Chronic pain is rarely relieved with a single therapy or after a single treatment. Finding a way of treating back pain that works—and works well—depends as much on your condition and the options that your physician offers as it does on your willingness to take an active role in your treatment. When you suffer from chronic pain, the pattern, intensity, and frequency of your pain and your response to treatments may be very different from someone else with the same diagnosis. Also, your pain can change—not just over time but also from day to day and hour to hour—according to your activity, mood, stress level, and general health. This is what makes chronic pain such a challenge to treat.





The Chronic Pain Treatment Steps

When traditional treatments do not provide enough relief, primary care physicians often refer their patients to pain physicians. Pain physicians are specialists who study, treat, and help rehabilitate people in pain.

When treating back pain and other types of chronic pain, pain physicians often follow a treatment strategy called the chronic pain treatment steps. This series of treatment steps can help you and your physician decide the best treatment for your pain. It can also help ensure that no potential solution is overlooked.





Remember, though, that the chronic pain treatment steps are only general guidelines and can vary depending

on your condition, your response to previous treatments, and the recommendation

of your pain physician.



After making an initial diagnosis, your physician will take specific steps to treat your pain. He or she will usually start with the less complicated and less expensive therapies in the treatment steps. These therapies can include medications, physical therapy, TENS, and nerve blocks. Some of these treatments may work at first, but often they do not offer lasting pain relief.

If your pain does not respond to these therapies, pain physicians look at more advanced therapies among the treatment steps. Spinal cord stimulation (SCS) is one of these therapies and is used for treating back pain and other types of chronic pain. For some patients, SCS is a way to regain their quality of life and return to a more normal lifestyle.

Depending upon your diagnosis, medical history, type of pain (neuropathic pain or nociceptive pain), and severity of pain, you may be a candidate for an implantable spinal cord stimulator. Spinal cord stimulators use low levels of electrical energy to partially or completely interrupt the sensation of pain. In cases of severe, chronic stubborn (intractable) pain that do not respond to any other treatment, surgery or neuroablative procedures may be considered.





Learning About Chronic Pain

As you consider treatment options for your chronic pain, it’s important that you learn as much as possible about your condition and how the treatments can affect it. You should also consider how well these treatments fit your lifestyle. That way you and your doctor can work together to choose the treatment that is right for you.

Here are a few things you can do to take an active role in finding relief:

Learn all you can about your condition and find a physician who specializes in pain management.

The Web and your local library are good sources of information—so is your physician.

Join a patient support group.

Joining a patient support group can lift your spirits and provide you with important information about new therapies for treating back pain and other types of chronic pain, pain physicians in your area, and personal treatment successes. It also allows you to talk with people who understand what you are going through.

Study the chronic pain treatment steps.

The chronic pain treatment steps will help you learn about the many options for treating back pain and other types of chronic pain that are available.

Explore current and emerging treatments.

The Web is one of a number of great resources, which include patient support groups and professional societies and organizations (like the American Pain Foundation). Your healthcare team—physician, nurses, physician assistants, and therapists—may also have information to share.

Enlist the help of friends and family.

You do not suffer pain alone. Those who care about you suffer too. So don’t be afraid to ask for help finding information about treating back pain and other types of chronic pain. Invite a spouse or friend to go with you to your next appointment. Family and friends often welcome the chance to help, especially in such an important way. This will also help your family and friends better understand what you are going through.

Talk to your physician.

Take all you have learned and make a list of questions to discuss with your physician. Ask your physician to explain the pros and cons of treatment options for your condition. You might also ask what your physician’s experience has been with chronic pain management and spinal cord stimulation.

Learning what questions to ask is an important step to finding the right treatment for your chronic pain.

Treatment Steps For Chronic Pain

Chronic pain treatment can be prescribed in steps. This means that treatment often begins with simple and less expensive therapies—such as bed rest, oral pain medications, and physical therapy—and moves to more advanced therapies—such as opioids, nerve blocks, or surgery.

Step One

The first step in the chronic pain treatment steps begins with conservative treatment and progresses to more aggressive approaches.

Exercise Programs

One of the first treatments for chronic pain may be light exercise, such as walking. Exercise stimulates the release of the body’s natural pain relievers called endorphins. It promotes flexibility, strength, and endurance, and it helps reduce stress. Exercise can also strengthen unused or weak muscles to help take over the work of a muscle that is overworked and causing pain.

Over-the-Counter Pain Medications

Another early treatment for pain is an over-the-counter analgesic (such as aspirin or acetaminophen) or an anti-inflammatory agent (such as ibuprofen), combined with bed rest.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

When over-the-counter medications do not provide adequate relief, your physician may prescribe an NSAID. NSAIDs may provide pain relief within the first 24 to 48 hours of treatment, but it may take up to three weeks to get the full benefit from these medications, which includes relief from pain, swelling, and inflammation.

The most important treatment is exercise.

Rehabilitative Therapy

Rehabilitative therapy includes a variety of techniques—physical therapy, occupational therapy, massage therapy, chiropractic therapy, and retraining of physical activities—to reduce pain and increase function. Therapists may use stretching exercises, heat or cold therapies, water therapy, muscle relaxation techniques, biofeedback, traction, or weight training and conditioning. Rehabilitative therapy is an important part of early pain treatment and is often combined with other treatments, such as oral medications.

Transcutaneous Electrical Stimulation (TENS)

In TENS therapy, electrical impulses are applied to nerve endings through electrodes placed on the skin over the painful area. Researchers theorize that these impulses temporarily interrupt the transmission of pain signals from small sensory nerves at the site of the pain. TENS may also stimulate the release of endorphins, which produce analgesia and feelings of well-being.

Cognitive and Behavioral Modification

Chronic pain is a tremendous psychological burden, and the way a person responds to and tolerates pain depends on factors such as their personality, culture, and past pain experiences. Cognitive and behavioral therapies take these factors into account in an effort to help a patient learn new skills and strategies for dealing with chronic pain. These skills and strategies can include relaxation techniques, visualization exercises, and one-on-one counseling sessions with the patient and family to build coping skills.





Step Two

The second step in the chronic pain treatment steps includes procedures or treatments that are more invasive and costly.

Nerve Blocks

Systemic Opioids

Neurolysis

Thermal Procedures

With nerve blocks, a local anesthetic and/or steroids are applied directly to the nerve causing the pain. Nerve blocks typically provide temporary relief of pain due to their numbing (anesthetic) effect. They also can help decrease the swelling of tissues around the nerve, which can irritate the nerve and result in pain.

Powerful pain medications known as opioids are often prescribed when severe chronic pain does not respond to first-step therapies and when surgery is either not an option or has failed. Opioids are effective in relieving the most severe pain. However, side effects—ranging from drowsiness and constipation to an increased risk of addiction—are common, particularly when opioids are administered by pills or skin patches.

With neurolysis, a chemical is used to destroy nerve tissue in order to stop a nerve from functioning. The chemical (usually alcohol or phenol) is injected around the specific spinal nerve that serves or activates the painful area. With neurolysis, the goal is to stop the nerve from sending pain signals to the brain. This procedure is usually effective in relieving pain for weeks or months.

Thermal procedures, such as cryoanalgesia and radio-frequency (RF) lesioning, use temperature to disrupt a nerve’s ability to transmit pain signals. With cryoanalgesia, extreme cold is applied to a nerve. The length of time the nerve is exposed to the cold and the intensity of the exposure determine how much the nerve is affected. Nerve damage can be minimal, with loss of sensory function for several weeks, or full, with complete loss of sensory function and possible motor impairment. Cryoanalgesia is often used for chronic pain of the chest wall, face, and other neuralgias.

With RF lesioning, high-frequency energy is used to produce heat and thermal coagulation of affected nerves in order to disrupt the nerves’ ability to transmit pain signals. The RF energy is directed only at the affected nerves, which minimizes the risk of damaging nerves and tissues next to the affected nerves. RF lesioning can provide pain relief for up to a year or more and is repeatable.

Note: RF lesioning should not be confused with RF spinal cord stimulation, because they are different therapies.

Advanced Steps

Relieving stubborn pain takes time and patience—and some trial and error. Certain chronic pain conditions can be very resistant to first- or second-step pain therapies. If this is the case, your physician may consider more advanced treatments to relieve your pain.

Surgery

Spinal Cord Stimulation

Implantable Drug Pumps

Neuroablation

Surgery may be performed to repair or correct an anatomical defect or a defect due to an illness or injury. Or surgery may be performed on a nerve to interrupt the transmission of pain signals. Surgery carries a greater risk than noninvasive procedures.

Spinal cord stimulation (SCS) is used to treat certain types of chronic neuropathic pain in the body (trunk) and/or arms and legs (limbs). Spinal cord stimulation uses low-level electrical impulses to interfere with or to block pain signals from reaching the brain. This therapy replaces painful sensations in the affected areas with a more pleasant sensation. Spinal cord stimulation is part of a broader category of therapies called neurostimulation. Neurostimulation devices include spinal cord stimulators (also called pacemakers for pain), which use electrodes placed in the space above the spinal cord (epidural space), and peripheral nerve stimulators, which use electrodes placed directly over any nerve that does not branch directly from the spinal cord.

For certain types of pain, including persistent nociceptive pain and cancer pain, an implantable drug pump (also known as a pain pump or an intrathecal drug pump) can be an appropriate therapy. Pain pumps deliver pain medications directly to the fluid (cerebrospinal fluid) in the space (intrathecal space) surrounding the spinal cord. This direct approach allows powerful pain medications, such as opioids, to be used in much smaller doses than are needed with pills or skin patches, reducing the likelihood of unpleasant side effects.

Neuroablation is a surgical technique that permanently blocks nerve pathways to the brain by destroying the nerves and tissue causing the chronic pain. Several procedures are used. Cordotomy is the surgical cutting (division) of a tract of the spinal cord. Rhizotomy involves selective destruction of a nerve close to the spinal cord. Thalamotomy and pallidotomy use radio frequency to heat and destroy specific cells deep in the brain. In addition to the risk of causing unplanned motor or sensory dysfunction in an area other than the affected area, neuroablative procedures are sometimes only temporarily successful because pain can redevelop in a nearby or different nerve pathway.