Chronic Pain

I Can't Talk But I Can Feel

Dr. Angela Mailis, Founder

Dr. Angela Mailis, Founder

An administrator in the hospital called me on the phone quite distraught. Her father with Alzheimer’s was residing in a nursing home. While he was forgetful, he was quite self sufficient in personal care, pleasant and well interacting with the family who visited often. That is, until he was diagnosed with neck cancer and was sent for a number of radiation treatments localized to the neck. Unfortunately, the radiation caused some serious burns in the neck that needed lots of local treatments and dressings to help the burns heal. This is when the man changed. The bewildered daughter described him as unable to speak or respond to close family members, thrusting violently at times and quite unable to even feed himself. So, she called me to discuss him as the nursing home staff had no clue what to do. One of the reasons people with substantial cognitive loss get derailed and confused, is when there is big change in their environment. The old man had been taken frequently for a number of treatments in an outside unfamiliar facility. That could partially explain his behavior.  The other big reason is untreated pain. I strongly recommended that he is given some liquid morphine regularly, so the daughter went back to the nursing home staff and suggested this. The change was dramatic. Within 20-30 minutes after the ingestion of liquid morphine her father would be able to sit up, eat and communicate. A couple of hours later, when the drug wore out or when the dose was insufficient, he would resort back to silence and inability to do his basic things, wincing and unable to interact or talk. I suggested dose increase and also more liberal use of the drug in frequent intervals. Two weeks later, as his burns were healing well, the morphine was much reduced and he was returning to his old good self.

In another extremely sad case I saw, a 45 year old woman was brought to me from a nursing home outside the Greater Toronto area by her caring sister. She was bound to a reclining wheelchair, the left leg was in a brace with the knee straight and the left hand curled under the covers. Her story was the stuff horror movies are made off. About 5 years ago she was shot by her husband in the head while he committed suicide afterwards. This lady survived but with huge injuries. The bullet went behind her eyes and destroyed her eyeballs, so that the eyes had to be removed from their sockets leaving her blind. The neurosurgeons tried to clean up the bullet fragments from her brain. After this surgery, unfortunately, she got a stroke that damaged the right part of her brain. Specific areas of the brain control both movements and sensation in our body. When this lady’s right brain was damaged, it was the left side of her body that got paralyzed. So, here she is, blind, brain damaged and paralyzed in one side, which left him totally dependent on others for everything. But the tragic story did not finish here. Shortly after the stroke she started complaining bitterly (whichever way she could, with some words, sounds or body jerks) of pain across the whole left paralyzed side. Moving her from chair to bed and vice versa was an ordeal, and the staff (inpatient, untrained and not educated in her condition) let her and the relatives know that probably this “was all in her head”.

They were absolutely right, it was all in her head, but to be correct, not the way they meant it (as a “figment of her imagination”). This unfortunate lady had suffered a serious and very difficult to treat neuropathic pain syndrome seen in about 8% of all people with stroke, that we call “central post stroke pain syndrome”. When I examined my patient with a soft feathery make up brush, she found it very painful. Over the years she had been able to recover her ability to speak and respond to questions, so she told me clearly how uncomfortable my little brush felt on her skin. Touching her with a sharp pointy object was even worse, while the slightest movement of her paralyzed side was unbearable. Her very long toenails on that left leg were the proof of her inability to tolerate the slightest touch or movement and the skin over the toes was dry and scaly as water on the skin was not tolerated.

Probably my most important contribution to this lady’s care was a scalding note to the nursing home indicating what the diagnosis is with advice to handle her very gently and stressing “this was in her head, but in her brain”!

Why did I tell you all this? Simply to show you that pain in institutionalized settings in a huge issue, untreated and poorly understood for people who are seriously  physically impaired and/or have reduced cognitive capacity or ability to communicate. This goes as well for young kids with cognitive impairment but I am not a kids’ pain doctor, so I leave this to specialists in pediatric pain. Stats Canada told us that in institutionalized seniors, chronic pain affects  close to 4 people out of every 10. 

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Long Winding Road To Pain Relief

Dr. Angela Mailis, Founder

Dr. Angela Mailis, Founder

Mr. J. an 89 year old gentleman, bright and well educated, saw me 3 years ago, on the desperate plea of his son and daughter. Dad had developed a painful condition in his left lower leg with sharp jabs of knife-like and burning pain and bouts of uncomfortable pins and needles sensation.  To make the story short, the moment I saw Mr. J. I noticed very slow movements of his toes in that affected leg. He had become aware of them since the onset of the pain but did not know what to make out of these movements. I thought of a very rare and painful syndrome named “painful legs, moving toes”.  The commonest abnormality associated with the syndrome comes from the spine when a nerve root is pinched and compressed usually because of degenerative changes. There was only one problem: Mr. J. had nothing but minor back pain for years to the point he felt it was not worth talking about. I sent Mr. J for a spinal MRI and nerve tests. The MRI was clear: he had an absolutely lousy back and his nerve root was squeezed at the site of the painful leg. A nerve test  was able to confirm that Mr. J. had a pinched nerve in his back. The tests made me confident that my original diagnosis of “painful legs, moving toes” was right. 

Since there is no cure for this condition, I decided to target different issues that contributed to Mr. J.’s pain.  I prescribed a medication to sleep, another one to sooth the nerve pain (which by the way is not covered by the province of Ontario even for those over 65) and a powerful opioid, liquid morphine. Mr. J originally reacted to my last proposal:  “My God, doctor, I do not want to get hooked and addicted”! It took me time to convince Mr. J. and his daughter who always comes with him, that he needs the drug, he will not get hooked because he has a good medical reason to take it, and I promised I will start him with baby doses. Three years later, at the remarkable age of 92, though he hardly looks early 70s, Mr. J. continues to use the medications I prescribed, and he is doing very well. His pain is much better controlled and he has a very active life as he is a widow living alone. As a matter of fact he just went to Europe for a long holiday. Leaving my office, ready to pack and go with the family to his trip, he gave me a big hug and a warm kiss. “Without you doctor, I would have been unable to go to this trip”. “By the way” he continued, “did I tell you, you are my #41 doctor”? I certainly did not believe my ears. My good old Mr. J. had seen 40 doctors before me over the course of few years seeking  diagnosis and treatment and had kept meticulous notes, so I had to believe him.

Why did Mr. J. made the rounds of 40 physicians and countless non medical practitioners before he got diagnosis and treatment? Why were some of his important medications not covered by the system even if he was over 65? How much money did my patient spend out of pocket throughout the years of  his ordeal? Where did Mr. J. get his fear of being hooked on drops of morphine? The answer is simple: because the province of Ontario and several other provinces do not have a comprehensive strategy for pain management, a strategy that will equip professionals, public at large, patients, administrators and policy makers with necessary education and knowledge to tackle the problem, define the gaps of care, coordinate existing resources, reallocate funds from money wasted in the system to processes that are useful and effective, provide smooth flow from one level of care to the other and even provide the public with techniques to prevent and self manage pain. 

Another time I will explain how the  province of Ontario tries to address the issue of chronic pain.

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Strange Things About Chronic Pain

Dr. Angela Mailis, Founder

Dr. Angela Mailis, Founder

Acute pain is kind of straightforward. For example, when you break a bone it hurts. Once the fracture is stabilized in a cast, the pain stops.  We can also understand why a chronic injury like bad knee arthritis or a permanently damaged nerve can hurt for long. 

Chronic pain, however, can be strange and difficult to understand in many fronts and not just where it comes from. Here is a long list of questions:  

  • Why does pain persist after an injury that seems to be very little and insignificant or for all practical purposes has healed long time ago? 
  • What about pain that seems to start in one part of the body localized to the site of a sprain or other injury, and then spreads everywhere? 
  • Why two people with the same injury seem to be affected very differently?  
  • Why do women seem to suffer from a lot of painful conditions unlike men? 
  • Why do people with the same condition respond differently to the same treatment? Why do kids who come from homes with relatives who have chronic pain seem more prone to develop painful conditions later in life? 
  • What is the reason people from different cultures and races feel and express pain differently?

I will address each of these questions in future blogs.

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PWC Success Stories: Multi-Step Therapy

Dr. Angela Mailis, Founder

Dr. Angela Mailis, Founder

A 46-year-old businessman was involved in a multi-vehicle accident and experienced immediate nausea, dizziness, headache and disorientation. When he sees us 3 weeks after the injury, he is unable to drive and continues to complain of significant post-concussion symptoms and post-traumatic headaches. After our medical and manual therapy assessment, he decides to come back to our centre for manual therapy and medical acupuncture as well as proper nutritional guidance from our naturopathic doctor, with quick and substantial improvement, while he manages to return to work full time.

TAKE HOME MESSAGE: Proper manual and other physical therapy can assist recovery from a concussion, as  many of the symptoms are due to dysfunction of the neck structures.

KEY MESSAGES

  • Pain must be treated early to prevent it from becoming chronic.
  • Proper pain management requires the close collaboration of many health care professionals, including pain doctors, psychiatrists, psychologists and neuropsychologists, manual therapists, nutritional experts, mindfullness facilitators and others.
  • A holistic approach to pain management must address simultaneously the physical, emotional and mental aspects of pain. 
  • Empowering the patient to self-manage aspects of his or her pain together with health providers, guarantees a much higher level of success. 

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What is Suffering: Part 2

Louisa Mailis, Mindfulness & Meditation Instructor

Louisa Mailis, Mindfulness & Meditation Instructor

My last blog entry talked about how suffering is inevitable and even small grievances can give us a lot of unwanted anxiety. Let’s dig a little deeper into what is actually going on in the brain.

If you find yourself consistently sweating the small stuff, then you should consider the physiological effects stress has on you. I’m sure all of you are somewhat familiar with the sympathetic nervous system, also known as the fight or flight response.  I won’t bore you with too many scientific details, but, in a nutshell, stress activates the sympathetic nervous system (SNS), which then soaks our system with a cascade of stress hormones, including cortisol.  Stress hormones are important for us and can be beneficial in the short run, but chronic exposure to stress hormones is actually detrimental to our health. For example, too much cortisol, even by way of low-level stress responses, can shrink the hippocampus, the part of our brain that is responsible for thinking and remembering. 

When you’re under stress and your SNS is activated, your brain is focused on getting you out of the stressful situation and nothing else. We often times can't think straight when we're stressed out because our brains are much too busy avoiding danger to be stringing together a coherent sentence. That's why it is common to say or do dumb things in a moment of high stress. Hear that? There is actually a scientific reason why you sound like a bumbling idiot when you're arguing with your spouse!

The biological system of fight or flight has significant evolutionary advantages; it kept us alive by allowing us to either fight the sabre-toothed tiger or run for our lives. But ongoing, unmanageable stress is not something we are meant to experience on a consistent level, and suffering from stress has serious consequences. Here are some of the side effects stress can cause (do any sound familiar?).

Physical:

  • Low energy
  • Headaches
  • Digestive problems
  • Muscle pain
  • Insomnia
  • Low immune system

Emotional/Cognitive:

  • Inability to regulate emotions
  • Irritability
  • Self-esteem issues
  • Lack of social skills
  • Constant worrying
  • Forgetfulness
  • Inability to focus
  • Poor judgement
  • Pessimism

It’s easy to see how low-level or high-level stress is in fact physical and emotional suffering when you read through this list. The good news is that there are ways to regulate it and to take back control. 

In the third part of this blog series, I will reveal tools and techniques that can help you conquer stress from the inside out! 

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PWC Success Stories: Motor Vehicle Accident Patient

Dr. Angela Mailis, Founder

Dr. Angela Mailis, Founder

A 38 year old woman who was involved in a serious car accident when her car was broadsided by another vehicle on Highway 400 and subsequently flipped over in a ditch. Neck x-rays in emergency were reported as normal, but her right knee was not x-rayed despite the fact she had severe knee pain. She came to our clinic 10 days after the accident in horrific pain, unable to walk without a cane and needing help to even put her clothes on. Her husband had to take a leave of absence to take care of her. An extensive medical examination as well as an examination by our chiropractor showed multiple tender areas. Additionally, she had severe anxiety and nightmares from the accident. Our psychologist saw her the same day and diagnosed her with severe post-traumatic stress disorder. We submitted her to quick investigations (x-rays, bone scans, etc.) to make sure we were not missing a fracture. At that point we started treating her intensely with a combination of medications for pain and sleep disorder, manual therapy, postural and other exercises, as well as with a psychological intervention for her  post-traumatic stress disorder. 

TAKE HOME MESSAGE: A quick interdisciplinary approach, addressing the proper diagnosis and both physical and psychological components of the patient’s condition, is the best way to prevent pain from becoming chronic and very difficult to treat.

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PWC Success Stories Part 1

Dr. Angela Mailis, Founder

Dr. Angela Mailis, Founder

I wanted to share a few examples of success stories that I've experienced in the short time that our clinic has been open. Here is the first installment. These are the types of things that keep me going and bolster my commitment to bringing comprehensive pain treatment and care to the city of Vaughan and the surrounding neighborhoods.

A 51 year old bank manager with a weak left leg from an old polio infection broke her thigh bone slipping off her staircase at home 1.5 years ago. She had 3 knee surgeries and was left with a hot, swollen and extremely painful (due to nerve damage) knee, which is permanently locked. Within a week we had arranged for an urgent appointment with one of our expert orthopedic surgeons at the Toronto Western Hospital, where she was placed on the urgent list for surgery. At the same time we prescribed appropriate medications for her pain and the nerve damage in her knee, while she sees our psychiatrist for support.

TAKE HOME MESSAGE: Quick referral to an academic hospital, appropriate pain management, and treatment of depression, is the best way to treat such a serious and complex problem.

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