When Is It Time To Refer?

Pain can be a survival trait, warning us of imminent danger or the need to seek help. It can be a vital sign providing clues in diagnosing an acute illness or injury. But when it lingers too long without adequate treatment, pain can become the problem.

The neuroplasticity of the brain and nervous system is what creates body memory. It allows us to learn to tie our shoes without thinking about it. It’s how budding tennis prodigies and young violinists improve with practice.

As one observer put it, “neurons that fire together, wire together” to form neural connections. Pain that persists too long can form pathways for chronic pain that may continue long after the initial cause of symptoms is gone.

Physicians are accustomed to treating the acute pain that comes with an injury, illness or procedure. When that pain doesn’t resolve as expected, it may be time to consider contacting a pain specialist for an evaluation

“Better early treatment usually helps us achieve better outcomes,” Scott Kendrick, MD, of Southside Pain Specialists, said. “If a patient isn’t responding to early treatment, if the pain is greater than expected, or if it lingers too long, an evaluation can help to clarify what is going on and what type of interventions may bring relief.”

More Americans suffer from chronic pain than from diabetes, heart disease and cancer combined. Medical economists from Johns Hopkins have estimated that the annual cost of medical care for pain in the United States is as much as $635 billion. There is also the cost of lost productivity and wages, lost quality of life, and sometimes the loss of life itself when unrelenting pain leads to organ damage from too much self medicating or an overdose.

”We see two types of pain,” Kendrick said. “Sometimes there are verifiable, objective findings that correlate with the pain patients are reporting, or nociceptive pain. In other cases, the source of the pain may not show up in tests, but that doesn’t mean it isn’t there. It can be neuropathic pain from nerve injury, diabetic neuropathy, or something developing through a neuropathic process. There are also mixed conditions, complex regional pain syndrome, failed back surgery syndrome, and other disorders.”

All patients who come to Kendrick and his colleagues are referred by their physician. The most common complaint is low back pain. However others seek help with discomfort from other pain sites such as the neck, knee, hip or spine.

“We treat the whole patient with a multimodal approach that may include a combination of medications, blocks, physical therapy, psychological support and help with coping strategies,” Kendrick said. “All pain is impacted by psychology and is higher when the patient is under stress or dealing with any source of anxiety. We rely on consulting psychologists, rheumatologists, surgeons and other medical professionals available to help as needed.”

Medications are selected in a combination and tailored to the patient. These include opioid and non-opioid adjunctive medications.

“Opiates are not always appropriate for every pain condition or patient. Often it will respond to the right combination of other medications,” Kendrick said. “Physical therapy, gradual conditioning and in some cases targeted procedures may be part of the treatment plan.”

When it hurts to move, there can be a tendency to inactivity to avoid pain. That leads to deconditioning and more pain, which may limit range of motion and make achieving optimal recovery more difficult. Rebuilding strength and flexibility can often be an important part of improving function and reducing discomfort.

“Depending on the type of pain and where it’s coming from, a range of procedures can be performed to ease the discomfort,” Kendrick said. “We can do epidural injections into the spine and inject joints and trigger points. For more refractory pain, we can perform neuroablation or spinal cord stimulation to interfere or decrease the transmission of pain impulses.”

In most cases, with a clear diagnosis and a treatment plan tailored to the patient, pain management can bring significant relief.

“Chronic pain tends to come in cycles of improvement and exacerbation,” Kendrick said. “We’re here to help patients feel better and get past those flares. We follow progress regularly and monitor improvement. Our goal is to help them improve function and enjoy a better quality of life.”