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Pain Management
Dr. Sherri Haas, a pain medicine physician at Twin Cities Pain Clinic in Edina, regularly sees patients who are frustrated after recovering from back surgery. They still feel relentless pain, even though the operation fixed their physical problem. She and other pain specialists then set to work, striving to pinpoint its root cause and squelch the pain.
Haas uses the analogy of a damaged house. The carpenter fixed the damaged walls, but the electrician still needs to repair the wiring to get everything running smoothly again. Pain medicine doctors and a multidisciplinary team of clinicians play a similar role. They work to stop pain signals from traveling along human wiring (the nervous system) from the original source.
“With chronic pain, the nervous system remembers the message and reinforces it after receiving the painful signal for so long,” Haas says. “We can block that pain before it gets to the brain and prevent that hypersensitivity.”
Chronic pain has long confounded people experiencing and treating it. Pain can linger and upend people's lives after an injury, after surgery, or from overuse. It often keeps people from engaging in their normal routines and doing the things that bring them joy. Managing pain is especially challenging because there are numerous contributing players, including the spinal cord, brain, nerves, joints, muscles, biological systems, and chemicals in the body, as well as the way everything interacts.
That makes easing chronic pain one of the most complex areas of medicine. Yet it’s also one of the most promising. In the past 20 to 30 years, physicians, scientists, and medical device manufacturers have learned significantly more about pain and how to help people feel better, says Dr. David Schultz, a pain medicine physician at Nura Pain Clinic in Edina.
The golden years of improving pain management started in 2002 when pain medicine became a medical specialty with fellowship training and board certification. In parallel, medical device companies began pouring billions into developing new therapies. One inspiration for their work came from the opioid crisis and a search for nonaddictive ways to treat pain. “In the last five to 10 years, there has been a great coming together of knowledge and skills and technology that we can use to help pain,” Schultz says. “It’s a super exciting field to be a doctor in. There are new things happening all the time for these patients.”
Breaking the Cycle of Pain
Pain medicine physicians see people for diverse conditions, with stubborn neck and back pain being the most prevalent. Pelvic pain, headaches, nerve pain and neuropathy, joint pain, and fibromyalgia are some of the many other conditions they treat.
When in pain, people typically start with their primary care physician, orthopedist, chiropractor, or other specialist for treatment over several weeks or months. They likely have tried physical therapy, chiropractic treatments, steroid injections, and/or surgery. When these efforts don’t control the pain, it’s time to see a pain medicine physician, Schultz says.
Haas agrees. “If the pain has persisted pretty much daily for three to six months, then they should come to see us. Really, the sooner the better, because then we can break the cycle of pain as soon as possible.”
Some patients even avoid surgery thanks to early intervention, minimally invasive treatments, and regenerative medicine. Dr. Lou Saeger, a pain medicine doctor at Premier Spine and Pain Clinics in Edina, has found the use of biologics in regenerative medicine an effective way to foster healing. Injections of amniotic fluid to relieve pain often perform better than traditional epidural steroid injections for herniated disks, stenosis of the spine, joint pain, or nagging chronic conditions like tennis elbow or rotator cuff tears.
Amniotic fluid can be safely collected and preserved for medical treatment, Saeger says. It’s a practice that has been used by orthopedic physicians for many decades. Research shows that the nutrient-rich fluid reduces inflammation, stimulates new cell growth, repairs cartilage, and more. Similarly, platelet-rich plasma, typically generated from patients’ own blood, is another biologic that is gaining steam as an effective treatment for pain.
“By concentrating on what your own body produces, it promotes a healing response,” Saeger says. “Biologic factors and growth factors can help heal and get the tissue back to more normal functioning without the not-very-helpful side effects that steroids have.”
“With chronic pain, the nervous system remembers the message and reinforces it after receiving the painful signal for so long. We can block that pain before it gets to the brain and prevent that hypersensitivity.” —Dr. Sherri Haas, Twin Cities Pain Clinic
Nerve Busters
Neuromodulation is another method for helping people with chronic pain when it radiates from nerve injuries. It comes in two forms that target the spinal cord: neurostimulation with small electrical pulses or targeted drug delivery. Spinal cord stimulation has been around for decades. But in recent years, physicians have been able to use high-frequency transmission that eliminates an annoying buzzy feeling. “It can modulate nerve pain that’s hard to control and offer people relief from intractable chronic pain,” Saeger says.
Innovation in neurostimulation allows physicians to target nerve pain coming from a specific place, like the hip or groin, Schultz says. Mild electrical pulses are delivered to a dorsal root ganglion, which is a junction between the nerves of the body and the spinal cord. These pulses relieve pain by interrupting pain signals to the brain. Patients can control their devices to relieve pain as needed.
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Knee Pain
woman having acute pain in the knee
“We now know how to precisely target the nerves that affect an area of pain. If you had a total knee replacement but the pain is still there, we can target the knee. If you have pain in your foot, we can target just the foot,” Schultz says. “It’s very impressive.”
The treatment doesn’t work for everyone, or it sometimes will stop working after several years. In such cases, pain medicine physicians can try a targeted spinal drug delivery via an implanted pain pump. Considered a last-resort treatment, these targeted drug-delivery systems direct local anesthetics and opioids to the spinal cord to block pain. One benefit is that the medications—and their side effects—don’t impact the brain like traditional drugs, Schultz says. These pumps work well for helping cancer patients manage their pain.
Physicians implant the device directly under the skin in the abdomen or upper buttock. It holds two to three months’ worth of medication. Downsides include having to go regularly to the clinic for refills. “We use it with a lot of difficult patients who have tried everything else,” Schultz adds. “The medications are very effective, and 95 percent of people who go through a trial say they want to have the pain pump implanted.”
“We now know how to precisely target the nerves that affect an area of pain. If you had a knee replacement but the pain is still there, we can target the knee. If you have pain in your foot, we can target just the foot. It’s very impressive.” —Dr. David Schultz, Nura Pain Clinic
Radiofrequency ablation is another way to target troublesome nerves causing back pain. Often, the pain originates from facet joints on the vertebrae. They can degenerate or fail to heal after an injury. First, the physician will numb the nerve associated with the troubled joint to see if that relieves the pain. If it does, next comes the X-ray-guided ablation, which burns the troublemaking nerves during a same-day procedure, Haas says. The procedure can be repeated when the nerves grow back after a year or more.
If people don’t want to come back regularly to have the procedure repeated, Saeger uses endoscopic surgery to permanently eliminate the nerve pain. During the minimally invasive procedure, Saeger fully removes the nerve tissue to prevent it from regenerating. He also uses endoscopy to avoid major back surgery for people with spinal stenosis, which involves inserting spacers to reduce pressure on affected nerves.
Holistic Care
Many pain management specialists work in integrated teams of providers from varied disciplines. Clinics unite pain medicine physicians, nurse practitioners and physician assistants, pain psychologists or other behavior pain management specialists, physical therapists, experts in prior authorizations and insurance appeals, and more. The team collaborates on finding the most effective ways to help people feel better, Haas says.
This is especially true at the Northwestern Health Sciences University Sweere Clinic, a holistic pain management clinic in Bloomington. Clinical lead Dr. Greg DeNunzio says the clinic does well with easing pain for people with acute and chronic conditions by bringing together multidisciplinary views of the same problem.
“If I’m treating you and I’m not getting the results I expect, I have someone who is looking at different elements than what I’m looking at. It’s multiple providers looking at the same pain but from different perspectives,” DeNunzio says. “It’s very powerful to practice this way, and it’s very healing for patients.”
When people arrive at the Sweere Clinic with nagging injuries or chronic pain, it’s often because one part of the body is compensating for weakness or structural issues in another area. Taking a holistic approach to diagnosing and treating patients often gets at the foundational causes of this pain, DeNunzio says.
Say someone comes in with headache pain. A functional neurologist will evaluate the person’s eye movements, looking for abnormalities that reveal issues in the nervous system. Another practitioner will use a 3D CT scan to evaluate the cervical spine for developmental anomalies. The clinic also has a 3D biomechanics lab that allows clinicians to study patients in motion to evaluate their gait, their balance, forces on their joints, and more.
With a diagnosis in hand, physical therapists, nutritionists, acupuncture providers, and corrective exercise specialists then collaborate with the other practitioners. Together, they develop treatments that help relieve patients’ pain by resolving injuries and abnormalities. The team uses a menu of therapies, stretches, and exercises for strengthening or reactivating muscles that might not be firing correctly, DeNunzio says.
“We work on the complicated cases that haven’t responded to other treatment,” DeNunzio adds. “We’re here to figure out the problem, get you feeling better, and get you out of the clinic.”
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Headache
3d rendered medically accurate illustration of a man having a migraine
Head Game
There are one-off headaches from dehydration, illness, or stress. And then there are the headaches that return regularly and resist over-the-counter medications. But headache sufferers don’t have to live with the recurring pain.
As physicians learn more about headaches, new therapies have been developed to target the causes. The FDA recently approved calcitonin gene-related peptide (CGRP) inhibitors that decrease blood vessel dilation in cranial nerves—a cause of migraines, says Dr. Oliver Ni, a neurologist at the Noran Neurological Clinic in Minneapolis. CGRP inhibitors are the first medications designed specifically for headache prevention, and they don’t have as many side effects as traditional drugs like beta blockers, Ni adds.
When people have chronic migraines—headaches 15 days each month or for four hours every day—they can be considered for botulinum toxin (Botox) injections. Ni cautions that it’s not a first-line treatment for headaches. Most people have tried at least three other medications that didn’t work before undergoing Botox therapy. That’s because it takes 31 small injections on the head every 12 weeks.
Botox relieves headache pain by breaking down pain signals to the brain. It also decreases tension in the muscles that can cause migraines or other headaches. “It does work very well for patients,” Ni says, adding that many people see continual reductions in the frequency and severity of headaches after two to four series of injections.
Nerve blocks are another method for pain relief that can eliminate the need for prescription medications. It might take trial and error before the right treatment is identified, Ni says, but physicians often find a way to make those throbbing heads feel better.
This article originally appeared in the September 2021 issue of Mpls.St.Paul Magazine.
