I still have pain! Now what?

By Ward Gypson, MD
Associate Professor, Department of
Orthopaedic Surgery
Director, Department of Orthopaedics
Complementary and
Alternative Medicine Services
niversity of California San !rancisco
"ntroduction #y David S$ Bradford, MD
Professor and Chairman, Department of
Orthopaedic Surgery,
niversity of California San !rancisco

Over the past decade, complementary
and alternative medicine innovations
have received increased a%areness and
interest #y the medical as %ell as the lay
community$ "n part, this could #e
e&plained #y an article #y David
'isen#erg, pu#lished in the (e%
'ngland )ournal of Medicine in *++,,
%hich stated that over ,-. of the $S$
population had sought unconventional
medical treatments in the preceding
year$ /his outnum#ered all the visits to
primary care providers that same year$
"t is estimated that over 0*, #illion %as
spent, and that no% over 1-. of the
population has sought alternative
interventions %ith currently over 023
#illion #eing spent each year$ /his does
not appear to #e due to dissatisfaction
%ith conventional medicine and is not
predictive of the use$ 4ather, patients
%ant to address their health and
medical issues %ith a variety of methods
that go along %ith their o%n values,
#eliefs, and philosophical orientations
to%ard life and health$ At the niversity
of California at San !rancisco, many
physicians are actively e&ploring a
variety of complementary and
alternative medicine interventions in an
effort to #etter understand them and to
provide safer, more effective medical
treatment for their patients$ Dr$ Ward
Gypson, a faculty mem#er in the
Department of Orthopaedic Surgery at
CS!, is a specialist in physical
medicine reha#ilitation and provides
e&pertise %ithin our department as %ell
as a clinic for patients see5ing
alternative and complementary
interventions$
David S$ Bradford, MD

Does the following sound familiar?
You injured your back quite some time
ago You went to your doctor and
initially some medications were
prescribed and some physical therapy
!he physical therapy either did not help
much or in fact it made you worse "fter
several weeks to months of trying
physical therapy you had further testing
including #$rays or maybe an %&I scan
"fter these tests you may have been
referred for some special steroid
injections into your back of which you
had at least three !hese may have
helped temporarily' but did not
significantly resolve the severe pain you
are having (ventually' you underwent
surgery !hen after a period of
rehabilitation you may have felt some
improvement particularly if you had had
some pain in your leg )owever' you
continue to have significant pain in your
lower back *y this time many months
have past and you are not able to do the
things you enjoy and may not have been
able to return to work You are now
trying many different medications
including opiate containing medications
You have been to see many doctors but
what they are telling you is there is not
much else they can do for you and what
you need to do is learn to live with your
pain
You would be a rare individual indeed if
you were not somewhat frustrated'
angry' and even depressed at this point
If any of this sounds familiar' please
read on because there may be some
things that can be done to help you
%ultidisciplinary "pproach
!he first thing I would suggest is to stop
looking for a solution I am not being
facetious +hat I am talking about is
when you fall into the unfortunate
circumstance of suffering from chronic
low back pain we have found that there
is no single solution to the problem
Instead multiple interventions need to be
utili,ed to improve your condition !his
is termed a -multidisciplinary. approach
/ften a combination of different
treatments may help even if some of
these treatments have been tried before
but not in the same combination !his
point cannot be emphasi,ed enough
0nderstanding 1ain
"nother very important step toward
getting better is to understand what pain
is %ost of us' including health care
professionals' have a very simplistic
view of what pain is 1ain to us means
there is something that has been
damaged or is about to be damaged
" speciali,ed nerve ending senses this
pain and sends a message to our spinal
cord and up to our brain where we then
reali,e the pain "fter all' isn.t this why
we need pain? 2o that we can tell when
we are injuring ourselves or when we
are about to injure ourselves )owever
this simplistic view of pain does not
e#plain why $$ when your doctor has told
you there is nothing they can find wrong
$$ and the surgery has removed what
has been causing damage $$ and you
are all healed and $$ yet you still have
pain
1ain and Neurotransmitters
!his view of pain also does not e#plain
why when we are frustrated or angry our
pain seems to be much worse "nd
when we are distracted' such as
watching a movie or engrossed in good
conversation our pain may be somewhat
less " new concept of pain is emerging
that can e#plain these things !his
concept is based on the fact that there
are naturally occurring chemicals used
by our nervous system to transmit pain
messages !hese things are called
-neurotransmitters. and there are many
different types 2ome of these
neurotransmitters such as endorphins'
which you may have heard of' can help
decrease pain !here are other
neurotransmitters that may increase
pain
/ne theory in regards to chronic pain is
that the nervous system has an
imbalance of these naturally occurring
neurotransmitters !he ones that help
decrease pain do not seem to be
working as well $$$ and the ones that
increase pain seem to be working in
e#cess It is almost as though a
chemical switch has been turned on that
doesn.t turn off In these situations' the
pain message being sent does not
signify that something is being damaged
or is about to be damaged !hus it is not
a useful message for us and the system
is not working the way it should
/r you may find yourself in a situation
where you do have a disease process
such as degenerative arthritis' which is
continuing to send pain messages
)owever these pain messages are also
not useful because there is nothing we
can particularly do about the arthritis
!his theory of chronic pain being an
imbalance of chemical neurotransmitters
also will e#plain how our emotional state
and behaviors can affect our pain
(ffects of *ehavior and (motions
/ur behaviors as well as our emotional
state changes the chemistry in our
nervous system thus either enhancing
or diminishing our pain +ith this new'
much more comple# concept of what
pain is' we can then understand that
there are many other approaches that
may help manage the chronic pain that
you may be suffering from
3omplementary Interventions
%any useful interventions may be things
we would not associate with medical
treatment !hese things are also
referred to as -complementary. and
-alternative. medicines I prefer the term
-complementary. because this implies
multiple interventions' which includes
traditional medical interventions I have
found this to be the best approach for
the patient suffering from chronic pain
" combination I often recommend for
patients is to utili,e gentle massage to
reduce painful muscle spasms In
addition to this' weekly acupuncture
treatments seem to significantly help to
reduce pain
"cupuncture is the insertion of tiny
sterile needles into the skin at specific
points based upon some 3hinese
medicine principles In 3hinese
medicine' acupuncture is used to create
a balance of an energy force called the
3hi 4pronounced -chee.5 within the body
6rom a scientific standpoint' it has been
shown to alter those naturally occurring
neurotransmitters' which we talked
about
In addition to massage and
acupuncture' some gentle movement$
based therapies are often effective
/ften times your pain may be so bad
that traditional e#ercise just aggravates
it )owever' we do know that e#ercise is
very beneficial in decreasing pain
because it also changes those
neurotransmitters
" good way to get some gentle e#ercise
is to utili,e techniques such as !ai 3hi'
Yoga' or 1ilates !ai 3hi is also based
upon 3hinese medicine principles and
utili,es slow rhythmic movements to
increase strength' balance' endurance'
and mobility Yoga utili,es breathing and
rela#ation techniques to also increase
mobility and strength 1ilates is a
technique that is very popular with
dancers which seems to be particularly
effective for people with lower back
pain It is also a combination of gentle
strengthening and stretching' which
particularly helps strengthen the lower
back and abdominal musculature
(motional 3onsequences of 1ain
In addition to addressing the physical
components of pain' it is important not
to overlook the emotional consequences
of chronic pain "nger' frustration' and
depression will alter your
neurochemistry to actually increase your
pain )owever'
with a combination of meditation'
breathing techniques' and psychological
counseling to teach coping strategies'
these emotional consequences can be
effectively treated
6or some of my patients I even
recommend such things as humor
therapy or making sure they do
something daily that they enjoy such as
dancing !hese things are actually very
accessible You can watch something
funny on !7' rent a funny movie or read
something humorous 8ikewise it is
simple to listen to music and move
gently to the music even if in a seated
position Interestingly enough' these
things have been studied and have
been shown to also change those
neurotransmitters in a positive way to
help decrease pain
6eeling *etter
" combination of these interventions
with more traditional interventions may
not eliminate your pain completely'
however many chronic pain patients find
that they feel quite a bit better and then
are able to be more active' do the things
that they like do and enjoy their lives In
other words' they do learn to live with
their pain