pain with limited side effects. Using THC in place of narcotics may decrease the tolerance to narcotics that develops over time and diminish the constipation that is associated with chronic narcotic usage. Regulations regarding the use of legal THC agents such as dronabinol ( Marinol) has made prescribing them difficult. That may change in the current regulatory climate. Research is ongoing as to the best usage of these agents and they may soon find a place in our armamentarium for treating chronic painful conditions.

Tibiofibular pain

 

Tibiofibular pain
Tibiofibular pain

Tibiofibular pain is an uncommon cause of pain on the outside of the knee joint.  The tibia and fibula are two bones that support the lower leg.  There is a joint that forms between those two bones.  This joint may communicate with the knee joint and diseases that affect the knee may also affect this joint.  Tibiofibular pain occurs on the outside of the knee.  It is worse with motion, particularly pointing the ankle up and climbing up stairs.  There can be swelling, limited knee motion and locking or popping of the knee.  The pain is usually caused by injuries sustained through sports activities but may also occur with diseases such as arthritis , tumors, ganglion cysts, Lyme disease, collagen vascular disease and Pigmented Villonodular Synovitis.  X-rays and MRI scans of the area may be useful to look for tumors and fractures.  Bone scans can also be used to look for more subtle disease.  Laboratory test are used to screen for collagen vascular diseases.  Initial treatment includes conservative management such as non-steroidal anti-inflammatory medications, rest, heat, ice and physical therapy.  An injection into the joint of a local anesthetic and a steroid can be helpful.

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