Jonathan Aarons M.D.

Tired of Chronic Pain?

Pain After Breast Cancer Surgery

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Pain After Breast Cancer Surgery

A significant number of women report pain after breast cancer surgery. This pain can be in the area of the breast, chest wall or arm. Risk factors for post surgical pain include younger age, preoperative pain, anxiety, depression and the surgical approach.

The cause of persistent pain after breast cancer surgery can be multi-factorial. Nerve injury can occur during surgery. Phantom breast pain, which is the sensation of residual breast tissue with painful or non-painful symptoms, has been known to be a complication. Injury can occur to the intercostobrachial nerve causing pain along the medial and upper arm. Neuromas can lead to pain along the scar.

Reducing pain after breast cancer surgery can be accomplished. Preoperative nerve blocks can be used to decrease pain both during and before surgery. These nerve blocks may reduce the need for narcotics and thereby decrease post-operative nausea and speed recovery as well.

Furthermore, several other modalities have been used to decrease pain after breast cancer surgery. These include medications such as gabapentin, mexilitene, venlafaxine, EMLA and dexamethasone.

Non-pharmacologic approaches can also be used. These include exercise, physical therapy, TENS, and accupuncture.

In conclusion, pain after breast cancer surgery is an ongoing problem. Several strategies can be used to mitigate this pain. These strategies are particularly important in those patients with higher risk including those with pre-procedural pain. It is likely that a combination of nerve blocks, medications and non-pharmacologic therapies can be useful in decreasing this painful problem.

Fibromyalgia

Fibromyalgia Symptoms

Fibromyalgia is an abnormal condition causing widespread pain, fatigue, mood disorders and cognitive dysfunction. The pain can be described as stabbing, shooting, and throbbing with muscular aches. Patients with fibromyalgia often have fatigue, difficulty sleeping and sensitivity to touch, light and noise. These patients often have other associated problems such as headaches, irritable bowel, restless leg and temporomadibular joint dysfunction (TMJ).

No one knows what actually causes fibromyalgia but a combination of environmental and genetic factors have been proposed. An inflammatory model of disease has been studied. Changes in the central nervous system have been previously documented but their cause is unknown.

The American College of Rheumatology adopted criteria for the diagnosis of fibromyalgia which includes widespread pain for at least 3 months and the presence of pain at 11 of 19 predetermined tender points on the body. Fibromyalgia can also be diagnosed using the Widespread Pain Index (WPI) and Symptom Severity (SS) Scale. It can also be further divided into Type A and Type B using these indices. Treatment of fibromyalgia is multi-modal. Treatment includes psychological and social interventions. Medications for treatment include pregabalin(Lyrica), duloxetine (Cymbalta) and milnacipran(Savella). Each medication has its own mechanism of action and side effect profile.

Other treatments include cognitive behavioral therapy, acupuncture, and biofeedback. Physical deconditioning is a problem and physical therapy is an important component of treatment.

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.

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