Pain Management
Pain
“A localized or generalized unpleasant bodily sensation or complex of sensations that causes mild to severe physical discomfort and emotional distress and typically results from bodily disorder (such as injury or disease).” –Merriam-Webster
Pain is either acute or chronic (lasting greater than 6 months). Pain can be further categorized as Nociceptive (caused by thermal, mechanical or chemical stimulus), Neuropathic (damage or disease affecting the nervous system), or Psychogenic (pain produced by mental, emotional or behavioral factors).
Post-operative pain and acute pain is strongly correlated to how proactive/compliant you are with your post-operative care, activity and work-related modifications/restrictions, and therapy.
Activity Modification/Restrictions
During the acute phase of recovery, it is recommended that you modify/restrict your activity level. The more you do, the more you will produce inflammation, swelling and pain. Increased/unrestricted activity will only delay your recovery process, increase your pain and prolong your use of pain medications.
You are also encouraged to elevate as much as possible. Elevation uses gravity to assist fluid movement. This, along with gentle range of motion (when permitted), will promote the reduction of swelling and prevent additional swelling. Added swelling will only produce more pain and discomfort.
Wound Care
Wound care is important in promoting an optimal healing environment, preventing infection and reducing pain. Wound healing is greatly affected by a person’s overall health, activity level, past medical history (diabetes), nutrition, and recreational habits (smoking and alcohol consumption). See wound care for more information.
Casting/Splinting
Casting/splinting is intended to stabilize an extremity/body part following an injury or surgery to prevent subsequent injury during recovery. Rigid stability of the cast/splint will help reduce pain and promote healing. See cast care for more information.
Occupational Therapy
Therapy uses modalities (a method of therapeutic approach) that may include thermotherapy, cryotherapy, massage therapy, therapeutic ultrasound, manual therapy, range of motion exercises and patient educated home exercise programs to promote healing and improve function.
Thermotherapy/Cryotherapy
Thermotherapy is the application of heat (or cryotherapy-cold) with the intention of modulating pain, promoting healing and improving overall function. The general rule of thumb is to not apply heat to an acute or inflamed/hot area. Treatment time is often 15-20 minutes in duration. It is important to understand that the many ways to “applying” heat/ice can greatly impact the transfer of heat, thereby increasing the risk of tissue damage (burn). Talk to your provider for more detailed information.
Medications
Nonsteroidal Anti-inflammatory Drugs (NSAID’s)
Anti-inflammatory medications, such as Aspirin (ASA, acetylsalicylic acid), Ibuprofen (Advil, Motrin), Naproxen Sodium (Aleve), provide good pain relief for inflammatory conditions (arthritis, acute injury, post-operative pain). NSAID’s can be associated with an increase in gastric ulcers and GI bleeding, renal insufficiency, hypertension and cardiac events.
Acetaminophen (Tylenol)
Used for mild to moderate pain. Tylenol may be used in an alternating fashion with ibuprofen to supplement pain control. Risks with the use of acetaminophen include dose-dependent liver toxicity (DO NOT EXCEED 3000 mg of Tylenol in 24 hours), alcohol consumption and liver disease.
Topical Pain Relievers**
Topical pain relievers/analgesics come in patches, creams, ointments, rubs and sprays. The ingredients may vary from product to product in their approach to pain relief but often take advantage of the following ingredients to modulate your perception of pain.
- Counterirritants (menthol, methyl salicylate/oil of evergreen) create a cooling sensation that modulates/reduces your perception of pain. It “distracts” you from your pain
- Capsaicin (main ingredient of hot chili peppers) is also a counterirritant that creates a warm tingling/burning sensation when absorbed into the skin.
- Camphor, found in the wood of Cinnamomum camphora/evergreen tree, is strong smelling and used topically to relieve pain, irritation and pruritus (itching).
- Salicylates (Aspercreme) include the same ingredients as aspirin and can be absorbed in the skin. Salicylates creams can be particularly helpful for joints close to the skin (fingers, knees and elbows). Use as directed due to the risk of salicylate poisoning.
- Lidocaine is a local/topical anesthetic that reduces pain to the area applied. Over-the-counter patches come in 4% lidocaine and are produced by multiple companies (Salonpas, Aspercreme, IcyHot). Patches are best use for flat surfaces.
**The use of such pain relievers often do not directly “treat” the proposed area but only modulate/reduce your perception of pain. View it as a tool in your tool box to help you feel comfortable during your recovery process. Be careful not to use them as a way to continue unrestricted activity and return to work-related activities without making necessary activity modifications/restrictions and developing a treatment plan.
Do not use the above medications over damage skin or near wounds. Do not use along with heating pads or under tight bandages. Wash hands well after use and/or avoid touching your face/eyes while using the product.
Injections
Corticosteroids are often used in the treatment of pain. This potent anti-inflammatory is similar to one of your body’s natural anti-inflammatory hormones, cortisol. Within about 3 weeks, the corticosteroid administered has been absorbed. The lasting result can be attributed to the anti-inflammatory nature of the medication and can be further assisted by activity modifications and a home exercise program that focuses on muscular endurance (much the same way an athlete stays in shape to tolerated extended activity).
Side effects may include but are not limited to pain and aggravation at the injection site, temporary bruising, flushing, blood sugar elevation, elevated blood pressure, localized skin atrophy and depigmentation, and possible infection.
Narcotics
Narcotics are drugs derived from the opium poppy plants and are useful for acute/post-operative pain. They are metabolized in the liver and later excreted by the kidneys. Side effects included but are not limited to constipation, nausea, sedation, pruritus (itch), miosis (pupil constriction), confusion, hallucinations, euphoria, hypotension (low blood pressure), and respiratory depression.
These medications are often combined with acetaminophen (Tylenol) and care should be taken to not exceeding the maximally daily dose of acetaminophen as this may lead to hepatotoxicity (liver). Extended use of narcotics can also lead to dependency/addiction and cause severe constipation and GI complications.
Federal law requires all patients given a prescription for narcotics receive and sign the educational document, “Opioid Start Talking.” Providers are also required to use MAPS (Michigan Automated Prescription System) for each prescription request.
Narcotics are NOT intended to do away with all of your pain but only to modulate your pain and give you some comfort while you recover. Although effective for moderate to severe acute pain, the effectiveness of its use is in question beyond 3 months. In order to limit overuse and dependency, the quantity of narcotics given will be progressively reduced with each subsequent request.