Home Health Aide Digest
January/February 2006

What is Chronic Pain?
By Suzanne P. Campbell MS, QRC, CRC


Pain is the body’s early warning system. It signals that something is wrong. Without it we might not seek medical help. Pain becomes a problem when it continues after treatment has started and after an injury is healed. The word chronic literally means, something, which lasts for a long time. Chronic pain, therefore, is long term. Acute pain, on the other hand, is more short-lived. A sprained ankle or muscle strain would usually produce acute pain, for example.

Chronic pain affects as many as 75 million Americans, according to the American Pain Foundation. It has many causes such as disease, accidents, nerve damage, inflammation and chronic health conditions. It interferes with activities of daily living, quality of life, relationships and employment. If untreated, it can make other health problems worse and even delay recovery. Following cancer and heart disease, chronic pain is the third leading cause of physical impairment in the U.S. Not only does it affect individuals, it also impacts our economy. Lost workdays alone are estimated to cost the nation $100 billion annually.

Because pain is an intensely personal experience it has been hard to measure accurately. One recent study done at Wake Forest School of Medicine yielded objective results. Student volunteers were asked to rate their pain, from applied heat, on a scale of 1-10. Those reporting the most pain showed increased activation of several regions in the outer layer of the brain, when measured by magnetic resonance imaging (MRI).

Unfortunately many people avoid seeking treatment. “The most important message I can convey to patients who live with chronic pain is this,” says Jill Martin associate professor of pharmacy practice at the University of Cincinnati College of Pharmacy. “You don’t have to suffer in silence. The many safe medication choices available today –combined with other physical and cognitive therapies – can offer tremendous relief.” Nelson, who is also president of the American Society of Health-System Pharmacists, emphasizes that pharmacists are a wonderful source of information about various medications. This has become especially important, as some pain medications, such as Vioxx, have been taken off the market. Patients may not be confident about what they can safely take, even among over-the-counter drugs.

Care of patients with chronic pain is a joint effort among doctors, pharmacists, therapists, home care staff, nurses etc. It is important for patients to keep their health care team up to date on how their pain-control regime is working. This makes it possible to adjust treatment as necessary. As a HHA you can help by watching for signs of pain (see pain chart in this issue) and reporting them to your supervisor.


ENDOMETRIOSIS

The uterus is lined with a tissue called the endometrium. When this tissue migrates to other parts of the body, primarily in the pelvic area, it causes the condition called endometriosis. This illness can range from mild to severe and be intensely painful. It is a long-term disease that can occur on and off, despite treatment, until menopause. The cause is unknown at this time but symptoms often improve during pregnancy. It frequently occurs in females related to one another, those who have not had children and those in their 30’s and 40’s.

Symptoms
The condition can cause severe pain and even infertility. About 1/3 of infertile women are diagnosed with endometriosis. It is important to be aware of its symptoms so that treatment can be explored as soon as possible. This may help to prevent the condition becoming worse. The most common symptom is pelvic pain but the severity of that pain does not necessarily indicate the severity of the condition. Other symptoms include:

Diagnosis
Medical providers most often rely on pelvic exams to diagnose endometriosis. In order to evaluate how extensive the condition is they may recommend a medical procedure called a laparoscopy. The patient receives pain relief for this procedure. It involves making a small cut near the woman’s navel and inserting a laparoscope. The scope conducts light into the abdomen so the doctor can see inside of it. It is possible that the doctor will feel that a small amount of tissue should be removed during the procedure in order to do a laboratory biopsy. The tissue is then examined, usually under a microscope, to help make an accurate diagnosis.

Treatment

Treatment can include medications and/or surgery.

Medications
Nonsteroidal antiinflammatory medications (NSAIDS) or hormones are sometimes prescribed to relieve pain. Hormones, such as oral contraceptives and Progestin may slow further endometrium tissue growth and adhesions. Medications and hormones can have side effects, which should be discussed with the medical provider.

Surgery
Sometimes the doctor finds that the endometriosis can be easily removed during the diagnostic laparoscopy. If the case is more involved another procedure called a laparotomy may be required. The ovaries and fallopian tubes are left alone as long as possible if they are healthy. If nothing else relieves the pain, a hysterectomy may be recommended. The condition is less likely to reoccur if the ovaries are removed.

Some Holistic Treatments for Chronic Pain
By Suzanne P. Campbell

We often associate pain treatment with conventional methods such as surgery, physical therapy or medication. But there are many other options available to medical practitioners. Some fall into the area called holistic medicine. This term means that the focus is on the well being of the entire person, not just a limited area of the body. Here are some examples:

Music Therapy
“Music therapy can make the difference between withdrawal and awareness, between isolation and interaction, between chronic pain and comfort - between demoralization and dignity,” says Barbara Crowe, past present of the American Music Therapy Association.

As a HHA you may find that music therapy is part of your client’s treatment plan. It has been shown, for example, to increase or maintain the level of function in elderly clients. This includes physical, mental and social/emotional areas. For these reasons it helps to maintain the person’s quality of life.

It is often used to enhance cancer treatment and reduce the perception of pain. Hospice programs include it to bring comfort from pain and create a positive experience for patients and their families.

Music therapy is used to accomplish established therapy goals. A typical session might include the use of instruments, singing and listening to music. Patients may be encouraged to remember positive experiences associated with favorite songs. The use of music in guided imagery may enhance the function of the immune system and help manage pain. Patients may choose certain music they want played during treatments such as chemotherapy. Research has shown that this helps patients develop a more positive attitude about therapy and reduce anxiety.

Transcutaneous electrical nerve stimulation (TENS) Therapy
Another form of pain treatment many HHAs will encounter with their clients is the TENS unit. These can be used for acute or chronic pain. The TENS unit delivers electrical impulses through the skin to the surface and deep nerves of the body. The impulses are delivered through gel-like pads which are placed on the skin and connected to the TENS unit through wires. The strength of the impulses can be controlled easily with a hand held, battery operated unit. The unit itself can be worn on a belt for convenience and the device can be worn continuously if necessary. Unlike drugs and topical treatments, it has no known side effects.

There are two theories about how electrical stimulation relieves pain:

1. The first is the “gate control” theory. It maintains that impulses are sent to the brain from the local nervous system. These messages travel through the nerves on the surface of the skin to the deeper nerves. From there they move to the spinal cord and then the brain. As these impulses move through the system they pass through many “gates” which control how fast the brain receives messages. Pain and non-pain impulses can’t both flow through the “gate” at one time. The stronger electrical impulses from the TENS unit get through first. Thus the brain does not perceive the pain as easily.

2. The second theory suggests that the electrical stimulation encourages the body to produce natural painkillers called endorphins. These interact with receptors, blocking the perception of pain. In a way, this is like the way the drug morphine works, but without the side effects.

Relaxation Therapies

There are a variety of relaxation therapy techniques. They are all based on the fact that people in pain experience both physical and emotional stress. These affect the body by causing muscle tightness, shallow breathing, escalated heart and blood pressure rates. Relaxation can ease these effects and help sufferers feel that they have more control over what is happening in their bodies. Following are some popular techniques:


Guided Imagery – Often used by music therapists, guided imagery helps the mind to focus on pleasant images. Patients are told to begin by breathing slowly and deeply. Then think of themselves in a wonderful place. They are encouraged to imagine the sounds, smells and feelings. This takes the focus off the pain

Prayer – People of faith often find prayer very comforting. Sometimes making a tape of soothing inspirational messages or music helps them as they pray

Hypnosis - People who find hypnosis helpful in relieving pain also say that it is soothing and enjoyable. Hypnosis is a form of deep relaxation and guided imagery. It focuses the attention inward. It requires a professional practitioner at first but patients can learn self-hypnosis techniques to practice at home.

Massage – Massage brings warmth and relaxation to painful areas. The patient can practice it alone or with a massage practitioner. Tips to remember include:
1. stop if it’s painful
2. Don’t massage a swollen or painful joint
3. Don’t use heat treatment with menthol gel, it can cause burns
4. Choose a massage professional with care, seeking someone who has experience with your particular chronic pain condition.

Rhythmic Breathing –
1. Breathe in slowly and deeply.
2. As you breathe out, feel the tension leaving your body.
3. Continue to breath in and out slowly and regularly at a comfortable rate.
4. To help you focus on your breathing: breathe in and silently say to yourself, “in, two, three.” Breathe out as you silently say, “out, two, three.
5. If you prefer say a word such as “peace” to yourself silently as you breath in and out.

*Because HHA’s are very smart, you have already figured out that these techniques are also terrific for relieving your caregiver stress and making your job more enjoyable!



FIBROMYALGIA

One condition that can cause profound, chronic pain is fibromyalgia (FM). It is characterized by widespread aches, pain and stiffness. Patients experience increased pain due to abnormal sensory processing. Symptoms vary in intensity from day to day. It is estimated that 3-6% of the U.S. population have FM. It occurs most often between ages 25-55. Women are more likely to have it but it can affect men and children also. Medical providers in rheumatic disease clinics say 20% of their patients have been identified with the condition. It can be characterized by such things as:

It takes five years for the average FM sufferer to receive an accurate diagnosis. This is due to such things as doctors not being educated about the disease, symptoms that overlap with other diseases and sometimes negative lab test results.

One important factor in treatment is helping the patient recognize that they need to adapt their lifestyle to the disease. Other modalities include such things as: relaxation techniques, nutritional counseling, pain management, lidocaine injections, antidepressants (which also help patients to sleep better), gentle exercise, massage, chiropractic treatment, aromatherapy and psychological support.

The good news is that new research and better physician education are causing earlier diagnoses. In addition, with proper treatment, most FM sufferers do improve over time.


Here are some resources for further information:

© 2006 Home Health Aide Digest