Dr. Lynda Groh joined Mayfield Brain & Spine in December 2021 as an interventional pain specialist. We asked Dr. Groh about different ways to classify pain, emerging treatments and when surgery is the best option.
“In my opinion, pain should be treated not based solely on symptoms, but on its impact on a person’s life and well-being.”
What are the different types of pain?
Categorizing pain is not easy. It’s complex and confusing at times for both the patient and the physician. In “doctor speak,” we categorize pain in three categories: neuropathic (originating in a nerve, the spinal cord or the brain), somatic or nociceptive (from tissue damage) or visceral (organ-related). Neuropathic pain can include radiculopathy or sciatica, diabetic neuropathy or pain from multiple sclerosis or a spinal cord injury. Somatic or nociceptive pain includes the various types of arthritis. For you non-physicians out there, pain is often categorized by where it comes from or where it is felt – for example, joint pain, muscle pain, nerve pain or headache. Pain also can be categorized by its duration. Acute pain is temporary and resolves within a normal healing time, typically less than six weeks. Subacute pain might last up to three months. Chronic pain persists beyond normal healing time, generally more than three months, and may be associated with significant emotional distress or functional disability.
Is all pain something I need to fix?
Although we often think pain means something is being damaged in our body, that is not necessarily true. Sometimes pain signals are sent by the nervous system to the brain in error. Unfortunately, that does not make the pain any less painful or less real to the patient. It just makes it more difficult to evaluate, diagnose and treat.
What pain symptoms should cause a patient to seek medical attention? How long does the pain have to last?
In my opinion, pain should be treated based not solely on symptoms, but on its impact on a person’s life and well-being, assuming it is not catastrophic. As we get older, we all experience some pain. If you spend a day working in your yard and experience some soreness or minor pain, you may not need to seek medical care. If that pain does not subside within a week or two, if it continues to worsen or if it affects your ability to sleep, work or perform daily activities, then seeking treatment is important.
If the pain radiates from one place to another, is that a sign of something more serious? What about numbness or tingling down the arms or legs?
Radiating pain can indicate something more serious. Radiating pain is related to nerves, while “referred pain” is of mixed origin. Examples of radiating pain include “sciatica,” carpal tunnel syndrome, shingles pain/post-herpetic neuralgia or intercostal neuralgia (occurring after a rib fracture). Numbness and tingling are a strong indication that the pain is coming from a nerve. If these symptoms are mild and come and go, then seeking immediate treatment is not essential. But if they are severe and persistent, the patient should be evaluated. Referred pain can occur suddenly if you are having a heart attack and develop arm or jaw pain, or it can be more benign and chronic, such as headaches related to muscle tightness or strain in the neck or upper back.
How do you evaluate the severity of a patient’s back pain? Is it as simple as “scale of 1 to 10”?
Severity of pain is subjective. Asking patients to rate their pain on a 1-10 scale tells us what that patient is experiencing and the level of distress it is causing them. It does not mean that a 7 for one person is identical to a 7 for someone else. There are some objective signs, including increased pulse and blood pressure, sweating, restlessness, facial expressions, crying and distractibility. These signs are typically more obvious with severe uncontrolled pain, either acute or chronic, and show that the body is under stress. In chronic conditions, patients may position themselves in specific ways or avoid certain movements or clothing that aggravate their pain. An evaluation of a person’s pain takes all of these observable things into account. In children and adults with dementia, these signs are often the only way we have to evaluate their pain.
Do you start with a conservative approach in considering treatment for back pain? What are some of the first options?
Unless a patient shows signs of serious nerve damage – for example, numbness, weakness or loss of bowel and bladder control – the most conservative approach is a great starting point. That approach will vary depending on the patient’s examination, age, medical conditions and imaging results, if available. Initial options include over-the-counter medications, ice and heat, massage, physical therapy and time.
What are some of the emerging treatments for non-surgical back pain?
The importance of physical therapy and exercise is nothing new, and it is proven to be crucial for long-term back health. There is increasing evidence that mindfulness and meditation are also of great benefit in many pain states, including chronic low back or neck pain. Other “alternative” therapies like biofeedback, electrical nerve stimulation, acupuncture and massage can provide relief, particularly if practiced regularly. It is important to look at lifestyle changes to get a handle on ways that people can adjust activities and learn to “listen to their body.” Another area of focus is diet, and there is much interest in the impact of a non-inflammatory diet on chronic back pain, arthritis and general health.
There also is an ever-expanding arsenal of non-narcotic medications for pain, including anti-inflammatories and muscle relaxants that help decrease nerve pain. Narcotic pain medications are not a good option for long-term use and should not be an initial treatment. Interventional pain treatments involving injections to treat nerves or joints or other painful structures are an important part of conservative, non-surgical care. This is another area where we have more treatment options, not only for spine-related pain but also for pain related to the joints (arthritis) and muscular pain.
What about smoking?
Most people are aware that smoking is bad for you. What most people don’t realize is that smoking is particularly damaging to the discs in your spine. Those damaged discs are more likely to herniate and slower to heal from an injury in smokers.
When does a patient’s back pain require surgery?
Patients who present with some of the severe signs of damage to a nerve or the spinal cord are candidates for urgent surgery. For others, surgery depends on a wide variety of factors – response to treatment, lifestyle factors like work and sleep, other medical conditions, surgical outlook and the patient’s interest in surgery.
When is spinal cord stimulation an appropriate treatment for pain? Do I have to have surgery first?
Spinal cord stimulation is a fantastic tool for patients, including those who have had surgery and still have pain. The technology of these devices has improved markedly in the last few years and gives providers and patients more options, particularly for people whose age or medical conditions preclude them from having surgery. Spinal cord stimulation also can be used to treat pain conditions including diabetic neuropathy, shingles pain, post-herpetic neuralgia, complex region pain syndrome and phantom pain. The beauty of spinal cord stimulation is that in most cases we place a temporary lead through a needle and let patients go about their activities (with some limitations) with the stimulator in place for up to seven days. This allows them to see what this therapy can do for them so they can “try before they buy.”