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Updated TUESDAY August 10, 1999
Exploring the pathways of pain
Those who suffer say they're willing to try anything to find relief.
By Felice J. Freyer
Knight Ridder News Service
CHARLESTOWN, R.I. --Eileen A. Noble keeps a heating pad on her shoulder, a
knit cuff on her wrist, a pillow under her arm and a blanket over her elbow.
Her manicured hand curls a little, the fingers bent from disuse. From time
to time, she uses her left hand to gingerly adjust the coverings, as if
fussing over a baby at her side.
Her right arm has hurt, nonstop, for four years.
It started as a case of carpal-tunnel syndrome, followed by a related
inflammation in the shoulder. Surgery corrected the underlying problems, but
the pain nerves in Noble's arm took no note of the improvement.
Noble suffers from a form of neuropathic pain -- pain that emerges not from
an injury to tissue but from a malfunction of the nervous system itself.
Only in recent years have doctors begun to understand the physiological
processes that underlie such disorders, and they are still a long way from
finding a cure.
But in exploring the pathways of pain, doctors have developed a new
appreciation for how pain works and how important it is to keep it under
control.
"Pain, historically, was more a religious experience -- the idea that
suffering was good for you," says Frederick Burgess, an anesthesiologist who
directs the Interventional Pain Management Clinic at Rhode Island Hospital.
"Now we're realizing that suffering can lead to more pain and more
problems."
The function of pain is to alert you to an injury. If your broken ankle
hurts when you put weight on it, you'll know to ease up until it heals.
"Pain is useful in terms of making the diagnosis," says Burgess. "After
that, it's useless."
Pain is probably at its most troublesome when it's chronic. And in treating
chronic pain, Burgess says, "Realistically, our outcomes aren't that great."
He tries to bring the pain under control so people can function better in
spite of it, but rarely does he see a "cure."
Some forms of chronic pain, such as arthritis or certain backaches, occur
because of a continuing physical irritant. Other forms happen because the
nerves themselves are injured or sick -- such as when the pain of shingles
continues after the shingles attack ends; pain caused by cancer that has
infiltrated the nerves; pain at the site of a spinal-cord injury; or the
strange disorder that struck Eileen Noble.
It started in September 1995. Noble, 51, was working as a certification
nurse at Blue Cross & Blue Shield of Rhode Island, typing information about
coverage into computers. She developed carpal-tunnel syndrome, a common
injury in such jobs. The pain started in her wrist and progressed up her
arm.
The following May, she had surgery to open the carpal tunnel in her wrist,
relieving the pressure on the nerve. She waited for the pain to get better.
Instead, her shoulder started hurting. She was diagnosed with an
inflammation of the shoulder joint. Surgery, she was assured, would make
that better. She waited for the pain to stop.
Finally, in August 1996, her orthopedists diagnosed her with an ailment so
obscure that there's no agreement on what to call it. Most patients call it
RSD, short for reflexive sympathetic dystrophy. But doctors consider the
name misleading and prefer "complex regional pain syndrome."
Noble had a hard time believing the diagnosis. "I kept on thinking 'I'm just
taking longer than the average person to get over this.' "
In February 1997, Noble went to Burgess's pain clinic. He found her
clutching her tender arm to her side, her fingers constricted. She couldn't
bear to be touched.
There is no single treatment that consistently works for chronic pain,
especially for the syndrome that afflicts Noble. So Burgess had a menu of
options. He started at the top and worked his way down.
"If you look at how we treat pain," says Burgess, "it hasn't changed since
the 1800s." There are essentially two lines of attack: opiates, such as
morphine and its derivatives, which mimic the body's own natural painkillers
and work at the spinal-cord level; and nonsteroidal anti-inflammatory drugs
such as aspirin and ibuprofen, which block inflammation at the peripheral
nerves.
Recently, doctors have tried other medicines as well. Drugs that block the
glutamate receptors, including the common cough suppressant
dextramethorphan, sometimes can still the nerve excitability.
Drugs used to prevent seizures may block some of the sodium and calcium
channels in the nerves, reducing erratic pain signals. Antidepressants --
even when the patient is not depressed -- can help, possibly by releasing
natural painkillers.
Drugs to block selected nerves can sometimes cause things to calm down,
bringing long-term improvement for some people.
Eileen Noble tried them all. Most treatments didn't work, had intolerable
side effects or brought only temporary relief. "I was groping for anything
that would work," she says. "If they said, 'We need to take your head off,
rearrange it and put it back on,' I would have said, 'OK.' "
Finally she got to the last item on Burgess's list: the spinal stimulator, a
device implanted into the spine that provides a continuous electric current.
It produces a kind of static that prevents the spinal cord from "hearing"
the "noise" from the disordered nerves. It may also trigger the release of
natural painkillers.
"It worked for the first few months famously," Noble says. But over time the
stimulator was less effective, and in any case, her body rejected it. She
had it taken out.
Because emotions are such an important part of pain, Burgess usually refers
his patients to Ronald Thebarge, a psychologist who runs a group that helps
people cope with chronic pain. Some object at first, thinking the referral
means their pain is viewed as imaginary.
But Burgess knows the pain is real. He also knows that all the treatments in
his arsenal usually can't wipe it out. So people need to learn how to live
with it, and that takes guidance.
One of the first tasks Thebarge's patients face is to accept that they have
chronic pain. "Not to give up," he says, "but to accept that this is the
reality."
"The sooner you can accept it, the more chance you have of reducing
suffering and making effective choices about what to do with your life."