Frequently Asked Questions.
1. How do I know if I need a pain physician?
Acute pain is normal pain that serves as a warning that the body has been injured. When the injury heals, the pain goes away. Acute pain is a normal functional type of pain that does not typically need to be treated by a pain physician. The exception to this rule is shingles. If you suffer from shingles, your primary care physician can treat the condition with anti-viral medication. However, you should promptly obtain a referral to see a pain specialist. A pain specialist will augment the anti-viral therapy with nerve blocks which will minimize the chance of any permanent nerve damage. If not properly treated by a qualified pain physician, Shingles can lead to Post-Herpetic Neuralgia (PHN), an extremely painful chronic disorder which is very difficult to treat.
Chronic pain is pain that continues to plague the patient even after the injury heals. While acute pain is an uncomfortable side effect of an injury, chronic pain is a disease unto itself. Alternatively, chronic pain can be caused by an injury that the body is unable to recover from without treatment. Chronic pains does not serve any useful function and if not treated, a patient can be debilitated by chronic pain.
2. How do I select a practitioner that will best help me with my chronic pain?
There are many ways of approaching chronic pain. In order to have the best outcome, it is best that you find a practitioner who is familiar with all of the various pain conditions who will be able to quickly and properly diagnose the root cause of your your chronic pain. In addition, the practitioner should be intimately familiar with all potential treatments and have detailed knowledge regarding the benefits and risks associated with each treatment as well as who is a good candidate for each treatment. You will generally only be able to obtain this expertise at a multidimensional pain clinic run by one or more physicians who are pain board certified by the American Board of Pain Medicine (ABPM). A multidimensional pain clinic provides services to chronic pain patients which span a wide variety of disciplines. At a minimum, a good multidimensional pain clinic will be able to provide the following services either directly or by referral:
1. Physical therapy
2. Prescription medication management including anti-inflammatory medication, muscle relaxors, and a wide variety of medication to treat any co-morbidities in addition to narcotics.
3. Acupuncture
4. Spine and joint injections
5. Muscular skeletal manipulation and therapeutic massage
6. Advanced diagnostics such as EMG and discography
7. Spinal cord stimulator implantation
8. Spine surgery
9. Pain Pump
10. Mental health services that provide support for chronic pain related depression.
A multidimensional pain clinic coordinates the various therapies and the resulting synergies will lead to superior outcomes. If you instead initially choose a practitioner that specializes in just one or a handful of therapies, then they will apply the treatments that they know which may or may not be the optimum therapy your specific condition.
3. From a treatment perspective, is all pain the same or are there different types of pain each with different treatments?
From a treatment perspective, the are different types of pain. Treatments that work very well with one type of pain, may be relatively ineffective when applied to a different type of pain.
Nociceptive pain is caused by injury to the body's tissue and is a throbbing or aching pain. Most nociceptive pain is acute in nature such a sprains, broken bones and burns. However, some nociceptive pain in chronic in nature including arthritis and pain caused by cancers and other tumors when they grow and put pressure on neighboring body structures. Anti-inflammatory medication, narcotics, and other medications are typically effective in treating nociceptive pain. Neurostimulation typically is not a very effective treatment for nociceptive pain.
Neuropathic pain is caused by nerve damage. The nerve damage can be the result or injury, disease or, physical pressure on the nerve, e.g. a pinched nerve. Colloquially referred to as “nerve pain”, neuropathic pain is normally not as receptive to narcotics and anti-inflammatory medication as nociceptive pain is. Neuropathic pain is often treatable by neurostimulation. In the case of an entrapped, compressed, or otherwise impinged nerve, treatment with cortisteroids is often quite effective. As a last resort for entrapped nerves, surgical release may be necessary.
4. Please explain the basics of workman's compensation and auto insurance.
Too often overlooked sources of insurance coverage are workman's compensation and automobile insurance. These forms of insurance can provide you with important coverage but they are complex and can require care and effort to get the most out of them.
Regarding automotive insurance policies, the amount of Personal Injury Protection (PIP) a policy holder has determines their level of coverage if they are hurt in an auto accident. Each state has its own mandatory minimum amount of PIP. This minimum amount is usually inadequate for fully covering serious injury which causes chronic pain. If you do not have good health insurance coverage to fall back on, it is strongly recommended that serious consideration be given to purchasing a higher level of PIP. If you haven't already, you can take a defensive driving class to obtain a 10% safety discount on your insurance policy.
If you are injured, know how much PIP you have and keep track of how much is expended. Make an appointment with a multidisciplinary pain clinic that is familiar with all of the potential treatment options. A good multidisciplinary pain clinic will develop an individual treatment plan that is based on your specific injuries rather than a one size fits all assembly line treatment. The end result not only will lead to an optimal outcomes, it will also help you to avoid costly therapies that are unlikely to work for your particular injury.
If your PIP runs out and are being represented by an attorney, one option available to you is to have the attorney provide you with a letter of protection to give to your physicians. However, letters of protection are often not accepted by physicians unless the attorney has a well established relationship with the physician. For a list of attorneys whose letters of protection are accepted by AdvanceXing Pain and Rehabilitation Clinic, please refer to our Personal Injury page.
Workman's compensation protects those who have been injured on the job. Typically, if you are injured on company property, your injuries should be covered by your workman's compensation insurance. Another often overlooked aspect to workman's compensation insurance is that it covers injuries due to repetitive motion injury such as carpal tunnel syndrome or tendonitis. These sorts of injuries may not be immediately apparent. You might leave work feeling fine only to wake up the next morning, experiencing pain and/or a limited range of motion.
Workman's compensation insurance is extremely complex and if you are seriously injured, you should retain a lawyer. Physicians who treat workplace injuries can provide a list of attorneys that have a proven track record. Select an attorney with care because once you are represented by an attorney in a workman's compensation case, it is very difficult to switch to a new attorney.
When receiving treatment for a workman's compensation injury, the insurance company will assign a case manager to you. The case manager normally has a medical background, most often they have a nursing degree. The purpose of the case manager is to help guide you through the process. The case manager also has the job of documenting what medical treatment your physician is recommending and why it is needed.
If your injuries are substantial, you may have to go for an Expert Medical Exam (EME), also sometimes referred to as an Independent or Defensive Medical Exam (IME or DME respectively). EME doctors are selected by the insurance company to obtain a second expert opinion. In representing the client insurance company's viewpoint, the EME physician will typically advocate for more economically conservative therapy. Of course, the Delaware Industrial Accident Board is well aware of this and in my experience takes this bias into account when evaluating the merits of your case, so don't get too discouraged if the EME doctor disagrees with the necessity of your treatment. More often than not, if you have a competent ethical attorney, you will prevail in your worker's compensation hearing with the Delaware Industrial Accident Board.
5. How do spine and joint injections relieve pain?
Injection therapies therapies involve injecting medication directly into the injured location that is a significant source of pain. There is one exception to this description called dry needling technique which is a form of trigger point injection described below.
Injecting into muscles:
When muscles are in a permanent state of contraction forming a tense knot of muscle, this can cause local pain or referred pain in the attached tendon. The areas where muscle knotting can occur are called trigger points. Trigger point injections in the muscle can help the muscle relax and heal. When a needle is inserted into the muscle without injecting medication, it is called dry needling. Dry needling is essentially a form of acupuncture and is best performed by someone who is licensed to perform acupuncture. In some jurisdictions, it is illegal for someone who is not a licensed acupuncturist to perform dry needling. Alternatively, a local anesthetic can be injected into the trigger point. Trigger point injections can provide immediate relief to pain caused by a knotted muscle. If the relief provided is temporary, then it may be appropriate to conduct a follow-up injection of botox in the muscle. Steroids should never be injected into a muscle because this can cause significant muscle atrophy. Trigger point injections do not require any x-ray or ultrasound guidance.
Peripheral Joint Injections:
In this context, peripheral means any location in the body except the spine. Peripheral joint injections typically involve injection of cortisone directly into the joint. For knee joint injections, sometimes a lubricant such as Hyaluronan is used instead of cortisone. These injections can be performed with x-ray or ultrasound guidance but this is not a strict requirement.
Peripheral Nerve Blocks:
In this context, peripheral means any location in the body except the spine. An interventional pain physician will inject anesthetic along the outside of the nerve. This injection is a diagnostic injection. If the pain is effectively suppressed by the anesthetic, then the physician has confirmed that the nerve in question is the source of the pain. For more lasting relief, cortisone is injected along the outside of the nerve. The cortisone injection reduces inflammation and aids in healing.
Spinal Injections:
There are several types of spinal injections. Typically, a spinal injection involves injecting medication at the site of the injury. All spinal injections must be x-ray or ultrasound guided.
An epidural injection is an injection of cortisone into the epidural space in the spine. The epidural space is a cavity in the spine which contains the spinal cord. If the spinal cord becomes inflamed or the epidural space narrows, a condition called spinal stenosis, the spinal cord can become compressed which can cause serious back and/or leg pain. Epidural injections also can be used to treat herniated disks which also can cause significant back and/or leg pain.
Facet joint injections usually are a combination of injection of cortisone and/or local anesthetic into one side of the facet joints in the spine at one or more levels. Alternatively, these medications can be injected outside of the medial branch nerves which provide sensation to the facet joint. This alternative injection is called a medial branch block (MBB). Once again, local anesthetic is used for diagnostic purposes while cortisone is used to reduce inflammation and facilitate healing. If a cortisone injection in facet joint or medial branch block gives significant but short term pain relieve, a radiofrequency nerve ablation can be performed to achieve more long term pain relief.
The sacroiliac joint is located where the tailbone meets the pelvis. Sacroiliac joint injections involve injecting local anesthetic and/or cortisone directly into the sacroiliac joint. As with other such injections, local anesthetic is used for diagnostic purposes while cortisone is used to reduce inflammation and facilitate healing.
6. When should I obtain a second opinion and what is the procedure for doing so?
It is your right to obtain a second opinion. You should obtain a second opinion from another multidisciplinary pain clinic run by one or more physicians who are pain board certified by the American Board of Pain Medicine (ABPM). Once you have obtained a second opinion, you should decide whether you want to switch to the new provider or stay with the old one. You shouldn't try to receive treatment from two different clinics as this is highly problematic. For instance, by law you can only receive narcotic prescriptions from one pain clinic at a time.
If you want to see a different provider than an interventional pain physician, this isn't truly a second opinion, this is supplemental care. If you are interested in seeing a chiropractor or massage therapist, all you should need to do is ask your physician and they should have no problem providing you with a referral to the provider of your choice.