PAIN IS such a different experience for each person—different bodies, different brains—that effective treatment is frequently elusive. Many sufferers search over many years—and if they find relief, often have trouble determining which treatment did the trick.
Efforts to deal with pain—other than that with a clear cause, such as shingles, that can be treated directly—go in different directions depending on the methods as well as the medical professionals engaged: orthopedists, who focus on specific body parts, like knees; alternative and integrative medicine practitioners, who work on something besides the painful area, like trigger points; and pain specialists.
For DC resident W.C., pain that persisted for more than a year in her thigh and sometimes lower leg—especially in most seated positions—was determined by an orthopedist specializing in hips to require a hip replacement. The back specialist prescribed physical therapy for her back, as did the foot specialist for her feet and “gait.” On MRIs and X-rays, each area looked like a potential source of terrible pain.
Although pain is often broken down into different kinds, most could be used to describe W.C.’s pain, for example: arthritis pain, nerve pain, referred pain (coming from one place but felt in another) and chronic pain (when signals continue moving along pain pathways to the brain after the original injury has been resolved).
A different way of thinking about pain—commonly referred to as “Explain Pain” – is based on the idea that pain is an output of the brain—rather than a signal from the body to the brain; and, based on recent understanding of neuroplasticity, that “the nervous system moves and stretches as we move,” from Australian practitioners David Butler and Lorimer Moseley in books including the most accessible for patients, “The Explain Pain Handbook Protectometer.”
Explain Pain is a “biopsychosocial” approach that uses a curriculum for “teaching people that pain can be over-protective” and “that the brain can turn down the danger message at the spinal cord…it is always the brain that decides whether or not to produce pain,” writes Butler, founder of the Neuro Orthopaedic Institute, which organizes dozens of international seminars each year.
Among support for this concept, scans showing damage are notoriously unreliable—with the worst arthritis and degeneration showing up in areas that cause no pain at all and vice versa. Years ago, W.C.’s shooting leg pain was first explained by a “terrible” MRI of her back, for which she was prescribed physical therapy—until that therapist diagnosed a torn meniscus in her knee. When that was repaired surgically, the pain disappeared.
Also, people have vastly different responses to potentially painful stimuli, such as “fire-walking,” based on both scientific knowledge and personal experience of the levels of stimuli that cause actual physical damage to the tissues, muscles or joints.
Early on in her painful year, W.C. tried the non-steroidal anti-inflammatory drugs (NSAIDs) Advil (ibuprofen) and Alleve (naproxen) without success, in the process learning about gastritis (dubbed the “N-sad stomach”), provoked by taking NSAIDs. She also tried topical anti-inflammatories: Voltaren (the NSAID diclofenac); and “Ted’s pain cream” containing resveratrol (found in red wine) after it was touted in an NPR broadcast —to no avail.
She tried marijuana-based preparations purchased at a DC dispensary, both tinctures placed under the tongue and topicals. And she sampled several “alternative” treatments, including acupuncture and myofascial massage; also Pilates and Yoga—carefully. Over the years, she’d had a lot of physical therapy for gait as well as for problems in her knees and back, and had kept up most recommended exercises.
Then she went to a pain clinic physiatrist—a physician with a specialty in physical medicine and rehabilitation—who had three recommendations: stronger (prescription) naproxen; physical therapy from a practice reputed to have a more personalized approach than most; and an epidural injection of cortisone. Cortisone injections have not stood up well to long-term research: a 2017 study on knee pain showed a loss of cartilage over a two-year period—but years of anecdotal support convinced W.C. to try.
Only after the first injection offered no relief was she told it often takes two or three, and then she learned that the injections often need to be repeated several times a year to keep pain at bay. She said no to more for the time being.
The pain clinic also suggested other treatments supported by anecdotes but inconclusive evidence, such as dry-needling. Needles (called dry because they contain no medication) are inserted to relax overstimulated muscles— in contrast to needles used for acupuncture that are inserted more deeply and intended to affect energy pathways.
Meanwhile, friendly recommendations kept coming, such as lasers —the higher dosage and power the better, with up to five treatments usually needed—touted to release endorphins, decrease nerve sensitivity and have a pain-blocking effect on nerve fibers, though these are often most effective immediately following an injury.
Or, seeing an osteopath. Trained to look more at the whole body, doctors of osteopathy (DOs) specialize in “hands-on” diagnosis and treatment using osteopathic manipulation—the goal being to help the body heal itself by relieving impediments to correct structure and function.
Other treatments, focused on treating the injury, involve re-implanting or re-injecting the patient’s own stem cells or plasma, both offered by the pain clinic—costing thousands of dollars per procedure, usually requiring more than one treatment and not covered by insurance.
Although pain can drive patients to try unproven treatments until something works, that something can be time. Sufferers joke that particular kinds of pain, such as “frozen shoulder,” get better in six months or one year no matter what treatments are tried.
The problem is not knowing. DC lawyer J.F. had less pain after about two years spent trying first stem cell injections and then cortisone shots, but he wasn’t sure what made the difference.
For as long as WC’s pain persists, depending on insurance coverage, she plans to keep progressing through possible treatments and to keep hoping for relief—not a particularly medical approach.
Every Tuesday Mary Carpenter reports on the state of our well-being, taking on topics like medical marijuana, living longer and psychedelic therapy.