• Types of Pain
• Typical Pain Management
• A Common Example of Chronic Pain
• Pain in the Elderly
• Headaches
• Chest Pains
• "Stomach" or Abdomen Pains
• Low Back Pains
• Neck and Shoulder Aches

Pain often accompanies other problems. People with pain commonly report troubled sleep and limited ability to do physical exercises and daily activities. Pain is sometimes related to emotional problems. Please make sure your doctor understands the way your pain is affecting your life.

Try to describe your pain well because understanding the type of pain can sometimes help you and your doctor find the best treatment. If your pain is stabbing, throbbing or pressure, it is most likely from skin, bone or muscles.

If your pain is gnawing or cramping, it may be from deep in your body. If it is tingling, burning or shooting, it is probably from a nerve.

The second step is to provide the treatment or combination of treatments that gives the best relief with the least side effects. This is the hardest step because it usually requires trying different approaches to see how they work.

Relaxation and medications are the best ways to get relief for acute or new pain -- a recent injury, or surgery. For severe acute pain, the pain medicines should be taken regularly, every 4-6 hours for several days. If you wait until it hurts to take the pain medicine, muscle tightening will occur and the medications will be less effective.

For chronic or long lasting pain, the use of medication alone may not be practical or safe. Chronic pain is a common reason for patients to seek help from chiropractic, acupuncture, herbal, nutritional, or massage treatments. The section called "Making a Health Decision" provides some guidance if you are considering or using other treatments for pain.

If you have chronic pain, you may want to keep a pain diary so that you can be the best judge of what is working for you. (Please refer to the materials at the end of this chapter).

First, your doctor may try to prevent problems. If a person already has "wear and tear" degenerative arthritis, he or she can make the situation better or worse. You can help identify the things that increase the pain by writing down the level of pain, the date, and the activity that brought on the pain. (See the pain diary in this section.) Avoiding or changing how you do an activity may be very helpful for reducing pain.

Second, your doctor will try to keep muscles strong. Pain makes us not want to move. The less we move, the weaker we become. The weaker we become, the more likely we are to speed up "wear and tear." We also are more likely to have injuries. The knee, for example, gets most of its stability from the muscles around it. Knee stability depends less on the structures in the joint. Weight-moving exercise strengthens the muscles and can reduce wear and tear. Exercise also stretches the muscles. Please read Exercise and talk to your doctor or nurse about this approach to pain management.

Third, your doctor should always try simple solutions first. If a pain diary shows that the pain is usually predictable, you should try these approaches:

* Try local treatments for local pains. Simple examples include getting wider shoes for sore feet or using ibuprofen or aspirin creams over a sore joint.

* Relaxation, music, or imagery. Yes, these simple approaches do work for predictable pain. A simple relaxation approach requires that you turn on soft background music. (Without news or advertisements!) Lie down in bed or in a recliner, and let your jaw drop slightly, as though you were starting a small yawn. Keep your tongue resting on the bottom of your mouth. Let your lips get soft. Breathe slowly and evenly: inhale, exhale, rest. Allow yourself to stop forming words with your lips and thinking words. Think of pleasant pictures.

* Hot and cold. Sometimes warmth over a painful area, or cold above a painful area are effective. (Be careful not to lie on a heating pad because it can damage your skin.) For many, moist heat is more effective. Try using a damp cloth between your skin and the heat source.

Fourth, your doctor may try an aid (assistive device). For "wear and tear" arthritis, canes, and crutches are often useful to reduce pain that bothers you most of the time and gets in the way of daily activities. But unless weight-moving exercises are also used, an assistive device may make a person weaker and worsen the situation in the long run.

Finally, medicines are another approach your doctor might try. Here are the general categories listed by the type of pain.

General Pain such as muscle aches or headaches:

• acetaminophen (Tylenol), anti- inflammatory drugs (see below). Occasionally opiods (codeine)

Inflammatory Pain such as arthritis:

• salsalate, aspirin, naproxen (Naprosyn), ibuprofen (Motrin), and many other similar medications called NSAIDs. Of the NSAIDS, salsalate and low-dose ibuprofen seem to have the lowest risk for causing stomach ulcers.

For more severe inflammation prednisone and related steroids may be used for a short time only.

Special Pains such as neuropathy (nerve pain):

• antidepressants, anticonvulsants, and capsaicin- these may require several weeks to work

Your doctor should recommend the safest pain medications first: trisalicylate, salsalate, or acetaminophen. Pain medicines have to be tried for at least two weeks at an adequate dose before another is used. If the first medicines do not improve the pain, you have other choices that differ in cost and side effects. A medication that works wonders for one patient may have little effect in another. Your doctor often has to use a trial and error approach. Most pain medications have a ceiling effect: you can take more and more pills and get no more pain relief.

Narcotics are addictive; that is, you may need more and more to get the same level of pain relief. Doctors may use narcotics (like codeine) for pain. Low dose, long-acting narcotics can be very helpful. When narcotics are used special care is taken to avoid addiction and constipation.

Pain from diabetes, "shingles," and many other conditions affect different types of pain nerves (neuropathy). For example, shingles responds best if treated early with drugs called prednisone and acyclovir.

Neuropathy or nerve damage is common with diabetes. This nerve damage usually affects the feet and legs, and sometimes the hands and arms. Nerve damage may cause numbness, tingling, burning, muscular weakness, or problems walking. People with this problem may be less aware of heat, cold, touch, and pain. Prevention by keeping the blood sugar as normal as possible is important because there are no medications that can reverse this process.

Aging does not really change the amount or type of pain a person feels. Aging does change the way pain should be managed because:

• Compared to younger persons, older persons are at increased risk to be over or under treated for pain.
• Commonly used mild pain relievers like aspirin, ibuprofen, and tylenol are more likely to cause stomach upset and kidney problems in older persons. Try to avoid propoxyphene, meperidine, indomethacin, piroxicam, and phenylbutazone.
• Reactions like headache, worsening constipation, and thinking problems occur frequently from many types of pain medicines.
• Medicines for the anxiety, depression, and sleep disorders that may accompany pain can have additive side effects with the pain medications.

Older patients with very bothersome pain most often have arthritis and circulation problems. These persons commonly report trouble sleeping, and limitations in ability to do physical exercises and daily activities. Many complain of dizziness, but it is unclear how the pain is related to this complaint. Although many believe that pain is strongly related to emotional problems, doctors generally find that persons who have pain are no more likely to have emotional problems than those who don't have pain.

Migraine (vascular) headaches are often felt in the front and side of the head. They usually get very bad within 60 minutes and may make you feel sick to the stomach or want to avoid light. You often feel a pulsing or throbbing. You may have about a twenty minute warning before your headache begins (for example, flashing spots, sick to the stomach). Alcohol, exercise, some foods (chocolate, preserved meats, and ice cream), changes in the weather, and your menstrual period may cause the headaches. You may find that you can relieve the headache somewhat by pressing on the arteries just above and in front of your ears. Migraine headaches come and go on their own and may last from a few hours to a day.

Muscle Contraction Type headaches usually begin gradually and get worse by the end of the day. The pain feels aching and pulling and is usually worse around the entire head and in the neck. You may feel that your head is being squeezed. These headaches may last for days or weeks. Exercise and hot showers may help a muscle contraction headache but make a migraine headache get worse.

Mixed headaches are a mixture of migraine and muscle contraction headaches.

The first treatment for all types of headaches is to find out if there is something that usually causes them. Then try to avoid it. The next best approach is to use a safe treatment to try to reduce the headache. Aspirin, acetaminophen (Tylenol), ibuprofen, and naproxen are all effective medications that you can get without a prescription. A safe, effective mix includes one acetominophen and one aspirin with a cup of caffeinated beverage (also known as Excedrin). To treat severe migraine attacks, "triptans" have proved to be very effective.

To prevent migraine headaches, there are many prescription drugs: beta blockers, calcium blockers, anti-depressants; serotonin antagonists, and anticonvulsants. Riboflavin, a vitamin, also reduces the frequency of migranes. All medicines have a cost and side effects that could cause harm. Your doctor can talk to you about these choices.

Mixed and muscle contraction headaches are more difficult to treat with medicines alone. Therefore, many health professionals recommend that you try relaxation, music, or imagery for headaches that you can feel coming on.

Sinus headaches are another common headache. Usually it causes pains in the face that get worse when you bend over. You may notice that you have a cold or runny nose when you have a sinus headache. Nasal sprays or sinus/nasal decongestants for a few days (never more than 5 days) can help sinus headaches.

If sinus problems persist and you are a smoker, smoking is usually the cause. You will need to stop smoking. If you are not a smoker, a one month trial of a cortisone spray for several weeks may prove helpful.

The main concern is chest pain with shortness of breath or difficulty breathing. Contact a doctor immediately if you notice new or worsening chest pain with shortness of breath. Some people having asthma attacks can start with chest pain and shortness of breath as a first sign, rather than with coughing or wheezing. (See "Common Conditions"). Men having a "heart attack" often notice severe, squeezing pain with shortness of breath. A lung infection is another cause of pain and shortness of breath.

Angina heart pain caused by blockage of the blood to the heart is the most common cause of predictable chest pain. Managing angina is covered in "Common Conditions."

Lower abdomen pain in women can be a particularly difficult problem to solve. (See irritable bowel below and also Women's Issues)

Pain in the abdomen that comes and goes over the years can be caused by several conditions. The most common conditions are due to the irritable bowel syndrome, peptic ulcers or dyspepsia (dis-pep-see-ya), and acid reflux.

Irritable bowel syndrome often causes discomfort around the belly button area. It can be quite severe at times and changes in bowel pattern may be noticed with it. For a day or two you have diarrhea (lots of loose bowel movements) and then you may feel constipated (can't go). Usually the discomfort lasts for a few days. Other times, change of bowel pattern and discomfort can go on for weeks. Stress makes this condition worse.

Adding fiber each day to your diet -- unprocessed bran, vegetables, fruits, whole grain products -- and a regular form of exercise usually works well. Avoid excessively fatty or gassy foods (beans, cabbage). Different medications may still be needed for persons bothered by pain (dicylomine), diarrhea (loperamide), or constipation (lactulose). Peppermint oil is also often effective.

Peptic ulcers and dyspepsia cause a burning or gnawing ache in the upper middle abdomen just below the chest. It is often most noticeable 1 - 4 hours after meals. Usually the pain is made better by eating meals or antacids (like Tums, Maalox, or Mylanta). It is made worse by alcohol, aspirin, ibuprofen, coffee, and smoking. When the pain persists, an ulcer (an open sore in the lining of the stomach) may be present. Special tests may be done to see the ulcer with x-ray or a tube passed into the stomach.

When an ulcer is present, treatment may include antacids after meals, "stomach coating" pills (sucralfate), medications to cut down acid in the stomach (cimetidine, ranitidine, famotidine, omeprazole), and sometimes, antibacterial medications. Sometimes these treatments are tried for dyspepsia but antibacterial medications will less reliably help dyspepsia.

Antacids act within 30 minutes and need to be taken frequently: 1 and 3 hours after meals. Acid reducing pills are longer acting but expensive. The over-the-counter versions are about half as strong as the weakest prescription.

The most important thing you can do to help dyspepsia and ulcers is to avoid alcohol, aspirin, ibuprofen (and similar medications), coffee, and smoking. Persons who continue to smoke have great difficulty healing a peptic ulcer. Persons with ulcers or dyspepsia who notice tar-like bowel movement (old blood) or persistent pain while being treated should contact their doctor.

Acid reflux means that the "door" that normally keeps acid in your stomach allows some acid to leak back (reflux) into your swallowing tube (esophagus). You may notice pain or "burning" in the upper abdomen that is often made worse when you lie flat or bend over. The pain is often worse after a big meal or within an hour after eating. A key treatment is to raise the head of your bed by placing 6 inch blocks under the bedposts. Raising your head in bed by using pillows is not the way to keep acid in the stomach -- it often makes the problem worse.

Using antacids and acid reducing pills is another treatment similar to that for dyspepsia and peptic ulcers. Certain foods should be avoided that allow the "door" to open: those high in fat or sugar -- particularly chocolate. Finally, if you are overweight, weight loss can really help take the pressure off the "door." If these approaches do not work, you have other choices with different drugs and surgery.

What about "lactose intolerance?" Lactose is a sugar in milk and milk products. About 15% of the white population and as high as 90% of African and Chinese Americans may have bloating, gas, and cramps when they have lactose. They can either avoid eating lactose or try lactase pills. However, many persons who have a normal ability to digest lactose also have these problems. If you have bloating, gas, and cramps when you eat dairy products, you can try to avoid eating lactose or use lactase pills. If the approach works, great!

Every adult will get low back pain at some time. Many persons suffer from it and many workdays are lost as a result.

Lots of studies of back pain have been done and lots of treatments have been offered to sufferers. Out of all the studies, several patterns are clear: 1) almost all back pains get better over time. Few persons with back pain suffer disability -- even those who have a "slipped disc"; 2) attention to lifting, posture, and exercise can reduce repeat back pain and the severity of the pain when it occurs; 3) long bed rest, inactivity, avoidance of careful exercise, and the use of back braces may actually make the problem worse; and 4) x-ray or MRI results don't tell very much - persons with a lot of "wear and tear" on the xray or "disks" on an MRI may have no back problems whereas some with near normal x-rays may be bothered a lot.

For new, low back pain, taking mild pain pills (aspirin, acetaminophen, ibuprofen, etc.) and reducing activity while your back recovers seems to be the most effective approach. If you have to stand, put one leg up on a footstool -- this will take pressure off your back. About 80% of persons with new back pain who follow this approach will be able to return to normal activity in a week, although the average length of pain will be about two weeks.

Several days of bed rest with stronger pain pills or sedatives may be needed when the pain is really severe. However, bed rest may actually slow down the speed of recovery, so try to avoid it.

Find the position that is best for you. Applying heat or cold to the painful area sometimes helps.You may feel most comfortable when lying on your side. Try lying on your back, with a pillow under your knees.

Pain that increases when coughing or that goes into the legs suggests a "slipped disc." Part of the disc (a cushion between the bones of your back) can squeeze out and pinch the nerves that go to your legs and bladder. This disc will heal over time. If the pain is so severe or the nerves are damaged (numbness or weakness) and you cannot function, surgery or other procedures may be needed to treat the damaged disc.

Back surgery will make this problem get better quicker than waiting for the disc to heal on its own. However, after several years, persons who have had surgery are generally not better than those who have not had surgery.

What about chiropractic manipulation of the back? For low back pain without pain going into the leg, chiropractic care may help some persons get better faster. But exercise and good posture are needed to prevent future problems.

Once the pain is gone, exercises should begin and continue for years. For general exercise, refer to the Chapter called Exercising. For back pain, the results of studies suggest that you begin with exercise #8 p.30 while lying down. While lying on the floor, (with a small pillow under your head), bring your knees to your chest slowly, clasp your hands in front of your knees, pull them toward your chest and count up to ten. Relax, then repeat this three times and then relax with your knees bent, feet resting on the floor. Now tighten your abdomen and buttock muscles for ten seconds and you should feel your back flatten against the floor. Now repeat these three exercises again. Your doctor can discuss additional exercise programs with you.

Additional approaches to reduce the chance for having back pain include:

• Lifting correctly. Lifting is done with your legs by squatting with the back straight, knees bent, and weight held close to your body. Hand trucks or assistance is used for heavy weights. (More than 40 pounds for women and over 80 pounds for men).
• Face or hold the object to be lifted directly in front of you. Avoid twisting your back, particularly when lifting or bending.
• Sleeping on a very firm mattress or with a board under your mattress.
• Keeping your weight near the "ideal" for your height.

Please see a doctor if you notice:

• Neckaches that come on suddenly and have severe headache or fever. (Your doctor worries about meningitis.)
• Neck pains that go into the arms. (Your doctor worries about a badly pinched nerve or heart damage.)
• Neckaches and shoulder pains that do not increase with movement. (Your doctor worries about heart damage.)
• Shoulder pain with fever, swelling, or redness. (Your doctor worries about an infection.)

Neckaches and shoulder pains, like back pain, typically last for days or weeks. General principles of pain relief are the same for all three problems. Plain x-rays add very little useful information. Chiropractic treatment for neck pain, as with low back pain, may speed recovery in some patients.

Self-treatment for neck pain includes gently stretching your neck. Do not "over bend" it. Avoid using a big pillow since it over bends the neck. Use a thin pillow at night or tie your thick pillow with a soft band in the middle so that your head is held in a cradle. When the pain is severe, a soft collar should be worn around your neck to gently stretch and warm it until the problem gets better. (The "collar" can be made by taking a regular towel, folding it lengthwise in thirds, wrapping it around your neck and pinning it with a few safety pins). Wear this at night and during the day if nighttime use alone is not enough to help you.

If you move your arm to comb your hair and your shoulder hurts, you probably have "bursitis/tendonitis" of the shoulder. If this problem comes on suddenly, rest the shoulder for 24 hours and use ice packs repeatedly for 30 minutes out of every 45-60 minutes for 12 of those 24 hours.

Then, begin "stretching" by resting the hand of your "good" arm on a countertop, bending at the hips, hanging your "bad" arm down. Slowly draw small circles with it. Gradually make the circles bigger but don't force it if it feels painful.

Another exercise is to stand sideways about two feet from a wall so that you can reach it easily with your fingers. Now slowly use the fingers of your "bad arm" to "walk" your fingers up the wall.

Stop when you start to feel pain. Do each of these exercises for about five minutes, twice a day. Exercises 3, 4, and 6 can be added to strengthen your shoulder after the pain has decreased.

Persistently reduced shoulder movement may benefit from an injection of cortisone and exercise; however, the shot may not do very much for pain. Sometimes "shockwave ultrasound" can be helpful.

Use the Following Tools to Improve Your Pain Management:

The Diary and Pain Diagram help you keep track of the pain so that you can:

• better describe it to a doctor or nurse
• see what happens when you try different treatments
  Use the diary and pain diagram to direct how you will problem solve your pain.
  

To manage your pain, Go TO Problem Solving.

We have tried to make the How's Your Health error-free. However, those involved in its preparation can not warrant that all of the information is accurate and complete. When you use How's Your Health as a guide for your health and medical care, be sure to discuss any questions about it with your doctor, nurse, or other health care worker.