Guest Editorial
Pain can be incapacitating Ronald C. Auvenshine MedCenter TMJ, Houston, TX, USA On the 14th of March, I was involved in an unfortunate accident, and as a result, I severely injured my right shoulder. Knowing how to treat joint pain because of my years of experience dealing with TMD, I began a program of palliative care to restore the function of the joint. Because of my efforts, I began to see some improvement, but not a great deal of improvement. After 3 weeks of palliative care with limited results, I chose to seek the opinion of an orthopedist. Upon examination, I failed every test regarding range of motion, strength, and agility. The surgeon suggested that I have an MRI of my shoulder. The MRI showed a tear in the rotator cuff that was beyond the scope of nonsurgical treatment. Therefore, he recommended arthroscopic surgery to the right shoulder. One week later, I underwent the surgical procedure to repair the right rotator cuff. The procedure was performed arthroscopically and was approximately one hour of duration longer than the surgeon had initially expected. The total surgical procedure was slightly over two hours in duration. The surgeon indicated there would be a longer rehab period for my shoulder, due to the fact that the damage was greater than was shown on the MRI. Prior to the surgical procedure, as I was lying on the table being prepared for surgery, I asked the surgeon questions regarding what I could expect after surgery. He made the statement that he could not tell me from personal experience, but that recently he had performed the same surgery on his partner. He then stated that he was somewhat ‘‘jealous’’ because his partner had such authenticity to discuss details with his patients, far greater than the discussions that my doctor would have with his patients. This one statement led me to share with you the personal experience I had with the pain following the shoulder surgery. Thus came the topic for this editorial. Prior to the surgical procedure, the anesthesiologist embedded a port for local anesthesia into the brachial plexus of my right arm. This is referred to as a ‘‘neuraxial block.’’ The local anesthetic ß W. S. Maney & Son Ltd 2015 DOI 10.1179/0886963415Z.000000000119
(Marcaine and lidocaine) was injected through a pulsometer at regular intervals over a 48-hour period to numb the upper extremity. This greatly limited my need for stronger analgesics. The local anesthetic was to last approximately 48 hours. Therefore, I was told to remove the catheter early Sunday morning. However, the local anesthetic ran out at nine o’clock on Saturday evening. I was totally unprepared for that event. I had not planned on it happening that soon, so I did not have substantial analgesic support circulating in my blood stream. Even though I had been given opioids and NSAIDs for pain management, I had not prepared for the local anesthetic to end so quickly. I have never experienced such severe pain in my life. I have the esteemed honor of being on the faculty of the Institute of the American Academy of Craniofacial Pain. One of the subjects on which I lecture is Differential Diagnosis and Pain Mechanisms for Craniofacial Pain. As a practitioner of TMD for over 40 years, I am very familiar with the processes associated with pain: nociception, pain perception, and a number of secondary consequences, including suffering and pain behavior. I am also very much aware and lecture extensively on ‘‘neuroplasticity.’’ However, I had never experienced any of these processes until that infamous Saturday night when the local anesthetic ran out. From that point forward, any type of movement or touch-evoked pain or any other stimulation was totally intolerable. The word ‘‘hyperalgesia’’ took on new meaning. Nociception now became foremost in my mind. The dual system of the pain pathway to the central nervous system was totally operative. Not only was the ‘‘discriminative system’’ intact, which allowed me to identify the painful area exactly, but also the ‘‘motivationalaffective system’’ was at a heightened vigilance. I became nauseated, irritable, almost incapacitated by the pain. As the pain continued, my ability to resist, even though I knew the origin of my pain, was weakened. I became totally dependent upon my caregiver (wife). I had no motivation. I had
CRANIOt: The Journal of Craniomandibular & Sleep Practice
2015
VOL .
33
NO .
3
165
Auvenshine
Guest Editorial
no drive. I was in the midst of a pain experience that affected my entire body. I now know the meaning of the pain response involving mind, body, and soul. Before the opioid medication could take effect, I began to experience a form of ‘‘central sensitization’’ with sustained and repetitive activation of primary afferent fibers producing substantial change to the function and activity of central neurogenic pathways. Fortunately, the medication took effect before central sensitization completely changed my pain response. I am now three weeks into my postoperative course of therapy. The pain has decreased from a nine (VAS), which I experienced on Saturday night, to a two or three (VAS). I have had five physical therapy sessions, and I am beginning to regain function of my right arm. However, there is very little strength as of yet. The rehab time for this surgery will be between three and six months before total function is restored. Since we know that there is no cure for orthopedic problems, I will have pain episodes with my right shoulder for the rest of my life. In order to minimize these events, I will have to manage the joint with palliative care and exercises every day. What have I learned so far from this experience? Foremost is the fact that the temporomandibular joint is like any other orthopedic structure. Therefore, the long-term success in treating TMD is our ability as practitioners to educate our patients in the continued maintenance of the joint. I know that I will have to manage my shoulder for the rest of my life, and at some point in time, may have to undergo further treatment as age and degeneration take their toll. The TMJ is no different. I have also learned the importance of pain management and the role that we as dentists have in helping people who live their lives in chronic pain. I was fortunate in my pain experience because I knew the origin of the pain and I knew that it would be of limited duration. There would ultimately be relief if I just simply
166
CRANIOt: The Journal of Craniomandibular & Sleep Practice
2015
took medication and waited patiently. This is not the case in many of our patients who come seeking treatment for chronic headaches, chronic orofacial pain, or TMD. Many of them have been to a multitude of practitioners and have submitted themselves to treatment, which in some cases, is either undertreatment, overtreatment, or inappropriate treatment. Many of these chronic pain patients have lost hope. I know from my experience that had the intense pain continued more than 16–18 hours, my behavior would have dramatically changed. So many of our patients live with this level of pain 24/7. By having gone through this event, I am now in a position to better understand my patients. This experience has made me acutely aware of my importance as a diagnostician. I have a renewed commitment to learn as much as I can so that I will not only be able to render proper treatment and medication, but also give the proper advice and counsel. Lastly, I realized, through my experience, the importance of the caregiver. Whenever a chronic pain patient presents and has no support from family or friends, a more critical situation arises. As the pain becomes more intense, the patient is no longer able to care for him or herself. I have become much more cognizant of the importance of supporting the caregivers as part of my treatment program. It is my hope that your reading this editorial will help you become a better pain practitioner. There are so many forces affecting today’s general practitioner of dentistry. I urge you to continue to pursue a deeper knowledge of craniofacial pain, a better understanding of pain mechanisms, in order to become a more effective practitioner for a population of patients who can only get the relief we provide through the dental model. My orthopedist was correct. It is an enviable position to have gone through a painful event that gives authenticity to your patient treatment through personal experience.
VOL .
33
NO .
3
Pain can be incapacitating Ronald C. Auvenshine MedCenter TMJ, Houston, TX, USA On the 14th of March, I was involved in an unfortunate accident, and as a result, I severely injured my right shoulder. Knowing how to treat joint pain because of my years of experience dealing with TMD, I began a program of palliative care to restore the function of the joint. Because of my efforts, I began to see some improvement, but not a great deal of improvement. After 3 weeks of palliative care with limited results, I chose to seek the opinion of an orthopedist. Upon examination, I failed every test regarding range of motion, strength, and agility. The surgeon suggested that I have an MRI of my shoulder. The MRI showed a tear in the rotator cuff that was beyond the scope of nonsurgical treatment. Therefore, he recommended arthroscopic surgery to the right shoulder. One week later, I underwent the surgical procedure to repair the right rotator cuff. The procedure was performed arthroscopically and was approximately one hour of duration longer than the surgeon had initially expected. The total surgical procedure was slightly over two hours in duration. The surgeon indicated there would be a longer rehab period for my shoulder, due to the fact that the damage was greater than was shown on the MRI. Prior to the surgical procedure, as I was lying on the table being prepared for surgery, I asked the surgeon questions regarding what I could expect after surgery. He made the statement that he could not tell me from personal experience, but that recently he had performed the same surgery on his partner. He then stated that he was somewhat ‘‘jealous’’ because his partner had such authenticity to discuss details with his patients, far greater than the discussions that my doctor would have with his patients. This one statement led me to share with you the personal experience I had with the pain following the shoulder surgery. Thus came the topic for this editorial. Prior to the surgical procedure, the anesthesiologist embedded a port for local anesthesia into the brachial plexus of my right arm. This is referred to as a ‘‘neuraxial block.’’ The local anesthetic ß W. S. Maney & Son Ltd 2015 DOI 10.1179/0886963415Z.000000000119
(Marcaine and lidocaine) was injected through a pulsometer at regular intervals over a 48-hour period to numb the upper extremity. This greatly limited my need for stronger analgesics. The local anesthetic was to last approximately 48 hours. Therefore, I was told to remove the catheter early Sunday morning. However, the local anesthetic ran out at nine o’clock on Saturday evening. I was totally unprepared for that event. I had not planned on it happening that soon, so I did not have substantial analgesic support circulating in my blood stream. Even though I had been given opioids and NSAIDs for pain management, I had not prepared for the local anesthetic to end so quickly. I have never experienced such severe pain in my life. I have the esteemed honor of being on the faculty of the Institute of the American Academy of Craniofacial Pain. One of the subjects on which I lecture is Differential Diagnosis and Pain Mechanisms for Craniofacial Pain. As a practitioner of TMD for over 40 years, I am very familiar with the processes associated with pain: nociception, pain perception, and a number of secondary consequences, including suffering and pain behavior. I am also very much aware and lecture extensively on ‘‘neuroplasticity.’’ However, I had never experienced any of these processes until that infamous Saturday night when the local anesthetic ran out. From that point forward, any type of movement or touch-evoked pain or any other stimulation was totally intolerable. The word ‘‘hyperalgesia’’ took on new meaning. Nociception now became foremost in my mind. The dual system of the pain pathway to the central nervous system was totally operative. Not only was the ‘‘discriminative system’’ intact, which allowed me to identify the painful area exactly, but also the ‘‘motivationalaffective system’’ was at a heightened vigilance. I became nauseated, irritable, almost incapacitated by the pain. As the pain continued, my ability to resist, even though I knew the origin of my pain, was weakened. I became totally dependent upon my caregiver (wife). I had no motivation. I had
CRANIOt: The Journal of Craniomandibular & Sleep Practice
2015
VOL .
33
NO .
3
165
Auvenshine
Guest Editorial
no drive. I was in the midst of a pain experience that affected my entire body. I now know the meaning of the pain response involving mind, body, and soul. Before the opioid medication could take effect, I began to experience a form of ‘‘central sensitization’’ with sustained and repetitive activation of primary afferent fibers producing substantial change to the function and activity of central neurogenic pathways. Fortunately, the medication took effect before central sensitization completely changed my pain response. I am now three weeks into my postoperative course of therapy. The pain has decreased from a nine (VAS), which I experienced on Saturday night, to a two or three (VAS). I have had five physical therapy sessions, and I am beginning to regain function of my right arm. However, there is very little strength as of yet. The rehab time for this surgery will be between three and six months before total function is restored. Since we know that there is no cure for orthopedic problems, I will have pain episodes with my right shoulder for the rest of my life. In order to minimize these events, I will have to manage the joint with palliative care and exercises every day. What have I learned so far from this experience? Foremost is the fact that the temporomandibular joint is like any other orthopedic structure. Therefore, the long-term success in treating TMD is our ability as practitioners to educate our patients in the continued maintenance of the joint. I know that I will have to manage my shoulder for the rest of my life, and at some point in time, may have to undergo further treatment as age and degeneration take their toll. The TMJ is no different. I have also learned the importance of pain management and the role that we as dentists have in helping people who live their lives in chronic pain. I was fortunate in my pain experience because I knew the origin of the pain and I knew that it would be of limited duration. There would ultimately be relief if I just simply
166
CRANIOt: The Journal of Craniomandibular & Sleep Practice
2015
took medication and waited patiently. This is not the case in many of our patients who come seeking treatment for chronic headaches, chronic orofacial pain, or TMD. Many of them have been to a multitude of practitioners and have submitted themselves to treatment, which in some cases, is either undertreatment, overtreatment, or inappropriate treatment. Many of these chronic pain patients have lost hope. I know from my experience that had the intense pain continued more than 16–18 hours, my behavior would have dramatically changed. So many of our patients live with this level of pain 24/7. By having gone through this event, I am now in a position to better understand my patients. This experience has made me acutely aware of my importance as a diagnostician. I have a renewed commitment to learn as much as I can so that I will not only be able to render proper treatment and medication, but also give the proper advice and counsel. Lastly, I realized, through my experience, the importance of the caregiver. Whenever a chronic pain patient presents and has no support from family or friends, a more critical situation arises. As the pain becomes more intense, the patient is no longer able to care for him or herself. I have become much more cognizant of the importance of supporting the caregivers as part of my treatment program. It is my hope that your reading this editorial will help you become a better pain practitioner. There are so many forces affecting today’s general practitioner of dentistry. I urge you to continue to pursue a deeper knowledge of craniofacial pain, a better understanding of pain mechanisms, in order to become a more effective practitioner for a population of patients who can only get the relief we provide through the dental model. My orthopedist was correct. It is an enviable position to have gone through a painful event that gives authenticity to your patient treatment through personal experience.
VOL .
33
NO .
3
