Transcription:
The Many Approaches to Pain Management

Melanie Cole (Host): Welcome to Back To Health, your source for the latest in heath, wellness and medical care keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics, and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I am Melanie Cole and today we are discussing a multi-faceted approach to pain, and my guest is Dr. Vincent Miccio. He's a physical medicine and rehabilitation physician that specializes in interventional pain medicine at Weill Cornell Medicine. Welcome to the show, Dr. Miccio, what are the basic types of pain? Explain for us a little bit about chronic pain and acute pain, and since they're somewhat subjective, how do you measure pain?

Dr. Vincent Miccio, MD (Guest): Absolutely. First off, Melanie, thank you so much for having me on this program. I'm very excited to be speaking with you today. So when we talk about pain, the first thing we have to do is we have to characterize it, because pain is such a difficult topic for everybody to wrap their brains around and to really put into words and describe. We have to really try to break it down.

So the first thing is we have to figure out if this pain is a new pain, something that has just popped up, something that has just started to bother them, which would be more of an acute pain versus a chronic pain, something that's been lingering, nagging, slowly increasing over the last couple of months. Usually people put a cut-off at about three months or so. If something has been bothering you for about three months, that would be labeled as a chronic pain.

Then beyond that, we try to characterize the pain as being a somatic type pain, which is a type of pain that comes from the bone, the muscles, the ligaments, things like that versus neuropathic pain. Neuropathic pain is a fancy way of saying pain that comes from the nerves themselves, which usually is characterized by kind of a sharp burning tingling sometimes kind of a pins and needles sensation. And then unfortunately some patients also have pain due to other underlying structures such as cancer, tumors, things like that that can be described as a neoplastic type of pain that can also cause pain.

So we try to break it down in terms of the time course of the pain, and then we try to characterize the pain into a couple different categories of somatic, neuropathic, and in time, neoplastic in order to have sort of a road map as to how to proceed.

Melanie: How do you work with a patient? Discuss your multi-faceted approach to painful disorders. What are some of the first things you do when someone comes to you in pain? How do you determine the source? What are you looking for if you take a history?

Dr. Miccio: Absolutely. This is fascinating because sometimes I'll have patients that come in and they're so excited to tell me about their pain, they're so excited to tell me about every little detail, and everything that's going on in them. And I have to say, the approach to that patient is much different than the patient that comes in and they are quite sad about what they're going through, and they're tired of dealing with their pain and such.

And so needless to say, everybody needs a customized approach to treating their pain, and so really the number one thing is to sit back and listen. You have to listen to the patient's story, because they will tell you what they need. Beyond that, some of the things that I'm looking for is I'm really looking for what brings on the pain. So when patients can say to me, "Okay, when I bend over, I get a pain in my back and it shoots down my leg." That allows me to narrow things down to the point that I can sort of guide their care in a specific direction. And so kind of guiding patients through an interview where we ask pointed questions about their pain that allows us to really characterize when it happens, where it happens, and what brings on symptoms really leads us in the right direction.

After an interview, equally as important is the physical examination, and the physical examination is important because believe it or not, we have some of the most advanced treatments for all types of cancers, most advanced treatments for all kinds of medical issues these days, but back pain, simple back pain has been very frustrating for physicians, and it's somewhat still a black box phenomenon for a lot of physicians. Primarily the reason behind that is because there's simply so much anatomy in the lower back area that can cause acute and chronic back pain. So the physical examination is key because what you're trying to do is you're trying to find little clues, little clues that point you in one direction or the next.

Is this more of a muscular pain? Is this more of a joint mediated or joint bone mediated pain? Or is this more of a nerve type of pain? And the physical exam is wonderful because at times patients will come in and they say, "My foot hurts. Dr. Miccio, my foot hurts." And as it turns out, it's not the foot that's causing them their pain at all. As it turns out, it may be coming from the back. It may be coming from the leg and radiating down their leg. So very important, so listen to the history, get a good exam, as well as you have to have a really good handle on their past medical history as well as their past surgeries because my first order of business, the first thing that I need to do, is to do no harm. So we do a thorough search into the patient's allergies, we do a thorough search into whatever medications somebody might be taking, just to make sure that there's absolutely no reason why they shouldn't move forward with either supervised exercise, medications, or various types of interventions.

Melanie: Doctor, what are some best practices for managing either short-term or long-term chronic pain? What are some non-surgical approaches to pain medicine that you might try first?

Dr. Miccio: Years ago, people prescribed bed rest for pain. People would lie in bed for weeks on end as their body healed. And we now know that that is not helpful for patients. So the first thing that patients need to do, is they need to try and go about their normal activities. It doesn't mean that patients need to immediately participate in aggressive exercise, but it means that they need to stay active, they need to stay mobile.

To a certain extent, pain tells us when there is some damage going on in the body, but a certain level of pain is acceptable and can be to a certain extent expected. And so when I advise patients about things, I advise them to try and stay as active as possible from the outset. Movement, mobility, trying to regain normal range of motion, and participating in the activities of daily living all accelerate relief, all move patients in a direction of getting better and getting back to their normal lives. So there are a variety of non-surgical techniques and approaches that we can use for treating chronic pain. These include exercise, they include acupuncture, massage, manipulation, as well as various mind body techniques. Exercise has been proven across the board to help pain, especially back pain, joint pain, and things like that.

When we look at studies across the board, and we pull all those studies together, there is overwhelming evidence that exercise helps with pain. The fascinating thing about this is that there is no one particular type of exercise that has been shown to be the best exercise because otherwise everybody would be doing it, right? So as far as exactly what types of exercise, when a patient is in my office, often what I will do is I will look at the types of issue that they have, I will look at the exact pathology that they have, and depending on the biomechanics of their body, how they move and such, I will advise them to do certain activities whether it's exercises that are involved in bending forward versus bending backwards, and I will sort of correlate that with their overall clinical picture, as well as various things like MRIs, x-rays, and other imaging modalities.

A lot of my patients will branch out and try many different things. I have found acupuncture to be very helpful, and we have many years of quality research that shows that there is mild to moderate improvement in things like back pain when patients use acupuncture. And acupuncture is wonderful because it has relatively few side effects, and recently some insurance programs do pay for it. So I do encourage my patients to explore acupuncture if they have the means to do so.

More and more, as we get away from more of an approach of managing pain by using medicine, we have started to encourage patients to explore the mind body connection between what they're experiencing in their everyday lives and their mindset about their pain and how they're dealing with their pain, how they're processing their pain. Cognitive behavioral therapy is one of the first line psychological treatments that patients are often recommended when they have chronic pain, and it's a fascinating type of psychologic treatment that allows patients to explore their own feelings about their pain and their own experience of it, and it can be quite successful, and many of the highest professional associations such as the American Pain Society recommends exploring these options of mind body therapy for patients.

Melanie: So do you- pain is worse for people at some times than others, and as you say, you explore in the history what's going on in their lives. Are anti-depressants sometimes prescribed for pain? And if so, why?

Dr. Miccio: Anti-depressants are sometimes prescribed for pain. The reason though is multi-faceted. Most of the medications that we prescribe, they have several different effects, and so my job as a physician is to be well-acquainted with those effects, and then try to use those effects to my advantage. For instance, there are some medications that make people slightly drowsy and sleepy and reduce pain at the same time. So what I will do, is I will prescribe those medications at bedtime to take advantage of the fact that they cause some amount of sleepiness, but they also treat pain, so that helps me.

There are other types of medications that do treat a patient's mood as well as treating their pain, and I see that as an advantage because at the same time as we're treating a patient's pain, we may see an improvement in their mood, and we all know that mood and pain are intimately connected. Feeling unwell and in pain certainly does not make you feel particularly good and feeling depressed and such can also make you feel like you're in more pain. We all know this. A lot of the pain medications that were initially used for things like depressed mood and such, and believe it or not even for seizure disorders, some of those medications have been found throughout the years to be useful in pain syndromes. So often we do prescribe those medications for pain.

Of course whenever we prescribe a new medication, we talk about all the different side effects, we talk about the different effects that that medication could have including on one's mood and on their level of pain. The main thing is to look at their medication list, make sure that there's no contraindication, nothing that interacts with another medication, and to go from there.

Melanie: Then as this field of pain medicine is such a burgeoning field, Dr. Miccio, tell us about some of the interventions that you might use that- such as spinal cord stimulation, or cortisone shots, or viscosupplementation. People hear about all of these different kinds of things - epidurals - there's all sorts of names that people hear. Tell us about some of those that you might try for pain, and really how they work.

Dr. Miccio: The first thing that I'll say is that it's my job to make sure that patients stay safe. That is the number one thing, that they stay safe and that we relieve their pain. So we progress along a spectrum from very conservative treatment to more aggressive treatment. So we start out with the exercise, start out with the medications- the simple pain medications that have relatively few side effects, and we work our way upwards. My goal is to also try and prevent larger interventions, larger surgeries that may bring extra risk with them. So I always start out with simple things.

As far as interventions and injections go, it can be as simple as an injection, often called a trigger point injection into a muscle group that can help stimulate oxygen flow to the area, it can stimulate blood flow to the area. From there we can start to do various types of joint injections into knees, and hips, and shoulders and such. And right now the ultrasound technology that we have is very, very good. It's very easy to clearly see where the needle is and where it's going, which has revolutionized the field of providing good care of people with painful joints and chronic pain in general. From there, especially if patients have issues with their back or any kind of spinal condition, we can do epidural steroid injections in order to help them with their pain. These injections are most commonly guided using x-ray technology. Sometimes you'll hear it called fluoroscopy. Fluoroscopy is a fancy way of saying it's just x-ray guided. We use that x-ray to guide the needle to exactly where it needs to go. At that time, when we see it enter exactly where we want it, we put some contrast in, and then we inject the medication.

Most often we are targeting a very space called the epidural space. This is the space around the nerves, and injecting medication around those nerves provides an anti-inflammatory effect. We target epidural space, and by putting medicine into the epidural space, medication travels around the nerves reducing swelling of those nerves and the discs around those nerves which may be pinching those nerves or pressing on those nerves.

Once we've explored epidural injection, we can go even further from there. So for patients who have chronic pain often is a neuropathic character, which is to say that the pain is coming from the nerves themselves. Sometimes patients will have a burning sensation traveling from the back down the leg, or the neck down in the arm. What we can do is we can provide the patients with a therapy called spinal cord stimulation therapy. Spinal cord stimulation is very, very interesting. It involves taking a very small wire and putting it in that epidural space, the same epidural space that we targeted with medication, but this time it's taking a wire, we put a wire in there, and then what we do is provide electronic stimulation to stimulate the nerves coming out of the spinal cord and the spinal cord itself.

There are various types of spinal cord simulators, but we are very fortunate that in the last about two or three years, the technology of spinal cord stimulation has gone through a revolution, whereas before we had spinal cord stimulation that would give patients a tingling sensation often in their legs or their arms and they would have that tingling sensation pretty much throughout the day. Now with this second generation of spinal cord stimulation, patients are able to experience what is called paresthesia-free stimulation, which is to say that there is none of that pins and needles sensation. Instead of that, patients simply experience pain relief. So the technology has improved considerably, and there are many different options that are available.

Melanie: Dr. Miccio, can you please describe for us a patient case study where your patient had tried many other specialties for their pain, or treatments, and then they came to see you and you were able to help them?

Dr. Miccio: I had a patient who came to me after getting pretty much every injection that I know of. He had done various types of fluoroscopic injections, x-ray guided injections, and ultrasound guided injections, and I sat him down and I said, "We're not at the end of the road here. There are other options." And we sat and we talked about spinal cord stimulation. At the time, he was on quite a high dosage of opioid medication. We walked him through the process, we did a- what is called a spinal cord stimulator trial where he actually tried the technology for about seven days, he loved it, he had wonderful relief, and he actually had a permanent implant of a spinal cord stimulator, and now his pain is greatly improved and he is off of opioid medication.

Melanie: Thank you so much, Dr. Miccio. So wrap it up for us with your best advice about how someone can manage working with their physician, acute or chronic pain, and what you tell people every day about working with their physician to manage that pain.

Dr. Miccio: Stay active. That's what I would say. Stay as active as possible, and really allow your doctor to educate you on what the concerning symptoms are. Is there pain that's radiating down to your toes? Is there new and progressing numbness, weakness, tingling? Are there issues with higher order neurologic functions such as bowel or bladder dysfunction, things like that? Those are all red flag symptoms. Your doctor will educate you about that, however pain comes and goes, it fluctuates. To a certain extent, we have to get up, stay active, and get moving, but you want to allow your doctor to work as a guide for you, and that's what he or she should be; a guide to help you navigate exercise, medications, injections, and other advanced therapies.

Melanie: Thank you, Dr. Miccio, for being with us today and sharing your expertise on this topic. . This concludes today’s episode of Back To Heath. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back To Health on Apple Podcast, Spotify, and Google Play Music. For more health tips go to weillcornell.org and search podcasts. Parents – don’t forget to check out Kids Health Cast!