Pain, no matter where it is located, is your body's way of telling
your brain that something is wrong. For that reason, neurologists say
that "all pain is in the brain." That is not to say that feeling
pain is "all in your head." Pain, especially chronic pain, is
very real, should be taken seriously and requires evaluation by a trained
An important concept to understand about Pain Medicine, is the notion that
a neurologist's approach to pain is based on a thorough knowledge
of how the body works and how the brain contributes to suffering from
pain; not just how injections and pills can "cover" or "block"
pain. We want to manage pain for patients so that they can continue to
live their everyday lives, but ultimately, we want to get to the bottom
of what is actually causing the pain and fix it.
Understanding Ascending and Descending Pain Pathways
In order to successfully manage chronic pain, two things must be addressed.
The first involves ascending pain pathways. These neural highways allow
the brain to locate the source and sensation of pain and assign to it
an emotionally unpleasant response. Equally important are the descending
pain pathways. These neural highways descend from the central structures
of the nervous system and serve to lessen the pain signals that are travelling
up from the ascending neural pathways in the body to the brain.
Here is an example to illustrate how the ascending and descending pathways
work: It's early morning and you've decided on toast for breakfast.
You turn the toaster on, drop the bread slices in and wait for the beep.
When it's ready, you reach to grab the toast and accidently burn your
forearm on the toaster. What happens first is a pain withdrawal reflex
– you jerk your arm away from the hot toaster. Next, you feel an
acute, intense sensation of pain (this is the result of the ascending
pain pathway), then the acute sensation subsides and it is replaced with
a duller, less intense pain or ache (this is the result of the descending
Why is an understanding of pain pathways important for appropriate pain
management? Because different types of pain treatment act at different
places along those pain pathways we just discussed. The right type of
treatment depends upon the source of the pain and how it is felt.
Pain Medicine Begins with an Accurate Classification of Pain
Beyond addressing the ascending and descending pain pathways, also important
to successful pain management for patients is an accurate classification
of the pain they are feeling. After all, the best treatment depends largely
upon matching it with the kind of pain that is being felt. Pain classifications
generally fall into the following categories:
Neuropathic Pain – This type of chronic pain can have various causes, but develops
as a result of problems with nerve signals, usually resulting from damage
to or diseases affecting the nervous system. Neuropathic pain is frequently
felt as shooting or burning pain or tingling and numbness which is often
accompanied by damage or injury to the nerve fibers themselves. This type
of pain doesn't typically respond well to traditional pain medications
Nociceptive Pain – This type of pain is usually caused by tissue damage or injury
– like a severe cut or broken bone, for example. The sensation of
nociceptive pain is typically felt as a dull or sharp aching pain which
can vary from mild to severe. This is a type of pain that can be temporary
or chronic. Cancer and arthritis, for example, are chronic conditions
that elicit nociceptive pain. However, unlike neuropathic pain, this type
of pain does usually respond well to certain pain medications including
Myofascial Pain Syndrome – This is a chronic pain disorder. It is characterized by something called
"referred pain," when pressure on sensitive points in the body's
muscles causes seemingly non-related pain in other areas of the body.
The pain is usually caused by repeated muscle contraction as can be the
case in certain manual labor jobs, sports or hobbies.
Mixed Pain – In some cases, the chronic pain felt by the patient is a mixture of neuropathic
and nociceptive pain. One example of mixed pain is migraine headaches.
Mixed pain syndrome benefits greatly from a varied treatment approach.
Effective Pain Management Relies on Accurate Diagnosis
Our practice is skilled in the use of Ultrasound and Fluoroscopy to identify
specific pain generators.
Ultrasound helps identify pain conditions in patients who find it difficult
to describe or define the source of their chronic pain, especially when
other types of tests have been inconclusive. Using ultrasound technology,
it is possible to see inflammation and damage to soft tissues and cartilage.
This ability to view soft structures allows for deeper investigation of
pain sources when externally, they appear to be anatomically fine.
During Fluoroscopy, a powerful tool called a fluoroscope is used to diagnose
persistent pain and allows the physician to see the structure, shape and
size of the body's internal bony structures. Using this technology,
it is possible to deliver anesthetic injections to identified sources
of pain. If pain relief occurs, then it is identified as the generator
and is targeted for further pain management therapies in the future. These
therapies can include additional injections, neuromodulation procedures
and more to reduce or eliminate pain.
Pain Medicine – So Much More than Medication
While most people think of Pain Medicine as the use of drugs to minimize
pain, that's really only part of what expert pain medicine physician
use in helping patients find lasting relief. From specific medication
therapy to targeted alternative therapies that don't involve any medication
and even more options, the field of Pain Medicine has never been as diverse
as it is today.
Medication Therapy – Even when medication therapy is part of a patient's chronic pain treatment
plan, medication management can be personalized by an expert. Traditional
trial and error approaches can be replaced with rationale and logical
options based on results of blood and genetic testing. Equally important
is the pain medicine physician's responsibility to help restore patients
to active, healthy and pain-free living after treatment. To do this, we
provide assistance with wean and withdrawal from dangerous narcotic pain
medications that may have been appropriate for acute pain but can cause
significant side effects and problems when used chronically.
Cognitive Behavioral Therapy – This is an effective type of mental counseling designed to address thought
patterns about the self and the world in order to modify negative behavior
patterns or mood disorders such as depression. The goal is to develop
skills and tools to view challenging situations and respond to them in
a more effective way. Since all pain is in the brain, learning effective
coping mechanisms for dealing with the pain is an instrumental goal of
cognitive behavioral therapy.
Biofeedback – This is a learned technique designed to help a patient gain more
control over involuntary functions in the body. The concept is quite simple,
though it takes time and practice to develop. By harnessing the power
of the mind and developing an awareness of what's going on inside
the body, one can gain control over pain.
Acupuncture – Many people suffering chronic pain conditions, from migraine headaches
to sports injuries, have experienced significant pain relief when acupuncture
is included as part of their pain management treatment plan. Though this
type of treatment does involve the careful use of needles inserted into
various pressure points on the body, when performed by an expert, it can
help reduce and in some cases eliminate the need for medication therapy
in some patients.
Goal Directed Physical Therapy – Physical therapy is an important part of any treatment plan for
patients suffering from chronic pain conditions. Goal Directed Physical
Therapy takes this notion a step further by involving the patient in the
therapy plan. The plan is designed around achieving the patient's,
physician's and caregiver's important goals for recovery. Whether
it's the ability to strongly grasp objects after a stroke or the desire
to jump higher after a sports injury, goal directed therapy gives the
hard work of physical therapy a tangible "finish line." This
is important for patients not only physically, but psychologically as well.
Electric Stimulation – The benefits of electrical therapy on both acute and chronic pain have
been extensively studied and documented. Though this treatment modality
is most frequently used for short-term pain relief, it is used to block
transmission of pain signals along nerve pathways. Electric stimulation
therapy has also been demonstrated to encourage endorphin release, promoting
the body's natural "painkiller" response.
Focused Cold Therapy – Considered a promising alternative treatment therapy for pain
management, Focused Cold Therapy involves the use of a special device
that externally delivers temporary and targeted freezing temperatures
to the nerves it is applied to. The technology is intended to force the
nerves into a hibernation-like state, inhibiting their ability to signal
and effectively reducing pain in the applied area.
The Emerging Promise of Neuromodulation in Pain Medicine
Neuromodulation is a critically important and emerging approach to pain
medicine. It is rapidly replacing the historical approaches using pills
and injections. Learn more about Neuromodulation
Pain Medicine – Expertise Required
As we have extensively explored, Pain Medicine is about so much more than
a prescription for medication when it comes to treating and relieving
chronic pain. For patients looking for answers to and relief from their
chronic pain, expert care is required. Dr. Williams is fellowship-trained
in Multidisciplinary Pain Medicine, in the Department of Anesthesiology
and Critical Care at the world-renowned Johns Hopkins Hospital in Baltimore,
MD. Learn more about his qualifications and expertise