Making The Pain Scale Work For You

Physical pain is one of the few incidents that are experienced virtually by all living creatures. Nonetheless, unlike animals we as human have the existential ability to apprise and be consciously aware of what we are feeling. Although pain, whether acute or chronic, can be very difficult to describe especially when trying to convey the feeling to a physician. This is why numerous subjective pain scales have been developed in the hopes that doctors may better understand a patient’s current level of pain. As mentioned, there are a variety of pain scales such as the Pain Quality Assessment Scale (PQAS), the Visual Analog Scale (VAS), the Numeric Rating Scale (NRS), and the Wong-Baker FACES® Pain Rating Scale (WBFPRS); to name a few. But for our conversation, let’s view pain scales as either a Verbal Rating Scale (VRS) or a Nonverbal Rating Scale (NVRS). Research has shown that patients prefer the VRS; unfortunately, it lacks sensitivity and the data it produces can be easily misunderstood. This misunderstanding is largely due to the fact that everyone tolerates pain differently, where someone’s “5” could be an “8” for another person based on a 1 to 10-pain rating scale. Thus, patients and doctors alike can find it difficult to arrive at an appropriate prognosis when someone’s pain is not easily defined or relatable.

Diabetic Neuropathy Vignette

Treating patients based solely off a pain scale would not only be difficult, it would also be a disservice to the patient. Let’s use two patients both with diabetic neuropathy as an example. Dr. Smith has two diabetic neuropathy patients; patient #1’s pain is a “10” and patient #2’s pain is a “7”. Given only this subjective information, Dr. Smith places patient #1 on a higher dose of Lyrica® for pain-relief while Dr. Smith puts patient #2 on a lower than average dose. Three weeks later for each patient’s follow-up appointment, patient #1, unfortunately, presents with similar diabetic foot pain and labored breathing, confusion, and difficulty in bowel movements. Patient #2 presents with similar (if not slightly worse) foot pain subsequent to being prescribed Lyrica®. Ostensibly something is wrong. Not only did both patients receive slim-to-no pain-relief because of a dose that did not fit their level of foot pain, but also unwanted side effects resulted that could have been avoided. Being provided with a subjective explanation of pain does not allow a physician to tailor a precise prognosis. So what’s the best way to convey as to how you’re truly feeling?

Sharing is Caring

It is clear that pain scales need accompanying objective context. For example, the National Institutes of Health (NIH) do use a numeric pain scale, but also ask questions that bring a more reasonable, albeit imperfect, assessment. Below we have provided some example questions that your doctor may ask. Note, although your doctor may not ask you these exact questions, still be sure to talk about these points of reference; for the more your healthcare practitioner knows about your current pain, the better chance you have of a pain-free (or reduced pain) outcome.

  1. Elaborate on what was the worst pain you have ever experienced. Maybe it was when you broke your arm or during childbirth. Whatever, the case, make it known that it is your worst pain ever felt. This can be used as a metric for what your “10” feels like and can be compared to the pain you are currently experiencing.
  2. Elaborate on your mental state. Let your doctor know if you are feeling anxious, depressed, irritated, hopelessness, etc. By identifying your feelings and emotions, it will give your doctor a better picture on how pain is affecting you overall.
  3. Show your doctor exactly where the pain is located. Instead of giving an overall-general pain level, try to pinpoint where on your body the pain is located. If the pain is radiating away from the focal point, be sure to tell your doctor the varying intensity you may be experiencing.
  4. Tell your doctor what makes the pain go away or what makes it worse. Are you taking any over-the-counter (OTC) medications once a day, or every few hours? Are you having to turn to stronger medications (e.g. opioids) for pain-relief? Does your pain get worse when doing normal daily activities, or is your pain only worsened by strenuous activity?
  5. Elaborate as to how frequent your pain is occurring. If you are struggling with chronic pain, let your doctor know the frequency and length of a pain episode. Be sure to describe a chronic pain episode that parallels how you are feeling when talking to your doctor. That way your doctor will get a “feel” as to how you are feeling on a regular basis.

Any subjective diagnostic tool that a doctor may use is always going to have its drawbacks; and yes, a pain scale is subjective. Use the five examples we mentioned as objective evidence that you can provide your doctor; but solely see our examples as a guide for communicating your current pain level. You of course can come up with your own points of reference to convey to your doctor how you are feeling. Look at your pain management regimen as a team between you and your doctor. Communication is key in any team and the more you and your doctor understand one another, the more effective you will be in reaching the goal you both are striving for, complete pain-relief. What’s the best way you have found to communicate your level of pain with your doctor? Please let us know!

Tags: pain scale, acute pain, chronic pain, diabetic neuropathy


  1. de C Williams AC, Davies HT, Chadury Y. Simple pain rating scales hide complex idiosyncratic meanings. Pain. 2000 Apr;85(3):457–463.
  2. Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986 Oct;27(1):117–126.
  3. Lang EV, Tan G, Amihai I, Jensen MP. Analyzing acute procedural pain in clinical trials. Pain. 2014 Jul;155(7):1365–1373.
  4. Paice JA, Cohen FL. Validity of a verbally administered numeric rating scale to measure cancer pain intensity. Cancer Nurs. 1997 Apr;20(2):88–93.
  5. Robinson-Papp J. Barriers to Chronic Pain Measurement: A Qualitative Study of Patient Perspectives. Pain Med. 2015 Jul;16(7):1256-64

5 Points To Know When Dealing With Peripheral Neuropathy


Living with peripheral neuropathy can be full of ups and downs from day to day, especially if you have been recently diagnosed. Managing this painful condition is frustrating at best, and can feel overwhelming at times. Patients often experience changing symptoms and debilitating pain. Learning more about potential treatment options should be a first step for anyone confronted with this condition, since treatments can go a long way to improving quality of life for those who are suffering.

Physiology & Pathology

Understanding a little more about the physiology of peripheral neuropathy, let’s start at defining the nerves involved in this debilitating condition. Peripheral nerves are the longest nerves in the body, extending all the way from the hands to the feet. When damaged, common symptoms are pain, numbness or tingling in the hands and feet. Unfortunately, these symptoms are far more severe and far-reaching than this. Some have reported experiencing such symptoms as stabbing pains and incapacitating weakness.

Better Insight For A Better Outcome

Today, 20 million people in the United States are affected by this condition, yet many are not aware of how it affects our loved ones, leaving the patient and their family helpless as to how to improve their overall quality of life. Below are five common conceptions that those with or know someone with peripheral neuropathy should be aware of for better understanding this condition.

 1. Diet Can Exacerbate Symptoms

Your diet may either help or hurt your nerves. To improve symptoms, avoid foods with excess sugar, artificial sweeteners, and refined grains. These foods may irritate the nerves causing nerve pain. In fact, studies have shown that a diet consisting of low-fat and whole foods supplemented with exercise may have a positive impact on neuropathy in reducing pain symptoms.

 2. Symptoms Are More Complex Than Just Tingling

While pain and tingling are common and the easiest symptoms to recognize they are not the only ones. There are three types of peripheral nerves: sensory, autonomic and motor. Each can show different symptoms. Sensory nerve damage causes the frequent pain, tingling and numbness. Motor nerve damage may cause difficulty walking or picking up items, and moving the arms. Autonomic nerve damage affects more of your involuntary functions, like breathing, sweating, blood pressure and more.

 3. Diabetes Is the #1 Cause of Neuropathy

Diabetes is the leading cause of neuropathy today. Over 70% of diabetes patients develop symptoms. To avoid diabetes manage your blood sugar carefully. This can be a great way to prevent or even reverse the effect of diabetic neuropathy.

4. There Are Other Causes Besides Diabetes

While diabetes is the leading cause of peripheral neuropathy, other causes may include: alcoholism, traumatic injury, chemotherapy, as well as a vitamin B12 deficiency. It is well documented that it may be very difficult for the medical community to identify the exact cause of each patient’s peripheral neuropathy. For cases where the cause cannot be defined, doctors will diagnosis the patients with “idiopathic neuropathy”.

5. Certain Medications Can Damage Nerves

For those suffering from diabetes, drugs such as metformin have been shown to encourage damage to the nerves. This association has been linked in a recent study to vitamin B12 deficiency, which may result in neuropathy.

Peripheral neuropathy is a very serious condition that should be managed as soon as even the simplest symptoms arise. Talking to your doctor and following their specific treatment plan, as well as being equipped with better insight into this condition, may better equip you in combatting the symptoms associated with peripheral neuropathy allowing you to still live a healthy and high quality of life. What other things have you heard about peripheral neuropathy? Let us know!

Tags: peripheral neuropathy, diet, medications, diabetes, b12 deficiency, pain, tingling



  1. Allet L, Armand S, de Bie RA, Pataky Z, Aminian K, Hermann FR, et al. Gait alterations of diabetic patients while walking on different surfaces. Gait Posture. 2009; 29:488–493. [PubMed: 19138520]
  2. Hastings MK, Gelber JR, Isaac EJ, Bohnert KL, Strube MJ, Sinacore DR. Foot progression angle and medial loading in individuals with diabetes mellitus, peripheral neuropathy, and a foot ulcer. Gait Posture. 2010; 32:237–241. [PubMed: 20570153]
  3. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990; 13:513–521. [PubMed: 2351029]
  4. Sawacha Z, Gabriella G, Cristoferi G, Guiotto A, Avogaro A, Cobelli C. Diabetic gait and posture abnormalities: a biomechanical investigation through three-dimensional gait analysis. Clin Biomech. 2009; 24:722–728.
  5. Shull PB, Shultz R, Silder A, Dragoo JL, Besier TF, Cutkosky MR, et al. Toe-in gait reduces the first peak knee adduction moment in patients with medial compartment knee osteoarthritis. J Biomech. 2013; 46:122–128. [PubMed: 23146322]
  6. Zimny S, Schatz H, Pfolhl M. The role of limited joint mobility in diabetic patients with anat-risk foot. Diabetes Care. 2004; 27:942–946. [PubMed: 15047653]

When Immunity Works Against Us: Lupus


Our immune system is a very tenacious system. Our bodies are confronted with hundreds if not thousands of microbes a day. The reason why we are not constantly plagued with illness is because our immune system combats these microbes with a vigilant effort without us even realizing it. Picture your immune system as the “warriors” and “defenders” of your body and overall health. Our body’s defense cells have naturally evolved into perfect machines for fighting off the majority of foreign microbes that we may encounter in a given day. Under normal circumstances, your immune system’s “defenders” are known as proteins called antibodies. These antibodies are specific to each microbe where their job is to identify and kill any foreign threat. Now imagine if your immune system’s antibodies began to attack your body’s healthy tissues and cells. Your immune system can no longer distinguish between a foreign invader and a normal cell. Consequently, antibodies would have the same killing effect on normal and healthy cells as it would on foreign microbes. Your immune system, the defender of your body, has for lack of better words turned into the worst Benedict Arnold and now threatens your own vitality.

Unfortunately, it is very common when the bodies’ own immune system begins to attack normal cells. These types of conditions are term autoimmune diseases (“auto” meaning “self”) and can display a plethora of symptomologies. A common, but a disease that is difficult to detect is a disease known as lupus.

Defining Lupus

The U.S. National Library of Medicine defines lupus as an autoimmune disease that can damage almost any part of the human body specifically skin, joints, and/or organs. Due to the nature of this disease, it is frequently defined as a chronic disease due to signs and symptoms lasting for six week and longer. In lupus, the immune system produces autoantibodies that attack the healthy parts of the body resulting in severe damage and inflammation. It is a disease that is marked by cycles of “flare-ups” followed by periods of remission. The reason lupus can be difficult to detect is because it displays many symptoms that mimic other disease-states. Lupus is a very serious condition; however, it is well known that lupus is not a universally fatal disease and with proper medical care, it is still very possible to live a complete, and happy life.

According to the Lupus Foundation of America it is estimated that 1.5 million Americans, and at least 5 million people worldwide have a form of lupus; systemic lupus being the most common type (more on this later). Even though lupus can threaten men and women, 90% of individuals diagnosed with the lupus are women. Most people will develop lupus between the ages of 15-44. It is also more frequently diagnosed in African-American, Hispanic, and Asian decent. Given that there are many forms of lupus and each one in a given person can present differently, it is very difficult for doctors to produce an exhaustive list of symptoms. However, doctors have been able to observe a couple conventional symptoms that are associated with the majority of cases, including:

  • Chest pain upon deep breathing
  • Butterfly-shaped red rashes, most commonly on the face
  • Extreme fatigue
  • Mouth ulcers
  • Painful or swollen joints and muscle pain
  • Unexplained fever
  • Hair loss
  • Pale or purple fingers or toes from cold or stress (Raynaud’s phenomenon)
  • Sensitivity to the sun
  • Swelling in legs or around eyes
  • Swollen glands

Several Kinds of Lupus

According to the John Hopkins Lupus Center, there are five main types of lupus:

  • Systemic Lupus Erythematosus (SLE). As mentioned above, this is the most common type of lupus with 70% of cases being of this type. Systemic simply put means that the disease can affect many parts of the body. Symptoms of (SLE) can range from mild severe where chronic inflammation presents itself in the skin, kidneys, and joints. This form of lupus can also have serious effects on the lungs, nervous system, and heart.
  • Discoid Lupus Erythematosus. This kind of lupus only affects the skin. Symptoms observed are large, red, and raised rashes that appear on the face, scalp, or elsewhere. These rashes are scaly but are not itchy and may last for a couple of days to years. A small number of cases of (DLE) may develop into (SLE).
  • Subacute Cutaneous Lupus Erythematosus. This kind of lupus is caused by a high sensitivity to the sun where large, red, raised rashes appear on parts of the body exposed to sun. The lesions typically do not cause scarring.
  • Drug-Induced Lupus Erythematosus. This kind of lupus is caused by medications. Many classes of medications can cause this type of lupus. Some better known classes are: oral contraceptives, blood pressure medications, thyroid medications, antiseizure medications, antibiotics, and antifungals. Symptoms are similar to those of (SLE) and typically go away after the drug is discontinued.
  • Neonatal Lupus Erythematosus. This is a form of lupus that affects babies of women who carry certain antibodies. Doctors suspect that neonatal lupus is caused in part by autoantibodies in the mother’s own blood. At birth, the child may have a skin rash, liver problems, and low blood counts. These symptoms gradually go away over several months. In rare instances, babies with neonatal lupus may have congenital heart block. Only 40% of women who give birth to children with neonatal lupus actually have lupus themselves; on the contrary, neonatal lupus is rare, and most infants of mothers with (SLE) are entirely healthy.

Understanding the Cause of Lupus

Lupus is a very complex disease and the direct cause is not fully understood. Researchers are beginning to understand that genetics and the environment play a significant role in developing lupus; but more is still to be discovered. Scientists believe there is no single gene that predisposes someone to lupus but rather a number of different genes that may be involved in determining someone’s chances of developing lupus. Hopefully, in the near future researchers will have completely identified the genes involved, which could eventually lead to better ways to treat and perhaps even prevent lupus.

Diagnosing Lupus

As mentioned above, it can be very difficult to diagnose lupus. It may take months to even years for your medical team to accurately diagnose you with lupus. Because of the transient symptoms of lupus, your doctor will conduct a thorough medical exam as well as have complete knowledge of your medical history. These two components, along with laboratory tests will give your physician a more clear understanding as to if you truly have lupus or a disease-state that is mimicking the symptoms of lupus.

There is not one test alone that can determine if someone has lupus. Usually your doctor will order several laboratory tests to rule in or out lupus. The most useful tests identify certain autoantibodies often present in the blood of people with lupus. For example, the antinuclear antibody (ANA) test is commonly used to look for autoantibodies that react against the nucleus of a normal and healthy cell. Most people with lupus test positive for ANA; however, there are a number of other causes of a positive ANA besides lupus, including infections and other autoimmune diseases. In addition, some doctors may order a blood test to identify specific antibodies that are frequently observed in people with lupus, although not all people with lupus test positive for these and not all people with these antibodies have lupus. A medical exam, history, laboratory tests, and even certain biopsies will give your doctor a complete picture to determine if a person has lupus.

Treating Lupus

Thanks to the advances in medicine, there is not a wide range of effective treatments for treating lupus. Given that lupus is such a varying disorder, the symptoms, age, sex, and lifestyle will all contribute to what your doctor decides is the best plan for you. Physicians use a wide spectrum of medications throughout the lifetime of the patient when combating lupus. Some patients have found relief from the following options when treating lupus:

  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
  • Antimalarials
  • BLyS-specific inhibitors
  • Corticosteroids
  • Immunosuppressives

Your physician has several goals in mind when developing a tailored treatment plan. Some goals include: treat and prevent flares ups, reduce inflammation, minimize organ damage, and stabilize other symptoms such as fatigue and joint pain. Making a correct diagnosis of lupus is going to require great communication between you and your physician. Be honest and upfront with your physician as to what is or is not working within your treatment plan. Staying in regular contact with your physician about new symptoms and your treatment plan will lead a much more fulfilled and happier life when having to live with lupus.

How long have you suffered from lupus and what has helped you persevere? Please let us know!

Tags: Systemic Lupus Erythematosus, lupus, butterfly rash, autoimmune disorder, immune system, pain management, chronic pain


  1. Danchenko, N.; Satia, J.A.; Anthony, M.S. (2006). “Epidemiology of systemic lupus erythematosus: a comparison of worldwide disease burden”. Lupus. 15 (5): 308–318.
  2. Giannouli, S (1 February 2006). “Anaemia in systemic lupus erythematosus: from pathophysiology to clinical assessment”. Annals of the Rheumatic Diseases. 65 (2): 144–148. doi:10.1136/ard.2005.041673. PMC 1798007. PMID 16079164.
  3. Hughes GR (1998). “Is it lupus? The St. Thomas’ Hospital “alternative” criteria”. Exp. Rheumatol. 16 (3): 250–2. PMID 9631744.
  4. Tebbe, B; Orfanos, CE (1997). “Epidemiology and socioeconomic impact of skin disease in lupus erythematosus”. Lupus. 6 (2): 96–104. doi:10.1177/096120339700600204
  5. Weinstein, A; Bordwell, B; Stone, B; Tibbetts, C; Rothfield, NF (February 1983). “Antibodies to native DNA and serum complement (C3) levels. Application to diagnosis and classification of systemic lupus erythematosus.”. The American Journal of Medicine. 74 (2): 206–16. doi:10.1016/0002-9343(83)90613-7. PMID 6600582.

How To Classify Your Pain

Did you know that over 1.5 billion people worldwide suffer from chronic pain and roughly 100 million Americans deal with chronic pain on a daily basis? Did you know chronic pain costs society at least $560-$635 billion annually, an amount equal to about $2,000.00 for everyone living in the U.S.? Did you also know that chronic pain is a general, “non-descriptive” term used for a plethora of conditions? We would have to admit that such a generalized and universal phrase that affects such an astounding number of people and at such astronomical costs needs more clarification. That is why we would like to get more specific and talk about what chronic pain entails and how we can be more specific when identifying a chronic pain condition. Such understanding would certainly bring more awareness to each condition in the hopes of truncating the number of sufferers and associated costs.

Let’s begin by classifying pain as either acute pain or chronic pain.

Acute Pain

Acute pain is a quick and sudden onset of pain. It can range from being mild to extremely severe. Typically acute pain is identified as any pain that lasts less than six months. A vital identifier of acute pain is that it is associated with an identifiable cause; for example, a bacterial or viral infection, an injury, or a cut to the skin. Acute pain is typically well treated where the pain gradually resolves at the injury begins to heal. It is worth noting that untreated or improperly healing injuries may cause acute pain to develop into chronic pain.

Chronic Pain

Chronic pain is a little bit more complex to categorize. The simplest determination of chronic pain is pain that lasts longer than 6 months (again, from improper healing from an acute pain injury or from other causes we will get into) and just like acute pain, can range from mild to extremely intense pain. Now it gets a little tricky. Chronic pain should more appropriately be identified as [persistent pain].

2 Types of Intensities of Chronic Pain

Nonetheless, since chronic pain is a more acceptable term, we will use it for the remainder of this article. Chronic pain based off its duration of intensity can be broken down into:

  • Recurrent pain. This can be thought of as a short-lived increase in pain, especially for someone who has relatively stable and controlled level of baseline pain. It may be caused by changes in an underlying disease, withdrawal symptoms from a medication, emotions such as stress & anxiety, involuntary physical actions such as angina, or voluntary physical actions such as getting out of bed.
  • Continuous pain. Continuous pain is any condition that causes pain that is typically present for at least half the day.

Subclasses of Chronic Pain

In either case of recurrent or continuous, chronic pain is characterized by the underlying pathophysiology as being:

  1. Nociceptive pain. This type of pain is caused by harmful stimuli anywhere on the body that then travels along nerve fibers via the spinal cord to the brain. The various types of nociception are proprioception, thermoception, and chemoception; but in simpler terms, damaging mechanical, thermal, or chemical stimuli are sensed by pain receptors (i.e. nociceptors) which are found internal organs & surfaces, joints, and skin. Some common conditions causing nociceptive pain are internal organ referred pain, arthritis, myofascial pain, bone fractures, and chemical burns to name a few. You would be correct that some of these examples seem to be injuries causing acute pain but remember, improper healing injuries may develop into nociceptive pain.
  2. Neuropathic pain. This type of pain caused by disease or damage to the brain, spinal cord, or peripheral nerves. Neuropathic pain is typically caused by an injury to the spinal cord with there being a few exceptions such as diabetic neuropathy and other metabolic diseases. Common conditions causing neuropathic pain are cancer, carpal tunnel syndrome, multiple sclerosis, Parkinson’s disease, tumors, toxins, HIV-related symptoms, immunological disorders, or direct trauma to the brain or spinal cord. Symptoms are often described as being numbness, burning, or pin-and-needles sensations. Again, the pain could be recurrent or continuous.


  1. A mixture of nociceptive and neuropathic pain. Migraine headaches are an excellent example of a mixed chronic pain condition.
  2. From an undetermined cause. This can also be known as psychogenic pain where there is no visible sign of damage or past injury that is causing the pain. A couple good examples of conditions that cause pain are fibromyalgia and in some cases myofascial conditions such ad complex regional pain syndrome.

Each Pain Type Has A Specific Treatment

As we mentioned above, from a doctor or patient’s perspective, it is very difficult to treat “acute” or “chronic” pain. However, by knowing the type of pain it will be much easier and more efficient in communicating with your healthcare provider your symptoms. Injuries causing acute pain can be treated with antibiotics, braces or casts, stitches, and prescribed or over-the-counter medications to name a few. Chronic pain types are generally treated with physical therapy, holistic approaches, and a very strategic and specific drug regimen. For example, in some cases opioids are more effective in treating nociceptive pain over neuropathic pain. Various interventional procedures may also be used for different forms of chronic pain.

The Bottom Line

So what is the benefit of knowing all this information? It provides us with the understanding of how to best treat each pain type in the hopes of improving someone’s quality of life, well-being, and overall level of function Please consult your healthcare provider if you are experiencing any level of pain for he or she will tailor a regimen that will give you the most pain relief. Nonetheless, by being equipped with this knowledge as a patient, you will be able to be more efficient in identifying different types of pain allowing you to control your symptoms better.

Think you can identify what type of pain you’re having? Come and talk to us for more information on how to treat your specific pain-type.

Tags: neuropathic pain, nociceptive pain, chronic pain, acute pain, pain management


  1. Fishbain, David A.; Cole, Brandly; Cutler, R. Brian; Lewis, J.; Rosomoff, Hubert L.; Rosomoff, R. Steele (1 November 2006). “Chronic Pain and the Measurement of Personality: Do States Influence Traits?”. Pain Medicine. 7 (6): 509–529.
  2. Foley P, Vesterinen H, Laird B, et al. (2013). “Prevalence and natural history of pain in adults with multiple sclerosis: Systematic review and meta-analysis”. Pain. 154 (5): 632–42.
  3. Grichnik KP, Ferrante FM. The Difference Between Acute and Chronic Pain. Mt Sinai J Med. 1991 May;58(3):217-20.
  4. Hansson P (1998). Nociceptive and neurogenic pain. Pharmacia & Upjon AB. pp. 52–63.
  5. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011.
  6. Portenoy RK (1989). “Painful polyneuropathy”. Neurol Clin. 7 (2): 265–88.
  7. Rusanescu G, Mao J (2014). “Notch3 is necessary for neuronal differentiation and maturation in the adult spinal cord”. J Cell Mol Med. 18 (10): 2003–16.
  8. Vadivelu N, Sinatra R (2005). “Recent advances in elucidating pain mechanisms”. Current Opinion in Anesthesiology. 18 (5): 540–7.
  9. Vaillancourt PD, Langevin HM (1999). “Painful peripheral neuropathies”. Clin. North Am. 83 (3): 627–42

Most Effective Ways to Treat Trigeminal Neuralgia

Have you ever asked yourself, “Why do I have to have a condition that is so noticeable”? Do you feel embarrassed that your face is going through constant cycles of intense burning and stabbing sensations yet do not know where to start on getting treatment? We understand how you feel, especially how having a chronic illness on such a personal part of your body like your face can be quite debilitating. What we have done is compiled a list of tips that you can use to seek relief from trigeminal neuralgia. What exactly is trigeminal neuralgia? It is a chronic pain illness that affects the muscles that are innervated by the 5th cranial nerve, also known as the trigeminal nerve. Some common symptoms of trigeminal neuralgia are sharp stabbing, aching, and burning pain throughout different regions of the face. So, if you think you are suffering from the symptoms we just described, the tips below may help alleviate some of your pain.

Keep in mind, that consulting your physician is always a great option when trying to get an accurate diagnosis and trying to determine what might be of help for you. Once your doctor has completed a medical history and a physical exam; they may prescribe some medications that treat trigeminal neuralgia.

Relief Through Medications

Below is a list of most commonly prescribed medications for trigeminal neuralgia:

  1. Antispasmodic Agents. Antispasmodic agents are used to ease pain sensations caused by trigeminal neuralgia attacks. These agents may also be used in conjunction with anticonvulsant medications.
  2. Anticonvulsant Medications. Anticonvulsant medications are one of the most commonly prescribed medications for this condition. Your doctor may prescribe one or more anticonvulsants until he or she determines which medication is the most beneficial in reducing your pain symptoms.
  3. Botox injections. If you become unresponsive to anticonvulsants, tricyclic antidepressants, and antispasmodic drugs, your doctor may consider putting you on a regimen of Botox. Botox has been shown to be effective for pain management in a high percentage of patients with trigeminal neuralgia, especially those with rapid muscle twitching.
  4. Nonsteroidal Anti-Inflammatory Drugs (NSAID’s) & Analgesics. NSAID’s and analgesics can be purchased without a prescription and are very efficient in reducing the inflammation and pain associated with trigeminal neuralgia. Your doctor may recommend an anticonvulsant medication before starting a NSAID or analgesic because these may not be as effective at blocking the electrical signals from the misfiring neurons that are causing the sensations of pain. Also, be sure to talk to your doctor before beginning a NSAID or analgesic for they do pose a risk for developing ulcers.
  5. Tricyclic Antidepressants (TCA’s). Tricyclic antidepressants are commonly used to manage symptoms of depression, but they can also be prescribed to manage chronic pain. Tricyclic antidepressants are often effective in managing chronic pain conditions, such as atypical facial pain, but may not be useful in classical trigeminal neuralgia.

Pain Relief Through Medical Procedures

Although medications may be helpful for stabilizing symptoms over time, more aggressive cases of trigeminal neuralgia can lead to permanent damage of the trigeminal nerve. Such damage could result in severe pain or partial permanent facial numbness. If you do not respond well to medications, more complex procedures may be a viable option. The degree of severity of your trigeminal neuralgia, prior history of neuropathy, and general health all factor into the options that are available to you. You doctor can help make treatment determinations. The overall goal of these procedures is to minimize damage to the trigeminal nerve as well as to improve the quality of life when medications no longer useful in managing pain.

  1. Balloon Compression. This type of procedure has been shown to provide up to two years of pain relief, which is great! Also, many patients have mentioned that they experience temporary facial numbness when doing actions such as chewing; but this goes away within a short amount of times after the procedure. How this method works is a small balloon is inserted into the skull through a catheter and as it inflates, the trigeminal nerve is pressed against the head. This is typically an outpatient procedure that is performed under general anesthesia.
  2. Glycerol Injection. This process has been shown to offer 1 to 2 years of pain relief. Glycerol injection is used to “damage” a portion of the trigeminal nerve. Sounds counterintuitive but the damage caused by the glycerol injection results in pain relief. This is typically an outpatient procedure where a thin needle is inserted through the cheek into the base of the skull and near the portion of the trigeminal nerve.
  3. Microvascular Decompression (MVD). This is the most effective surgical treatment for trigeminal neuralgia where about 70-80% of patients have immediate, and complete pain relief and 60-70% remain pain-free for up to 10-20 years. Nonetheless, MVD is also the most invasive surgical procedure for treating trigeminal neuralgia. During surgery, your doctor makes a hole behind the ear. Then, using an endoscope to visualize the trigeminal nerve, your doctor will place a cushion between the nerve and the blood vessel that compresses the nerve. The recovery time for this procedure varies from person to person and often requires a hospital stay.
  4. Neurectomy involves removing a part of the trigeminal nerve. Much like MVD, this too is an invasive procedure and is reserved for patients who do no respond to other treatments. Neurectomies are often performed when a blood vessel is not found pressing on the nerve during an MVD. During the procedure, different portions of the trigeminal nerve’s branches are removed thus allowing pain relief.
  5. Radiofrequency Thermal Lesioning. Radiofrequency thermal lesioning (or RF ablation) has been shown to offer pain relief up to 3 to 4 years following the procedure in about half of patients. RF Ablation is an outpatient procedure where a needle with an electrode is inserted into the trigeminal nerve. Once the area of the nerve that causes the pain is located, your doctor sends small electrical pulses through the electrode to damage the nerve fibers, resulting in numbing of the site.
  6. Stereotactic Radiosurgery (or Gamma Knife). Most patients who undergo gamma knife report pain relief after a few weeks or months, but pain often reoccurs within three years. This procedure uses computer imaging to send focused radiation to the trigeminal nerve. During the procedure, the radiation creates a laceration of the trigeminal nerve, which disturbs sensory signals to the brain and reduces pain. A gamma knife procedure is typically an outpatient procedure where patients can leave the same day.

Pain Relief Through Holistic Approaches

More and more doctors and patients are looking towards more conservative and noninvasive approaches for treating pain condition, trigeminal neuralgia included. Although the data in these approaches is mixed, you and your doctor can decide if you would benefit from one of them. Always make your doctor aware if you do consider trying one of these approaches.

  1. Acupuncture is a traditional Chinese medical technique that involves inserting small needles into specific points throughout the body for pain relief. A recent study in the journal Medical Acupuncture demonstrated a significant beneficial effect when acupuncture treatments were administered to patients who were suffering from trigeminal neuralgia. Thus this would be a good option for anyone looking for a more “holistic” approach to pain relief.
  2. Chinese Herbs. Several Chinese herbs provide pain relief for those suffering from trigeminal neuralgia. Such herbs are available from Chinese medicine practitioners and acupuncturists who include herbal medicine in their practices. They are also sold at herbal shops selling traditional Chinese medicines. They can guide you as to what combinations are most suited for offering pain relief for trigeminal neuralgia. However, please talk to your healthcare provider before beginning a regimen of any herbs.
  3. Creams & Ointments. Topical use of capsaicin cream or cayenne pepper for pain relief for trigeminal neuralgia has been shown to be effective. Creams or ointments such as IcyHot can be purchased at almost any pharmacy or grocery store. Alternatively, a pinch of cayenne pepper can be mixed with olive oil or other unscented facial cream and applied to the painful area.

Trigeminal Neuralgia is a very painful and debilitating condition to live with. Fortunately, as you can see, there are some treatments, regardless of what level of pain your case may be at, to treat your symptoms. It is worth noting that many of these approaches can be done concertedly and different methods will work better for some and not for others. With that being said, your healthcare provider is your number one resource for obtaining a therapeutic regimen that works for you.

What methods have been shown to help relieve your symptoms? Let us know!

Tags: trigeminal neuralgia, face pain, medications, medical procedures, holistic, chronic pain, pain management

The In’s & Out’s of Complex Regional Pain Syndrome

We have been getting quite a few questions about Complex Regional Pain Syndrome as of late; thus we would like to take this time to go into detail about this condition as well as some treatments that have been shown to be effective. Please talk to your doctor before implementing any of these treatments and if you have any questions, please comment below!


Complex Regional Pain Syndrome (CRPS) is a long-term and a very painful condition. CRPS can affect any age, but it becomes more common with increasing age. It is 3-4 times more common in women, in whom it is also likely to be of a more severe type, than in men. Patients with CRPS describe the pain as a constant and extreme burning sensation in the affected arm or leg. Cases of CRPS affect the arm over more than the leg where 60% of cases affect the arm, and the remaining 40% have an impact on the leg. Unfortunately, the exact cause of CRPS remains unclear; nonetheless, it appears to be triggered by an abnormal response to an injury. Such an injury may result in damage to the nerve fibers at the site of harm. Examples of an injury are an infection, surgery (12%), trauma, stroke, sprain (18%) or a fracture (45%) to name a few. Typically, the injury that triggers CRPS is mild compared with the pain that follows. However, the condition also can develop into more severe injury or paralysis. The medical community agrees that the nerves do in fact become overly sensitive in CRPS, for example, painful signals become more painful. And common stimuli, such as light touch and temperature changes also are experienced as pain.


To offer a little bit more clarification into CRPS, the medical community has broken down this condition into two classifications:

  • CRPS I: Pain that develops in the absence of a nerve injury.
  • CRPS II: Pain that develops in the presence of damage to a major nerve.


As mentioned above, the exact cause is unknown; but we did give a few typical examples as to what may trigger CRPS. There have also been documented uncommon causes of CRPS that include abnormal nerve impingement from having a cast on the limb, vasculitis, herpes zoster, as well as leg ulcers. Again, the exact cause is not known, but all of the conditions or events mentioned have been shown to be precipitating factors for CRPS.


The symptoms of CRPS vary in severity and duration. The characteristic symptom is that of pain – typically burning in nature and out of proportion to the seriousness of any injury. The affected area, which may not be localized to any particularly damaged nerve fibers, may have other symptoms such as:

  • Sweating
  • Sensitivity to touch
  • Symptoms of depression
  • Muscle weakness or tremors in affected limb
  • Swelling or pitting edema in the affected limb
  • Pain from otherwise non-painful stimuli (e.g. light touch)
  • Severe pain from mild to moderate painful stimuli (i.e. hyperalgesia)
  • Spontaneous temperature changes between the injured and non-injured limb. Occurs in 80% of CRPS cases.
  • Abnormal skin changes; for example, skin can initially be smooth then become dry, hair can initially be coarse then become brittle, nails can grow fast then suddenly grow slow, as well as abnormal goosebump activity.


Your doctor will complete a comprehensive history and physical exam. For most cases, your doctor will also evaluate the range of motion, nerve function, and any tissue texture abnormalities of the affected limb. You doctor will also be using specific criteria to make a definite diagnosis of CRPS. Such measures include severe pain that was not present before injury, temperature differences between the limbs, reduced range of motion or weakness, sporadic swelling or sweating occurrences, and dermal changes to name a few. It is worth noting that X-rays, electromyography (EMG), nerve conduction studies, CT scans, MRI, and blood tests may all be entirely normal. Thus in most cases, your doctor will make a diagnosis of CRPS based on your personal history as well as their objective assessment of your symptoms.



Most cases of CRPS can are treated with a conservative treatment of a drug regimen. Drugs that have been shown to be effective in treating CRPS:

  • Non-Steroidal Anti-Inflammatory Drugs (NSAID’s)
  • Analgesics
  • Neuropathic drugs (e.g. gabapentin, neurotin)
  • Antidepressants [e.g. tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRI’s)]
  • Baclofen for cases of CRPS with sudden muscle contractions
  • Bisphosphonates which stop the breakdown of bone tissue


  • Physical Therapy. This is most likely one of the most important treatments for CRPS. Regardless of what stage CRPS has progressed to, everyone dealing with this condition should be taking some physical therapy. The regular exercise, stretching, as well as muscle strengthening that come with doing physical therapy will help to reduce the pain and stiffness associated with CRPS.
  • Behavioral Therapy. Research has shown that patients with CRPS are more likely to suffer from depression and anxiety when compared to a control group. For this reason, seeing a therapist or learning cognitive behavioral therapy will help when it comes to reducing the negative thoughts that accompany suffering from CRPS.
  • Support Groups. These groups allow you to meet others that may be going through similar experiences where you can receive as well as offer emotional comfort and moral support. Please click on the link to find a group near you:

Other Treatments

  • The N-methyl-D-aspartate (NMDA) receptor antagonist ketamine has been used in intractable CRPS but has to be given in anesthetic doses.
  • Steroid or local anesthetic injections into the affected limb have been shown to be an effective treatment for pain reduction.
  • Spinal cord stimulation trials have also been used to reduce pain over time.

It is very unfortunate that there has yet to be a cure for CRPS, but with an effective therapeutic regimen, proper education, as well as a willingness to get better, symptoms can be controlled and often reduced. The duration of CRPS varies yet we cannot stress enough that if you are experiencing symptoms of CRPS, it is crucial that you see your doctor as soon as possible. If undiagnosed and untreated, CRPS can spread to other extremities such that this condition becomes extremely debilitating. This can make subsequent rehabilitation much more challenging. Researchers hope to discover the mechanisms that cause the spontaneous pain of CRPS; that discovery may lead to new ways of blocking pain. So do not give up hope if you find yourself with this condition. Again, with your willingness to be proactive and control your care, you can still live a full and happy life!

Are you looking for which treatment option may be best for you? Please make an appointment and let us know.

Tags: complex regional pain syndrome, medications, physical therapy, cognitive behavioral therapy, support groups, CRPS I, CRPS II



  1. Harden RN, Oaklander AL, Burton AW, et al; Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. Pain Med. 2013 Feb;14(2):180-229. doi: 10.1111/pme.12033. Epub 2013 Jan 17.
  2. Logan DE, Carpino EA, Chiang G, et al; A day-hospital approach to treatment of pediatric complex regional pain syndrome: initial functional outcomes. Clin J Pain. 2012 Nov-Dec;28(9):766-74. doi: 10.1097/AJP.0b013e3182457619.
  3. Logan DE, Williams SE, Carullo VP, et al; Children and adolescents with complex regional pain syndrome: more psychologically distressed than other children in pain? Pain Res Manag. 2013 Mar-Apr;18(2):87-93.
  4. Marinus J, Moseley GL, Birklein F, et al; Clinical features and pathophysiology of complex regional pain syndrome. Lancet Neurol. 2011 Jul;10(7):637-48. doi: 10.1016/S1474-4422(11)70106-5.

8 Tips On How To Treat Sciatica Naturally


Sciatica, also known as lower extremity radiculitis at L5/S1 or radiculopathy, is a common condition defined by sensory changes or weakness along the pathway of the sciatic nerve. The sciatic nerve roots start at the lower spine and descend through the buttocks, down the posterior portion of the leg (back of the thigh), and ends at the foot. Patients often describe the sensory changes similar to that of “pins and needles” and can be felt along the entire backside of the leg.

Sciatica can be a severe condition, especially when symptoms do not solely affect with the lower limb. Some serious results of Sciatica are bowel incontinence, bladder incontinence, severe nerve impingement, lower extremity weakness, and overpowering loss of sensation. The loss of bowel or bladder function resulting from sensory weakness is Cauda Equina Syndrome and is a critical medical emergency.

Picking A Treatment That Works For You

There are a number of treatments available for treating Sciatica. Your doctor will start you off on a conventional regimen of prescribed medication and bed rest. For more advanced cases, epidural/trigger point injections and spinal cord stimulations may be used; however, these procedures come with their risks.

Fortunately, if you would like to seek a more noninvasive approach as well as without relying on medications, we have put together eight tips on how to find pain relief. It is worth noting that these treatments are to be used for mild to moderate conditions of sciatica. For more advanced cases, surgical or injection treatments are going to be the optimal and only choice. Be sure to consult your doctor before implementing any of the following tips.


  1. Nutrition & Exercise

Reducing the pain associated with sciatica could be as simple as implementing an exercise regimen and a healthy eating plan. Physical activity over time can increase your range of motion, consequently increasing your flexibility. This flexibility allows the muscles that may be impinging the sciatic nerve to become relaxed. Our muscles require an exurbanite amount of nutrition, and if we lack in any vital nutrients, our muscle could be more prone to muscle cramps, stiffness, and even sprains.

  1. Physical Therapy

Doing activity when you’re in pain does sound counterintuitive when your buttocks are in severe pain. Nevertheless, activity could be just the treatment to reduce the pain associated with sciatica. Physical therapy focuses on stretching and exercising the muscles that are activated by the sciatic nerve. Lower limb exercises increase blood flow to the affected area, which subsequently may improve flexibility, reduce inflammation, strengthen muscles, as well as stabilize your core. Physical therapy helps improve symptoms of sciatica by increasing flexibility, range of motion, posture, and improving muscle strength.

  1. Trigger Point Massage Therapy

The major muscle in the buttocks that lies directly over the sciatic nerve is known as the piriformis and is most often the muscle that becomes inflamed, leading to impingement and irritation of the sciatic nerve. Trigger-point massage therapy applies direct pressure to the piriformis to loosen the muscle and alleviate the compression that causes pain, numbness, and tingling down the affected leg. Numerous studies have found trigger point massage therapy to be advantageous, especially when done on a weekly basis. There are also available foam rollers and therapy balls that can be used to focal rub tender areas in the hope of relieving muscle spasms or contractions and improve the discomfort associated with it.

  1. Alternate Ice & Heat

There has been an agreement in the medical community that alternating between ice then heat for periods of 15 minutes each can reduce the discomfort associated with sciatica. Although this method does not diminish the inflammation associated with sciatica, it can still be a beneficial practice for it provides alternating stimuli, which may reduce the pain.

  1. Acupuncture

Be sure to consult your doctor before you try acupuncture. With that being said, acupuncture has been shown to be beneficial for those suffering from sciatica. One study found that over 50% of participants reported some level of pain relief. Acupuncture is the practice where small needles are inserted into the skin. These needles cause your body to release neurotransmitters known as endorphins, which are your body’s natural pain relievers. The release of endorphins has been shown to reduce muscle-spasm contractions, reduce stress, as well as reduce tension.

  1. Yoga

Research has shown that a consistent regimen of gentle yoga has been demonstrated to improve muscle strength, flexibility, and mobility. There are numerous types of yoga classes that you can find are suitable for you. Once you and your doctor have decided an appropriate intensity level, ask yoga instructors as to what practice will best fit your needs.

  1. Biofeedback

Biofeedback therapy involves training a patient to control internal physiological processes such as heart rate, blood pressure, and even muscle tension. By becoming more in tune with your body, ailments such as sciatica pain can influence and reduce your level of pain. A better awareness of your body teaches you to relax effectively, and this can help relieve your pain.

  1. Natural Oils and Ointments

An array of natural creams and oils has been shown to have positive effects on sciatica. Simple over-the-counter skin creams include a compound known as capsaicin that is naturally found in peppers. These compounds work by obstructing the release of pain-causing compounds from the nerves. Thus an efficient and noninvasive route in reducing pain can be to simply use a cream or patch.

It is worth mentioning that some treatment options might work for some but not others. Thus pick a couple from the list above that you believe would be beneficial and give it a try. If you are not finding relief, try another option. Also, a combination of treatment options is often the most practical course, and many patients will try some combination of treatments listed above. Let us know if these tips helped you!



  1. Basmajian, J. V. (1967). Muscles alive: Their functions revealed by electromyography. Baltimore: Williams and Wilkins.
  2. Casey, E (February 2011). “Natural history of radiculopathy.”. Physical Medicine and Rehabilitation Clinics of North America. 22 (1): 1–5.
  3. Dorsher PT (May 2006). “Trigger points and acupuncture points: anatomic and clinical correlations”. Medical Acupuncture. 17 (3).
  4. Dupler, Douglas; Frey, Rebecca (2006), Gale Encyclopedia of Medicine, 3rd ed, ISBN 978-0787618681; Retrieved 30 August 2012.
  5. Fattori, V; Hohmann, M. S.; Rossaneis, A. C.; Pinho-Ribeiro, F. A.; Verri, W. A. (2016). “Capsaicin: Current Understanding of Its Mechanisms and Therapy of Pain and Other Pre-Clinical and Clinical Uses”. Molecules. 21 (7): 844.
  6. Gothe, N.; Pontifex, M. B.; Hillman, C.; McAuley, E. (2013). “The acute effects of yoga on executive function”. Journal of physical activity & health. 10 (4): 488–495.
  7. Hagen, KB; Hilde, G; Jamtvedt, G; Winnem, M (Oct 18, 2004). “Bed rest for acute low-back pain and sciatica.”. Cochrane database of systematic reviews (Online) (4): CD001254. doi:1002/14651858.CD001254.pub2. PMID15495012.
  8. Hsueh TC, Cheng PT, Kuan TS, Hong CZ (November–December 1997). “The immediate effectiveness of electrical nerve stimulation and electrical muscle stimulation on myofascial trigger points”. American Journal of Physical Medicine & Rehabilitation. 76 (6): 471–6.
  9. Leininger, Brent; Bronfort, Gert; Evans, Roni; Reiter, Todd (2011). “Spinal Manipulation or Mobilization for Radiculopathy: A Systematic Review”. Physical Medicine and Rehabilitation Clinics of North America. 22 (1): 105–125.
  10. Ropper, AH; Zafonte, RD (26 March 2015). “Sciatica.”. The New England Journal of Medicine. 372 (13): 1240–8.
  11. Valat, JP; Genevay, S; Marty, M; Rozenberg, S; Koes, B (April 2010). “Sciatica.”. Best practice & research. Clinical rheumatology. 24 (2): 241–52.

The Science Between Physical Pain & Mental Disorders


Have you ever questioned how feeling mentally numb started after your physical pain? Ever feel that the intensity of your pain has increased when you’re in a state of sadness are despair? Do you feel confused and alone while physical pain and mental depression are occurring? Don’t fret; you’re not alone. In fact, research has shown that 30-50% of individuals suffering from chronic pain also have a behavior disorder where depression and anxiety were shown to be the two most significant behavior disorders. There is no doubt an association between chronic pain and mood disorders so let’s explore this connection and how consulting and strategizing with your doctor can go about treating these symptoms.

Acute Vs. Chronic Pain

Pain can be defined as either being acute or chronic based on the length that the pain has persisted. Any injury associated with pain that persists for three months or longer means that the normal healing process is irregular. Thus pain associated with this injury is identified as chronic. There is some disagreement within the medical community as to what identifies acute or chronic pain; nonetheless of physicians are beginning to consider chronic pain as an underlying factor that may contribute to mental illness.

Chronic Pain and Mental Disorders; Which Came First?

This is a question of which came first, the chicken or the egg? However, concerning chronic pain and mental illness, it can work both ways. Pain can cause depression and anxiety. Depression and anxiety can also cause pain. It can create a cycle where one continually worsens the other. For example, someone in pain from an injury may cut back on their activity because they are reluctant to exacerbate their injury.

Let’s look at another example. Chronic pain may be causing someone sleep problems. Lack of sleep has been shown to create the thought of anxiety, helplessness, and worthlessness. A continuation of these feelings may lead to someone to a diagnosis of mental illness.

Treatment Options

A comprehensive approach to treatment involves a thorough evaluation to determine what might be contributing to both the pain and the mood disorder. If it’s something physical, like arthritis contributing to pain, treating the pain may improve the depression. Treatment may involve medication, physical therapy or other treatments, such as nerve blocks. For other cases, it is important to address the psychological aspects of counseling or with drugs that may help improve both pain and depression.

Other options for treating both pain and depression include:

  1. Education. This is essential for both the one with the ailments as well as for their family. Talk to you doctor, ask questions, and absorb as much information as you can.
  2. Self-help Groups. These can be helpful because it will allow you to understand that you are not alone in your battle. Talking with others is not only therapeutic, but it can also begin changing your mental affect, which in turn may reduce your pain symptoms.5, 8, 9
  3. Cognitive Behavioral Therapy. This for of therapy may help you develop coping skills so that you can manage your pain as well as your mental thoughts.2, 3
  4. Hypnosis. This sort of treatment has been shown to help patients reach a relaxed state that may allow for positive suggestions.6, 11
  5. Exercise. Exercise has numerous health benefits. One being that it can boost your mood as well as reduce pain symptoms.1, 6, 10
  6. Meditation. This practice has been shown to contribute to reducing the stress response that often worsens pain and increases the symptoms of depression and anxiety.4, 7

It’s important for people to treat their pain and depression, and to take part in activities. Rather than focusing on what they cannot do, it is important that patients realize what they can do.

Did any of these alternative treatment options work for you? Let us know!

Tags: anxiety, chronic back pain, chronic conditions, chronic knee pain, chronic neck pain, chronic pain, depression


  1. Abenhaim L, Rossignol M, Valat JP, Nordin M, Avouac B, Blotman F, et al. The role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain. Spine 2000; 25: 1 S–33S.
  2. Ayen I, Hautzinger M. [Cognitive behavior therapy for depression in menopausal women: a controlled, randomized treatment study] Zeitschrift fur Klinische Psychologie und Psychotherapie. 2004;33:290–299.
  3. Cuijpers P, Smit F, Bohlmeijer E, Hollon SD, Andersson G. Efficacy of cognitive-behavioural therapy and other psychological treatments for adult depression: meta-analytic study of publication bias. Br J Psychiatry. 196:173–178
  4. Felipe A. Jain, Roger N. Walsh, Stuart J. Eisendrath, Scott Christensen, B. Rael Cahn, Critical Analysis of the Efficacy of Meditation Therapies for Acute and Subacute Phase Treatment of Depressive Disorders: A Systematic Review, Psychosomatics, 2015, 56, 2, 140
  5. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression – A cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166:2314–2321.
  6. Maren Nyer, James Doorley, Kelley Durham, Albert S. Yeung, Marlene P. Freeman, David Mischoulon, What is the Role of Alternative Treatments in Late-life Depression?, Psychiatric Clinics of North America, 2013, 36, 4, 577
  7. Michael de Manincor, Alan Bensoussan, Caroline Smith, Paul Fahey, Suzanne Bourchier, Establishing key components of yoga interventions for reducing depression and anxiety, and improving well-being: a Delphi method study, BMC Complementary and Alternative Medicine, 2015, 15,
  8. Paul N. Pfeiffer, M.D. Efficacy of Peer Support Interventions for Depression: A Meta-Analysis. Gen Hosp Psychiatry. 2011 Jan–Feb; 33(1): 29–36
  9. Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, Niederehe G, Thase ME, Lavori PW, Lebowitz BD, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. Am J Psychiat. 2006;163:1905–1917.
  10. Skouen JS, Grasdal AL, Haldorsen EM, Ursin H. Relative cost effectiveness of extensive and light multidisciplinary treatment programs versus treatment as usual for patients with chronic low back pain on long-term sick leave: randomized controlled study. Spine 2002; 27: 901–910.
  11. Tomonori Adachi, Haruo Fujino, Aya Nakae, Takashi Mashimo, Jun Sasaki, A Meta-Analysis of Hypnosis for Chronic Pain Problems:A Comparison Between Hypnosis, Standard Care, and Other Psychological Interventions, International Journal of Clinical and Experimental Hypnosis, 2014, 62, 1, 1