If the cost of health care is to be reduced in the US, new methods should be established to pay clinicians, pharmaceutical companies and device manufacturers. If graduating medical students are so laden with debt that paying it off is more important than the possibility of ongoing study and academic pursuit, we must lower the cost to the student of medical education. If the cost of drug development is so high that huge prices must be charged for pills, we must find ways to reduce the cost of development of new pharmaceuticals. These fundamental issues in health care have an impact on the standard of care of back pain in the USA. Read the rest of this entry
Author Archive
How can we know what back pain treatments make sense?
Monday, July 1st, 2013 at
10:32 AM
Bedside Manner and the power of suggestion in back pain
Sunday, June 30th, 2013 at
6:30 PM
Prior to drawing blood, saying a word to patients that suggested pain increased the likelihood of them experiencing pain. You might think of this study as just another example of the importance of “Bedside manner”- the awareness of the importance of the behavior and speech of the physician or other care-takers, on the feeling of well-being of the patient. Eugene Bauer, M.D., a Viennese physician, said in 1931: “A word in the mouth of a physician is as important as the scalpel in the hands of a surgeon”. Words can cut, soothe, and rattle. How you are approached by a doctor is determined not only by their personality but also by the beliefs concerning your problem.
Obesity, poverty, and community influence- back pain
Sunday, June 30th, 2013 at
6:28 PM
Obesity is more prevalent in neighborhoods with a high incidence of poverty. A study in the New England Journal of Medicine showed that encouraging families to relocate to higher income neighborhoods could lower the rate of obesity and signs of diabetes. This finding may lead to a better understanding of how we can combat the obesity epidemic. Read the rest of this entry
End Back Pain Forever: Chapter 2, part 5 #endbackpain
Thursday, May 31st, 2012 at
10:00 AM
In this next segment, I take Hans up on his offer to examine one of my patients. Read what happens next!
Click here for the Part 4 segment.
Chapter 2
You Are Not Alone: The Back Pain Epidemic (Part 5)
Dr. Kraus and I met a week later at Lenox Hill. I had chosen a patient whom I shall call Beth. She was a forty-five year-old woman so defeated by pain after three unsuccessful spinal operations that she could no longer hold a job. Her life had revolved around her work, which was at the core of her sense of self. She was devastated. No one had found a truly successful treatment for her, and I did not believe that anyone could. She was on high doses of morphine, 60 milligrams orally five to six times a day, to relieve her pain.
After reviewing her case history, Dr. Kraus gave her a comprehensive and thoughtful mental and physical examination. Starting with her neck, he used his fingertips to palpate her muscles to distinguish between those that were supple and pain free and those that were stiff and painful. He found five pairs of painful muscles on both sides of the lower back, buttocks, and thighs. “If these muscles are treated properly,” he told me, “it should reduce or eliminate her pain.” Read the rest of this entry
End Back Pain Forever: Chapter 2, part 4 #endbackpain
Monday, May 28th, 2012 at
10:10 AM
This excerpt from my book End Back Pain Forever, is about my mentor and friend, Dr. Hans Kraus. He changed the way I viewed pain and the treatment of pain, and enhanced my life and ultimately my patients’ lives for the better.
Chapter 2
You Are Not Alone: The Back Pain Epidemic (Part 4)
Then, in 1993, I met Dr. Hans Kraus. He was to transform my life and the life of my patients. He was eighty-five years old and had just retired from his practice as a specialist in physical medicine and rehabilitation. He had also given up mountaineering and rock climbing. In all those pursuits, he had won international acclaim. Originally trained as an orthopedic surgeon at the University of Vienna, Dr. Kraus was well known for having successfully treated President John F. Kennedy’s back after all prior treatments had failed. Yet his nonsurgical approach to treating patients with muscle pain, especially low back pain, was not accepted by other doctors, including some of the very doctors who referred their own patients to him for what proved to be successful treatment.
For example, one prominent orthopedic surgeon at the Columbia University School of Medicine, Dr. Frank Stinchfield, who routinely sent many of his back pain patients to Dr. Kraus, underwent spinal surgery rather than consult him for his own back pain after a herniated disk was diagnosed. The surgery failed, and Dr. Stinchfield was never able to work again because of unrelenting pain.
Another disappointing example was that of Dr. Jonas Salk, best known for developing the first safe and effective polio vaccine. Dr. Salk did consult Dr. Kraus for back pain, and the treatment was successful. It eliminated Dr. Salk’s pain and allowed him to avoid surgery. Yet when Dr. Kraus needed Dr. Salk’s help to obtain research support, the famed medical researcher declined. He said that muscle pain didn’t have a “scientific foundation.” That has since changed, and we will look at the basic research explaining the mechanisms of muscle pain in Chapter 4.
In our first meeting, Dr. Kraus asked what I did. I told him that I treated patients with chronic pain.
“How do you do that?” he asked.
“I teach them how to manage their pain, how to deal with it, live with it.”
“Why not get rid of their pain?”
“Because it’s chronic pain,” I said. “You can sometimes reduce it, but you can’t get rid of it.”
He persisted. “Have you treated the muscles?”
“We treat the muscles with aerobic exercises.”
“Aerobic exercises? Really? Muscle pain caused by muscle spasm, tension, stiffness, and trigger points does not respond to aerobics. But it will respond to other types of exercises: prescribed exercises designed to treat the specific source of pain. That’s what I’ve done.”
“Low-impact aerobics are the standard way,” I said.
“They may be the standard way,” he replied. “But they are sure to make many of your patients feel worse.”
He asked if I had “very difficult cases,” and I told him that I did. “Some,” I added, “are impossible to treat.”
“Would you mind if I were to examine one of them?”
——————————————————————————————————————————————–
End Back Pain Forever: Chapter 2, part 3 #endbackpain
Thursday, May 24th, 2012 at
10:00 AM
This excerpt from my book End Back Pain Forever, provides a small summary of my early involvement in pain medicine.
Chapter 2
You Are Not Alone: The Back Pain Epidemic (Part 3)
In 1975, I became a staff physician in the Montefiore Department of Neurology’s Headache Unit, founded by Dr. Arnold Friedman. Two years later, with Dr. Edith Kepes, an anesthesiologist at the hospital, we started the first outpatient pain center in New York City, effectively following the lead of Dr. John J. Bonica, a medical giant to whom we owe the study of pain as a recognized discipline. As a young army anesthesiologist during World War II, he pioneered pain-relieving techniques and treated ten thousand wounded soldiers. Dr. Bonica went on to write a 1,500-page medical classic, The Management of Pain, Dr. Kepes and I began a team approach with practitioners from different fields – including colleagues from anesthesiology, neurology, orthopedic surgery, neurosurgery, physiatry, psychiatry, and psychology – all of whom were interested in what could be done for patients tormented by chronic pain.
I subsequently expanded on this concept by starting the New York Pain Treatment Program at Lenox Hill Hospital in 1983. It was considered a state-of-the-art treatment center in a hospital setting, with an integrated team that involved not only doctors but also physical and occupational therapists, psychologists, and pain rehabilitation nurses. We used a variety of treatments: biofeedback and relaxation training; physical therapy to increase strength, mobility, and endurance; hypnosis to help control pain; stress management to provide coping skills for handling daily upsets that may increase muscle tension; occupational therapy to teach patients how to complete their routine tasks effectively through proper time management; individual, family, and group psychotherapy to resolve personal difficulties related to living with chronic pain; and medication management to eliminate many ineffective drugs that patients were taking in their journeys from doctor to doctor.
But our program had a basic flaw. We were convinced that teaching people how to live with their pain was usually the best we could do. We didn’t believe that we could eliminate their pain. Many of our patients remained on strong medication indefinitely. If a patient had a 35 percent decrease in pain, I considered that good. If we got it down to 50 percent, it was considered a success.
Along with the vast majority of physicians, I was committed to the fallacy that most chronic pain couldn’t be cured. Then, in 1993, I met Dr. Hans Kraus. He was to transform my life and the life of my patients.
——————————————————————————————————————————————-
End Back Pain Forever: Chapter 2, part 2 #endbackpain
Tuesday, May 22nd, 2012 at
10:00 AM
I wrote End Back Pain Forever to open up a discussion on back pain and provide insights on effective treatments. I have posted the first two chapters of the book on my blog.
Chapter 2
You Are Not Alone: The Back Pain Epidemic (Part 2)
As a physician specializing in pain medicine, I know how intimately mind and muscles interact. I can literally see a patient’s mental stress in tense, taut muscles. Early on in my training at Montefiore Medical Center in psychosomatic medicine, which is the study of how the mind and body interact, I could see that the separation of mind and body in medical practice made little sense. This drew me to a newly introduced technology, biofeedback, which enabled me to integrate my medical education with my psychiatric practice at the time.
End Back Pain Forever: Excerpts from Chapter 2 #endbackpain
Monday, May 21st, 2012 at
3:05 PM
Chapter 2 of End Back Pain Forever delves into the ever-increasing problem of the back pain epidemic. Please review this blog for Chapters 1 and 2 from my book.
Chapter 2
You Are Not Alone: The Back Pain Epidemic
If you suffer from back pain, you are not alone. The widespread failure by doctors to recognize muscles as the primary source of back pain is helping to fuel an epidemic. Back pain is now the most common disability in the United States. Every year twelve million Americans make new-patient visits to physicians for back pain and a reported one hundred million visits to chiropractors. At the current rate, eight out of ten Americans will experience back pain sometime during their lives.
In addition to the human suffering, medical costs are soaring. The cost of back pain, together with related neck pain, came to $86 billion in 2005, the most recent year for which figures were available. That was an increase of $34 billion from 1997. More amazingly, 25 percent of patients reported being significantly impaired, compared with 20 percent eight years earlier. Spending on back pain now equals the amount spent on cancer and is largely the result of failed surgeries, various nerve block procedures, and the cost of pain medications. We are spending more and getting worse results.
Why does back pain appear to move or change intensity?
Tuesday, January 24th, 2012 at
7:52 PM
There are three different mechanisms that affect your back pain when it is related to muscles- and that means most of the pain you will experience in your life.
1. Referred back pain patterns- Pain may be referred from one muscle to another when the nerves carrying painful sensations in a muscle stimulates the same area in the spinal cord as an adjacent muscle.
2. Central sensitization- When a painful area of the body stimulates the spinal cord and makes the cord more active, other sensations coming in to the cord that would usually not be experienced as painful are now experienced as pain- like turning up the volume on your stereo and hearing things that you don’t hear when the volume is low. So when the original area of damage causing the pain is properly treated the other scattered areas of pain may disappear.
Read the rest of this entry
Your bulging disc is not what’s hurting
Friday, January 6th, 2012 at
6:24 PM
Two days ago I reported on a study that showed we are frequently doing a disservice to patients in inappropriately ordering imaging studies such as MRIs. Yesterday I saw a patient who could be the poster person for the study. This patient had a back injury one year ago when a fall onto the buttock produced lasting severe low back pain. The pain doesn’t radiate-it is only in a discrete area on the buttock. She felt a tender sensation when the area was pressed.
Despite the obvious findings suggesting the cause of her pain was muscle and not spine and nerves coming from the spine, an MRI was ordered and it showed a bulging disc and she was told this was the cause of her back pain. She has had a variety of physical therapy interventions and injections without relief.
Her physical examination showed that she could touch her toes and her straight leg raising was 90 degrees, rarely if ever seen with a patient whose pain was the result of a disc. She did have two muscles, the Gluteus Maximus and Piriformis, which were tender when stimulated by the Muscle Pain Detection Device. This showed that these muscles were the probable cause of her pain. A ketamine based cream was applied to the skin over these muscles and her pain was gone, further supporting the connection between the muscles identified and her long-standing back pain.
Read the rest of this entry
Hip pain and surgery
Tuesday, November 15th, 2011 at
6:27 PM
A bony abnormality of the hip called Femoral Acetabular Impingement Syndrome (FAIS), where the head of the femur (the thigh bone) is found to be irregularly shaped rather than its “normal” spherical shape, is sometimes treated with a surgical procedure to shave the head of the femur. FAIS can affect young individuals in contrast to osteoarthritis (OA) of the hip which usually occurs in older patients. It is thought that FAIS can cause pain in the hip, and can in addition if left untreated, result in OA. Read the rest of this entry
Osteoporosis Prevention and Treatment
Saturday, September 17th, 2011 at
6:31 PM
Osteoporosis in women is a growing public health challenge with an aging population. New approaches are needed to prevent and treat decreases in bone density and strength. Two recent articles present different and potentially complementary approaches.
Diet: Lanou reviews the studies on soy diets for the prevention of osteoporosis and bone fractures. Although the results are not consistent, soy based diets that are part of a diet rich in fruits and vegetables appear to be effective. Other studies have suggested that such a diet has a wide range of health promoting effects. Although there is not yet strong enough evidence to suggest that everyone become a vegetarian, at least for women, increasing the amount of fruits and vegetables and having soy in your diet, is a good idea.
Read the rest of this entry
How to decrease headache frequency
Thursday, June 9th, 2011 at
6:33 PM
A recent study of a simple resistance exercise program for the neck and shoulders, in office workers who complained of weekly headaches (HAs), showed an approximately 50% reduction in HA frequency vs. a weekly health education control group. The exercise groups were 2 minutes or 12 minutes of daily exercise. The remaining HAs were no different in terms of intensity or duration of pain.
HAs are the most commonly reported pain problem. If brief exercise could have such a dramatic effect on HA frequency, it should be considered as a standard intervention for all office workers who appear to have muscle tension type headaches. However it is not clear why neck and shoulder exercise reduce HA frequency. It is understandable that exercising muscles that are tense and stiff from repetitive strain, for example bending your head and neck over a desk for hours at a time, could help relax stiff and tense muscles. which can cause back and neck pain. But just performing an action to address HAs on a daily basis may make you more aware of the circumstances surrounding a headache episode. Since headaches are frequently brought on with emotional stress, being more aware of and addressing stress has been shown to reduce HA frequency through various interventions.
Read the rest of this entry
New possibilities for painful knees
Friday, May 27th, 2011 at
6:39 PM
The body can sometimes heal itself in painful conditions. A study of patients with painful osteoarthritis of the knee showed that by mechanically separating the bones in the knee that were touching and causing pain, cartilage regrew and pain and function improved. No other treatment is available that can produce structural change in an existing osteoarthritic joint. This is a potentially revolutionary discovery, and if shown to be effective in larger studies, may help patients with knee pain avoid or forestall knee replacement surgery. And give at least some temporary pain relief.
~ Norman Marcus, MD Norman Marcus Pain Institute, New York NY “Your New York City Pain Relief Doctor”Above all else, do no harm!
Tuesday, May 24th, 2011 at
6:34 PM
In our desperate wish for pain relief, we sometimes receive treatment that is harmful. One of those treatments may be botulinum toxin, frequently provided as Botox injections to tender muscles. A recent article showed how Botox could produce permanent damage in muscles with normal muscle fibers being replaced with fat cells.
Read the rest of this entry
Knee pain, back pain, and muscles
Thursday, May 12th, 2011 at
6:36 PM
A large study of army recruits demonstrated the protective effect of exercise on the development of knee pain. Male and female recruits who performed 4 stretching and 4 strengthening exercises for 7 weeks, were 75% less likely to develop anterior knee pain.
Read the rest of this entry
Follow-up to recent Failed Spinal Fusion post:
Friday, April 15th, 2011 at
6:41 PM
The patient mentioned in the blog posted in March, 2011 copied me on an email he sent:
“I’ve been waiting for clearance from my surgeon who finally declared my fusion as failed (FBSS) in early March and offered no additional hope for pain reduction. At one-year post surgery I could be evaluated for an implanted morphine pump or spinal cord stim. Pain management started experimenting with oxymorphone and hydromorphone, which both had bad side effects and were less effective than the oxycodone. I’ve had the first two weeks of treatments with Dr. Marcus. The first week he did my left side lower back and leg, this Monday he did the right side lower and mid back. Pain reduction is at least 90%! I have much more energy, am more active and I’m beginning to feel flexible. He is also working on my mid-back and legs. I’ve been able to reduce oxycodone from ~180mg+/day to 60-80mg/day.”
Read the rest of this entry
MRI, CT, and X-rays may mistake the cause of your back pain
Friday, January 28th, 2011 at
6:43 PM
MRI, CT and X-rays may fool us. A recent article concluded that the amount of constriction of the nerves exiting the lower spine thought to be the reason for back and leg pain was not correlated with the amount of relief a patient experienced with steroid injections around that nerve(s).
Beautiful clear pictures of the spine and nerves seduce us into believing we can see the reason for the pain. Focusing too much on imaging and not enough on the physical examination, results in many patients receiving surgery and nerve blocks that were assumed to be the right treatment but didn’t relieve the pain. Did that happen to you?
Read the rest of this entry
Obesity and Understanding BMI with back pain
Tuesday, December 21st, 2010 at
6:46 PM
People in all industrialized countries are being harmed by a world-wide obesity epidemic. We generally determine if we are the proper weight by calculating the BMI (Body Mass Index): dividing your weight in pounds x 703 by your height in inches squared. If you weigh 140 pounds and are 5 feet, 8 inches, your BMI would be 21.28-
(140 x 703/68 x 68). Normal is 18.5-24.9, overweight is 25-29.9 and obese is over 30. A study of patients in 30 European countries found that over 70,000 new cancer cases were attributable to excess BMI in 2002. Obesity is also associated with an increased incidence of diabetes, hypertension, arthritis, coronary artery disease and dementia.
Read the rest of this entry
Painless back and muscle injections
Friday, December 10th, 2010 at
6:53 PM
Pain is a deterrent to many patients when offered a therapeutic injection. There is some encouraging news on ways to make injections more comfortable.
A Cochrane review found that adjusting the pH, with bicarbonate, of a lidocaine injectate for local anesthesia, reduced the discomfort for patients without reducing analgesic effectiveness. The burning sensation produced by the acidic pH of lidocaine injectable is diminished by adjusting the pH upwards from the 3.5 -7.0 usually found in commercial preparations, to approximately 7.4.
Read the rest of this entry
END BACK PAIN FOREVER
by Dr. Norman Marcus
If you or someone you love has been suffering with back pain, this book could change your life.
