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Melanie Cole: (Host): Medications are often a precarious and expensive route to manage chronic pain but are often the first avenue people think of. With many alternative treatments, understanding your pain and what options are out there for you are the first steps to healing. My guest today is Dr. Matthew Monsein. He's a physician specializing in chronic pain management with the Courage Kenny Rehabilitation Institute. Welcome to the show, Dr. Monsein. So, we hear about chronic pain, how do you assess someone's level of pain and then determine what's causing it?

Dr. Matthew Monsein: (Guest) Well, that is a very difficult and challenging question and part of the difficulty in treating this condition is because we don't have any good way of assessing someone's pain other than asking them on a one to ten scale what their pain level is. So, pain, by definition, is a very private and personal and subjective experience, that's really only known to the person who's having that experience. One of the things that I think is important particularly for chronic pain, and we're talking about pain that lasted for six months or longer, is that frequently it's a very complex issue and it's not just the matter of the physical injury but it's the person's response and reaction to the injury. And so, there are multiple physical as well as psychological and social factors that ultimately can contribute to how that person experiences their pain.

Melanie:  Well, that's true and some of us, as they say, have a higher tolerance or a higher threshold for pain than others but when you're in chronic pain, it's something that really, really affects every single day in your life. So, people go right for the first thing which would be maybe NSAIDS or something. What do you tell people when they say, “what should I do for this pain?”

Dr. Monsein:  Well, again, with our patients, the people that I tend to see have had pain issues for six months, one year, two years, five years, ten years and many of them have tried various medications. The sort of standard treatment for pain are medicines; some sort of either manual therapy--physical therapy or chiropractic; injection therapy, which has become very popular in the last ten to twenty years; or surgery. Ultimately, what we do is one of those approaches and, unfortunately, for many patients who have chronic long term pain, they've tried all of those modalities and they still have significant pain issues. So, our focus is really more of a rehabilitative model in which we say to patients, "Yes, you have chronic pain and you've tried all these things and none of them have really taken care of the problem. What we can do is to try to help you get a better handle on living with this experience and, hopefully, making it not so overwhelming and depressing and limiting in terms of the quality of your life?”

Melanie:  Before we get to some of those modalities that you use, what are some of the things you don't like people to do to manage their pain?

Dr. Monsein:  Well, I think one of the critical issues and I think we're going to talk a little bit more about that in another segment, is the use of chronic opiates or narcotic analgesics, which has become, as everybody knows, in this country a tremendous problem with misuse and abuse. While there may well be some individuals where that is their best option, for many patients that get started down that trail, they ultimately end up developing--even if they don't become addicted in the sense that they are misusing or abusing or overusing narcotics--they still can become physically dependent. They become tolerant. There are oftentimes significant side effects and opiates themselves can make people hypersensitive to pain. So, at least in our practice, we try to minimize the use of that class of medication. That's the one thing that we look at. The other issue, and I think particularly people that have musculoskeletal pain, is when they're given the message by their doctors that “if it hurts don't do it”. I think that's a bad message to give patients because what happens is that if you have musculoskeletal pain in particular, if you avoid physical activities, you become more and more deconditioned, your muscles become weaker and it can actually ultimately contributes to your condition.

Melanie:  So, that takes us right into what do you want people to know about exercise and chronic pain because, as you said, people maybe think that they're not supposed to do that or don't exercise through the pain but yet sometimes it can be a life saver in terms of pain.

Dr. Monsein:  It can be and it depends on what's causing the pain. If somebody, for example, has a mechanical type of problem with their back, while exercise might be important, they may need to avoid certain types of bending and twisting, which is just going to aggravate their back. But exercise, number one, it helps to maintain—particularly if we are talking about back injuries--core back strength. There's a lot of emphasis on the importance of core which has to do with your abdominal muscles and your paralumbar muscles which provide the support for your spine. If you're not exercising, those muscles tend to become weak and if you have problems with degenerative disease, that's only going to tend to make your spine more unstable. There's also good evidence that if you can help people get into an aerobic type of fitness program, you could get your own natural endorphins going which are natural pain killers and they can be very effective in helping people manage and cope and deal with their long-term pain issues, particularly conditions like fibromyalgia and myofascial pain. Exercise could be critical.

Melanie:  What are some of the most successful alternative or complementary treatments you use, doctor?

Dr. Monsein:  Well I'm a big fan of yoga myself. I think there's a misconception about that sort of thing. It doesn't mean you have to be flexible. People say, “I can't do yoga. I'm too inflexible.” I've been doing yoga for forty years and I can still barely touch my ankles when I bend forward. So, it's not a question of how flexible you are but it's learning to listen to your body and incorporate stretching with breathing and awareness. I think a lot of the exercises that could be helpful for people with chronic pain are more non-traditional forms of exercise as well, like yoga; like Pilates which is, if you will, sort of a western form of yoga; and Tai Chi because I think the people think “I’ve got to exercise” and they try to push through things. It doesn't work. But, by developing a sense of body awareness and learning how to listen to your body and work with it, and not try to force through it, then people can make progress and benefit. So, those are the exercise modalities that we work with, as well as traditional aerobic types of things: bike riding, walking. Using an elliptical can be very helpful. A lot of people can't obviously jog for lots of reasons. I think pool therapy can be incredibly beneficial for people. We're fortunate because we have a warm therapeutic pool for patients to use and it's a very nice modality.

Melanie:  In just the last few minutes Dr. Monsein, give your best advice to a person that are seeking help for chronic pain. They just can't deal with it anymore, what do you tell them every day?

Dr. Monsein:  The first thing I tell people is “buyer beware” because I think patients that have chronic pain become desperate, which is understandable. They just want somebody or something to make their pain go away and so, frequently or not infrequently, patients will go through multiple invasive procedures including surgeries and they're no better. So, I think that it's important for patients to be able to step back, look at their condition, and try to look at what options are available for them. Again, my orientation is towards rehab, the use of mind/body therapies, cognitive behavior therapies, relaxation training. There is a tremendous amount of medical data recently published in the medical literature that supports a more holistic approach to try and help people manage and deal with chronic pain versus a modality approach which is going to someone, getting injections, going to another doctor, taking narcotics pain medication. That, in general, for chronic pain it's not particularly effective.

Melanie:  Thank you so much, Dr. Monsein for being with us today. It’s such important and great information. You're listening to The WELLcast with Allina Health. For more information, you can go to allinahealth.org. That's allinahealth.org. This is Melanie Cole. Thanks so much for listening.