Jan 7, 2014 — What does it mean to have chronic pain? If your shoulders are constantly hurting, is that considered chronic pain? Anesthesiologist Dr. Jill Sindt talks about the different types of chronic pain, causes, treatments, and what can be done to prevent it. She also discusses why some people with the same injuries and rehabilitation treatments might experience different types of pain.

Interview

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Dr. Harriet Hopf: I'm Harriet Hopf, professor of anesthesiology at the University of Utah. I'm talking today with Dr. Jill Sindt, an assistant professor at the University of Utah who is an anesthesiologist and a chronic pain specialist. This summer Dr. Sindt opened a satellite chronic pain practice at the South Jordan Health Center. I asked her to sit down with me today to talk about chronic pain, what causes it, and how it can be treated.
What does it mean to have chronic pain? My shoulder hurts a lot of the time. Does that mean I have chronic pain? Is there some cutoff for the degree of pain you have?

Dr. Jill Sindt: There's not really. We focus less on how severe a pain is and more on how much it affects someone's life. If someone has pain, say, in their elbow a lot of the time but they're doing everything they want to do and it doesn't hold them back, then do they have pain, yes, but we don't really consider them to need care for their chronic pain. Its patients whose chronic pain, pain that's been around for probably at least a year, is stopping them from living the life they want to live and doing the things they want to do.

Dr. Harriet Hopf: Are there different types of chronic pain and, if so, how are they different?

Dr. Jill Sindt: There are a number of different types of pain, and often people have more than one pain type going on. For example, there's neuropathic pain. That is pain that's resulting from either injury or dysfunction to the nerves. Again, that can be anywhere in the nervous system - the brain, the spinal cord, nerve roots, out to the nerves in the tissue.
Another type of pain would be called mechanical pain. That's things like knee pain in someone who has bad arthritis where it's bone on bone. That can be a mechanical type of pain.
There's also cancer pain which is its own kind of type of pain that results from a lot of different ways but is specific to cancer. There are things like no susceptive pain which is pain in organs that can be from a cancer or from any kind of tumor or mass or inflammation inside the body.
Finally, another major type of pain is what we call myofascial pain which is pain that originates in the muscles or in the connections between muscles.
Again, most people who have chronic pain have a combination of all these different types.

Dr. Harriet Hopf: It seems like with your patients it must be very complicated for you to figure out what's going on when they come into your office.

Dr. Jill Sindt: It is, and that's what we try to do initially is sort out what kind of pains is this person having, because each type of pain has different things that can be used to treat it.

Dr. Harriet Hopf: What do we understand about the underlying causes of chronic pain.

Dr. Jill Sindt: Well, the causes are many, and we don't understand a lot of why some people get chronic pain and others seem to heal well after an injury or some other kind of insult to their body. What we do know is that in patients who have chronic pain it seems that there's a pain pathway set up from the area of injury to the brain. For example, if someone has a low back injury that persists, it seems that there's a pain pathway set up between their low back and their brain that's constantly on and sending pain signals. We don't know why that happens in some people.
But, it also can be part of a bigger term we call central sensitization. That means that in some people the whole nervous system, what goes from the brain, the spinal cord, the nerve roots, all the way out into the nerves in the tissues, seems to be hyperactive. It seems to be more sensitive to pain signals in general. So, some patients seem to develop pain where others don't.

Dr. Harriet Hopf: Do we have any idea how you might be able to turn that off in someone?

Dr. Jill Sindt: That's most of what our treatments try to do in one way or another. Medications are used sometimes to target the nerves or to quiet the nervous system or to cover up those signals. A lot of the procedures we do aim at stopping the transmission of pain signals. Then, other therapies, things like physical therapy and psychology, aim to use the power of the mind and the power of the body itself to disrupt those signals.

Dr. Harriet Hopf: Let's say I have two people and they both have low back pain. In one of them it goes on to being chronic. For one of them somehow that signal gets turned on. One of them, they just move on with life and they're able to do what they need to do. What's the difference between those two people?

Dr. Jill Sindt: You know, it's part of what a lot of the research is focusing on, it's why do some people essentially recover and stop noticing or stop experiencing their pain and why do other people with the same injury and same rehabilitation go on to continually experience their pain. It's something we don't understand. It's probably a combination of genetics, the way you were born, for whatever reason your pain pathway or your nervous system is a little heightened, and other things we haven't figured out yet.
Some people's tendency, we know people who have a little more anxiety or more what we call catastrophizing, which means that something happens and they automatically think it's bad or think it's the worst, those patients somehow seem to be more likely to go on to have chronic pain. That may, again, go along with the idea that the whole nervous system is a little heightened in some people. But, we don't know yet. That's part of what the main areas of research are in pain medicine right now.

Dr. Harriet Hopf: Are you doing any work on advancing the frontiers of chronic pain management?

Dr. Jill Sindt: We're certainly trying to. We have a number of things underway looking at research studies for some invasive therapies, things like pain pumps, especially in cancer pain, and also in using non-invasive devices, things that don't have side effects like medications, to treat pain that may offer some significant benefits for patients.

Dr. Harriet Hopf: I know that some people in your group have looked at things like music and non-analgesic interventions for pain. Do you have any experience with using those in the clinic, or is that just part of the research arm of that chronic pain group?

Dr. Jill Sindt: It is certainly part of the research arm of our group, but we're trying to incorporate it as much as we can. We know that things, certainly psychological treatments, music therapy, deep breathing exercises, relaxation exercises, all of these have a role to play, even things like acupuncture, acupressure. Any kind of non-invasive treatment that is helpful for a patient we are absolutely 100% behind for them.

Dr. Harriet Hopf: I was thinking of chronic pain specialists as sort of an end group of people that you get to after you've gotten into some big trouble, but this makes me wonder are there things people could do to help prevent themselves from getting chronic pain? Now every time I have an ache I'm going to think uh-oh, is this going to turn into a long term problem. Are there any ideas you have preventative?

Dr. Jill Sindt: Absolutely. It is unfortunate that we do end up seeing patients kind of once they've tried a lot of different things and failed, but there are things we know earlier in the course of someone's pain that can be helpful to get them off this train track toward a life with chronic pain.
One of the biggest things we know is it's really important to appropriately rehabilitate from any type of injury or chronic pain condition. That requires a lot of time and commitment and focus to meet with an occupational therapist or a physical therapist or sometimes a psychologist all together. We know that when we start those kinds of therapies earlier, rather than just relying on medications and procedures right away, people tend to do better. Their body recovers better.
It takes some knowledge up front that most pain is short lived and gets better with therapies that have very low risks, things like physical therapy in particular.

Dr. Harriet Hopf: That's fantastic. I've learned a lot about chronic pain and now I'm going to start thinking about being better about going to physical therapy when I have an injury. I really appreciate your time.

Dr. Jill Sindt: Great. Thank you.

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