Just what is a pain clinic, anyway?

Thursday, May 6, 2021

If you’ve never been to a “pain clinic” before, you might wonder what goes on in these places. Everyone knows what to expect when they go to the dentist. Pain is an unusual specialty in that it focuses on a sensory experience that is not even one of the five senses! There are no “smell clinics”, or “taste clinics”. Not in the way a pain clinic exists. We start with the symptom, wherever it happens to be, and go to work. So we’re an unusual field, to say the least.

Some history: The field of interventional pain medicine goes back over 100 years, and started with nerve blocks for pain relief. It’s since evolved and melds together a complex array of knowledge and skills found in multiple medical specialties: anesthesiology, neurology, physiatry, orthopedics, neurosurgery, psychology, and psychiatry. Doctors who identify as pain specialists come from all backgrounds, although anesthesiology, neurology, and physiatry are most common.

So what should you expect at your appointment?

Expect to be interviewed and examined, then presented with an assessment of your condition. A plan should follow, which may be simple, or have multiple components. The plan may include further assessment, imaging, tests, or a referral to another specialist. It may also include medications, physical therapy, recommendations for exercise, referral to a pain psychologist, or any of a number of other options that may help manage your pain. Finally, there will probably be a plan for an interventional pain procedure. Some clinics like ours can do same-day procedures, but others will need to schedule you to come back. The procedure will be explained, and you will be asked to sign a consent.

Procedures: Interventional pain procedures usually involve some kind of injection targeting the suspected origin of the pain. We do this with image guidance, so expect a “c-arm” x-ray machine to be swung over you on the procedure table. Needle-based procedures, when performed well, are usually very tolerable, and sometimes almost painless. Occasionally, truth be told, they are very uncomfortable and can leave you sore for days. Certain procedures are more uncomfortable than others, but a bad experience is still not the rule. Let’s take sacroiliac joint injections for example. I can comfortably say that it’s not a well-liked procedure. The pressure of injecting the joint really bothers maybe 30% of patients. But that 30% is quite vocal. Even if the remaining 70% do fine, it’s not fun hurting even a few people. So it’s definitely not my favorite procedure to do, but if you need one (and I’m the doc), try not to worry. We can always slow down, add more anesthetic- or even stop!

Patient factors are a subject worth bringing up. Anxiety almost certainly affects the perception of pain. A study was done to see how far patients moved in response to an injection of local anesthetic. Prior to the injection, patients rated their anxiety. Guess which patients moved the most? Those who rated their anxiety the highest! In addition to anxiety, there is physical hypersensitivity that seems to exist independent of emotional anxiety. Physical hypersensitivity is readily apparent when I examine patients and simply palpate their back muscles. It is normal to not have any pain with this exam. Some patients, however, express a great deal of pain. That’s because they have changes at the level of the spinal cord and brain that cause normal sensations to be perceived as painful. The medical term for this is allodynia. Patients with allodynia are more likely to report significant pain with injection procedures. There are ways we can adapt procedures to make them tolerable to people with allodynia.

Sedation: Some clinics have a policy of sedating all their patients, which I find expensive, unnecessary, and inconvenient to the patient. Do you get sedated for a flu shot? I only rarely find it necessary to sedate anyone, and even then, a Valium will usually suffice. I did an epidural injection in a patient’s neck a few weeks ago, and it was his first one. He said he had been worried sick about the procedure for two weeks and “it was totally painless, didn’t feel a thing”. I never get tired of hearing that refrain!

Aftercare: You will be given advice on what, if anything, to do afterward. You should also be told when to expect pain relief. A follow-up visit will be scheduled, and you will be on your way.

When to expect pain relief: This varies, but for most procedures you will be feeling better within 5-10 days. Some people feel better immediately, for others it takes a few weeks. We’ll make a plan to re-assess your problem in light of the original goals of care, and adjust if needed, or celebrate success!