PSORIATIC ARTHRITIS MEDICAL NEWS

One thing we all share in common, in one form or another is PAIN. We feel it,
know it exists, deal with it as best we can, live with it 24 hours a day -
seven days a week, medicate for it, and know that sometimes our friends,
spouses, and children can't or are not able to understand our condition,
complaints, fatigue, and frustration.

I am devoting this entire issue to the understanding and treatment of chronic
pain and how we can teach ourselves to
deal with it. We are all striving for a level of "normalcy" in our every day
living. We know pain will never go away.

Due to the length of this information, I will be sending Part 2 in a second
newsletter issue tomorrow.

This first article is from the Mayo Clinic-Pain Management Center in
Rochester, Minnesota and represents their professional medical approach to
pain. I hope you find it informative.

YOU HAVE CHRONIC PAIN: NOW WHAT? After years of uncertainty, you've finally
learned what's causing your discomfort. Perhaps it's arthritis, fibromyalgia
or any number of conditions. The result is the same. It's chronic.
Knowing the source of your pain isn't enough to alleviate your discomfort.
There aren't any quick fixes for chronic pain. And often, there's only so
much doctors can do. You're the key ingredient. If you want your life to
improve, you need to take steps to manage your pain.

UNDERSTAND YOUR ROLE
The first and most important step in controlling your pain is accepting the
fact that you may always have pain. Some people can significantly reduce or
eliminate their pain. But if you're like most people with chronic pain, your
pain always will be a part of your life.

Managing chronic pain isn't about making your pain disappear. It's about
learning how to keep your pain at a tolerable level. It's about enjoying life
again, despite your pain. And it's about accepting that only you can control
your future.

FIND THE RIGHT DOCTOR
Being in charge of your pain doesn't mean that you can't or shouldn't look
for help from others. A doctor can be especially helpful when you have
questions or need assistance. But make sure it's a doctor who understands
your condition and communicates well with you. The right doctor for you could
be your family physician or a specialist who's overseeing your condition. Or
you may want to see a physician or a psychologist who
specializes in pain management. If you're not sure where to find a pain
specialist, ask your doctor to refer you to one.

When selecting a doctor, in general, look for someone who has these
characteristics:
Is knowledgeable about chronic pain
Wants to help
Listens well
Makes you feel at ease
Encourages you to ask questions
Seems honest and trustworthy
Allows you to disagree
Is willing to talk with your family or friends
Has a positive attitude toward life and your condition
Before selecting a new doctor, however, check with your health insurance
provider to make sure that the doctor is covered under your policy.

PAIN CENTERS AND CLINICS
Major life changes sometimes require personal guidance. Learning how to
manage chronic pain is one instance where one-on-one help may make the
difference. If you feel that you might benefit from more individualized care,
consider visiting a facility that specializes in pain management. There, you
can benefit from the knowledge of professionals who deal with chronic pain on
a daily basis.

A pain clinic is a facility with one or more physicians who specialize in the
treatment of painful conditions. For example, they may specialize in the
treatment of back pain or headache. A pain center is a multidisciplinary
group of physicians whose collective expertise allows for the management of a
wide variety of pain problems. A pain center, for instance, can handle all
types of pain, frequently has ongoing research programs and participates in
the training of pain physicians.

WHERE TO START
In seeking care for your pain, the first step is to obtain the correct
diagnosis. You want to make sure that your pain doesn't signal an underlying
disease, infection or cancer. This process usually starts with your primary
care physician, who may refer you to one or more specialists. Often a number
of diagnostic tests are performed and initial steps are taken to relieve your
pain.

If the pain persists and initial treatments aren't bringing relief, then you
may consider a pain clinic or pain center. Physicians there perform a
thorough history and physical exam. Additional diagnostic tests often are
performed. These tests may be noninvasive, such as an X-ray, or invasive,
such as diagnostic nerve blocks. Once a diagnosis is reached, a treatment
plan is proposed. Understand and consider the risks and benefits of any
treatment suggested.

Hopefully the treatment will help your pain. Treatments that aren't helpful
should be stopped before trying new ones. If no effective treatment can be
found for your pain, there are still ways to help you cope with that
situation. This process is called pain rehabilitation. Pain rehabilitation
programs help you get the most out of life even if you have unrelieved
chronic pain.

PAIN REHABILITATION PROGRAMS
Pain rehabilitation programs support the belief that chronic pain affects
many aspects of your life and, therefore, require a broad treatment approach.
These programs explore various ways to help you control your pain. In the
process, they also help you identify factors in your life that may contribute
to your pain, or make it more difficult to manage. Often, but not always,
pain rehabilitation programs are associated with medical schools or large
medical centers.

In many pain rehabilitation programs, pain specialists integrate behavioral
and lifestyle changes with physical and occupational therapy and selective
use of medications or injections. Depending on the location or cause of your
pain, other therapies, such as biofeedback or transcutaneous electrical nerve
stimulation (TENS), also may be incorporated into your treatment plan.

BIOFEEDBACK
Research on pain rehabilitation programs is positive. It shows that people
who take part in a program generally get more relief from their pain and have
an improved outlook on life than people who receive a single form of therapy
or none at all. People in pain rehabilitation programs are also more likely
to return to work, generally feel less need to visit doctors or other health
care providers, and typically maintain their progress over longer periods.

THE PAIN MANAGEMENT TEAM
The staff members who make up pain rehabilitation programs vary. But most
programs include some or all of these key professionals:
Physicians: A physician who has extensive training in the area of chronic
pain typically heads up the team, providing coordination and direction. This
person may be a family practitioner or have trained in one of several medical
specialties, such as neurology, psychiatry, anesthesiology or physiatry
(physical medicine and rehabilitation). Just one or a group of doctors may
work at the center or clinic.
Psychologists: Psychologists help sort through and address the many
behavioral and emotional issues that can accompany chronic pain, such as
depression, anger and fear. They also help pinpoint issues that may be
contributing to your pain, such as strained relations with family members or
stress at work. In addition, psychologists teach important skills such as
stress reduction and relaxation techniques.
Nurses: Nurses help monitor medication use or medication withdrawal. They
provide information on various treatments and monitor your progress. In many
programs, nurses act as case managers, serving as advocates for you and your
family and acting as an intermediary to other professionals on the team. A
nurse may be the team member you interact with most often.
Physical and occupational therapists: Therapists are vital to the task of
rebuilding your strength, endurance and confidence in your ability to
function in everyday life.

Physical therapists do this through individualized instruction for a complete
fitness program. Occupational therapists bolster your independence by
focusing on increasing competency in specific, day-to-day tasks. Instruction
on proper body mechanics and self-care for sore muscles and stiff joints also
are goals of physical and occupational therapy.

Others: Additional professionals who may be part of the pain team include:
A registered dietitian to help you eat more nutritiously and control your
weight.
A social worker to help you deal with financial, work, educational or family
concerns.
A vocational counselor to help you develop the skills you need to return to
work or keep your job.
A recreational therapist to help you safely take part in various recreational
activities.
A chaplain to assist with religious and family issues.

WHAT TO EXPECT
Not all pain rehabilitation programs operate exactly the same, but their
approach is often quite similar.

Once you've been admitted, you'll receive a thorough evaluation. This may
include having staff members review your physical and psychological
condition, your use of medication, your work situation and your relationship
with your family. The evaluation helps staff devise a treatment plan and
personal goals that addresses your specific problems. These goals might
include helping you get off your medication, return to work, become more
physically active and learn to relax.

In some programs, the therapy and attention you receive are intensive. You
spend most of your day at the center for about 2 to 4 weeks. During this time
you work with physical and occupational therapists and spend time in group
sessions. You also meet daily with your case manager to discuss your progress
and any areas that remain difficult for you.

With other programs, the schedule is more relaxed. You meet for just a few
hours each week over several weeks.

HOW TO LOCATE A PAIN FACILITY
To find a reputable pain program that fits your needs, talk with your doctor.
Some programs require a letter of referral from your doctor and a copy of
your medical records.

If you have a medical school nearby, check to see if it operates a pain
center or clinic. Or if you're attending a support group, you can ask members
of the group if they've been to a pain facility and listen to what they have
to say about that program.

You also can obtain a list of approved pain centers from the Commission on
Accreditation of Rehabilitation Facilities. This organization certifies pain
rehabilitation centers.
Other organizations that you can contact for references include the American
Pain Society or the American Academy of Pain Medicine

WHAT TO LOOK FOR
Pain centers and pain clinics abound. But because facilities and personnel
vary in their qualifications and focus, consider these factors when
evaluating your options:

What are its goals? Is the program focused strictly on relieving your pain,
or does it include services to help determine the cause of your pain or the
personal problems that may be associated with your pain?

What methods does it advocate? Be particularly careful in evaluating programs
that advocate long-term use of potentially addictive drugs, such as opioids,
or that routinely include surgery or rely on unproven therapies, such as
homeopathy or herbal supplements.

Are staff members friendly and willing to listen? It's important that you
feel comfortable with those around you. Members of the staff should be
interested in you and your condition and take time to listen to your
concerns.

Is the program accredited or certified? It's not required that pain centers
or clinics be accredited or certified to operate. However, some states
require accreditation to receive insurance reimbursement. Certification also
helps ensure that the program meets the basic requirements for appropriate
medical care.

Does it have a good success rate? Ask what the long-term success rate of the
program is. No program can offer a 100 percent success rate. However,
generally about half of people who visit comprehensive pain centers are able
to return to work.

Does it include follow-up services? If you need additional care once you've
completed your treatment, there should be a number you can call or person you
can contact. Avoid programs that offer no follow-up care.

How much does it cost? Cost is always a concern. Make sure that you know
approximately how much the treatment will cost beforehand. And check with
your insurance company to see what expenses will be covered. Some insurance
companies cover treatment provided by comprehensive pain programs, others
don't. And depending on the type of treatment offered, services associated
with specialized pain facilities may or may not be covered.

YOUR ROLE
Pain centers and clinics are similar to many things in life - you only can
get from the program what you're willing to put into it. If you're unwilling
to learn new skills and you continue to have a negative attitude, the program
may help you very little. But if you enter the program with a positive
attitude and realistic expectations, you can come away with a better
understanding of what you need to do to manage your pain, and confidence in
your ability to do it.

INPATIENT OR OUTPATIENT?
When selecting a pain rehabilitation program you may need to consider whether
you want to take part in the program as an outpatient or as an inpatient -
staying at the facility over the course of your treatment. Both approaches
have inherent benefits and disadvantages.

The inpatient approach can be beneficial because you're with staff members
who can constantly keep a lookout for your negative pain behaviors and help
you work on them in a constructive way. The extra support an inpatient clinic
offers also can be advantageous if you need to wean yourself from addictive
medications.

However, because of this intense, 24-hour-a-day approach, inpatient pain
programs generally are more expensive than outpatient programs.

An outpatient pain center provides most or all of the same services as an
inpatient program. But you're at the center only during the day - spending
nights and weekends at home or elsewhere.

The advantage of outpatient programs is that the cost is usually less. They
also allow for time away to be with family or at work. However, outpatient
programs often run for a longer period than inpatient ones. And if you don't
live close to the facility, you may need to pay for overnight accommodations.

Sometimes, people with an addiction to painkilling medications start out in
an inpatient facility and then transfer to an outpatient program to continue
treatment.

LEARN ABOUT YOUR CONDITION
Finding the right doctor isn't the end of your job. It'll take teamwork to
manage your pain. To make this easier, make an effort to learn all that you
can about your condition and your pain.
In addition, check the reference areas at your local library for medical
dictionaries, books on health topics and health magazines. You also can
browse through the health section in your local bookstore.

It's important to be informed about your health, but don't overdo it.
Spending too much time reading about your condition or discussing your pain
can be counterproductive. It draws your attention to your pain, instead of
away from it.

CAUSES OF PAIN
Pain can strike just about any part of your body - from your head to your
toes, from your skin to your well-protected internal organs. The causes are
as varied as the sensations they produce. Some common causes of chronic and
acute pain:
Arthritis
Back pain
Bursitis
Cancer pain
Chronic pelvic pain: Puzzling, frustrating condition
Endometriosis
Fibromyalgia
Headache
Irritable bowel syndrome
Mouth, jaw and face pain
Neck pain: Sometimes serious
Overuse strain injuries
Peripheral Neuropathy
Post herpetic Neuralgia
Reflex Sympathetic Dystrophy Syndrome
Sickle Cell Anemia
Unknown causes of chronic pain

COMMON QUESTIONS ABOUT CHRONIC PAIN
Living with chronic pain can be frustrating. Some people don't know what is
causing their pain. Others know the source of their pain, but are still
searching for an effective treatment to manage it. David Martin, M.D., is an
anesthesiologist who specializes in pain medicine at Mayo Clinic, Rochester,
Minn. Here he answers questions that he's frequently asked when working with
patients.

What's the difference between a pain clinic and a pain center? Do pain
clinics only do injections?
A pain clinic is a facility with one or more physicians who specialize in the
treatment of painful conditions. For example, they may specialize in the
treatment of back pain or headache. Many pain clinics do provide injection
therapy, but it depends on their focus.

A pain center is a multidisciplinary group of physicians that specializes in
the comprehensive treatment of pain. Their collective expertise allows for
the management of a wide variety of pain problems. A pain center, for
instance, can handle all types of pain, frequently has ongoing research
programs and participates in the training of pain physicians.

Oftentimes, a physician who refers a patient to a pain clinic or pain center
has ruled out easily treatable causes of pain. But don't be surprised if the
first step for your physician in the pain clinic or pain center is to perform
additional tests to find a specific, treatable cause of pain.

What is the likelihood of addiction to pain medications?
People need to understand that there is a big difference between physical
dependence and addiction. Dependence and tolerance are natural reactions of
your body to the drug, while addiction is a psychiatric and behavioral
problem. When taken as prescribed for pain, opioid medications do not cause
addiction. Nevertheless, addiction can be a devastating problem, and it's a
possible risk if people take their medications in ways that aren't
prescribed. In addition, those who have a prior history of substance abuse or
addiction need to be very open and tell their doctor about that because
they're at a higher risk of addiction.

For how long should pain medications be used?
It depends on the cause of the pain and the specific medications used. In
general, we first find the proper dose of medication that controls the pain.
Then the patient begins a gradual increase in their activities. Once a
patient is able to do the activities they want without pain, or with
manageable pain, we usually continue medications at a steady level for about
3 months. Then the patient can try a break from the medication, by slowly and
gradually cutting back on the amount of medication taken. This is commonly
called tapering off.

It's important to use a diary to monitor your progress with the decreasing
amounts of medication. If the pain comes back, then you should discuss it
with your doctor and consider resuming the medication, again using the
tapering method to get by with the least amount necessary. You can try this
every 3 to 6 months, tapering off and monitoring your progress to see if you
can get away with less medication.

What are the chances of overdose while using patient-controlled analgesia
(PCA)?
Patient-controlled analgesia (PCA) is often used to control pain after
surgery. PCA is designed to let the patient control the amount of pain
medicine he or she receives. The patient pushes a button and a machine
delivers a dose of pain medicine into the blood stream through a vein. You
shouldn't worry about overdosing, because the dispenser is programmed so that
you can't give yourself too much medicine. In fact, the machine will ignore
the request if you push the button too frequently. This way each dose of pain
medicine has sufficient time to work before you receive another dose.

But it's important to remember that only the patient should push the button.
The system can be dangerous if, for example, family members get involved,
because you might receive too much medicine. As levels of pain medicine rise
in your body, you become sleepy and are less likely to push the button. But
if other people push the button, that safety mechanism no longer works. As
long as you're the only one pushing it, you'll be safe.

What is a safe number of injections to receive?
Injections are most effective for joint, muscle or nerve pain confined to a
specific location. They may include an anesthetic to control the pain, a
steroid to reduce inflammation - such as cortisone - or a combination of the
two. There's no set limit for the number of injections you should have - it
depends entirely on what kind of injections they are. For example, if they're
local anesthetic injections - numbing medicine - for diagnostic purposes,
then there's really no limit to how many you could receive, just like there's
really no limit to how many times you can have numbing medicine in your mouth
for dental work. But if we're injecting a corticosteroid, then we have to
respect the fact that these steroids may have side effects at high doses. In
general, it's best not to exceed the maximum amount of corticosteroid
medication to be taken over a specified period of time. The specifics depend
on the actual drugs injected.

Is cortisone harmful?
Cortisone is a natural hormone found in the body. Nobody's allergic to it,
and it's essential for life. It can be used to treat allergies, asthma, skin
inflammations, arthritis and connective tissue diseases, such as lupus and
arteritis, which is inflammation of the arteries. At high doses, particularly
when it was first discovered, it had the appearance of a miracle drug. But
now we know that high doses of cortisone can cause a number of side effects,
such as osteoporosis, changes in the body's normal hormonal balance, weight
gain and fatty deposits under the skin. Although we want to avoid too much of
it, it's all a matter of dosage. For short periods of time and at low doses,
there are no problems with it, and it can be life-saving with certain medical
problems. But be sure you know how much you're getting and that you don't get
too much. A number of chemical derivatives of cortisone, called
corticosteroids, can be used that may have specific advantages over the
original cortisone.

How long do injections last?
Corticosteroid injections take 3 to 5 days to have an anti-inflammatory
effect. In fact, your pain may initially be worse from the injection itself,
especially once the numbing medicine wears off. Typically, the
anti-inflammatory effects of the injections last for 3 to 4 weeks. This can
give you a window of opportunity to initiate exercises, stretches and the
body's natural healing process, so the injection may be all you need to get
better for the long term. On the other hand, sometimes the injections wear
off after 3 to 4 weeks and then the pain comes back. If therapy fails to
work, begin to consider pain rehabilitation programs.

How long does it take for pain to go away?
I often tell patients I don't have a crystal ball. I can't predict what the
future holds as far as when they'll get better. But I do emphasize that there
are a lot of options for pain management. And even if we can't completely
relieve the pain, there are things that we can do to help them live a good
and meaningful life with the pain. I try to provide a range of options for
them. First, we'll start with some of the initial therapeutic options, such
as medications and injections, and if those aren't panning out then I start
to plant seeds about considering pain rehabilitation.

What is pain rehabilitation?
Pain rehabilitation is a process by which you learn to live better with your
pain. Sometimes it's not possible to relieve most or all of your pain,
despite medications and injections. In these cases, chronic pain can have a
significant impact on your life and the lives of your friends and family. The
next best thing to relieving the pain is to learn to live the best you can
with it. This often involves learning techniques of relaxation, moderate
exercise and stress management. It can also include a critical evaluation of
the use of additional medications for your pain. Pain rehabilitation programs
often employ a multidisciplinary team of physicians, nurses, psychologists,
counselors and physical therapists.

Can you usually tell the cause of a person's pain?
It can be very hard to say definitively what is causing a person's pain.
Let's say you were in a car accident and your neck started to hurt. You have
a lawsuit against the person who hit you, and you've taken time off from
work. Eight months after the accident you come to me and ask for relief from
your painful neck. There may have been intervening therapy, medications or
surgeries. I'll do what I can to help your neck, but I may not be able to
determine specifically why your neck is hurting.

In addition, remember that not all abnormalities cause pain and not all pain
is associated with an abnormality. This can be extremely hard for patients
and doctors to accept. We're quick to assume that if you have a pain, there
must be some abnormality causing it. And we're almost as equally quick to
assume that if an abnormality is present, it must be causing a problem that
can be cured with an easy intervention. But this isn't always the case. One
example is a herniated disk. A large number of people have herniated disks,
but don't feel any pain. At the same time, just because you have a herniated
disk and are in pain, it doesn't mean necessarily that the herniated disk is
the cause of the pain.

A lot of times the patient says they just want to know what's causing their
pain so that they can go home and tell their family and friends why they hurt
all of the time. It's not always possible to know the cause and sometimes it
can be very frustrating for a patient.

Is pain all in a person's head?
I tell my patients that I'm going to believe whatever they tell me, and I'll
take it at face value. But people have to recognize that, in essence,
everybody's pain is in their head. It's always a subjective, personal
experience because we can't see pain on an X-ray or a lab test. So I reassure
them that I take them seriously and will do everything I can to help, but
sometimes we're not going to find an anatomic reason for their pain, and
sometimes we won't be able to relieve it.

HEALTH WEB SITES: WHICH ONES DO YOU TRUST?
Imagine a health library with millions of articles you can access for free.
But there's a catch. Those volumes are shelved in random order. And there's
no librarian you can ask for help. Welcome to the Internet.

With the click of a mouse, you can access thousands of Web sites devoted to
health. But combing those sites for the exact information you want is like
wandering through the floors of an imaginary library. And the material you'll
find ranges from solid research to outright quackery.

Remember the three D's of evaluating health information:

Dates. Health information is dynamic. Ongoing research constantly leads to
new insights. Look for the most recent information you can find. Reputable
Web sites include a date for each article they post.
Documentation. Check for the source of information. Notice whether articles
refer to published medical research. Look for a board of qualified
professionals who review content before it's published. Turn to sites created
by major medical centers, national organizations, universities or government
agencies. Be wary of commercial sites or personal testimonials that push a
single point of view or sell miracle cures.
Double-checking. Visit several health sites and compare information. And
before you follow any medical advice, ask your doctor for guidance.

Due to AOL page limitations, the remainder of this newsletter will be
published in Part 2 on 3/22/02

Good health to all.

Jack Nicholas
Newsletter Editor
Issue 2002 3/21/02 -6