Dealing with a Pet in Pain

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Hi everyone,

Wow, it’s been quite a while since I posted on here.  It’s been great to see some new followers roll in, and I’m looking forward to getting to know you.

One of the reasons I haven’t had much time to write recently is that Ruby, my family’s 14-year-old Lab mix, has been having a rough time.  Old age has begun to set in.  She has a large, benign tumor growing over one of her hips, as well as arthritis in her joints.  She is in pain a lot of the time, and sometimes limps and has trouble going up and down stairs.

I’ve been feeling really guilty because it took us a long time to realize how much pain she was in.  Yes, even me—someone who’s lived with pain, read about it, and written on the subject for almost a year now.  Even I missed some of the signs.

In my defense, the first symptom she showed wasn’t exactly an obvious sign of pain.  Instead, she became restless and started asking for food all of the time.  Now, Ruby’s always been a little food-obsessed (what dog isn’t?) but this was just completely beyond the pale.  It was like she never got tired, never needed to sleep anymore.  Every thought in her head seemed to revolve around getting one of us to follow her over to the treat cabinet.

We took her to the vet, thinking that instead this might be some kind of age-related neurological change– perhaps the dog version of dementia.  But what the vet told us is that, although it’s not uncommon for older dogs to start acting strangely for no apparent reason, sometimes it’s because they are in pain.

He suggested we try giving her tramadol, which is a mild opiate pain medication.  And boy, what a difference it made.  Suddenly, we had our old dog back—the dog that actually slept from time to time.   And of course, she’s still food obsessed, but now when she’s medicated, she’s the old Ruby who would only ask for treats a few times in an evening (not once every five minutes).

Napping happily.
Napping happily.

I don’t know why her pain first manifested itself as a heightened desire for food.  Maybe she just wanted something to change the way she felt, and treats are the only thing she really knows how to ask us for.  Maybe the “reward chemicals” her brain released when she got a treat—that’s a big thing for dogs– helped to block out the pain signals, and all she could do was repeat that process.  Or maybe she literally felt less pain when she was standing in front of the cabinet, anticipating the treat.  I would really love to know.

Her physical symptoms have actually gotten more pronounced since this first started, and now there’s no mistaking the fact that this dog is in pain.  She limps from time to time, and has trouble climbing stairs and getting in and out of the car.  Sometimes she starts to lie down only to pop back up, as if the way she had distributed her weight was pressing on something sore.

Now that we understand how much pain she’s in, we’re being a lot more proactive.  The vet said she had some muscle loss around her hips, simply due to the fact that she has been in too much pain to actually use those muscles.  So she will be starting aquatic physical therapy in a few weeks (yes, they have that for dogs!).

In the meantime, I have been taking her swimming a few days a week at a river near our house, hoping some non-weight bearing exercise will help her feel better.  Of course, it is Massachusetts in November, but Ruby’s Labrador ancestors were specifically bred to deal with these temperatures and she doesn’t get cold.  It’s pretty amazing to watch!

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The river where Ruby swims is just behind those trees.

We’ve also talked to our vet about additional pain medications that won’t conflict with each other.  For now we are adding gabapentin, which is technically an anti-seizure medication that can also be used to slow the nerve impulses that signal pain.  In a few weeks, if she’s still in pain, we might also add a non-steroidal anti-inflammatory (basically, dog ibuprofen).

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Throughout this whole ordeal, I keep thinking about something I read recently, about how veterinary students receive five times more education on pain than medical students do.  (Technically speaking, this study was done in Canada, but I would bet this is a worldwide trend).

I have a lot of things to say about this disparity, but for now I will just say that I’m grateful that Ruby’s vet was able to see that she was in pain when we couldn’t.   I’m grateful that a medication like Tramadol exists, and that we were able to get it for her.

And that I wish it was always this easy for human pain sufferers.  No one asked Ruby about her mental health, or insisted she go to psychotherapy.   No one tried to give her an antidepressant instead of a painkiller.  The average human pain sufferer would be lucky to receive care that was this comprehensive and straightforward.

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Anyway, to end this post on a more cheerful note, Ruby still has plenty of good days (more so, now that her pain is being adequately treated).  As I write this, she is sacked out on the floor next to me.  We’re having some really warm weather this week, and tomorrow I will probably take her for a long walk and swim.

In the car on the way to her next adventure.
In the car on the way to her next adventure.

What do you guys think?  Have you ever had a pet in pain?

And are you surprised by the differences in the amount of training medical and veterinary students receive on the subject of pain?  What do you think the reason for that is?

Breaking up muscle knots, without completely breaking your budget

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Sometimes, there’s nothing like a good massage.  Exercise and stretching are incredibly important, but sometimes you really just need someone to dismantle the knots that have taken over your muscles, and give your body a “reset.”

Unfortunately, if you’re dealing with a chronic condition, the cost of things like massage, acupuncture, and other bodywork can add up quickly.   How you can you pay for these things without completely ruining your budget?

Here are some of the best strategies I’ve learned over the years for using your money as effectively as possible to get the help you need.

*Before booking anywhere, look the place up on Yelp to see if other people had a good experience there.  This is especially true if you’re following my next tip:

*Check websites like Groupon and Living Social.  Many massage therapists post deals on these sites to try to bring in new clients.  I’ve saved a lot of money and met some interesting, helpful people this way.   I’ve also seen people start to post deals for other types of therapies, such as acupuncture and chiropractic.

*Check the massage therapist’s or business’s own website.  A lot of places offer a discount to first-time customers, or a monthly special.  (Many also offer a discount for people who book multiple appointments, but leave that until after you’ve had at least one massage there).

*Check to see if your insurance company will help you pay for massage.   Some companies, at least in the US, will pay for about 15% of the cost of your massage, if you go to someone that’s in-network.

*Ask if there is a sliding scale.  Sometimes people in the helping professions offer a “sliding scale” to those with financial difficulty.  It isn’t something they always advertise, however, since they (quite understandably) don’t want to be taken advantage of.

This is sometimes an awkward conversation, but if it’s the difference between you getting help or not, it can be worth asking.

*Try to find a massage school near you that runs a student clinic.

Massage students have to perform a certain number of hours of massage before they can be licensed.  Most massage schools operate a student clinic where members of the public can come and get a discounted massage performed by a student.

This probably won’t be a spa-like experience.  You might end up sharing a room that has multiple massage tables in it with other people.   But it is a way to get a low-priced massage, without having to book too far in advance.  (Thanks to Jezzybel for this suggestion!).

*See if you can find a physical therapist who specializes in massage. 

Unfortunately, not all physical therapists consider massage to be an important part of treatment.   Some PT’s haven’t had very much training in it.  Others are discouraged from performing massage on patients by the companies they work for because insurance companies do not reimburse as much for massage.  But once in a while, you’ll find a PT who considers massage to be an important part of treatment, and whose place of employment allows him or her to perform it.

I am currently seeing a physical therapist who specializes in massage, and it’s incredibly helpful, convenient, and cost-effective, as my insurance company pays for most of it.  But it took me forever to find her.

Unfortunately, there is no obvious way to find a physical therapist like this.  I would suggest looking for someone who mentions manual therapy or soft tissue release among their techniques.

*Check out Community-Oriented Businesses

I’ve come across a few really awesome places over the years which follow a slightly different model than the traditional spa or health center.

Many of them have had the word “community” in their name, and they place an emphasis on being affordable and accessible to everyone.   These types of places generally offer a sliding scale upfront—everyone pays what they can.

I make it a policy not to post the names of businesses I currently frequent.  (Maybe I’m being paranoid, but the internet freaks me out).

I am, however, comfortable posting the names of businesses in places I no longer live, so here is a place I went for acupuncture when I was in college.  You can check this out as an example of a community-oriented business, and see how it’s a little bit different from other places.

http://amherstcommunityacupuncture.com/welcome.html

Many businesses that follow the community model offer other services, such as massage, counseling, and nutrition therapy.

*Self-Help Techniques for Muscles

Of course, there are plenty of things you can do for yourself to help ease muscle pain and prolong the length of time you are comfortable between appointments (for example: ice packs, heating pads, and self massage with a tennis ball and other tools).  However, there is so much to say about this that it will have to wait for another post!

Thank you to Foundry Park Inn for the use of the above photo!

How a physical therapist helped me through my lowest point: Part Four

This is the fourth part in a series about an amazing new approach to physical therapy for chronic pain patients.  To start from the beginning, check out Part One, Two, and Three.

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For the first few visits, all Tim and I did was talk.  He didn’t have me in the gym doing exercises like all the other patients I walked by on the way in.  Instead, we sat in a quiet area and talked about what I had learned from Neil Pearson’s lectures.

What I learned is that pain is so much more complicated than we think.  When I first learned about the nervous system in high school biology, I was taught that nerve impulses travel through the spinal cord to the brain, where they are interpreted.

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This is a very simple model, and on a basic level it’s true.  That is how nerve impulses get to the brain.  But when it comes to the experience of pain, there are many additional factors.

Normally we think about the nervous system as a one way street, where signals are only travelling to the brain. But what I learned from Tim is that the experience of pain is a lot more complicated.  Our brains are constantly evaluating input from our nervous system, trying to sort out which signals are important for us to know about, and which aren’t.

Our brains are filtering our experiences all the time, determining what is and what isn’t important for us to know about.  After all, it wouldn’t make sense for us to be aware, on a conscious level, of every little thing that’s going on in our bodies.  We don’t need to feel, at all times, the sensation of clothing on our backs.  We don’t need to wake up out of a deep sleep just because there is a blanket touching our legs.  Our brains filter out information all the time, so that we can focus on more important things.

On the other side of this equation, the brain can actually “turn up the signal” on something it thinks we need to know about.  If a part of your body hurts and you try to ignore the pain and go about business as usual, your brain will make that pain louder.  It isn’t doing that to be annoying; it’s trying to protect you.

Lorimer Moseley tells a revealing story about the time he was walking in a nature preserve when a stick brushed against his ankle.  He had once been bitten by a poisonous snake in that same nature preserve, also on his ankle.  He freaked out and fell to the ground, writhing in excruciating pain.  He told his friends to call for help, thinking he needed to get to a hospital as soon as possible.

A few moments later he looked at his ankle and realized there were no bite marks.  There was, instead, a stick lying on the ground next to him with a sharp point.  He was then faced with the awkward task of telling his friends he was wrong, that there was no snake, that he’d freaked out over nothing.

This is how the nervous system works.  It is not meant to be “accurate.”  It is meant to protect us.

When Moseley’s nervous system felt the stick scrape his skin, it knew that the last time it felt those sensations, there had been great danger.  It also knew that not only was he outside, but he was walking in the exact same nature preserve where that same danger lurked.  His nervous system decided to tell him about the dangerous thing that had just happened to his ankle, and it told him about it loudly.  This is how the nervous system works; it decides how much danger we are in based not only on physical sensations but also on context.

Normally when we notice these little idiosyncracies of the nervous system, we are embarrassed.   These little errors in judgment can make it seem like we’re crazy, or overly anxious or neurotic.  But this is how the nervous system works.  It is not meant to be “accurate,” it is meant to protect us.   Even when our nervous system doesn’t have the whole story, it fills in blanks as much as possible, taking our fears and beliefs about the situation into account.

In people with chronic pain, the body’s protective response has gone haywire.  It’s as though the nervous system’s threshold for action has been lowered, and things that didn’t seem dangerous before now seem very dangerous.

It’s like we’re Lorimer Moseley walking through the nature preserve, all the time.  The difference is that Moseley’s case was a singular event based on coincidence: the stick brushed up against him in the same place that the snake had bit him, and he was walking in the exact same park where he had encountered the snake before.  While Moseley’s experience had a concrete end, every day chronic pain patients encounter “sticks” that our bodies interpret as “snake bites.”

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The good news is that, because the nervous system takes our conscious beliefs about pain into account when making judgments, we can actually affect how it reacts to various stimuli.  (I want to be very clear here: we do not cause chronic pain with our thoughts and beliefs.  This is an oversimplification, and it’s also insulting).  But the nervous system does pay attention to context when deciding how dangerous something is.

In his lectures, Neil Pearson says that when your pain starts to get worse, you should ask yourself “Is this really dangerous?”  An increase in pain is a sign that your nervous system has decided whatever you’re doing is dangerous.  But is that really the case?  If you’ve been living with pain for a long time, it might not be.

This is where your conscious thoughts and beliefs can play a role in breaking the cycle of pain.

I had lived with pain for so long that my view of what my body could and couldn’t do had gotten very warped.  I felt pain every time I tried to walk, or lift something, or go up and down stairs.  I thought my body was weak, that there was something fundamentally wrong with it, and every time I pushed myself it seemed to get worse.

Tim helped me to recognize that the pain I felt was not necessarily an accurate barometer for what was wrong in my body.  The reason I had a setback every time I exerted myself, he said, had more to do with my nervous system freaking out than the fact that I had actually pushed my healthy twenty-five year-old body to its limits.  When my body began to hurt, I was to say to myself, “There’s my nervous system again.  Freaking out.  But that doesn’t mean anything is wrong in my body.”

Tim and I talked a lot about how the body works, and how I wasn’t going to hurt my back, or my legs, or my ankle just by doing basic things.  Because one of my major complaints was back pain, we talked about the anatomy of the back, and how my MRI showed I didn’t have any serious pathology.  Tim promised me that my body was so much more capable than I thought it was, and that once I could help my nervous system calm down a little bit, I would see that.

We also talked about what kinds of things would produce pain in a person whose nervous system wasn’t freaking out.  It honestly really helped me to have a trained physical therapist to bounce ideas off of.  I trusted Tim.  If he told me the pain I felt was likely coming from my freaking-out nervous system, rather than any physical damage, I believed him.

We talked about my leg surgery several years before, and how I was afraid my compartment syndrome was going to come back if I pushed my legs too much.  We sat down and had a rational discussion about this; how unlikely it was, but what the worst case scenario really would be if it came back.  This helped to reduce some of my fear, and give back a sense of control.

We also talked about my ankle, which I had sprained a few months earlier.  It still hurt a lot of the time, and I had a lot of trouble walking and driving.  Tim explained that I wasn’t going to re-sprain my ankle just by performing normal activities.  Since it had been a few months, he said, the majority of the healing had already occurred.  As long as I kept my ankle within the normal range of motion, I wouldn’t be doing anything to make the sprain worse.

This actually made a striking difference in the amount of pain I felt in my ankle.   My nervous system had been interpreting the sensations in my ankle as very dangerous, and as a result it was very painful.  But once my brain understood that my ankle wasn’t in any real danger anymore, my nervous system no longer saw the need to tell me about it all the time. Over the course of the next few weeks, the pain in my ankle gradually melted away.

It’s almost embarrassing to admit something like this– that my ankle, which had been bothering me for months, stopped hurting as soon as someone explained to me that it wasn’t really dangerous.  But it shouldn’t be embarrassing.  This is how our nervous systems work: they take into account both physical signals as well as our mental interpretation of events.

If you’ve undergone the process of central sensitization, your nerves, spinal cord, and brain have changed in ways that cause you to be more sensitive to pain.  Scientists don’t yet know whether or not these physical changes are actually reversible.  But the good news is that whether or not you can undo the effects of central sensitization, you can still break the cycle of pain by changing how you react to pain on a conscious level.

Continued in Part 5.

**The top picture was taken in the Australian Outback, which is where many of Lorimer Moseley’s stories take place.  Published by Mark Veerhart under a Creative Commons license.**

**Mulberry sticks picture courtesy of JodiGreen**

The Benefits of Acute Stress for People in Pain

This was a really thought-provoking article from Neil Pearson on balancing acute versus chronic stress in the body.  While chronic stress is harmful on the body, acute stress actually has a lot of benefits.  Pearson explains,

“If you want to make a muscle stronger, use it more. If you want to grow more tolerant of an irritating or bothersome sensation or experience, step up to it. Face it. In time, it will bother you less. Try playing a string instrument for the first time, and feel the intense pain from pushing down strings with your fingertips. Keep doing it and your body will adapt, even creating a callous as a protective response, just like woodworkers and carpenters have on their hands and dancers have on their feet. In other words, when you stress your body, typically it responds by being better able to tolerate that stress next time.”

His advice is:

“Create acute stress while limiting the chronic stress of a flare-up: Make a daily plan to try an activity (or part of an activity) you want to do, but do it while you do your very best to keep your breathing even, your body tension low (only use as much as you need for the activity), and your stress level as low as possible.”

I thought this was great advice.  So often we get the message that all stress is bad; that in order to be healthy, you must eliminate all sources of stress in your life.  I think some of this advice is a little overblown– you’re never going to be able to cut out everything that stresses you out from your life, and if you are, you probably won’t be very engaged with the world.

Instead, I think it’s best to strike a balance between eliminating unnecessary stresses and learning to handle the ones you aren’t going to be able to control.  One way to do this is to becoming more conscious of acute stress– the pounding of your heart during exercise, the strain on your muscles when you lift a heavy weight.  These are all stresses that can help you grow in a positive direction and, unlike chronic stress, they have an endpoint.  When you learn to observe acute stress in a mindful way, it can help to put chronic stress in a different perspective.