Back surgery patients are often frustrated and disappointed to experience lingering pain once the recovery period is over. It’s completely understandable. Surgery should have been the golden ticket to a pain-free life, or so they thought. It’s not uncommon to have persistent pain post-surgery. But it’s also important for patients to understand why it’s happening and that they have treatment options to correct the problem at its source.
Persistent spinal pain after surgery is a common issue that many patients face. Despite undergoing procedures like discectomy, some individuals continue to experience discomfort. This article will explore the causes of ongoing pain, the importance of diagnosing its source, and effective relief strategies. Readers will understand how proper nutrition and appropriate medication can alleviate their pain, helping them regain mobility and improve their quality of life. If persistent spinal pain is affecting daily activities, this guide will provide valuable insights and solutions.
Introduction to Persistent Spinal Pain After Surgery
Persistent spinal pain after surgery is a common issue affecting many patients. Understanding the prevalence of post-surgical spinal pain is vital, as chronic pain can significantly impact daily life. This section will explore how to differentiate normal healing pain from persistent symptoms, while addressing key factors, such as behavioral changes, potential infections, diagnosis processes, and the role of injections for conditions like sacroiliac joint dysfunction.
Understanding the Prevalence of Post-Surgical Spinal Pain
Persistent spinal pain after surgery is prevalent, affecting a considerable number of patients. An observational study revealed that many individuals report varying degrees of discomfort following procedures, particularly around the lumbar vertebrae. Moreover, complications such as arachnoiditis can develop post-operatively, contributing to chronic pain and requiring further assessment and treatment.
Patients may experience persistent pain due to muscle tension or inadequate pain management strategies, such as the use of local anesthetic post-surgery. Understanding the factors that lead to ongoing pain can help medical professionals implement more effective relief strategies, ultimately improving recovery outcomes for those undergoing spinal surgery.
The Impact of Chronic Pain on Daily Life
Chronic spinal pain can significantly disrupt daily life, affecting individuals physically, emotionally, and socially. Many patients experience limitations in mobility and strength, leading to challenges in performing everyday tasks. Moreover, the psychological toll can be considerable, as ongoing pain may result in feelings of frustration and anxiety, exacerbating their overall condition. Issues such as nerve irritation from inflammation of the meninges and biological responses, like acid-induced pain from damaged cells, can intensify these feelings.
In addition to physical limitations, chronic pain can lead to inadequate pain management strategies, including suboptimal anesthesia techniques during and after surgery. Complications, such as bleeding in the surgical area, can further complicate recovery and lead to longer-lasting discomfort. This combination of factors highlights the need for comprehensive treatment plans that address both the physiological and psychological aspects of pain, ensuring patients regain their quality of life and functionality.
Differentiating Normal Healing Pain From Persistent Symptoms
Differentiating between normal healing pain and persistent symptoms involves understanding the body’s response to surgical interventions. Normal healing pain typically diminishes over time as tissues recover, while persistent pain may indicate underlying pathology, such as nerve damage or infection. Clinical research shows that if weakness persists or pain intensifies beyond the usual recovery period, further examination is warranted to identify any complicating factors.
An effective approach to managing persistent pain can include targeted drug delivery, which aims to address localized discomfort more efficiently. This method helps to alleviate symptoms associated with tissue inflammation and disruption, promoting a quicker return to normal function. Patients experiencing ongoing pain should work closely with their healthcare providers to explore these advanced strategies and ensure they receive comprehensive care tailored to their individual healing process.
Common Causes of Persistent Symptoms Post Spinal Operation
Persistent spinal pain after surgery can arise from various factors, including surgical complications leading to ongoing pain and nerve damage from incomplete nerve decompression. Additionally, the formation of scar tissue, known as epidural fibrosis, can contribute to discomfort. Degeneration of adjacent spinal segments and psychological factors influencing pain perception also play crucial roles in a patient’s recovery journey.
Understanding these underlying issues is essential for effective pain management, whether through the use of nerve blocks, pumps for localized pain relief, or careful assessment following procedures like a lumbar puncture. The following sections will address these topics in detail, providing insights into effective strategies for relief.
Surgical Complications Leading to Ongoing Pain
Surgical complications that can lead to ongoing pain include the leakage of cerebrospinal fluid, which may occur post-operatively. This leakage can cause irritation in the spinal area, resulting in persistent discomfort that hinders recovery. Primary care providers must monitor patients following surgery for signs of this complication, as it can significantly impact mobility and overall well-being.
Infections introduced during surgery, often due to bacteria, can also contribute to chronic pain. Should an infection develop, it may necessitate additional interventions to address symptoms and prevent further complications. Identifying and treating these surgical-related issues promptly is essential to improve recovery outcomes and enhance the quality of life for those dealing with persistent spinal pain.
Nerve Damage or Incomplete Nerve Decompression
Nerve damage or incomplete nerve decompression is a significant factor contributing to persistent spinal pain after surgery. Many patients may experience ongoing discomfort due to insufficient relief of nerve compression during orthopedic surgery. This situation can result in symptoms such as fatigue, decreased mobility, and heightened pain, necessitating further evaluation by the surgeon to identify the underlying issues.
For some patients, the pressure on nerves may not be fully alleviated, leading to chronic pain symptoms that can hinder recovery. Awareness of potential complications, such as deep vein thrombosis, is essential, as these can compound issues related to nerve function. Engaging in a dialogue with healthcare providers about any new or worsening pain following surgery can be crucial in addressing these concerns effectively, paving the way for improved management strategies.
Formation of Scar Tissue (Epidural Fibrosis)
Formation of scar tissue, known as epidural fibrosis, can occur after spinal surgery, leading to persistent pain and discomfort. This condition arises when the body attempts to heal itself following an operation, resulting in fibrous tissue that can restrict nerve movement and contribute to conditions such as edema. Physical examination often reveals signs of this scar tissue around the surgical site, which can inhibit mobility and exacerbate pain symptoms in patients, particularly those with underlying diseases or factors like obesity that may influence recovery.
Understanding epidural fibrosis is crucial for both patients and healthcare providers, as it may require specific treatment strategies to manage pain effectively. Interventions such as targeted injections or physical therapy may be recommended to alleviate symptoms and improve function. Engaging in open discussions about persistent symptoms following surgery can help healthcare professionals make informed decisions about intervention strategies, ultimately leading to better recovery outcomes.
Degeneration of Adjacent Spinal Segments
Degeneration of adjacent spinal segments often occurs in patients who have undergone spinal surgery, leading to persistent pain. Research indicates that when one segment is stabilized or altered during surgery, increased stress may be placed on neighboring segments. This phenomenon can result in skeletal muscle tension and, in some cases, lead to a spinal cord injury if not appropriately assessed and addressed.
Patients may experience symptoms such as headaches and localized pain due to the changes occurring in these adjacent spinal segments. A thorough evaluation and proactive management plan can help mitigate these effects, ensuring that the patient’s recovery is not adversely impacted by degeneration. Engaging with healthcare providers to explore treatment options may alleviate discomfort and improve overall function following surgery.
Psychological Factors Influencing Pain Perception
Psychological factors play a significant role in the perception of pain following spinal surgery. Research from sources like the Mayo Clinic indicates that stress and anxiety can heighten the experience of pain in patients, including those recovering from conditions such as scoliosis. When patients are under stress, their bodies may have heightened sensitivity to pain, complicating the recovery process and leading to an elongated perception of discomfort.
In addition to stress, the way individuals interpret their pain can also influence their healing journey. Studies published in JAMA show that patients who maintain a positive outlook are more likely to report improved outcomes post-surgery. Understanding the psychological aspect of pain perception is crucial, as targeted interventions like counseling or pain management strategies can help alleviate stress and support patients in their recovery efforts.
Diagnosing the Source of Persistent Spinal Pain
Diagnosing the source of persistent spinal pain after surgery requires a comprehensive medical evaluation and careful consideration of patient history. Advanced imaging techniques and electrophysiological studies play crucial roles in identifying issues such as degenerative disc disease. A differential diagnosis is essential to rule out various conditions, while collaboration with a multidisciplinary team ensures a holistic approach to healing and pain management, utilizing appropriate nursing strategies and medication options.
Comprehensive Medical Evaluation and Patient History
A comprehensive medical evaluation is essential for diagnosing persistent spinal pain after surgery. This process begins with gathering the patient’s history, which should include details about previous conditions like kyphosis and any surgical interventions they have undergone. Understanding the patient’s medical history enables healthcare professionals to identify the underlying etiology of the pain, including factors such as inflammation or fibrosis that may have developed post-operatively and contributed to the ongoing discomfort.
In addition to patient history, detailed examinations and imaging studies are crucial for accurate diagnosis. Anesthesiology considerations play a significant role as well, especially in evaluating pain management strategies employed during and after surgery. By combining insights gained from both patient interactions and advanced imaging techniques, healthcare providers can develop targeted approaches to address the root causes of pain, ultimately guiding patients toward effective relief strategies tailored to their individual needs.
Utilizing Advanced Imaging Techniques
Advanced imaging techniques are essential for diagnosing the source of persistent spinal pain after surgery. Utilizing methods such as MRI and CT scans allows medical professionals to visualize spinal structures accurately and assess for conditions like stenosis or peripheral neuropathy. These imaging modalities can identify issues like fluid accumulation, scar tissue from spinal fusion, or impingements on spinal nerves that may explain ongoing discomfort.
In addition to routine evaluations, advanced imaging can reveal complications that may not be apparent through physical examinations alone. These tools aid in pinpointing the root cause of pain, whether from previous substance abuse leading to spinal degeneration or structural abnormalities affecting nerve function. By understanding the specific causes of persistent pain, healthcare providers can develop targeted treatment plans to alleviate symptoms and promote healing.
Conducting Electrophysiological Studies
Electrophysiological studies are critical for diagnosing the source of persistent spinal pain following surgery. These tests assess the function of nerve roots and the intervertebral discs by measuring electrical activity in muscles and nerves. By identifying abnormal pressures or responses in the epidural space, healthcare providers can pinpoint nerve damage or compression that may be contributing to ongoing discomfort.
These studies not only help in diagnosing specific conditions but can also guide treatment strategies. For instance, understanding the nerve function can lead to the exploration of alternative medicine options like traction therapies. Such strategies aim to alleviate pressure on affected nerves, promoting healing and enhancing the overall recovery experience for patients facing persistent spinal pain.
The Importance of Differential Diagnosis
The importance of differential diagnosis in understanding persistent spinal pain after surgery cannot be overstated. This process involves meticulously evaluating various potential causes of discomfort, including fluid accumulation that may impact the central nervous system. By identifying specific issues, healthcare professionals can tailor interventions, such as targeted drug delivery systems, to address the root causes rather than merely alleviating symptoms.
Moreover, recognizing the diverse range of factors contributing to post-surgical pain, including issues like nausea that may arise from complications, enables doctors to implement effective treatment strategies. For instance, differential diagnosis helps in distinguishing between typical healing pains and those indicative of deeper problems, allowing for timely interventions that enhance recovery and reduce further discomfort for patients.
Collaborating With a Multidisciplinary Team
Collaborating with a multidisciplinary team is vital in diagnosing persistent spinal pain after surgery. Specialists, including neurologists, pain management experts, and physical therapists, contribute diverse perspectives on conditions such as radiculopathy. This collaboration helps in understanding the complex pathophysiology and ensures that each aspect of the patient’s pain is addressed, reducing the risk of relapse and treatment failure.
To effectively tackle ongoing discomfort, a coordinated approach among healthcare professionals is essential. For instance, combining insights from imaging specialists with pain management providers allows for the identification of varied causes of pain. This teamwork enhances the likelihood of successful outcomes by ensuring comprehensive care tailored to the unique needs of the patient, ultimately improving recovery and quality of life.
Non-Surgical Relief Strategies for Persistent Spinal Pain
Non-surgical relief strategies for persistent spinal pain offer various methods to improve quality of life for individuals suffering from back pain. Engaging in physical therapy and rehabilitation aids in restoring movement, while pain management through medications, including opioids for severe low back pain, addresses discomfort effectively. Lifestyle modifications and exercise enhance overall health, complemented by psychological support and counseling to manage emotional challenges. Additionally, exploring alternative therapies, such as acupuncture and massage, can further alleviate symptoms, including the option of radiofrequency ablation for targeted pain relief.
Engaging in Physical Therapy and Rehabilitation
Engaging in physical therapy and rehabilitation is an essential component for individuals experiencing persistent spinal pain after surgery. By focusing on targeted exercises and stretches, therapy can help strengthen the muscles surrounding the vertebra and improve overall mobility, reducing stress on the spinal canal and joint structures. Physical therapists utilize specific techniques designed to alleviate pain and improve function, facilitating a smoother recovery process following neurosurgery.
Moreover, rehabilitation programs often incorporate methods to address the underlying inflammatory responses, such as the activation of microglia, which can contribute to ongoing pain signals in the nervous system. Through a combination of guided movements and educational sessions, patients gain valuable insights on maintaining a healthy spine, achieving better alignment during daily activities, and preventing further complications in the recovery journey. Engaging with a qualified physical therapist enables individuals to take proactive steps toward managing their pain effectively and enhancing their quality of life.
Pain Management Through Medications
Pain management through medications is a crucial aspect of addressing persistent spinal pain after surgery. Patients often experience ongoing discomfort from chronic conditions, such as osteoarthritis, making effective medication essential for improving their quality of life. Commonly prescribed options include nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid medications, which can help alleviate pain and support recovery, especially for those facing health equity issues that limit access to other forms of treatment.
Healthcare providers play a significant role in tailoring pain management strategies to meet the unique needs of each patient. For example, those with a history of osteoarthritis may benefit from specific medication regimens that target inflammation and improve mobility. Moreover, consistent evaluation and adjustment of treatment plans can lead to better patient outcomes, ultimately facilitating a more efficient healing process and enhancing overall well-being.
Implementing Lifestyle Modifications and Exercise
Implementing lifestyle modifications, such as maintaining a healthy weight, can significantly alleviate persistent spinal pain post-surgery. Weight loss is particularly beneficial, as excess weight can place additional strain on the spine, exacerbating symptoms associated with neuropathic pain and hindering recovery. Patients should focus on a balanced diet and regular physical activity, which can promote overall health while helping to manage discomfort related to surgical scars.
Incorporating exercise into daily routines not only enhances mobility but also plays a vital role in palliative care for those suffering from chronic pain. Engaging in low-impact activities, such as swimming or walking, can improve strength and flexibility, ultimately reducing the need for pain medications, including those administered under general anaesthetic. By adopting these practical strategies, individuals can gain better control over their recovery process and enhance their quality of life.
Utilizing Psychological Support and Counseling
Utilizing psychological support and counseling plays a critical role in the effective management of persistent spinal pain after surgery. Patients often grapple with emotional stress related to their condition, which can exacerbate pain perception, especially in cases of spondylolisthesis or facet joint issues. Counseling provides patients with coping strategies tailored to their unique circumstances, enhancing overall evaluation and treatment outcomes.
Furthermore, psychological support can assist individuals in understanding the biological aspects of their pain, including how molecular biology affects nerve sensitivity. This deeper understanding can empower patients to engage more actively in their recovery process, and in some instances, it may even complement treatments like spinal cord stimulators for more effective pain management. Addressing psychological barriers becomes essential as patients work toward regaining their quality of life.
Exploring Alternative Therapies (Acupuncture, Massage)
Acupuncture and massage therapy are two alternative treatments that can provide relief for individuals experiencing persistent spinal pain after surgery. Acupuncture, which focuses on the body’s anatomy and aims to restore balance, may ease symptoms associated with conditions like complex regional pain syndrome. By stimulating specific points, acupuncture can help reduce muscle tension in the neck and leg areas, thereby alleviating discomfort and promoting a sense of relaxation. Massage therapy complements this approach by enhancing blood circulation and reducing stress, which can be beneficial in managing pain levels.
Both therapies can be integrated into a comprehensive pain management plan for patients recovering from spinal surgery. For example, patients attending regular massage sessions may notice a decrease in overall pain sensations, including those stemming from nerve-related issues or previous surgical scars. It is important for healthcare providers to consider these non-surgical relief strategies as viable options for enhancing recovery outcomes. By promoting a holistic approach to pain management, these therapies may empower patients to regain control over their healing processes.
Advanced Medical Interventions for Ongoing Spinal Pain
Advanced medical interventions for persistent spinal pain include various strategies addressing sequelae from surgery. Minimally invasive procedures offer treatment options that minimize recovery time. Spinal cord stimulation techniques can alleviate signs and symptoms of chronic discomfort, while radiofrequency ablation targets pain relief effectively. Intrathecal pain pumps provide localized medication delivery, and revision surgery is considered when instability or underlying conditions persist.
Minimally Invasive Procedures as Treatment Options
Minimally invasive procedures have become a vital option for addressing ongoing spinal pain following surgery. Techniques such as endoscopic discectomy or facet joint injections utilize smaller incisions, leading to less tissue damage and reduced recovery times. With advancements in imaging technology, such as magnetic resonance imaging (MRI), healthcare providers can accurately diagnose the source of pain, tailoring minimally invasive interventions to the specific needs of the patient.
These procedures focus on relieving pain with lower risks compared to traditional open surgeries. For instance, radiofrequency ablation can provide targeted pain relief by disrupting nerve signals with high-frequency energy, while spinal cord stimulation may alter pain perception without extensive recovery time. Patients often benefit from incorporating physical therapy into their treatment plans, enhancing recovery and improving functionality through customized physical medicine and rehabilitation strategies.
Spinal Cord Stimulation Techniques
Spinal cord stimulation techniques are emerging as a valuable intervention for patients suffering from persistent spinal pain after surgery. These techniques involve implanting a device that sends electrical impulses to the spinal cord, effectively disrupting pain signals before they reach the brain. For individuals with conditions like ankylosing spondylitis or those at risk for complications such as venous thrombosis, spinal cord stimulation can provide significant relief and enhance mobility by reducing reliance on medications.
The process of spinal cord stimulation requires careful consideration of each patient’s unique anatomy, including the positioning of nearby blood vessels and nerve pathways. Once the implant is successfully placed, patients often report considerable improvements in pain levels and overall functionality. Furthermore, this approach is minimally invasive, allowing individuals to return to regular activities sooner than they might with traditional surgical methods, thereby improving their quality of life after experiencing ongoing spinal pain.
Radiofrequency Ablation for Pain Relief
Radiofrequency ablation (RFA) is a minimally invasive procedure that provides significant pain relief for patients experiencing persistent spinal pain after surgery. By using heat generated from radio waves, RFA targets specific nerves responsible for transmitting pain signals, effectively interrupting their function. This technique aligns with advancements in neurology, as understanding the underlying mechanisms of pain can lead to improved treatment options, ultimately promoting healthier metabolism throughout the body.
The procedure is guided by imaging techniques, such as fluoroscopy or resonance imaging, to ensure accurate targeting of the affected nerves. Patients often report successful outcomes with reduced pain and improved mobility, showcasing the effectiveness of RFA as part of a comprehensive pain management strategy. As medical schools continue to emphasize the importance of multimodal approaches in the field of pain relief, understanding the epidemiology of chronic pain can help tailor interventions like radiofrequency ablation to meet individual patient needs.
Intrathecal Pain Pump Implementation
Intrathecal pain pump implementation is a valuable option for managing persistent spinal pain, particularly after surgeries like laminectomy. This advanced medical intervention delivers medication directly to the spinal fluid, allowing for effective neuromodulation that targets pain more precisely than traditional oral medications. By bypassing the respiratory system and acting directly on the central nervous system, intrathecal pumps can significantly reduce the incidence of pain and enhance overall mobility.
Another notable benefit of this technique is its potential to reduce the reliance on systemic pain relief methods such as oral opioids, which can lead to adverse side effects. In many cases, patients who have struggled with ongoing discomfort and inadequate pain control find relief through the targeted approach of intrathecal pumps. This intervention exemplifies how integrating innovative strategies into pain management can lead to improved outcomes for individuals with chronic pain conditions.
Considering Revision Surgery When Necessary
When persistent spinal pain continues despite comprehensive therapy, considering revision surgery may become necessary. Neuroscience insights suggest that certain patients may experience ongoing discomfort, including myalgia and phantom pain, due to unresolved issues from the initial procedure. By reevaluating the original surgery, healthcare providers can determine if anatomical problems, like nerve compression or scar tissue formation, warrant another surgical intervention to alleviate persistent symptoms.
Revision surgery can effectively address issues that conventional treatment methods, such as therapy and medication, may not resolve. For example, in situations where oxygen supply to the nerve tissues is compromised or chronic pain persists, a surgical approach may be essential to restore function and improve quality of life. Engaging with a qualified team of experts ensures patients receive a thorough assessment, paving the way for informed decisions regarding the potential benefits and risks of additional surgical options.
Preventing Persistent Spinal Pain in Future Surgeries
Preventing persistent spinal pain in future surgeries involves several key strategies. This includes the importance of thorough preoperative planning and education to address conditions like sacroiliac joint dysfunction. Choosing the most effective surgical approach, optimizing postoperative care and monitoring, and early intervention to address complications such as thrombosis are essential. Furthermore, maintaining regular follow-up appointments can help ensure that potential issues with the nervous system or recovery, including aspects like sleep, are addressed promptly for better outcomes.
Importance of Preoperative Planning and Education
Preoperative planning and education play a crucial role in minimizing the risk of persistent spinal pain following surgery. By collaborating closely with a physician, patients can better understand the factors impacting their recovery, including how blood coagulation affects surgical outcomes. Proper risk assessment and tailored pre-surgical guidelines from resources such as the National Institutes of Health can greatly enhance the safety and efficacy of spinal procedures.
Additionally, educating patients about their individual health conditions and the specific surgical techniques to be employed can foster a sense of preparedness and engagement in their recovery journey. For instance, understanding the impact of various organs affected during surgery can guide physicians in their approach, potentially reducing complications linked to postoperative pain. A comprehensive preoperative plan allows for strategies to be implemented early on, addressing concerns related to healing and long-term outcomes.
Choosing the Most Effective Surgical Approach
Choosing the most effective surgical approach is critical in minimizing persistent spinal pain after surgery. Surgeons should consider individual patient factors such as existing conditions, gait issues, or neck pain when planning the operation. By integrating insights from fields like immunology and emergency medicine, healthcare professionals can better assess potential complications and tailor surgical techniques to improve overall outcomes.
Using advanced imaging and diagnostic tools allows surgeons to understand the specific anatomy of the spinal cord and the surrounding tissues before surgery. This precision in planning helps in selecting the best approach, such as minimally invasive techniques that can reduce recovery time and enhance mobility. A well-informed surgical decision not only addresses the patient’s immediate needs but also focuses on long-term success, promoting better quality of life post-surgery.
Optimizing Postoperative Care and Monitoring
Optimizing postoperative care and monitoring is essential in preventing persistent spinal pain following surgery, especially in cases of failed spine surgery. Timely assessment of the surgical site allows healthcare providers to identify complications early, such as infections or issues related to nerve compression. Engaging in regular follow-up appointments ensures that patients receive personalized evaluations and adjustments to their care plans to address any emerging concerns effectively.
Additionally, effective pain management strategies post-surgery play a pivotal role in recovery. Healthcare teams should consider implementing multimodal pain control approaches, including medication adjustments and physical therapy, tailored to each patient’s recovery progress. By maintaining open communication between patients and healthcare providers, any signs of persistent pain can be managed promptly, reducing the risks associated with failed spine surgery and improving overall outcomes.
Early Intervention to Address Complications
Early intervention to address complications following spinal surgery is essential for minimizing persistent spinal pain. It involves regular monitoring of patients to promptly identify issues such as infection, nerve compression, or fluid accumulation. Healthcare professionals must stay vigilant during the postoperative phase, as timely assessment and intervention can significantly improve recovery outcomes and enhance overall patient well-being.
In addition, open communication between patients and their medical team plays a critical role in this process. Patients should be encouraged to report any unusual symptoms or worsening pain immediately. For instance, if a patient experiences increased discomfort or changes in mobility, it may indicate a developing complication that requires attention. Addressing these concerns early can lead to the implementation of effective treatment strategies and ultimately reduce the likelihood of chronic pain after surgery.
Maintaining Regular Follow-Up Appointments
Maintaining regular follow-up appointments is crucial for patients recovering from spinal surgery. These appointments allow healthcare providers to monitor healing progress, address any emerging complications, and adjust treatment plans as necessary. By keeping these scheduled visits, patients can receive timely interventions that significantly improve recovery outcomes and help prevent persistent spinal pain from developing.
In follow-up appointments, doctors can evaluate the surgical site for signs of infection or nerve compression, critical factors that may lead to ongoing pain. Additionally, these visits provide an opportunity for patients to voice any concerns or changes in their condition. Engaging in open discussions during these appointments helps ensure that any issues can be addressed promptly, contributing to a smoother recovery process and enhancing the overall effectiveness of the pain management strategies employed.