Understanding Major Pains A Lal
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1Understanding Major Pains2
The only book that explains major pains and their crippling effects together with the latest information and new research on:
Have you any pain?
(English)
Ha dolori?
(Italian)
Haben Sei Schmrerzen?
(German)
Avez vous mal queloque?
(French)
I Tien dolor?
(Spanish)
3Understanding Major Pains
• Headaches
• Migraines
• Arthritis
• Back Bone Pain
• Angina
And a Host of Abdominal Pains
Genesis, Prevention and Relief
A LAL Former Fellow of Royal Society of Health (London) Atlanta, Georgia The United States of America
A life free from pain there is no virtue in endurance
4
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
EMCA House, 23/23B Ansari Road, Daryaganj
New Delhi 110 002, India
Phones: 3272143, 3272703, 3282021, 3245672, 3245683 Fax: 011-3276490
Visit our website: http://www.jpbros.20m.com
Branches
Understanding Major Pains
© 2003, A Lal
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition : 2003
Publishing Director: RK Yadav
9788180610356
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A-14, Sector 60, Noida
5
This book is
for
Pain Relief Seekers
and
Pain Relief Providers
6NOTE TO THE READER
PAIN HURTS. IT CAN BE EFFECTIVELY CONTROLLED IN SOME SITUATIONS, BUT EXTREMELY DIFFICULT TO REIN IN OTHERS.
NO PRESCRIPTION OR COURSE OF TREATMENT HAS BEEN RECOMMENDED IN THIS BOOK; FOR SUCH PURPOSE A DOCTOR BE CONSULTED.
7Preface
The sub-title of the book reads: “A life free from pain—There is no virtue in endurance.” But for some pain never ends—they become accustomed to it, for once “genie” is out of the bottle, it is sometime extremely difficult to put it back. Managing pain, especially chronic pain, is not making it disappear altogether—rather keeping it under control.
Pain is an all pervasive reality of everyday life—complex and unique to each individual who feels it. It is so personal in nature that it cannot be shared with anyone—a subjective experience that cannot be proved to others who can only empathize finding a robust athlete hobbling along the crutches or depending upon others for the basic needs.
This book is not on a particular type of pain, but covers a number of most common crippling pains and aches like headache, migraine, angina, arthritis, back pain and a host of abdominal pains together with their pathogenesis, prevention and treatment options. Again, because many physiological and anatomical factors involved in pain mechanism are complex and confused, simplified models of pain specific to a particular organ or area of human body have been employed throughout the book. Many examples of pathological physiology are provided to illustrate the nature of body system failure to understand the pain process. Commonly held concepts have been updated, as has also the role of analgesics.
While a lot has changed in pain treatment over the years, but one thing has not changed. Analgesics or pain killers as a common man understands, remain an important part of any treatment plan. An average man first response to pain is to look towards biomolecular solution to his pain. But while 8many types of pain busters have arrived, demons of pain may remain unappeased from whatever measure we take to propitiate them.
This book is needed because there are very few books which deal with major crippling pains in one volume, and the ones available are too technical and written in a manner to be appreciated by the common man. Or they are too over-simplified that they are shun by medical profession as “too basic”. What is needed a book which combines breadth and brevity without sacrificing accuracy and authenticity—a book that meets the need of both camps at the same plank; even though a professional may feel a bit wary at times at the lack of in-depth analysis. This is the risk worth taking in targeting two distinct groups with a single shot to internalize the ideas on pains I am trying to put across.
Treating pain is a two-way street. A bipolar communication between the doctor and his patient is essential to getting the most effective and safe medical treatment. A patient must communicate fully with his doctor about every aspect of pain, because as is to be said umpteen times in the book that it is the patient alone who knows what his pain is like. Barring certain medical emergencies, a doctor has obligation to provide with an accurate information about the medical condition and available options (both surgical and non-surgical) so as to enable the patient weigh pros and cons why the doctor has made certain recommendations. A doctor is obligated to understand his patient's concern about his suggestions, including his ability to afford the regimen being prescribed. Is the patient worried about cost and convenience? Is the patient worried about side effects and quality of life after the treatment? If a patient has such concerns, he should communicate them. A patient's knowledge of his medical condition and treatment options greatly influence prospects of his recovery. This is both the 9reason and message of my book which I am explaining in a simple yet candid manner to make it a part of mainstream thinking on pain. For me it is an ideal which I passionately hold.
The view of the future on pain horizon from here appears to be bright and pregnant with positive possibilities—heretofore undreamable now seems likely. The causes, prevention and treatment, if not a complete cure, of major crippling pains appear to be within the realm of reach. More than ever, pain scientists are working upon new modes and modalities to rein in pain.
The new ideas, new technology, newer groups of analgesics and innovative surgical procedures backed by a manpower of bright young biochemists, biophysicists, molecular biologists and medical scientists promise dramatic advances during this decade of “freedom from pain”. The art of life is to avoid pain by understanding body's warning signals of pain which we are simply too afraid to listen. There is no virtue in endurance. Attend to pain.
A Lal10
11Acknowledgements
This book is a high point of my associations with an outstanding group of public health and medical workers in different parts of the world where I had the opportunity to work. I acknowledge my debt of gratitude for their professional comments. In particular, I am indebted to Dr (Mrs) Tripti Sakhuja for her valuable suggestions on psycho-somatic aspects of pain and to Dr Ripple Lamba for his observations on the role of alternative therapies in pain management.
Over a long period of time as a health worker I had been in contact with a multitude of pain sufferers in the community and pain relief providers in hospitals and clinics. By sharing with their experience they taught me much more about pain than I ever read in books, and what it means to be a pain victim. I, therefore, dedicate this book to them with a note of caution that the book should not replace the physician, nor I recommend that they try to diagnose and treat their pain—apart from minor pain and aches.
My thanks to Dr Herbert L Whittier, Associate Director of the Institute of International Health, Michigan State University, East Lansing, USA, whose academic association over the last decade I prize the most as a source of great inspiration in my academic pursuits and publications.
The editorial staff of Jaypee Brothers Medical Publishers, New Delhi, India, have done a great job “to put an icing on the cake” by way of their professional expertise to make my work reader-friendly.
And special thanks to my wife, Santosh, who read chapters of the book and whose critical schoolteacher's eye uncovered many confused concepts and grammatical errors and 12patiently provided me an environment to continue with this project.
There is a special pleasure for me in writing this book on pain, since my father, (Late) Dr Khushi Ram of Amritsar, Punjab, India, was a renowned doctor, who had a passion for medical books and would have loved to see this book on his shelf of medical collections.
Pain is an all pervasive reality of life-something that we all experience but handle differently.
The art of life is avoiding pain.
There is no virtue in endurance.
Attend to your pain.
13Introduction
This book is on man's most common and crippling pains. Pain seldom kills, but an unabated pain is a body's warning signal that something serious is in the making. Pain is more than an expression of agony. Understanding genesis of particular pains and their manifestations, prevention and amelioration is an important step to ensure a life free from pain.
Without the risk of over-simplification pains can be described according to their site of occurence—head, chest, abdomen and musculo-skeletal system. Pains specific to these areas have specific names. Headaches, including migraine, belong to the head region. Then comes the chest which is the seat of most feared pain—angina pectoris and myocardial infarction linked to dreaded heart attack. Down below the muscular partition wall called diaphragm lies abdominopelvic cavity comprised of abdomen and pelvis which together house a number of organs. The abdomen comes first and contains stomach, small intestine, large intestine (including appendix, colon, rectum and anal canal), liver, gallbladder, pancreas, spleen and kidneys. In the lowest end of the abdominopelvic cavity called pelvis lie the terminal part of large intestine, the urinary bladder and reproductive organs (uterus, uterine cavity and ovaries in the female and seminal vesicles and prostate in the male). The plethora of organs in the abdominopelvic cavity means a pain-prone area of the body where majority of organ specific pains occur. Finally, it is the musculoskeletal system or human scaffolding that gives shape to the body and keeps it erect and in upright position. Like a scaffolding at the construction site human scaffolding is also subject to great stress resulting in a lot of wear and tear, i.e. fractures inflammation and pain in the body.
Beginning with the head, headaches are man's most common affliction. Fortunately a good number of them are not life-threatening 14and therefore escape medical attention. Most headaches—say from 60% to 70% are tension headaches and go of their own or get resolved through over the counter analgesics, though going to a chemist's shop and buying such pain killers may not always be the right course. Overuse of self-prescribed analgesics can lead to serious health problems. Only in extremely rare instances a headache can be more worrisome when the cause of headache is traced to brain tumor (benign or malignant) or brain hemorrhage due to intracranial bleeding caused by ruptured angioma—a tangled knot of blood vessels containing abnormal interconnections between arteries and veins or bursting blood filled tiny blisters called aneurysms and blood gushes out to fill the intracranial space—the burst triggering the worst headache. Looking for causes and characteristics of headaches is thus a fascinating area of study for medical researchers.
Like headaches migraine by itself has never killed any one but causes a horrid disability. Physicians from antiquity to this day have tried to solve migraine mystery—but the mystery, by and large, lingers on. Probing the process of migraine through its phasic progression and its treatment modalities based on old and new drugs and non-conventional remedies to provide relief, if not a complete cure, has attracted a good deal of medical research. But the door to fuller understanding of migraine headaches remains shut.
A pain in the chest immediately brings to mind the fear of an impending heart attack. Nothing is more frightening than this realization. But to appreciate when “a” chest pain is “the” pain of cardiac origin is a complex task so as not to sound a false alarm bell. A number of pains in the chest only mimic a heart attack but are otherwise quite innocent and benign in their outcome. But in case of a real heart attack an early attention to the event is of crucial importance to thwart an impending attack.
Because an abundance of organs that lie in the abdominal cavity this area is the seat of a variety of pains. Fortunately most of these pains are transitory in nature and disappear without treatment, 15but some ones are recalcitrant and show symptoms which presage some serious illness. Pains in this region range from gastritis, colic, diverticular disease and irritable bowel syndrome to all the way to appendicitis, renal colic, pancreatitis—among others. A deeper insight into these organ specific pains provides better treatment options to choose from. This includes surgical solutions as well.
Arthritis has to do with bones, joints and their attachments. It can strike any one irrespective of age, sex and racial background causing a varying degree of incapacitation. But it is more often in older persons as over 80% persons past 70 years show radiological evidence of some form of arthritis. This has always been so and prevalence of arthritis dates back to antiquity. The CAT scans of ancient mummies show, just like us, ancient humans suffered from pain due to arthritis and osteoporosis.
Currently over 100 conditions are covered by the general term arthritis which include osteoarthritis characterized by pain, swelling, stiffness of joints and cartilage breakdown; rheumatoid arthritis with its special features of chronic inflammation of membrane lining joints and tendons and joint deformity; osteoporosis or “porous” bones when bones start losing their mass and become brittle, and finally gout, another debilitating condition triggered by faulty body chemistry when body makes too much uric acid that kidneys are unable to get rid off it fast enough. This results in the deposition of crystalline form of urate called “tophi” settling in the joints and triggering inflammation and pain.
Ubiquitous back pain is the lot of almost all of us at one time or the other. This is the number one health complaint today. Even though it is non-fatal medical condition, it is the second most important reason, after blood pressure, which brings adults to medical facilities to seek a remedy for back pain. Prolapsed/herniated vertebral discs and spinal stenosis are most often get cited as the likely culprits requiring surgical solutions. But the need and effectiveness of surgery for back pain carry a big question mark. Many unnecessary scans (or “scams” as some call them) to profit 16a few at the cost of many gullible patients desperate to seek relief from their pain carry health risks. But the number of surgical solutions for this malady is still climbing.
While good news on back pain is that most patients will substantially and rapidly recover, the bad news is that recurrences are common. Many myths surround around relief measures for back pain. Perhaps doing nothing about back pain is not a bad idea.
It has been a dilemma for medical science which pain killer to administer with the least side-effects or if/which surgical intervention to proceed with. There is a lot to choose from starting with man's oldest analgesic, opium, which to this day remains to be the gold standard for pain drugs and aspirin, the “old faithful” and its cousins in the form of NSAIDs, DMARDs to bullet action steroids to the latest commissioned into battle against pain front are COX-2 inhibitors which perhaps is the biggest advance in NSAIDs safety; the key difference being they are more kind to the stomach and less likely to cause stomach ulcers. And them much hype around nutritional supplements like glucosomaines and chondroitin showing old couples bouncing back to life on race tracks and in tennis courts. Indeed, millions owe their peace of mind to analgesics, nutritional supplements and pseudo-remedies. Anything that lightens the day for those who suffer pain is a good thing. However, a large part of the problem in assessing the effectiveness of these pain busters is the maddening complexity of pain itself, its wide range of symptoms and many levels of incapacitation. Finally there are surgical interventions to restore mobility to immobilized arthritic joints. Queen Elizabeth II of England, Elizabeth Tylor Oscar winning actress and Atal Behari Vajpayee (Indian Prime Minister) are some of the current examples of hip or knee replacement procedures.
Adequate statistics to throw light on man's common and crippling pains are hard to come by for most of the countries. But analysis of epidemiological data provided by health care facilities 17and individual surveys shows the magnitude of pain problem that involves millions across the world at a colossal human and economic cost in terms of personal tragedy that pain involves, work hours lost and cost of medication. World over consumption of pain killers available over-the-counter (OTC) and those available through prescription exceeds that of any other drug. In terms of social cost, many pain sufferers develop a pattern of drug abuse that carries its own lethal effects on human health. In their anxiety to free themselves from the perpetual misery that pain afflicts, many turn to pseudo-therapies some of which border onto sheer quackery. Pain is inevitably depressing, and longer the pain continues deeper the depression. Depression is a passive state of mind in which the worst is inevitable.
Safeguarding one's health requires prudence and moderation. It also requires information and communication. But information should not tempt to become one's own doctor to self-prescribe and determine which medicine is the best. This is a “measure in the grass.” Nor should one ever prescribe medicines to others. This is the job of doctors. Admittedly doctors are not comfortable with being upstaged by a patient's knowledge of disease and therapy. In any event it is better to keep the channel of communication open between patients and doctors as patients seek treatment for their ailments. This is especially true when pain is of chronic nature and requires long-term attention. In particular, a patient should always inform his doctor about OTC (over-the-counter medicines which are available without prescription) or alternative medicine treatment he has been taking to allay his pain (and for that matter any other health problem). There can be a problem since drugs interact which can have a negative impact on the disease. “The road to polydrug use is paved with good intentions. But when a number of different specialists are contributing to the medication ‘stew’, the drug list will need a through going-over” comments Dr Gideon Bosker in Pills That Work—Pills That Don't (1997). This could be a high risk “medication misadventure” because 18medical checks and balances are lost when patients sojourn from one medical specialist to another in search of remedy for their medical malady, and in the process invariably failing to mention the therapies that other doctors had prescribed. There is no wisdom in number when it comes to medical matters.