Wordless Wednesday

Wordless Wednesday

It’s often hard to like pictures of ourselves – post your favorite picture of yourself. Today’s post was recommended by Christina of www.stickwithitsugar.com

Left to Right: my husband, Garrin Porter; my "adopted" nephews, Ramsay Sadler  & John Sadler (on Ramsay's lap); my Mom, Norma Nichols; my son, Sebastian Porter; my bestest friend & "adopted" sister, Mary Sadler (standing); my "adopted" niece, Tai Sadler (standing behind wheelchair); me   — Taken March 2011 Conway Manor, Conway, SC

First Steps in 3 years. With my PT, Jim. At Conway Manor

Recapping #HAWMC

 Recapping #HAWMC

I finished! Sorta. Why? Because while there is a post for each day of April, I did not do one every day. I bent the rules a bit to work with my pain and energy levels. I also think I need to read over the last two week's posts to look for errors that spell-check would not have found, because while the words are spelled correctly, they're just not the right words for the spots they're in! I know I have some that I spotted late last night as I was chatting with my Mom about some of the posts. I was in the middle of typing a post, so I did not wanna stop working on one post to fix another one. I made notes on the issues I saw so it won't take much to fix them. They're tiny things. But first, I'll catch up on mail and other things I've let slide!

It is hard to decide which of the posts are my favorite. I had fun doing all of them. If you notice, there are some days I did not do the posted prompt. I didn't do them because I would have hated every bit of writing it. And if I hate the thought of writing something, I just am not likely to write it. I'll put it off and put it off, until I just forget about it or just decide to not do it. The last week or so, I have not felt great so it took me forever to write some of the posts. I certainly did not write one a day! And while one of them was not completely posted until today, I had it written in April. All of my posts were written in April. I just got behind on typing them up because of my occasional habit of composing on paper in long hand. Then typing it up. Some posts I compose at my desk on the computer. But others, I just need to be comfy and so I write while I am in bed. Until last week, I wasn't able to use my computer from bed. But my son and I figured out how to do that so now it's not so hard. I had just gotten behind and catching up took awhile.

The six-sentence story was tough. I had my husband read my first draft and he said I needed to cut a lot of fluff out. So I did. It likely still has run on sentences and other grammatical issues. But it did the job. Sometimes, to stay within one set of rules, you have to break or bend other rules.

The five challenges/victories post got me to thinking. What are the victories I am most proud of that they more than outweigh the challenges? I think I got victories that did that.

The taglines post was fun. I could never just write a line such as that. I have to find a graphic to put with it! It's the same with the health mascots post. I had fun with that, but also used it to provide some basic treatment information. Learned the Hard Way was a  fun post. It let me get out some of my story. I had a good time creating the Pinboards. Ten Things I Could Not Live Without had me counting blessings. On one of the activist choice days, I chose to make a Mind Map. That was pretty interesting to do. It opened me up to a new way of getting things organized for a writing project, as I am more used to outlining, although I do it very loosely. For the ekphrasis post, I decided to create some images that were the "monsters" that I fight against health-wise. I was not so comfortable with the concept of ekphrasis so I felt more comfortable making an image fit a disease. Almost a reverse ekphrasis in a way! But, creating the monsters, gave the mascots something to battle I guess. Hmmm maybe I need to add small pictures of the monsters to the mascots posts as a representation of who the mascot fights against. Or I can just add a line to each mascot's description and link it to the appropriate monster? Maybe split the monster post into three separate ones so that each mascot links to the post for that monster? I will need to think about it!! The quotes I found interesting was an interesting post. I had to really think about the hundreds of quotes I have copied down and pick the ones that speak to me most of all. It was not easy by far. I did have fun making graphics for the later post on Things We Forget. The stickies were fun to make.I've used the site that I made the stickies on for other things as well. 

Those are the posts that really stand out in my mind. I enjoyed this challenge. I may not have followed it to the letter in writing a post a day, but I did write a post for EVERY day in April. Some days I wrote and posted 3 or 4 posts, others I didn't get any done. I am a realist enough to know that I cannot guarantee I will do anything EVERY day. My pain, fatigue and other health issues will stop that real fast. But, I know that about myself so I try not to stress over it.

#HAWMC Post # 30

 Word Cloud

Today's prompt from WEGO was to "make a word cloud or tree with a list of words that come to mind when you think about your blog, health, or interests." So I picked 3 different things to make word clouds of. I used 2 items I wrote and then my blog as a whole. In the first cloud, it is from a piece titled What RA is Like: A Letter for Family and Friends. I wrote that because over the years I have heard so many people have various complaints about how people close to them in one way or another, whether it be family, friends, co-workers, or employers, just do not get certain aspects of their RA. So I took some of the issues that people mentioned frequently and began to think of something that could be said to those people who were making those statements. I was blunt, One or two people even accused me of being dark. A few said I was too "in your face" to the offenders. I may have been. But, I was writing from the viewpoint of the person with RA, who, having heard many of the comments I addressed one too many times, was very much wanting to be heard. And unfortunately, with some people, it takes a 2x4 to the side of the head to get them to truly hear the person with RA and not only listen but to realize the emotion behind the statements. They're borne not of trying to be confrontational, but of trying to be heard and being ignored time after time. 

The piece on pain, Chronic Pain:Addiction, Dependence, and Tolerance,  came about because I found myself repeating things like "Just because I take pain medications, it doesn't mean I'm addicted." and also to address concerns I'd heard many times in the e-mail based support group on which I was a moderator. Theses concerns are valid, people do worry about getting addicted to pain meds because we have heard so much in the news about the evils of pain meds. Others worry because they've seen first hand what addiction does to the addict, and those around them. So I researched the issues, and what I found ended up in the long piece I wrote. I hope it has helped those facing the need for pain medication by putting some of their worries to rest.

Then the last word cloud comes from me using the link to my blog to make the cloud. It analyzed all of the words on here.

This is a Wordle Word Cloud of What RA is Like: A Letter for Family and Friends

This is a Wordle Word Cloud of Chronic Pain: Addiction, Dependence and Tolerance

This is a Wordle Word Cloud of this blog!

#HAWMC Post #29

Getting Diagnosed With Fibromyalgia
A Six-Sentence Story

I'd been having and increase in pain that had lasted longer than a typical flare lasted, so I called to make an appointment with a rheumatologist because I figured my juvenile rheumatoid arthritis (JRA) was out of remission. After I arrived and seated myself in the waiting room, a nurse finally called me into the back; she then checked me in, took my blood pressure and temperature, weighed me, asked me about my sleep, appetite, fatigue and pain levels and then took me to an exam room where I waited on the rheumatologist to come into the room. The rheumatologist finally came in, asked a few questions, did a short exam which ended with him pressing very hard on certain areas to see if they hurt, then he stepped out. He returned with a short (a single 8.5"x11" tri-fold*) brochure about fibromyalgia, telling me he believed that was what was wrong with me rather than my JRA returning; he then handed me orders for lab work and left. As I was waiting to get lab-work, I was so frustrated and in so much pain that I ended up in tears, but tried to hide the because I was in a semi-public place and yet I didn't hide them well enough because the office manager saw me and asked why I was crying. The office manager's reaction after I explain what had happened, was to grab a tissue for me, take me back to the exam room, and returned with the doctor, who quickly wrote out a prescription for Celebrex which sadly only made me sick to my stomach. 

The 18 Fibromyalgia Tender Points

*This is not to say that the brochure isn't helpful, but to a newly diagnosed person, you hope for a bit more from your doctor than a single sheet of paper. Obviously this was NOT the doctor for me. I NEVER saw him again thankfully and now 

#HAWMC Post #28

The First Time I....Walked in Over Two Years

March 29, 2011Standing for the
first time with the help of Jim, my PT

I fell in Dec. 2008 and could neither stand nor walk afterward. MRIs, X-rays, Doppler imaging, and nerve conduction studies,  all showed nothing that would mean I couldn't walk. That led doctors to make the only reasonable conclusion, it was thought to be a soft tissue injury. As such, it may or may not heal and if it did, might be slow healing.

I spent months at Grand Strand Regional Medical Center with other problems, chronic infections of varying natures, and was pretty much unable to move on my own. I think part of my lack of movement was the fact that I was off of ALL of my RA medications because of the infections I kept getting. They'd get rid of one infection only to have a different crop up. Another affect of being off of my medications was that just being touched caused me immense pain. Thankfully, I do not remember much of that time.

I remember parts of that time. One time I remember is being told that I'd likely never walk again. Another was that I'd likely not live outside of a hospital or nursing home. One doctor even went so far as to very rudely state that I was "nothing but a terminal patient." Needless to say, that doctor was never allowed back into my room. The hospital PT gave me a bit different of a prognosis. His assessment was that it would take 2-3 years of daily, intensive physical therapy to stand let alone walk, IF it were possible.

On Nov. 22, 2009 I was transferred to Conway Manor nursing home. In the first few days I was there, the head of PT came to do an evaluation but we never started PT. At the time, I was too ill to care. The first week there I had such a horrible problem with nausea, vomiting and not having an appetite. I know part of it was a bit of depression and worry over the move. That was to be expected. I moved from the known to the unknown, not knowing anyone there made it hard to be comfortable. I had gotten to know the hospital staff and felt comfortable with them. I knew how each person worked and what to expect. So not knowing. especially being pretty much 100% dependent on people, was hard. It also did not help that because she did not know my reaction to milk, a nurse mixed my crushed medications in with some milk and put it in my stomach tube. That was not a good thing. I couldn't tell her to stop because literally the moment the milk hit my stomach, it came up. It's hard to talk while throwing up. It also came back out the tube which means I think I got her twice.

At my first care plan review, I finally questioned why PT had never been started. Of course that needed looked into. I was later told that I said I did NOT want PT. I do not ever recall saying I didn't want PT. If someone came in during the days I was sick, I wouldn't have said I didn't want it, I'd have said I was sick and didn't think I could do it while sick, but I'd not have refused it completely. So I started PT. I'd not had any exercise in at least two years because before getting sick I wasn't doing all that well and had been pretty sedentary since I'd had a high level of disease activity. My first day in PT, I was put in a group of residents who were doing various chair exercises. No one cautioned me to hold back and not try to keep up with the others in the group and I was not at 100% yet in thinking from the months I was out of it, so I didn't really stop to think how I'd be affected by doing 30-40 repetitions of 6-8 exercises. I kept up with the others, I was kinda proud of that. That bit of pride only lasted until a little while later. I paid for that bit of pride in that I ended up in bed for approximately 3 weeks, barely able to move on my own. I was miserable.

I asked about restorative therapy. They did things with residents who didn't quite need a therapist's help but still needed assistance. For some residents, in order to get better at walking, they needed someone to walk with them and hold onto a gait belt the person wore to keep them safe. For some who were bed-bound, restorative kept their arms and legs exercised by doing gentle stretching and range of motion (ROM) exercises. That was exactly what I needed until I was a bit stronger and able to be more active. I was supposed to get restorative therapy five days a week. But it was written down wrong in the orders and only written for three days, but knowing I'd asked for five, the restorative therapy staff tried to be there all five days. The only issue was on days they pulled restorative to the floor to work as a CNA. They were trained as CNAs and so when an area was short a CNA, they had restorative to be able to help. It's not the fault of the staff member doing my restorative exercises but in the approximately 6 mo. they worked with me, the only changes made were to add to the number of repetitions I did, once we got me to the point I was able to do all of the exercises we discussed in the beginning. No one ever re-evaluated me to see if we needed to add anything else. During the times restorative worked on the floor, our CNAs were supposed to do the restorative exercises with residents. It's not easy for CNAs to do exercises with a resident if they don't know what they're doing. That opens the door up for me being hurt and I didn't like risking that. So I began refusing restorative on days that I wasn't comfortable doing the exercises with the CNA I had.

In mid-Dec. 2010, while trying to play a trick on my husband, my son taught me how to get myself in and out of bed without assistance from anyone. We were getting ready to go out and my husband stepped outside to clean out my seat in the car. As he was doing that, my CNA came in to help me finish getting ready. She also got me into my wheelchair so that I was ready as soon as my husband came back inside. After she left, my son came up with the idea of telling my husband that he and I got me in my wheelchair, by ourselves.  I said he could, but that he'd have to tell Dad the truth eventually. My husband came in and as I knew he would, asked how I got in my chair. I just gave my son a pointed look. He change the subject very fast. A bit later, he said he was ready to show Dad how we got me up. I was waiting to see how much I'd end up hurting because of this. So he told me to lift my legs out in front of my like I did before. I did but didn't raise them up high enough. He said to raise them higher than the bed. Ok.... So I did. And he moved my wheelchair next to the side of the bed so that my legs were laying across the bed from right side to left. He set my brakes and told me to scoot over onto the bed. I gave my husband a look that said "Hey this might work." And he kinda gave me a look that said he agreed. So I scooted forward out of my chair and onto the bed. I had no trouble scooting. I think we were all a bit surprised. So I scooted back into my chair. I had a bit of trouble because the pocket on my jeans caught on the underside of the seat on my wheelchair, but was able to get over that. I just needed to have someone hold the chair so that I did not tip it over. I was so excited. I cannot tell how many people I drug into my room over the next few days to show them what I could do. The ones I didn't drag in, got told. One person I told came in to watch me. Then  Donna, who was also my OT, got me a transfer board and anti-tip bars for my wheelchair. She also wanted someone to be with me when I transferred, which I was ok with given she was just watching out for my safety. It got to where I didn't enjoy waiting on people just so I could slide two feet. But I also understood that it was a safety issue.

In early Jan. 2011, an issue happened that caused me to lose my temper and let out everything that had been bothering me. One of the things that came out was the fact that my restorative had become a joke since no one ever worked in restorative it seemed and none of my aides offered to do my restorative. I was doing the exercises on my own some of the time, just to keep up the habit. I was a bit unhappy over the fact that PT did nothing for me other than mess things up. The unit manager changed my restorative to 5 days when she found out I hadn't been getting it the first time. They had also made all of the CNAs watch my restorative so they knew what to do. But, it wasn't being done. And I was at a point that I really thought I needed to move beyond just ROM and stretching. The next day, social services let me know that someone was going to come by and see me to do a PT evaluation. I was thrilled. A bit later, one of the therapists, stopped to see me in the activity room. He asked if he could come by later that afternoon. I said that was fine because "...my son and husband wouldn't be there until around 6:30 or so for my bir....nothing". I caught myself because I didn't want people to know it was my birthday! I am not big on celebrations. So he stopped in, had me show him the things I could do, give him a history of what brought me to the point we were at, my goals etc. He had me transfer from chair to bed and back. He said I did well with that. Then he dropped a bomb on me....a good one though. He ended up giving me a wonderful birthday present. He said he saw no reason for me to need someone with me when I transferred! I was thrilled beyond belief. We also decided that I would go to the therapy dept. the next day to begin my PT. We'd start out low intensity and very slow, that way I did not have any trouble with flaring because of the sudden working of body parts that hadn't worked much at all in recent time. We decided we'd work three days a week and about an hour at a time.

My left hand prior to OT

Left hand with E-Stim
electrodes

The next day, I went to the PT dept and we started with stretching of my feet, some very light weights on the pulleys. As we worked, I'd get used to what we were doing. Then Jim would add a new exercise, increase the number of reps I did, up the weight I was lifting, etc. He did this progressively. He assigned me work to do on my own. On March 29, 2011 he felt I was ready to stand. So I did. I only stood a few minutes that first time, then rested about 20 min, then stood again. We kept that up for not quite another month after also increasing my number of days in PT to 4 days a week. We usually worked for about an hour at a time. I also began working with Donna on my left hand at this time. We did exercises using a wood cylinder with the loop part of Velcro wrapped around it and I used my left hand to roll it from the top to the bottom of a board that had the hook part of Velcro on it. It was helpful, as was having the E-Stim machine hooked up to my forearm to stimulate the nerves, tendons and muscles in my hand and arms to work properly. It was not painful. Apparently, I had enough damage in my hand that the machine needed to be turned up to levels needed for stroke patients to benefit from. In the few months we worked on my hand, the two fingers that were contracted, loosened up quite a bit.I have a bit better movement in those fingers. Yes, they are still contracted, but there is a lot more movement than there had been. I am thankful for that as I had so little to begin with.                                                                                                                                                                                                                                                                                                                                        

Left and with E-Stim electrodes
and hand exerciser

On Apr. 18, 2011 my son was on spring break at school. He got dropped off to spend the afternoon with me about 11am. I'd been in the activity room for the Monday church service with Rev. Scott Johnson from Union Methodist Church. The church came in on the third Monday of the month. Right before the end of the service, my son got there. He sat at the back of the room with me and I was surprised he knew the song that Scott ended the service with, "Victory in Jesus". After the end of the service, I was able to introduce him to some of the people at the nursing home.

April 2011Towel Wedge to
counter joint contractures

We then went and had some lunch. Hung out in my room for a little while before it was time for me to go to PT. That was something my son really seemed very excited about. So we went down to the PT dept. and I went ahead and got started on doing my pulley exercises. My son said, "I bet you can't lift 5 pounds on there."  Well how could I not take his challenge? I got the weight on the pulley and began to do my exercises. I did them, not easily but I did them. By that time, Jim was ready to begin working with me. So he came over carrying the towels he had made into wedges to compensate for the contractures in my ankles when I first started to stand.These were quite frankly and ingenious idea. Almost everyone on the therapy staff was amazed at Jim's idea. I was thrilled we had a way of getting me moving before I was able to see the orthotist. I think it's better this way, because we KNEW I could walk before getting my braces. 

April 2011 Getting ready
to walk

As Jim got the towels strapped to my feet, he was chatting with my son. Jim asked if he wanted to help us and he was all for it. So Jim told him that he would need to push my wheelchair as close to me as he could without hitting me or bumping me. That way he'd be able to be right in place if I HAD to sit down quickly. But if he bumped me, it could make me stumble. I'd not fall because I was wearing a gait belt and Jim had me. I knew beyond a shadow of a doubt that I'd never fall of Jim could stop it. I ended up walking approximately 14 ft that first time. We were in the parallel bars with Jim walking backwards in front of me, holding onto the gait belt and my son behind me with my wheelchair. I was so thrilled that I made it. But I definitely had to sit down after even that bit of a distance. Those were the first steps I'd walked since Dec. 2008, so they were big steps. We didn't want me to over do it, but I was so excited. Actually, I think everyone in the room was excited for me. Residents, PTs, OTs, the OTAs, PTAs, my son...everyone pretty much beamed, clapped, cheered or just made positive comments. I began walking with a platform walker, then switched to a regular walker.

Platform Walker

As time went by, I became better at walking and we eventually walked in the halls rather than just in the therapy department. As we walked, we'd get stopped by residents so that they could tell me I was doing a great job and then tell Jim how well he did at helping me. Even residents who could not speak for whatever reason, would stop us and grin or give a thumbs up to Jim. It was touching to know I had that many cheerleaders really. That was just residents at the nursing home. That was not the staff. The staff was also extremely excited for me when I began walking again. It brings home the fact that the staff at Conway Manor treats the residents like members of their family. They are so caring about the residents who come in. They make an effort to get to know you. Even to the point of getting to know your family. I know that has to help anyone who comes in and doesn't have the family support that I had. I figure if they treated me like family even with my family being there for me, how much more are the a replacement family for those who have been dropped off and left like you would take an unwanted animal to the pound? I know even the hardest of people to get along with had people that they would respond to. And those people worked hard to get a response, but when they did, it was usually the start of a special relationship. 

May 2011 Bilateral ankle-foot orthoses
before removing plastic calf support and
adding T-straps at ankles

I progressed throughout the summer, especially after I got my bilateral ankle-foot orthoses (AFOs) with T-straps, and heel lifts to compensate for my ankle contractures. Dr. Alexander Lyons, of Lyons Prosthetics and Orthotics and his staff were awesome! Dr Lyons was the first doctor who, during an outpatient office visit, offered to pray with me before we began the appointment. I was amazed. I'd had surgeons pray before surgery. One of the doctors at the hospital prayed with and for me often. I know one day, I woke up to him praying for me. Having a doctor pray prior to doing anything invasive doesn't seem too out of the ordinary to me. But, a doctor praying at the start of an office visit is a pleasant surprise. I've been blessed not only with great doctors but also doctors who seem to have faith and not be afraid to show it. The right shoe's insole insert was slightly padded on the underside to prevent the tips of the toes on my foot from rubbing on the inner sole of the show. The padding was added in Sept. after I had a problem with the big toe on my right foot. Due to joint contractures, all of the toes on my right foot have something wrong with them. A couple are bent in a way that when I put my foot on the floor (as best as I can), I basically stand with all of my weight on the tips of my toes. I didn't feel the sore forming because of the decreased sensation in my feet because of the peripheral neuropathy. I generally did look at my feet from time to time, but because I can't bend well enough to see the tips of my toes on my right foot, I never thought  to have someone else take a look to make sure there were no problems. By the time I felt the pain from the sore, it was a bit deep and had what everyone who saw it described as a "hole" in my toe. Yay! I was off my feet for much of Sept. Once Dr Lyons fixed the insole of my shoe so that the toe no longer rubbed, it only took a couple of weeks for me to be able to tolerate wearing the AFOs. But, even as late as Jan. 2012, it was still not fully healed. There was a piece of dry skin that came off of the tip of my toe that had a hole about 1/8" in diameter in it. I cannot imagine how big it was BEFORE it had healed up. I don't even want to know how deep it was. I almost think that the tip of that toe is a bit more sensitive now, it's either that or I am just paying more attention to how the toes feel. I now have my hubby at least peek at the tips of my toes once in awhile. Or when I shower I sit on my shower chair with my legs outside the tub and straight out in front of me so I can see them in the mirror on the back of the bathroom door. Even so, that's not the best way because I can't see it close up.

Sept. 2011 Right big toe
the reddest area on the tip is
where the hole ended up.

Loftstrand AKA forearm
or Canadian crutches

Around mid-summer, Jim had predicted  that I'd be home by Halloween. Unfortunately. the toe problem happened and I was off my feet much of Sept. because of the sheer pain in my toe from standing on it. I likely would have made his prediction had I not had that happen. In late Sept. or early Oct. I was able to make the switch to using Loftstrand (AKA forearm or Canadian) crutches. They provided me a lot more mobility. In grass, they are a lot less cumbersome than a walker. They can get you into tighter spaces than a walker can. Ever try fitting a walker into a non-handicapped bathroom stall? Not so easy! It's possible with crutches though. The only draw back is that they are not as stable as a walker in some ways. I mean with a walker, I had 6 contact points with the ground. With my crutches I have 4, my feet and 2 others slightly larger than a half dollar coin, about the size of regular crutch tips. It was my goal to be able to use the crutches before going home.  As it were, I made it home before the holidays, which happened to be my goal. So as long as I was able to be home by the holidays, I didn't care when I got there. I just wanted to be home by Thanksgiving and I made it a few days before. I've been doing fairly well at home. Nothing much that I hadn't been prepared for. The only thing I didn't really get any practice with was carrying things while managing my crutches. I cannot do that too well. Now, if it is my cell phone or a bottle of Coca-Cola, then I can carry those. But a plate? Not a chance, unless I WANT to spill whatever is on it. I needed to carry a laundry basket from my room to the washer and back from the dryer. It took me a bit to think of a solution but I came upon it one day while starring at the basket and trying to figure out how to carry it to the washer. I saw the gait belt out of the corner of my eye. That caused an idea to somehow pop into my head. I ran the belt through the openings on the basket and then fastened the belt around my waist. It's a bit awkward at times (it feels as if it is slipping past my waist), but it gets the job done. 

I am so very thankful to be home. I owe a lot of gratitude to all of the various people cared for me during the time I was sick and re-learning all the everyday things most people take for granted. I mean, come on, how many people does it take to blow my nose? There for awhile...it took at least 3, one to hold me in an upright position, one to hold the tissue to my nose and then me to actually blow. Same with a number of activities that people do on a daily basis for themselves. I was unable to do many things for myself and so have a bunch of people who helped me through that rough period. I also have a number of people to thank for just believing in me enough to make sure I got my PT and got the help I needed to get me on my feet and able to take those first steps in over two years. Having the wonderful support that I did, how could I do anything but succeed? I went from being in the hospital and not being alert or oriented, unable to remember things, unable to sit up for more than 2 minutes, unable to do anything for myself, etc....

At Grand Strand Regional
Medical Center Spring 2009

to me being out of the hospital and nursing home, able to walk, dress myself, care for myself, feed myself, etc.

At home Spring 2012

I am so very grateful for everyone who had a hand in my care. I was blessed to have relatively few problems with staff members who were not quite tolerable. I might have been a nightmare patient to some people because I expected people to do their jobs and to do them properly. I did not take well to people treating me as if there was something wrong with me mentally and was why I was in the nursing home. Neither did I let staff members slack off when it came to their care of my roommates, especially those who could not speak up for themselves. I did not hesitate to go to the unit manager or Social Services if there was a problem I couldn't fix on my own. I honestly tried to keep problems between myself and the person I was having the problem with, but when repeated attempts and requests did not get my point across, then it was time to seek more help. I had two CNAs that I had serious issues with. With each of them, the issue was the pain they caused me. In the hospital, I was a lot more sensitive to pain because I was not on my RA meds and even with morphine, my pain levels were horrendously high. At the nursing home, I was back on my RA meds as well as back on methadone for pain. I have found it to be the best pain medication for me and so I was not as sensitive to pain. In the hospital, even the gentlest of touches brought on tears. At the nursing home, it took more than that to make me hurt just by touching me. But there was one aide that I argued with for MONTHS over me asking her, then telling her to please be more gentle, that she was rough with me, that she was hurting me, etc. etc. And she had the nerve to tell me that there was NO WAY she could be hurting me. I apparently was too stupid to know what was painful simply because I was in a nursing home, I guess. In the hospital, my Mom took care of the issue by speaking to the charge nurse that she did not want that aide caring for me any longer. They honored that request, until fall when all the aides went back to school. But they at least asked me if I would let her care for me and then decide from there. I was fine with that, and she did fine. She didn't hurt me, except when something was painful no matter who did it or how they did it, such as washing my feet. That was completely unavoidable and in fact, still hurts quite a bit. At the nursing home, the aide that was the problem kept telling me there was no way she was hurting me, that no one else complained about her being rough with them (I never said this but I wondered to myself if they didn't speak up because they were afraid of her?) and that she...blah blah blah...I tuned her out. Other than those incidents, the staff at both the hospital and the nursing home were wonderful.  I am so grateful for the friends I made at both places. I keep in touch with some of them on Facebook. I also see the nursing home staff when I go back out a couple Fridays a month for Bible study and visitation. It's as if I am a long lost family member coming home when I go to the nursing home. The residents also make me feel missed and loved. Even a few staff members who are no longer at the Manor are friends of mine. I am so thankful that I had Jim to work with. Had he not been the inventive person he is, my therapy would have been delayed until July basically. We got the jump on me walking because he thought of the towels, otherwise I would have had to wait on my braces. Jim is the supportive type. He knew when to push me and when I needed held back. He often stopped me from doing more than I needed to be doing and causing myself a flare. He could take a look at me and know if I just did not feel well, or when it was time for me to either stop what we were doing or at least slow down or switch activities.Jim was so very modest. Anytime I tried to express my thank for all that he had done, he kinda brushed it off as just doing his job or made a bit of a joke about it. One day, as we were walking, we stopped to speak to a relatively new employee. Talk turned to me walking and she commented on how well I was doing. I spoke up and commented on how we started with the towels, which is is something I tend to tell people about because I think it was such an awesome idea. His reply on the subject? "Oh I stayed at a Holiday Inn last night!"

I am so glad things turned out the way they did. I am convinced things happen for a reason and now it's just about a matter of using the lessons I learned throughout this time.

#HAWMC Post #27

5 Challenges. 5 Small Victories. 

Today's prompt was to make a list of the 5 most difficult parts of our healthcare focus. Then we were to make another top 5 list for the little, good things (small victories) that kept us going.  So here are my top 5 lists. 

5 Challenges

1. Walking is painful.
2. I cannot drive (yet)!
3. I need quite a bit of help at times, especially during flares, to do simple things like laundry or other housework. 
4. It takes a lot of planning for me to go anywhere. I have to make sure I take medications, briefs, an extra set of clothes and my wheelchair. 
5. The exhaustion is terrible in spite of being on Provigil, which does help a great deal. I cannot imagine how bad the exhaustion would be without the Provigil. 

 5 Small Victories

1. I can walk, despite being told by doctors that it was highly unlikely I'd ever walk again. So what if I still use a wheelchair at times when there would be too much walking for me? So what if to walk I have to use forearm crutches or a walker? Who cares? As long as I am doing something I was told I wouldn't be able to do, I don't care how I do it! I limp and lurch along which causes people to stare at times. Oh well. I don't care what strangers think. All I care about is my family, especially my son. He has no problem with me using ANY item I need to use if it means I get to go to his school programs or that we get to go out and do things together as a family. If he doesn't care, why should I care what anyone else thinks?
2. I can live at home and not need someone with me 24/7. Another thing that I was told by the doctors was unlikely to ever happen. It was either the hospital or a nursing home for me in their eyes. 
3. I can safely shower ALONE. Pretty good for someone who, since 2010, had to have help in the shower until recently.
4. I can do dishes at times. I can also cook, help with laundry,  and mop the floors when I am not in the middle of a flare as I am now. So what if I need a bar stool to cook  and do dishes, it means I get to do something I love doing like cooking and makes something I really dislike doing, such as dishes, easier on my body. Who cares if I look silly with a laundry basket strapped around my waist? I can carry the laundry to the washer and bring it back when its done drying. Who cares if I mop sitting in my wheelchair so that I don't chance slipping and falling on the wet floor?
5. I recently took 2 steps. Not a big deal to most people, except these were steps I took without my crutches, walker, cane, or holding on to ANYTHING. These were 2 totally unsupported steps. Of course I had my braces on since I can't stand without those. 

I guess some of these victories are not all that small. But, I have learned to celebrate even the really small things. Such as being able to open a candy bar wrapper. The first time I opened a candy bar wrapper on my own after being sick and having the hand/wrist/arm contractions ease up, I took a picture of it and sent it to my hubby and Mom. At that time, even something that insignificant was HUGE for me. 

In PT at the nursing home, I learned to celebrate even the smallest of improvements since they often took a lot of hard work. And I was taught that the big improvements are made up of a series of smaller ones. So each step forward towards a final goal should be celebrated.

When a resident did something major for the first time in the therapy dept., it was usually acknowledged by the other residents and the staff.  I cannot tell how many times, while my therapist and I were walking through the halls, that we were stopped so that another resident or a staff member could congratulate me on how well I was doing, or by clapping, grinning, and giving encouragement. Even residents who couldn't speak would cheer me on in their own way! There were many days I might have been tempted to throw in the towel had it not been for all of the encouragement I got. It wasn't just what I got at the nursing home, it was my family, my friends, people online that I don't even know but who are friends of people I know...all of it together kept me determined to live up to that encouragement.

I kinda joke that I had three awesome men behind me(see last picture #HAWMC post #25), supporting me throughout my whole stint in therapy. My hubby and my son of course were behind me, cheering me on. But in a more literal sense, I had my therapist, Jim, behind me as well. Not only was he a major source of support and a huge cheerleader, he was, in a very literal sense, behind me all the way. Just the nature of teaching me to walking again means he walked behind me holding on to the gait belt to support me and keep me from falling. In all the months of working with him and hearing other residents speak of him, I only heard ONE negative comment about Jim. Given that the comment was from someone who has dementia, and given what I know of Jim, I had to discredit that negative comment. It simply cannot be true. The comment was that Jim came in very early on a Sunday morning wanting the resident to jog around the building outside in the cold. First, PT generally did not work on Sundays, an occasional Saturday, yes, but I don't recall EVER seeing any of the PT staff on a Sunday. Second, Jim generally worked as late as 6pm, which meant since the staff usually had 8 hr shifts, he came in at 10am. Even with me being a major night owl, I don't consider 10am to be "very early". Third, I certainly do not think Jim would ever ask a resident who has congestive heart failure to jog around the building, outside and in the cold. That just sounds so far from something the Jim I know would do that I have to believe it was the dementia talking. Aside from that one person, every single resident that Jim worked with who made a comment to me about him had only favorable things to say. I should say highly favorable to be honest. Even other staff members only had good things to say about Jim. The only things I ever heard that were remotely close to being negative about Jim were things like "Man he really worked us out hard tonight." or similar comments. Those were from the other therapists who had decided they needed to get healthy and begin exercising. So they all exercised together after work. And it seems as if Jim took the lead in making the plan of what exercises they'd do. So I hardly count those comments as negative. Even residents who didn't work with Jim but saw him in the therapy room while they were in there, or while he was working with their roommate, or walking with a resident in the halls, complimented him. It is no wonder that when the Resident Council began voting on an Employee of the Month, he was nominated in the first month and voted as the first Resident Council Employee of the Month.

#HAWMC Post # 26

Health Tagline

 

Today's prompt was to give ourselves, our blog, our condition, or an aspect of our health a catchy tagline. So here are my arthritis, chronic pain and fibromyalgia taglines. 

#HAWMC Post #24

Health Mascot

The prompt for today was to give my health focus a mascot. I decided to make them a fictional team of superheros. Face it, dealing with these conditions takes a superhero. I am a firm believer that anyone who manages their condition(s) has to be amazing. Living with any chronic illness is tough on the person who has the illness as well as all of their loved ones. It takes a certain strength to live day in and day out with all of what goes with these health conditions. Until one has lived with a chronic illness, they cannot imagine what its like. Even the most understanding, willing to help of loved ones can only guess what it is like for the person with the chronic illness. They get a very good picture and can most likely make a guess that is quite close to the truth, but they can't know how it feels unless they too have a chronic illness. As much as my family is awesome at understanding, accepting and helping me, they can't know what it feels like inside, especially if I cannot describe it. So using Superheroes as mascots is not a stretch!  So, here are the superheroes I've found to represent the health conditions I focus on. One note: the "special weapons" sections of information are NOT my own writing! I have used  medication information from articles copied from the sources I linked to under each section. I normally do not do that. but it is information about medications so it's not as if I could really supply it in my own words, as I am not a pharmacist, doctor, etc. It is used for educational purposes only.

Title: Arthritis Assassin
Team: Squadron of Salubrity
Report to: Head Honcho of Health
Duties: Assist Head Honcho of Health in fighting the effects of arthritis in ALL of its forms.
Specialized Weapons: Biological Response Modifiers (BRMs), Disease Modifying Anti-Rheumatic Drugs (DMARDs), Glucocorticoids (Cortisone-Related Drugs), Gout Medications, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Osteoporosis Medications

Biological Response Modifiers

Substances that modify the body's response to infection and disease. The body naturally produces small amounts of these substances. Scientists can produce some of them in the laboratory in large amounts for use in treating cancer, rheumatoid arthritis, and other diseases.

BRMs used in biological therapy include monoclonal antibodies, interferon, interleukin-2 (IL-2), and several types of colony- stimulating factors (CSF, GM-CSF, G-CSF). Interleukin-2 and interferon are BRMs being tested for the treatment of advanced malignant melanoma. Interferon is a BRM now in use to treat hepatitis C.

The side effects of BRM therapy often include flu-like symptoms such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Some patients develop a rash, and some bleed or bruise easily. Interleukin therapy can cause swelling. Depending on the severity of these problems, patients may need to stay in the hospital during treatment. These side effects are usually short-term and go gradually away after treatment stops.

Brand Name	Generic Name
Actemra IV	tocilizumab injection
Cimzia SubQ	certolizumab pegol
Enbrel	etanercept
Humira	adalimumab
Kineret	anakinra
Orencia	abatacept
Remicade	infliximab
Rituxan IV	rituximab
Simponi SubQ	golimumab

Disease Modifying Anti-Rheumatic Drugs (DMARDs)

While "first-line" medications (NSAIDs and corticosteroids) can relieve joint inflammation and pain, they do not necessarily prevent joint destruction or deformity. For patients with an aggressively destructive form of rheumatoid arthritis, medications other than NSAIDs and corticosteroids are needed. These "second-line" or "slow-acting" medicines (listed below) may take weeks to months to become effective. They are used for long periods of time, even years, at varying doses. If effective, they can promote remission, thereby retarding the progression of joint destruction and deformity. Sometimes a number of second-line medications are used together as combination therapy.

Hydroxychloroquine (PLAQUENIL) is related to quinine, and is used in the treatment of malaria. It is used over long periods for the treatment of rheumatoid arthritis. Side effects include upset stomach, skin rashes, muscle weakness, and vision changes. Even though vision changes are rare, patients taking PLAQUENIL should be monitored by an eye doctor (ophthalmologist).

Sulfasalazine (AZULFADINE) is an oral medication traditionally used in the treatment of mild to moderately severe inflammatory bowel diseases, such as ulcerative colitis and Crohn's colitis. AZULFADINE is used to treat rheumatoid arthritis in combination with antiinflammatory medications. AZULFADINE is generally well tolerated. Common side effects include rash and upset stomach. Because AZULFADINE is made up of sulfa and salicylate compounds, it should be avoided by patients with known sulfa allergies.

Gold salts have been used to treat rheumatoid arthritis throughout most of this century. Gold thioglucose (SOLGANAL) and gold thiomalate (MYOCHRYSINE) are given by injection, initially on a weekly basis for months to years. Oral gold, auranofin (RIDAURA) was introduced in the 1980's. Side effects of gold (oral and injectable) include skin rash, mouth sores, kidney damage with leakage of protein in the urine, and bone marrow damage with anemia and low white cell count. Patients receiving gold treatment are regularly monitored with blood and urine tests. Oral gold can cause diarrhea.

Brand Name	Generic Name
Arava	leflunomide
Azulfidine	sulfasalazine
Cuprimine, Depen	penicillamine
Enbrel also considered a BRM	etanercept
Humira also considered a BRM	adalimumab
Imuran	azathioprine
Plaquenil	hydroxychloroquine
Remicade also considered a BRM	infliximab
Rheumatrex	methotrexate
Ridaura	auranofin
Solganal	aurothiglucose

Glucocorticoids

Glucocorticoids are medications that include cortisone and related drugs. A glucocorticoid is hormone that predominantly affects the metabolism of carbohydrates and, to a lesser extent, fats and proteins (and has other effects). Glucocorticoids are made in the outside portion (the cortex) of the adrenal gland and chemically classed as steroids. Cortisol is the major natural glucocorticoid. The term glucocorticoid also applies to equivalent hormones synthesized in the laboratory. Glucocorticoid drugs are also called corticosteroids.

Corticosteroids have potent anti-inflammatory properties, and are used in a wide variety of inflammatory conditions such as arthritis, colitis, asthma, bronchitis, certain skin rashes, and allergic or inflammatory conditions of the nose and eyes. There are numerous preparations of corticosteroids including oral tablets, capsules, liquids, topical creams and gels, inhalers and eye drops, and injectable and intravenous solutions.

Dosage requirements of corticosteroids vary among individuals and the diseases being treated. In general, the lowest possible effective dose is used. Corticosteroids given in multiple doses throughout the day are more effective, but also more toxic, than if the same total dose is given once daily, or every other day.

Brand Name	Generic Name
Cortisone Injection	Corticosteroid Injection of Soft Tissues & Joints
Decadron	dexamethasone, oral
Deltasone, Liquid Pred	prednisone, oral
Prednisolone, Pediapred Oral Liquid, Medrol	prednisolone
Hydrocortone, Cortef	hydrocortisone, oral
Medrol	methylprednisolone

Gout Medications

There are three aspects to the medication treatment of gout. First, pain relievers such as TYLENOL or other more potent analgesics are used to manage pain. Secondly, anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs (NSAIDS), colchicine, and corticosteroids are used to decrease joint inflammation. Finally, medications are considered for managing the underlying metabolic derangement that causes high blood levels of uric acid (hyperuricemia) and leads to gout attacks and kidney stones.

Brand Name	Generic Name
see below	NSAIDS
Anturane	sulfinpyrazone
Benemid	probenecid
Colchicine	colchicine
Zyloprim	allopurinol

    

Non-Steroidal Anti-Inflammatories (NSAIDs)

Nonsteroidal anti-inflammatory drugs. These are medications that reduce inflammation and do not contain cortisone-related compounds.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed medications for the inflammation of arthritis and other body tissues, such as in tendinitis and bursitis. Examples of NSAIDs include ASPIRIN, indomethacin (INDOCIN), ibuprofen (MOTRIN), naproxen (NAPROSYN), piroxicam (FELDENE), and nabumetone (RELAFEN). The major side effects of NSAIDs are related to the gastrointestinal system. Some 10%-50% of patients are unable to tolerate NSAID treatment because of side effects, including abdominal pain, diarrhea, bloating, heartburn, and upset stomach. Approximately 15% of patients on long-term NSAID treatment develop ulceration of the stomach and duodenum. Even though many of these patients with ulcers do not have symptoms and are unaware of their ulcers, they are at risk of developing serious ulcer complications such as bleeding or perforation of the stomach.

NSAIDs are taken regularly by approximately 33 million Americans!

Brand Name	Generic Name
Advil, Motrin, Medipren, Nuprin	ibuprofen
Ansaid	flurbiprofen
Aspirin, Bayer, Ecotrin	aspirin
Celebrex	celecoxib
Clinoril	sulindac
Daypro	oxaprozin
Disalcid, Salflex	salsalate
Feldene	piroxicam
Indocin, Indocin-sr	indomethacin
Lodine	etodolac
Meclomen	meclofenamate
Mobic	meloxicam
Nalfon	fenoprofen
Naprosyn, Naprelan, Anaprox, Aleve	naproxen
Orudis, Oruvail	ketoprofen
Tolectin	tolmetin
Trilisate	choline magnesium salicyclate
Voltaren, Cataflam, Voltaren-xr	diclofenac

   

Osteoporosis Medications

The best treatment for osteoporosis is prevention. Quitting smoking and curtailing alcohol intake are helpful. Exercise against gravity can reduce bone loss and can even stimulate new bone formation. Additionally, exercise increases agility, strength, and endurance; factors that can reduce accidents. Exercise programs are individualized and should be regular; at least several times weekly. For patients with underlying musculoskeletal disorders, combining exercise with joint protection techniques is important.

Calcium supplements are useful, especially in women. Average women in the United States receive less than 500 milligrams of calcium per day in their diet. The recommended daily allowance (RDA) of calcium intake is 800mg per day. The National Institute of Health Consensus Conference on Osteoporosis has recommended a calcium intake for postmenopausal women of 1000mg per day if they are also taking estrogen and 1500mg per day if they are not taking estrogen.

Estrogen replacement in postmenopausal women is important in the prevention of accelerated bone loss. Estrogen can even reverse the bone loss that occurs after menopause. Estrogen is available orally (PREMARIN, ESTRACE, ESTRATEST, and others) or as a skin patch (ESTRADERM, VIVELLE, and others). Women with certain conditions, such as a history of breast cancer, phlebitis, or stroke may not be candidates for estrogen because of the potential for worsening or inducing recurrences of these conditions.

Vitamin D supplementation has been shown to be of benefit in elderly patients, particularly those in nursing homes. This is probably due to the fact that many patients in nursing homes are vitamin D deficient.

Brand Name	Generic Name
Actonel	risedronate
Boniva	ibandronate
Calcimar, Miacalcin	calcitonin
Evista	raloxifene
Fosamax	alendronate

References:

Arthritis Medications  Information on drug classes and medication lists for each class except for BRMs approve after article was written.

Common Drugs and Medications to Treat Rheumatoid Arthritis Information on BRMs not found in article above.

Title: Fibro Fighter

Team: Squadron of Salubrity

Report to: Head Honcho of Health

Duties: Assist Head Honcho of Health in fighting the effects of arthritis, fibromyalgia, and chronic pain.

Specialized Weapons: Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Antidepressants, Tricyclic Antidepressants, Selective Serotonin Reuptake Inhibitors (SSRIs), Mixed Reuptake Inhibitors, Benzodiazepines, Other Medications For Fibromyalgia, Symptom-Specific Drugs

NSAIDs

NSAIDs (nonsteroidal anti-inflammatory drugs) are used to treat inflammation.

Although inflammation is not a symptom of fibromyalgia, NSAIDs also relieve pain. NSAIDs include:

• aspirin
• ibuprofen
• naproxen

NSAIDs work by inhibiting prostaglandins, which play a role in pain and inflammation. These drugs, some of which are available over-the-counter, may help ease the muscle aches of fibromyalgia. They may also relieve menstrual cramps and the headaches often associated with fibromyalgia.

The Facts Of NSAIDs

 

Antidepressants

Perhaps the most useful medications for fibromyalgia are several in the antidepressant class. Antidepressants elevate the levels of certain chemicals in the brain, including serotonin and norepinephrine. Low levels of these chemicals are associated not only with depression, but also with pain and fatigue. Increasing the levels of these chemicals can reduce pain in people who have fibromyalgia. Doctors prescribe several types of antidepressants for people with fibromyalgia.

 

Tricyclic Antidepressants

When taken at bedtime in dosages lower than those used to treat depression, tricyclic antidepressants can help promote restorative sleep in people with fibromyalgia. They also can relax painful muscles and heighten the effects of the body's natural pain-killing substances called endorphins.

Tricyclic antidepressants have been around for almost half a century. Some examples of tricyclic medications used to treat fibromyalgia include:

• amitriptyline
• cyclobenzaprine
• doxepin
• nortriptyline

 

Selective Serotonin Reuptake Inhibitors (SSRIs)

If a tricyclic antidepressant fails to bring relief, doctors sometimes prescribe a newer type of antidepressant called a SSRI. As with tricyclics, doctors usually prescribe these for people with fibromyalgia in lower dosages than are used to treat depression. By promoting the release of serotonin, these drugs may reduce fatigue and some other symptoms associated with fibromyalgia. The group of SSRIs includes:

• fluoxetine
• paroxetine
• sertraline

SSRIs may be prescribed along with a tricyclic antidepressant. Doctors rarely prescribe SSRIs alone. Because they make people feel more energetic, they also interfere with sleep, which often is already a problem for people with fibromyalgia.

Cymbalta (duloxetine) is a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) that is also showing promise.

Mixed Reuptake Inhibitors

Some newer antidepressants raise levels of both serotonin and norepinephrine, and are therefore called mixed reuptake inhibitors. Examples of these drugs include:

• venlafaxine
• nefazodone

Researchers are actively studying the efficacy of these drugs in treating fibromyalgia.

Benzodiazepines

Benzodiazepines help some people with fibromyalgia by relaxing tense, painful muscles and stabilizing the erratic brain waves that can interfere with deep sleep. Benzodiazepines also can relieve the symptoms of restless legs syndrome, which is common among people with fibromyalgia. Restless legs syndrome is characterized by unpleasant sensations in the legs as well as twitching, particularly at night. Because of the potential for addiction, doctors usually prescribe benzodiazepines only for people who have not responded to other therapies. Benzodiazepines include:

• clonazepam
• diazepam
• triazolam
• temazepam
  
  

Other Medications For Fibromyalgia

Doctors may prescribe other medications, depending on a person's specific symptoms or fibromyalgia-related conditions. For example:

• Tegaserod and alosetron are FDA approved for the treatment of irritable bowel syndrome.
• Gabapentin is being studied as a treatment for fibromyalgia.
• Pregabalin (Lyrica) is the first medicine that is FDA-approved to treat fibromyalgia.
• Modafinil may help with fatigue.
• Sodium oxybate may help with excessive sleepiness.
  

Symptom-Specific Drugs

Other symptom-specific drugs include:

• various headache remedies
• sleep aids such as:
• zolpidem
• eszopiclone
• ramelteon
• zaleplon
• muscle relaxants
• such as:
• carisoprodol
• metaxalone
• methocarbamol

Resource:

Fibromyalgia Medications - How Is Fibromyalgia Treated?

Title: Chronic Pain Commando

Team: Squadron of Salubrity

Report to: Head Honcho of Health

Duties: Assist Head Honcho of Health in fighting the effects of arthritis, fibromyalgia, and chronic pain.

Specialized Weapons: Medications: Mild pain, Mild to moderate pain, Moderate to severe pain, Opioids, Non-steroidal anti-inflammatory drugs, Antidepressants and antiepileptic drugs, Other analgesics; Procedures; Physical approach: Physiatry, TENS, Acupuncture, LLLT;  Psychological approach: Hypnosis

 

Medications:

 

Mild Pain

Paracetamol (UK), Tylenol (US) (acetaminophen), or a non steroidal anti-inflammatory drug such as ibuprofen.

Mild to moderate pain

Paracetamol/Tylenol, an NSAID and/or paracetamol/Tylenol in a combination product with a weak opioid such as hydrocodone, may provide greater relief than their separate use.

Moderate to severe pain

When treating moderate to severe pain, the type of the pain, acute or chronic, needs to be considered. The type of pain can result in different medications being prescribed. Certain medications may work better for acute pain, others for chronic pain, and some may work equally well on both. Acute pain medication is for rapid onset of pain such as from an inflicted trauma or to treat post-operative pain. Chronic pain medication is for alleviating long-lasting, ongoing pain.

Morphine is the gold standard to which all narcotics are compared. Fentanyl has the benefit of less histamine release and thus fewer side effects. It can also be administered via transdermal patch which is convenient for chronic pain management. Oxycodone is used across the Americas and Europe for relief of serious chronic pain; its main slow-release formula is known as OxyContin, and short-acting tablets, capsules, syrups and ampules are available making it suitable for acute intractable pain or breakthrough pain. Diamorphine, methadone and buprenorphine are used less frequently. Pethidine, known in North America as meperidine, is not recommended for pain management due to its low potency, short duration of action, and toxicity associated with repeated use. Pentazocine, dextromoramide and dipipanone are also not recommended in new patients except for acute pain where other analgesics are not tolerated or are inappropriate, for pharmacological and misuse-related reasons. Amitriptyline is prescribed for chronic muscular pain in the arms, legs, neck and lower back. While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose.

Opioids

Opioid medications can provide a short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and intrathecally. In chronic pain conditions that are opioid responsive a combination of a long-acting or extended release medication is often prescribed in conjunction with a shorter-acting medication for breakthrough pain, or exacerbations.

Most opioid treatment is oral (tablet, capsule or liquid), but suppositories and skin patches can be prescribed. An opioid injection is rarely needed for patients with chronic pain.

Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are efficacious analgesics in chronic malignant pain and modestly effective in nonmalignant pain management. However, there are associated adverse effects, especially during the commencement or change in dose. When opioids are used for prolonged periods drug tolerance, chemical dependency, diversion and addiction may occur.

Clinical guidelines for prescribing opioids for chronic pain have been issued by the American Pain Society and the American Academy of Pain Medicine. Included in these guidelines is the importance of assessing the patient for the risk of substance abuse, misuse, or addiction; a personal or family history of substance abuse is the strongest predictor of aberrant drug-taking behavior. Physicians who prescribe opioids should integrate this treatment with any psychotherapeutic intervention the patient may be receiving. The guidelines also recommend monitoring not only the pain but also the level of functioning and the achievement of therapeutic goals. The prescribing physician should be suspicious of abuse when a patient reports a reduction in pain but has no accompanying improvement in function or progress in achieving identified goals.

Non-steroidal anti-inflammatory drugs

The other major group of analgesics are non-steroidal anti-inflammatory drugs (NSAID). Acetaminophen/paracetamol is not always included in this class of medications. However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such as ketoprofen and piroxicam, have limited benefit in chronic pain disorders and with long-term use is associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization

Antidepressants and antiepileptic drugs

Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome. Drugs such as gabapentin have been widely prescribed for the off-label use of pain control. The list of side effects for these classes of drugs are typically much longer than opiate or NSAID treatments for chronic pain, and many anti-epileptics cannot be suddenly stopped without the risk of seizure.

Other analgesics

Other drugs are often used to help analgesics combat various types of pain and parts of the overall pain experience. In addition to gabapentin, the vast majority of which is used off-label for this purpose, orphenadrine, cyclobenzaprine, trazodone and other drugs with anticholinergic properties are useful in conjunction with opioids for neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle relaxants and are therefore particularly useful in painful musculoskeletal conditions. Clonidine has found use as an analgesic for this same purpose and all of the mentioned drugs potentiate the effects of opioids overall.

 

Procedures

Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain.

An intrathecal pump used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour and postoperatively. The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. This approach allows a higher dose of the drug to be delivered directly to the site of action, with fewer systemic side effects.

A spinal cord stimulator is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord provides a paresthesia ("tingling") sensation that alters the perception of pain by the patient.

 

Physical approach

 

Physiatry

Physical medicine and rehabilitation (physiatry/physiotherapy) employs diverse physical techniques such as thermal agents and electrotherapy, as well as therapeutic exercise and behavioral therapy, alone or in tandem with interventional techniques and conventional pharmacotherapy to treat pain, usually as part of an interdisciplinary or multidisciplinary program.

 

TENS

Transcutaneous electrical nerve stimulation has been found to be ineffective for lower back pain, however, it might help with diabetic neuropathy.

 

Acupuncture

Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal, concluded there was little difference in the effect on pain of real, sham and no acupuncture.

 

LLLT

A 2007 review published in the journal Annals of Internal Medicine concluded low-level laser therapy has "not been shown to be effective for either chronic or sub-acute or acute low back pain; and a 2008 Cochrane collaboration review concluded that there was insufficient evidence to support the use of LLLT in the management of low back pain.

Psychological approach

Evidence for the usefulness of behavioral therapy (BT) and cognitive behavioral therapy (CBT) in the management of adult chronic pain is generally weak, due partly to the proliferation of techniques of doubtful quality, and the poor quality of reporting in clinical trials. The crucial content of individual interventions has not been isolated and the important contextual elements, such as therapist training and development of treatment manuals, have not been determined. The widely varying nature of the resulting data makes useful systematic review and meta-analysis within the field very difficult. 

In 2009 a systematic review of randomized controlled trials (RCTs) of psychological therapies for the management of adult chronic pain (excluding headache) found that "CBT and BT have weak effects in improving pain. CBT and BT have minimal effects on disability associated with chronic pain. CBT and BT are effective in altering mood outcomes, and there is some evidence that these changes are maintained at six months;" and a review of RCTs of psychological therapies for the management of chronic and recurrent pain in children and adolescents, by the same authors, found "Psychological treatments are effective in pain control for children with headache and benefits appear to be maintained. Psychological treatments may also improve pain control for children with musculoskeletal and recurrent abdominal pain. There is little evidence available to estimate effects on disability or mood."

Hypnosis

A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions, though the number of patients enrolled in the studies was small, bringing up issues of power to detect group differences, and most lacked credible controls for placebo and/or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions." (p. 283).

Resource:

Pain Management article from Wikipedia