PSORIATIC ARTHRITIS MEDICAL NEWS

The Understanding and Treatment of Pain

Part 2

Brooks Edwards, M.D., a cardiologist at Mayo Clinic, Rochester, Minn., and
medical editor of MayoClinic.com, recommends staying aware of privacy and
security issues. "Before you share information with a Web site about a
condition you have, be sure they don't sell data, which may identify
information about individuals. Also, remember that e-mail is not secure, and
information about your medical history could be traced back to you through
your e-mail address."

Don't get burned when you go online. Remember that anyone with a personal
computer and modem can create a Web site. The fact that information appears
online doesn't mean it's reliable.

Surfing tips from the Health on the Net Foundation: When you visit a health
Web site, look for a logo from the Health on the Net (HON) Foundation. Sites
that display this logo have agreed to abide by the HON Code of Conduct. Some
sites may choose instead to publish a statement that they are in compliance
with the HON Code of Conduct.

This code includes eight principles. For example, a site must provide
information from medically trained professionals, list funding sources and
distinguish advertising from editorial content. The site must also provide
contact addresses for visitors seeking further information or support.

MayoClinic.com spoke with Tim Nater, HON executive director, about health
information on the Internet.
What is HON's mission, and how does it help people who are searching for
medical information on the Web?
Nater: HON's mission is to help sick people get well by guiding them and the
people who care for them to reliable health care information on the Internet.
One of the ways we do that is through the HON code, which is a code of
conduct for the developers of medical information Web sites. The code holds
these developers to a certain standard of good and ethical management, in
terms of the way they present information.
The HON code doesn't tell the user that all the information on a particular
site is true or accurate. It tells the user that the providers of the
information have exercised a certain amount of scientific rigor in the
collection of their information.

What tips can you offer people who surf the Net for medical information, as
far as evaluating whether a site is trustworthy?
Nater: The key to success is probably by becoming a good, active, savvy Net
surfer. Learn to surf with a purpose. Become an expert in your chosen field -
build up a database, including a good index of URLs, a contact list and an
active network. Share good finds with your network, and alert them to bad
sites.
How do you recognize good Web sites? Ask yourself basic questions, such as
how responsive is this site? Does it offer me information immediately about
who's behind it? Does it offer me a nice site map? Am I immediately presented
with the opportunity to search the site? Does it give me a link to a
Webmaster right away? Look for these types of signs that a Web site cares and
is responsive and is trying to help its users.

We try to tell people not to be intolerant of well-meaning amateurism. What
people have to be intolerant of is persistent dishonesty.

Can you offer some tips to help people find the information they're looking
for?
Nater: Half of finding what you're looking for is knowing what you're looking
for - deciding what it is that you want information about. In order to
become a good surfer of the medical Internet, a person must become a very
informed consumer and user of medical information. And that means that he or
she has to learn some of the language. It's a matter of narrowing your search
down to the formal medical terms that care providers use for that condition.

Is the Web a good source of medical information?
Nater: Yes, it is. But it's certainly not the only one. The No. 1 principle
that HON code subscribers must adhere to is admitting that what they do can
never replace the relationship between a patient and his or her doctor.

Online medical information has had an immensely liberating and democratizing
effect. In general, it's a positive development for both patients and
doctors. I think the best doctors are using what the Web offers them to learn
and to get better at what they do.

Of course, the Web also is helping to unsettle patient-physician
relationships. Some of the information out there is wrong and misleading, and
it can make patients too worried, distraught or paranoid. Or they can be
openly encouraged - say by other members of a discussion group - not to trust
physicians anymore.

Should consumers assume that a site produced by a major university or
hospital is accurate and reliable?
Nater: Our users often tell us they feel safe with universities and
hospitals. But a good rule of thumb is: Always stay alert and critical,
whatever site you're on. A nonprofit organization might have a very specific
ax to grind, or it may be the expression of a specific group of experts or
backers who are convinced of the superiority of a given approach. The Web
offers all shades of opinion and information, and that richness allows the
serious surfer to match one piece of information with information from any
number of other Web sites.

Consumers of medical information on the Internet are never going to be
satisfied with one or two sites. Especially if they're patients, they'll
always want a second or third or even a 20th opinion. And if most of these
are good, well, then so much the better.

DESCRIBE YOUR PAIN
Accurately describing your pain will help your doctor learn about the pattern
of your pain, make a diagnosis, plan treatment and follow your progress. You
can help in advance of your doctor's appointment by preparing yourself to
answer these questions:

Where is the pain located?
How long have you had pain?
Does the pain come and go or is it continuous?
How long does the pain last?
What makes the pain better?
What makes the pain worse?
What is the intensity of the pain? You may be asked to rate your pain on a
scale of 0 to 10, with 0 indicating that you have no pain at all and 10
indicating that the pain is the worst possible.

What does the pain feel like? You can use words such as stinging,
penetrating, dull, throbbing, achy, nagging or gnawing. Be as specific and
descriptive as possible.
Has the pain changed since your last visit with your doctor?
What medications or treatments have you tried for the pain? How effective
were they?

HOW YOU FEEL PAIN
Pain is a unique experience for everybody. Your degree of pain and how you
react to it are the results of your own biologic, psychologic and cultural
makeup. Understanding how your body feels pain will help you appreciate how
individual your pain experiences are. It also will help you better understand
why chronic pain is often difficult to treat.

Pain basically results from a series of electrical and chemical exchanges
involving three major components of your body: peripheral nerves, spinal cord
and brain.

Peripheral nerves: Your peripheral (pe-RIF-er-ul) nerves encompass a network
of nerve fibers that branch throughout your body, including your hands and
feet. Attached to some of these fibers are special nerve endings that can
sense an unpleasant stimulus, such as a cut, burn or painful pressure. These
nerve endings are called nociceptors (no-sih-SEP-turs). You have millions of
nociceptors in your skin, bones, joints, muscles and the protective membrane
around your internal organs. Nociceptors are concentrated in areas more prone
to injury, such as your fingers and toes. That's why a splinter in your
finger hurts more than one in your back or shoulder.
There may be as many as 1,300 nociceptors in a patch of skin the size of a
quarter. Muscles, protected beneath your skin, have fewer nerve endings. And
organ membranes, protected by skin, muscle and bone, have fewer still.

Some nociceptors sense sharp blows, others sense heat. One type senses
pressure, temperature and chemical changes. Nociceptors also can detect
inflammation caused by injury, disease or infection.

When nociceptors detect a harmful stimulus, they relay their pain messages in
the form of electrical impulses along a peripheral nerve to your spinal cord
and brain. However, the speed by which the messages travel can vary. Dull,
aching pain, such as from an upset stomach or an earache, is relayed on
fibers that travel at a slow speed. Sensations of severe pain are transmitted
almost instantaneously.

Spinal cord: When pain messages reach your spinal cord, they meet up with
specialized nerve cells that act as gatekeepers, refusing or allowing the
messages to pass through to your brain.

For severe pain that's linked to a danger, such as when you touch a hot
stove, the "gate" is wide open and the messages take an express route to your
brain. Nerve cells in your spinal cord also respond to these urgent warnings
by triggering other nervous systems into action, such as your motor nerves.
Your motor nerves signal your muscles to pull your hand away from the burner.
Weak pain messages, however, such as from a scratch, may be refused entry
through the gate.

Within your spinal cord, the messages also can change. Other sensations may
overpower and diminish the pain messages. This happens when you massage or
apply pressure to the injured area. The result is that the warnings sent by
your peripheral nerves are downgraded to a lower priority.

Nerve cells in your spinal cord also may release chemicals that amplify or
subdue the messages, affecting the speed at which they travel to your brain.

Brain: Once pain messages reach your brain, they arrive at the thalamus
(THAL-uh-mus), a sorting-and-switching station deep inside your brain. The
thalamus quickly forwards them simultaneously to the cerebral (suh-RE-brul)
cortex and to your brain's limbic center. It's at this point that you
actually begin to feel the pain.

Cerebral cortex: Your cerebral cortex is the thinking part of your brain. It
reacts to the pain messages by locating the source of the injury, assessing
the damage and determining a course of action, such as ordering you to take
pressure off your foot if you've sprained your ankle. The cerebral cortex
also relays additional key messages. For instance, if you've cut your finger,
it signals your autonomic nervous system, the system that controls your blood
flow, to send additional blood and nutrients to the injury site. It also
dispatches the release of pain-suppressing chemicals and sends "stop-pain"
messages back to the spinal cord.

Limbic center: The limbic center produces emotions such as anxiety, fear or
frustration that often accompany pain. Your limbic center can affect the way
your cerebral cortex receives pain messages and can lessen or intensify your
pain.

Your pain response: When pain messages reach your brain, two components
determine how you respond to the pain: physical sensation and personal
makeup.

Physical sensation: Pain comes in many forms: sharp, jabbing, throbbing,
burning, stinging, tingling, nagging, dull and aching. Sharp and jabbing pain
generally produces greater discomfort than dull, aching pain. It's also more
likely to make you anxious or fearful.

Pain also varies from mild to severe. Severe pain grabs your attention more
quickly and generally produces a greater physical and emotional response than
mild pain. Severe pain also can incapacitate you, making it difficult or
impossible to sit or stand.

The location of your pain also can affect your response to it. A headache
that interferes with your ability to work or concentrate may be more
bothersome, and therefore receive a stronger response, than arthritic pain in
your knee or a cut to your finger.
Personal makeup: Your emotional and psychological state, memory of past pain
experiences, upbringing and attitude also affect how you interpret pain
messages and tolerate pain.

For instance, a minor sensation that would barely register as pain, such as a
dentist's probe, actually can produce exaggerated pain for a child who's
never been to the dentist but who's heard horror stories of what it's like.

But your emotional state also can work in your favor, reducing even major
pain messages. This was illustrated in a pain study that compared formerly
wounded war veterans with men in the general population. Men in both groups
had the same kind of surgery. The combat veterans, however, required less
pain medication than the others, perhaps because they thought that the
surgery was a minor matter compared with what they had experienced in battle.

Athletes also can condition themselves to endure pain that would incapacitate
others. In addition, if you're brought up in a home or a culture that teaches
"Grin and bear it," "No pain, no gain" or "Bite the bullet," you may
experience less discomfort than people who focus on their pain or are more
prone to complain.

Types of pain: In general, doctors divide pain into two general categories:
acute and chronic.

Acute: Acute pain is triggered by tissue damage. It's the type of pain that
generally accompanies illness, an injury or surgery. Acute pain may be mild
and last just a moment,
such as from a sting. Or it can be severe and last for weeks or months, such
as from a burn, pulled muscle or broken bone.

When you have acute pain, you know exactly where it hurts. In fact, the word
acute comes from the Latin word for "needle," referring to a sharp pain. A
toothache from a cavity, a burning elbow from a scrape and abdominal pain
from surgery are examples of acute pain. In a fairly predictable period of
time, the pain fades away - when the cavity is filled, the skin grows back or
the incision heals.

Chronic: Chronic pain can result from disease, such as arthritis, cancer, or
shingles, or from trauma, injury, or surgery. It also can occur without a
known injury or disease. Like a gate that's blocked open, nerves continue to
send pain messages even though there's no continuing tissue damage.
Chronic pain lingers long beyond the time of normal healing and can last from
a few months to many years. This is reflected in the word itself: Chronic
comes from the Greek word for "time."

As with acute pain, chronic pain spans the full range of sensations and
intensity. It can feel tingling, jolting, burning, dull or sharp. The pain
may remain constant or it can come and go, like a migraine headache that
develops without warning. Your discomfort can range from mild to disabling.

What causes chronic pain? Sometimes, chronic pain is due to a chronic
condition, such as arthritis, that produces painful inflammation in your
joints, or fibromyalgia, which causes aching in your muscles.

Occasionally, chronic pain may stem from an accident, infection or surgery
that damages a peripheral nerve or the spinal cord. This type of nerve pain
that lingers after the original injury heals is called neuropathic - meaning
the damaged nerve, not the original injury, is causing the pain. Neuropathic
pain also can result from diseases such as diabetes or shingles.

Once damaged, the nerve may send pain messages that are unwarranted. For
example, an increased blood sugar level associated with diabetes can damage
the small nerves in your hands and feet, leaving you with a painful burning
sensation in your fingers and toes.

There may be many reasons why injured nerves sometimes misfire and send wrong
messages. However, one reason is that when a nerve cell is destroyed, the
severed end of the surviving fiber can sprout a tangle of unorganized nerve
fibers (neuroma). This bundle of nerve tissue then starts sending warnings of
injuries that don't exist.

For some people, the cause of chronic pain is unknown. There isn't any
evidence of disease or damage to your body tissues that doctors can link to
the pain. However, laboratory tests and X-rays can't detect pain. Pain is
always a personal and subjective experience.

SET GOALS
Everybody differs in the amount of pain that they can tolerate. A level of
pain that is unbearable for you might be acceptable to another. Your doctor
may help you determine your tolerance for pain by having you rate your pain
on a pain intensity scale. Then you can set a goal for where you'd like to
be.

For instance, if you rate your pain as 6 out of 10 on average and you decide
you can tolerate 3 out of 10, then you and your doctor have a more tangible
goal to work toward. You may not be able to get your pain level down to a
zero, but usually you can make progress.

Focus on one pain problem at a time. For example, you may have both back and
knee pain, but your back pain is worse. Start by treating your back pain and
then, once your back pain is tolerable, work on your knee. The time it takes
to reach your goal depends on your diagnosis, but people often see progress
during the first several months. After that, you may work toward a general
pain management goal.
Learn steps for setting and achieving your goals to manage pain.
When you're in pain, it's easy for the discomfort to become the center of all
of your attention. Other things in life that were important to you, or that
you were trying to achieve, may have taken a back seat to the pain.

Setting goals helps divert your attention from your pain and provides an
opportunity to think about your lifestyle and what you can do to better
manage your pain. Goals also give you something to strive for.

But goal setting isn't as easy as it may sound. You simply can't identify a
couple of things you want and expect them to occur. You'll only be setting
yourself up for disappointment.

The key is to set goals that are SMART:

Specific: State exactly what you want to achieve, how you're going to do it
and when you want to achieve it. To begin with, set goals that you can
achieve within a week to a month. It's easy to give up on goals that take too
long to reach. If you have a large goal, break it down into a series of
smaller weekly or daily goals. After you achieve one of the smaller goals,
move on to the next.
Measurable: A goal doesn't do you any good if there's no way of telling if
you've achieved it. "I want to feel better" isn't a good goal. It's not
specific and it's difficult to measure. "I want to work 8 hours each day" is
a good goal. It's specific and it's measurable.
Attainable: Ask yourself if the goal is within reasonable reach. For
instance, completing a marathon may not be an achievable goal if you've never
run before. But completing a 3-kilometer run may be attainable.
Realistic: Is the goal realistic for you? One purpose of goal setting is to
take your focus off your pain and think about your future. But you can't
ignore your limitations. Your goals need to be within your capabilities. If
you've suffered a serious back injury, a goal of returning to work as a
bricklayer may not be realistic. Instead, your goal might be to find a sales
or consulting job in a related field. Or you might consider going back to
school and making a new degree your goal.
"Trackable:" Being able to track your progress encourages you to keep going
and reach your goal. Look for ways to chart your improvements.

Here's how
These are examples of goals that follow the SMART formula:

Goal: Eliminate use of over-the-counter pain medications.
When I want to achieve it: 2 weeks.
How I'm going to do it: Plan my day to include exercise, pace myself at work
and take frequent breaks, use relaxation techniques.
How I'm going to measure it: Each day, record in my journal the medication I
took and how much.

Goal: Meditate for 30 minutes each day.
When I want to achieve it: 4 weeks.
How I'm going to do it: Set aside 30 minutes every morning. Explain to my
family what I'll be doing and why I'll need privacy.
How I'm going to measure it: Record in my journal when I meditated and for
how long.

Think carefully about some short-term or long-term goals you want to achieve.
As you work on your goals, you may find that the strategies you use to reach
one goal will help you with others.

Once you've completed your goals, put them somewhere you can see them. Seeing
your goals can help motivate you. As you accomplish your goals, set new ones.

Use this form to set goals in many areas of your life, including physical
activity, work and relaxation. (The SMART goals form is a PDF file at
MayoClinic.com.

CREATE YOUR PERSONAL PLANNER
One challenge of living with chronic pain is making sure that you have enough
time and energy to get through everything you need to do each day. Planning
your day can help you find a healthful balance to your daily routine.

Use the daily planners that follow to schedule your day from the time you
wake up until you go to bed. You can plan a day at a time or make your plans
for an entire week.

Each day, include a mixture of work, rest, exercise, relaxation and social
activities. If you have trouble fitting everything in, ask yourself these
three questions:

What do I have to do today? That might include going to work, making it to a
scheduled appointment or getting some exercise.
What would be best done today? These are things you don't have to do, but
will need your attention at some point. This might include doing a load of
laundry, catching up on book work or completing a project at work. Instead of
having these activities pile up, try to spread them out over the week.
What do I want to do today? It's important to spend a certain amount of time
each day doing things that you enjoy and that help you relax. This could be
working in your flower bed, playing a round of golf, visiting with a friend
or reading a book.
Include at least one response to each of these questions as you plan your
day. If you're unsure of your plans on certain days, mark as best you can
what you think you may be doing. To help stay on track, refer to your planner
throughout the day. Periodically write down what you did and compare it with
your plan.

If you find that scheduling your day helps you to achieve your goals, then
continue to do so. You can purchase a daily planner in most office supply and
many discount stores. Or you can make your own. You also can use a personal
digital assistant (PDA) to record and remind yourself of activities. However,
once you get into a routine, you may find that you don't need to be as
detailed in your planning. Marking down a few key times or events may be all
you need.

A blank personal planner to schedule your day is available at the Mayo
website. Make as many copies of this as you want for the days, weeks and
months ahead. (The personal planner is a PDF file. To view and use the file
you need the Acrobat Reader, which you can download for free at Adobe's Web
site.)

Your daily routine can affect your ability to manage pain. Plan to ensure a
balance between work, exercise, recreation and rest.

TRACK YOUR PAIN PROGRESS
You don't have to put your life on hold while you wait for your pain to
subside. By monitoring your pain, setting realistic goals and planning your
time appropriately, you can move on with your life.

Keep a journal: Keeping a journal can help you track your pain management
progress and determine the activities that help most. Learn tips to start
your own journal.

As you learn techniques to manage your pain, you should see an increase in
your activity level and, perhaps, a decrease in your pain level. A daily
journal helps you track your progress and determine the therapies or
activities that seem to be helping you the most. A journal is also an easy
way to keep track of goals you want to achieve and your progress in reaching
them.

Many people think that their pain isn't influenced by factors such as work,
stress, sleep or physical activity. But after a few months of tracking their
pain levels and their activities, they begin to notice some common patterns.

In addition, a journal can be an effective way to express feelings about your
pain or other things that are happening in your life. Writing your thoughts
and feelings on paper helps you organize and sort through problems and
emotions and get them "off your chest," similar to the way you feel after a
heart-to-heart visit with a friend or family member.

Your journal can be as simple or as detailed as you like. However, try to
include the following information, especially when you first begin. As you
gain a better
understanding of your pain and learn how to manage it, you may find it more
helpful to focus on just one or two areas.

Pain level and activities: Health care professionals typically measure pain
on a scale of 0 to 10, with 0 being no pain and 10 being the worst imaginable
pain. Using this scale as your guide, a couple of times a day rate your pain
level and record it in your journal. In addition, briefly state your
activities that day and when you did them.

You can do this whenever it's convenient, but keep the times consistent. Many
people choose to record their pain level in the morning when they wake up,
after lunch and in the evening before bedtime.

Mood: On a scale of 0 to 10, with 0 being poor and 10 being excellent, rate
your mood. This exercise helps you realize that even though your pain and
your mood are closely aligned, they aren't bound together.

Typically, the worse your pain, the worse your mood, and vice versa. However,
as you begin to feel more in control of your pain, you may find that your
mood improves at a faster rate than your pain level does. Rating your mood
helps you realize that even though you may not be able to eliminate your
pain, you can learn to live with it and still be happy.

Sleep: A good night's sleep better equips you to handle your day. However,
getting enough sleep can be difficult because your pain may keep you up at
night. In contrast, some people spend too much time in bed. This also can
reduce your pain tolerance.

Once a day, record how many hours you slept during the past 24 hours. Eight
hours is average, but the amount of sleep each person needs varies. Your goal
should be to feel rested when you awake.

Medications: Record the medications you take each day, both prescription and
nonprescription. This will help you and your doctor determine both the
beneficial and negative side effects of your medications. Keeping a written
record is particularly helpful if you're taking more than one treatment for
pain because medications often can interact with each other.

Keeping a log of your pain levels, activities, mood, medications and amount
of sleep allows you to: Learn your pain pattern. Most people find that the
changes in their pain levels are quite consistent. For example, your pain may
generally be at its lowest level in the morning and its highest level in the
evening. Recording your pain levels helps you determine your pain pattern.

Link your pain with your activities. If your pain is always worse in the
evening, why? Look to see if certain activities seem to correlate with an
increase or a decrease in your pain level. Are you sitting or standing too
long? Is your rush to get dinner ready a contributing factor? Or are you just
tired?

Identify flares. Recording your pain levels helps draw attention to
inconsistencies. If your pain level at noon is normally a 3 and one day it's
a 6, seeing the difference may prompt you to think about your morning. Did
you do something different? Did you have an especially stressful morning?

See your progress. If you feel you aren't making progress, reading your
journal may help you to realize that your life has improved, even though the
process may seem slow. Your journal may also give you clues as to why some
areas remain difficult for you.
Whatever works: There is no right or wrong when it comes to keeping a
journal. Some people like to simply jot down their thoughts, others prefer a
worksheet format.

UNDERSTAND YOUR TREATMENT
Continue to be involved in your care when your physician recommends specific
treatments for you. Ask why certain treatments are being proposed and find
out their risks, benefits and alternatives. Be careful about accepting
medications, injections or other recommendations without being aware of what
each entails. Any intervention brings a chance of both benefits and
complications. Talk with your doctor to ensure that the balance is in your
favor.

Expect to commit some time to the treatment process. You may try a variety of
treatments before your doctor finds one that works for you, so don't become
discouraged if the first treatment isn't as effective as you had hoped. Your
doctor may adjust your treatment over time, as he or she monitors how your
body reacts to various regimens. People usually make progress in the first 2
to 3 months.

Editors' note: Because there has been so much written recently about the
subject of pain and pain medication, I am concluding this series with Part 3,
to be published on 3/23/02

Good health to all

Jack Nicholas
Newsletter Editor
Issue2002 3/22/02 -7