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Chronic Pain and its treatments: My pearls

The greatest challenge in managing musculuo-skeleatal (MSK) pain is intervening in time to prevent development of chronic pain.

Over 30% of consults in family medicine and emergency medicine are for musculo-skeletal pain. At any one time, 30% of the population is in chronic pain. Chronic pain is defined, depending on the literature, as pain persisting more than 3-6 months.

Acute pain, therefore is less than 3-6 months and resolves after the healing process is completed.

Chronic pain, on the other hand persists beyond a normal healing period. It is considered a disease in itself. It would mean the healing process in incomplete and/or has triggered a pathological biopsychosical response.

There is a strong bidirectional influence and interaction between MSK pathology and psychosocial trauma. For example, the risk of chronicity is much greater if childhood PTSD is present. The risk of chronicity is also high if the physical trauma coincides with a psychological trauma.

Physical rehabilitation via manipulation therapies is crucial (physiotherapy, kinesiology, osteopathy and chiropractics…). If too painful, pharmacology should be added to facilitate treatment and comfort.

If a ceiling is reached, infiltrations should rapidly be added and not wait for failure to be added. That is the most frequent mistake I see. Infiltrations will often promote success in an otherwise failing intervention.

The first goal in treating chronic pain is to improve pain at rest and sleep, then at effort.

Occasionally sleep apnea can cause or facilitate chronic pain.

Occasionally, food intolerances (gluten, lactose) can exacerbate and sometimes even (but rarely), cause chronic pain.

Very often therapeutic success depends more on the patient more than the doctor. The doctor proposes, the patient disposes according to will and body limitations.

No treatment works on all patients, even treatment with very high success rates such as PRP.

Narco-dependency is a biopsychosicial phenomena that threatens 3-5% of the population according to statistics of 20 years back. Narcotic therapy is often discouraged and feared by many doctors. It is however required when all else fails and the client is nonfunctional because of the pain. It needs to be seen as a privilege and not a right. It simply needs to be revoked if abused.

Cannabinoids have been introduced more aggressively after the opioid crisis of 2017. In my clinical experience, they are useful to only a minority for pain control. However they do relax and help sleep. Strangely, I see more success with topical use for pain control than from oral use.

Evidence Based Medicine in MSK therapy by infiltration is paradoxically biased by the huge technician bias. Studies often cannot show the efficiency some technically inclined doctors have.

Multimodality When one form of treatment caps, be it medical or non-medical, the combination with another non-medical or medical treatment often permits a more favorable outcome than stopping and going to another treatment. In other words infiltrations with a non-medical treatment is usually superior to one or the other alone…

Cortisone infiltrations do not cause the side effects prolonged oral cortisone treatments do. There is a concern that repeated cortisone infiltrations will weaken a tendon. I believe a maximum of 2 infiltrations should be attempted on a tendon before going to PRP as the preferred treatment. I do not believe the claim cortisone will damage joint cartilage to limit cortisone treatment at 3-6 months intervals when aged over 60.

It is well known that chronic inflammation on a joint will accelerate the degeneration of its cartilage. By extension, it can be concluded that cortisone will protect a joint. This being said, I still encourage PRP when cortisone will be needed too regularly.

PRP/platelet rich plasma infiltrations PRP infiltrations consist of centrifuging 25-36cc of a patient’s blood in order to separate 8-14cc of concentrated plasma containing 3-4 times the natural concentration of platelets and growth factors.

What the body cannot regenerate/repair at its physiological concentration of “one”, its concentrated form of 3-4 times can actually promote a level of repair/regeneration sufficient to control inflammation and pain. My success rate is close to 80% improvement in 90% of my patients.

Trigger point (TRP) infiltrations TRP infiltrations of spastic muscles can relieve pain for 4-6 weeks, sometimes more, sometimes permanently. We usually do them with xylocaine as substrate and muscle relaxant.

Xylocaine used for trigger points may cause dizziness for 10-30 minutes. That is why patients are asked to be accompanied. Rarely, xylocaine will trigger a fatigue for a few days.

These xylocaine trigger points are often completed with cortisone on enthesopathies and a botulinic agent if the trigger point effect doesn’t last long enough.

Viscosupplementation with hyaluronic acid can be injected with or without cortisone or PRP. I prefer to always use it accompanied. It increases success rates.

It involves injecting Hyaluronic acid (HA) in a joint and sometimes in a tendon or ligament. HA is naturally a molecule of long chains of water retentive sugars found in skin and joints. We use it as a joint lubricant. It is used in esthetics to pulp lips and skin. It is used in diapers to retain water.

I am personally not impressed by its success rate. I would agree with literature that claims it works in only 33% of patients. However, when it does work, it works well for often 3-6 months and more.

Ultra sound guidance is used to guide a needle on an anatomical structure. It replaces an art called infiltration by anatomical referencing that very few doctors master. However, when mastered, it is in my opinion superior to US guidance. In fact, both techniques require many years of training to declare oneself a true expert. I have personally taken 2 courses on US guidance and neither course trainers (Harvard U and Toronto U) was able to convince me of its superiority. It probably takes just as many years to truly master either technique.

The risk of infection from an infiltration is of the order of 1-6 in 100,000.