Archive for 'NMPI'

Ehlers-Danlos (EDS)

It is known that physically active patients who have stiff muscles frequently develop pain.  What is less known is that patients with overly flexible joints will also frequently develop muscle pain.

Congenital diseases, such as Marfan Syndrome and Ehlers-Danlos Syndrome (EDS), may cause joints to repeatedly dislocate, resulting in stiffness in the muscles surrounding the joint – a way that the body attempts to help the unstable joint.  The reflexive stiffness and spasms in the muscles surrounding the unstable joint cause pain.

Treatment to relax the muscles such as injections into trigger points or into the muscle attachments may do too good a job – that is, if the muscles become too relaxed, the joint may become too loose and  continue to dislocate.

An alternative treatment we have used is low level laser therapy (LLLT).  LLLT uses light energy in a narrow wavelength (810-980nm) to deeply penetrate through the skin into the muscles and tendons.  LLLT produces an increase in chemicals in the body (Cytochrome C Oxidase) that enables the production of ATP (adenosine triphosphate) which can aid in healing damaged tissue. Using LLLT to reduce pain in EDS patients has resulted in ~40% decrease in pain lasting for 3-4 weeks (or even longer!) without making the underlying muscle too loose.

Read more about EDS HERE

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In today’s world we are bombarded by information and ways to obtain it. Do you want to know how many steps you take a day? Just buy a device and it will calculate it for you. Care to know what your cholesterol levels are? Simply go get a kit at your nearest drug store. Is it possible we are gathering too much information for our own good?

The same question can be asked about medical testing. Is it useful or even helpful to know certain things about our bodies? Many of us have undoubtedly had the experience where we have gone to the doctor because we had pain and an imaging study was ordered. MRI, CT, and ultrasound can give us information about our bodies that would have been unimaginable in the past.

While technology in general is of course a huge benefit, at the Norman Marcus Pain Institute, we believe it is necessary to proceed with caution as we navigate through it all. At NMPI, one common problem we find in back pain, neck pain, and shoulder pain is the overuse and overreliance on imaging studies. “Abnormalities” are often found on imaging studies without any relation to one’s pain. In fact, seeing abnormalities is more common than seeing a “normal” spine!   For example, up to 40% of people without back pain can haveBack Pain herniated discs and as many as 70% may have degenerated discs. That is why the US Institute of Medicine suggests not getting an MRI too quickly since you are likely to see one of these problems and assume it is the cause of your pain. This can lead to unnecessary nerve blocks and surgery.

At NMPI, we often see patients who have a herniated disc, yet they only have pain in their back and buttock. They have not experienced any radiation into the leg(s) at all. In these patients, the pain generally has nothing to do with the disc herniation since disc herniation pain generally radiates down the leg and into the foot. Even when the patient is experiencing pain down the leg with a herniated disc found on MRI, muscles in the low back and buttocks may be the cause of the pain. If muscles are not examined as a potential cause, you may undergo an apparently reasonable surgery, without achieving relief of pain. Some studies show that up to 50% of spine surgeries fail (resulting in failed back surgery syndrome) and one of the reasons is the failure to identify muscles that were the true source of the pain.

Most back pain and neck pain is caused by soft tissue such as muscles and tendons. This is confusing because you may have been told your pain is from your spine, discs, or nerves. The problem is most people as they get older have signs of wear and tear on their x-rays and MRIs, but these common signs of aging may not explain your pain if the pain actually originates in your muscles. That’s why we say, when diagnosing persistent pain it’s not having “more” information at hand, it’s having the “right” information at hand.

At NMPI, we often see patients who experience persistent pain even after multiple spine surgeries. Our non-surgical, non-invasive treatment program has most of our patients leaving our office free of long standing back, neck, shoulder, and headache pain.

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Is Looking Good Worth Having Back Pain?

There is an old expression, “beauty is pain.” Does it need to be? Is it worth risking your long-term health? Why do women wear high-heeled shoes when they know that looking beautiful in the moment may cause them pain down the road? Scientists from the Universite de Bretagne-Sud recently conducted experiments, which studied the effects of high-heeled women on men. Women who wore higher heels (3-4 inches vs. 2 inch heels) were able to get more men to answer survey questions on the streets and were picked up faster in bars and clubs. These studies show some type of empowerment in women with high-heeled shoes.  heelsKnowing that this empowerment exists, and as fashion has increased the height of heels from 4 inches to 5 inches, we would like to remind you that walking for extended periods in high heels can cause calf tendons to shorten and possibly result in an increase in low back pain.

Here at the Norman Marcus Pain Institute, we see patients that run the gamut of factors causing their back pain. Prevention is always the best treatment; since low back pain affects so many of us a simple intervention is being more conscious of our shoes! While those Manolo Blahniks and Jimmy Choos may be stunning, they may be causing a problem for you down the line. At NMPI, we won’t say don’t wear them, just please, wear them in moderation.

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Is Bad Weather To Blame For Your Lower Back Pain?

A New York Times article Weather May Not Affect Back Pain, printed mid-July, cited a study showing that weather may not affect back pain. The purpose of the study was to explore the often-heard complaint from patients diagnosed with persistent pain related to muscles and bones (musculoskeletal pain) that weather changes cause an increase in pain. The study was based on an analysis of 993 patients who had seen their physician in 2011-2012 complaining of an episode of sudden back pain. These were not patients with a history of back pain.

So this article does not actually examine patients who already have back pain to see if the pain is increased with bad weather. In my practice, at NMPI, I have patients who can tell me a snowstorm is coming 3 days before it occurs. Although studies of the association between weather and pain are not uniformly supportive of the connection, a study done in 1995 of 558 patients with chronic pain found that 2/3 experienced an increase in pain and most of them prior to the occurrence of the bad weather.

bad weatherI have patients whose pain is so severe with bad weather that they can hardly get out of bed. Although there is no good scientific explanation for this association, some suggestions have been offered. When the barometric pressure falls, the air pressure in a painful joint may continue to be a little higher than the air pressure on the outside of the body, causing an increase in pain. Another explanation is that cold and/or inclement weather decreases the amount of time you are outside and active. Patients with musculoskeletal problems (i.e. muscle pain and arthritis) often feel worse with inactivity. In addition cold weather causes the blood vessels in the hands and feet to constrict, which can decrease the amount of available oxygen, resulting in increased muscle pain.

If your history indicates that bad weather causes an increase in your pain, it is likely that your flare up is most likely not an indicator of physical deterioration. Additional pain can be reasonably treated with increased medication for the brief period of weather related pain.

 

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Because of the growing problem of addiction, misuse, and diversion, 49 states have now adopted a state prescription drug database.  You may have read an article recently in The New York Times about Missouri being the only state that has not adopted such a database. In New York, as a prescriber of controlled substances, each time a patient is prescribed any type of controlled substance, I must log into the NYS website to confirm that a patient is not receiving other medications from other doctors.

prescriptionsI found a few patients who had not been honest with me and had received medications from other doctors. Unfortunately, the small occurrence of dishonest behavior has obliged all doctors to be alert for the possible misuse of medication.  At the Norman Marcus Pain Institute, I implement several rules for patients receiving any type of controlled substance from me. Here are a few of them:

•             Only one physician can prescribe all pain medications.

•             Only one pharmacy should be used to obtain all pain related medications.

•             All medications, including herbal remedies and over the counter medications, need to be reported since all medications can interact with one another.

•             Medications must be kept in a safe and secure place, such as a locked cabinet or safe.

 

Following these simple rules will help protect my patients and their families from improper use of pain medication.

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From 1991 to 2009, the number of prescriptions written for the strongest pain medications tripled. These medications are collectively named opioids and include morphine, oxycodone, and hydrocodone.Opioids are a type of pain drug that may cause serious side effects. From 2005 to 2009, the number of emergency room visits for nonmedical use of prescribed pain medication doubled. Therefore, the states and federal governments are acting to try to limit the amount of pain medication being prescribed.

At NMPI, we focus on finding the most effective treatment to relieve our patients’ pain – without surgery, steroid injections, or heavy painkillers. However, when a patient complains of severe pain and is not responding well to other pain medications, stronger, prescription opioids will be given.

 
Pain pills blog-Norman Marcus Pain Institute-blogSome opioids, such as oxycodone, are often combined with Tylenol (acetaminophen) in one pill. Some examples of these combination drugs are Lorcet, Lortab, Norco, Vicodin (are all hydrocodone and acetaminophen), and Percocet (oxycodone and acetaminophen). Most often, severe pain is related to a condition that will improve over time. Ideally, all prescription pain medications should be given only while severe pain persists. Like any medication, there are risks and side effects:

 

• Opioids can make you drowsy – which raises the risk of falling and severe injury
• Opioids when mixed with alcohol, anti-anxiety medication, seizure medication, muscle relaxants, or sleep-aids can be deadly.
• Opioids cause constipation and can lower sex drive.
• Patients can become physically and psychologically dependent on opioids.
• Overtime a patient with chronic pain can develop a tolerance for the opioid and need a higher dosage.

Keep in mind that not all pain requires such strong medication, and most patients with pain can be managed with drugs such as acetaminophen (Tylenol) and aspirin-like drugs, called non-steroidal anti-inflammatory drugs (such as ibuprofen and Naproxen). When taken as directed, these less powerful drugs may be all that you need. (There are potential serious side effects with acetaminophen and NSAIDs, which I will discuss in a future blog.) For certain pains, some drugs are better than others. Sometimes we find that a drug we have been using may not actually be effective. A New York Times article on July 23, 2014 reported that for treating low back pain, acetaminophen was no better than a placebo.

Physicians have a responsibility to properly care for patients in pain. Some of these patients may appear to be at a higher risk to abuse opioids. Occasionally, patients complain of non-existent pain to obtain opioids for its mood-altering affect, called a “high.” The fact is that physicians who had been writing too many prescriptions for pain medication are now wary of prescribing any potentially habit-forming pain drugs. This has resulted in a decrease in emergency room visits for drug overdose and deaths from overdose, but it has also resulted in depriving many patients of medication they legitimately need to function normally.

At NMPI, when we treat patients in pain who have a history of drug abuse or who test positive on a written test to determine the risk of abuse, I believe that these two basic American traditions should be the guiding principles:

1. Innocent until proven guilty; and

2. In the words of Ronald Reagan, Trust but verify. Those patients who have problems or are at risk to not properly use pain medication need extra attention, not condemnation. They may be more difficult to treat, but that is why there are specialists to deal with complex pain problems.

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At NMPI, we frequently see patients in our office with pain in their elbow. Most often it’s tennis players who complain of persistent pain in the forearm as the result of overuse from racquet sports but other sports and non-athletic activities can also put you at risk for this condition known as Tennis Elbow (TE), or lateral epicondylitis. Strain related changes in the tendons that join the forearm muscles to the outside of the elbow can be very painful.

I was not surprised to read in the British Journal of Sports Medicine, that a recent study (Strong Evidence Against Platelet-rich Plasma Injections for Chronic Lateral Epicondylar Tendinopathy: A Systematic Review) reported that PRP, which I recently reported as not being effective for hamstring injuries, is now found to be ineffective for persistent Tennis Elbow as well. PRP has been increasingly used for many painful conditions that athletes experience. This is based on the finding that in laboratory animals healing can be induced in damaged tissue if platelets are injected into the injured area. The popularity of PRP for TE has grown despite no strong evidence that it actually works. Sir William Osler, a renowned physician once said “use every new treatment as quickly as possible before it stops working.” At NMPI, we do not rush to use a “new” approach just because it is new. We are committed to eliminating our patients’ pain and preventing its recurrence.

TE is commonly diagnosed by producing pain when pressing on the tendons that attach to the lateral epicondyle along with pain when the wrist is pulled upward (dorsiflexion) against resistance. TE is generally self-limiting but in some patients it may take more than a year to get better with no treatment. When the pain and tenderness persist various treatments have been tried.

Here’s what works:

  • In a 2010 paper, an exercise treatment was found to be very effective in relieving TE pain and tenderness.
  • At NMPI, we treat these tender muscles successfully with a laser or with muscle injections.

Here’s what doesn’t work:

  • Steroids are not recommended since there is no inflammation in TE and steroids can actually damage the tendon.
  • PRP for tennis elbow has been found to not be effective

Newer treatments are often not better. It is always best to first treat any lasting pain problem with the least invasive, safest, and least expensive interventions. This is called the step-care model and the approach you will receive at the Norman Marcus Pain Institute.

tennis elbow.2

 

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PRP injections have become a frequently used treatment for painful muscle and tendon injuries despite there being no rigorous studies of its effectiveness[1]. PRP involves the drawing of blood from the injured patient, spinning it down to collect the platelets and then injecting the platelets into the injured tissue. The rationale is that platelets will provide growth factors that will make you heal faster.

A study[2] reported on in a letter to the New England Journal of Medicine found that athletes with hamstring injuries recovered no better with PRP than with placebo (a salt water injection). In a randomized double blind controlled study (RCT), in which 80 recreational and professional athletes with hamstring injuries received either PRP or placebo injections, there was no difference in the average amount of time it took for each group to return to normal activities. In other words, in this study, injections with salt water were as effective as the $1600 injection of platelets. It is often difficult to treat pain related to muscles and tendons. For anyone in pain, a suggested treatment that can get you better faster and is offered by respected physicians is hard to resist. The problem is that without carefully studying a new procedure, compared to a similar control treatment, it is not possible to be sure that the new treatment actually works better. This first RCT of PRP for hamstring injuries suggests that it may not be a reasonable approach to painful muscle injuries.

If the assessmeFusion x64 TIFF Filent of muscle pain was a routine part of the physical examination, time, money and suffering could be minimized. At the Norman Marcus Pain Institute, our approach to painful muscles following injury is based on the work of my mentor, Hans Kraus, M.D., President JFK’s physician for the treatment of his back pain. Painful muscles are frequently the result of tension, weakness, stiffness, spasm or altered muscle tissue (usually referred to as trigger points).

At the Norman Marcus Pain Institute, our physical examination tests for all these causes of pain so that the simplest cost effective treatments can be provided prior to using any invasive procedures. Sometimes severe pain is quickly eliminated with our exercise, electrical stimulation and laser protocols that are described in detail in my book End Back Pain Forever. Your pain may require medication and injections, because one size does not fit all.


 

[1] Moraes VY, Lenza M, Tamoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2013.

[2] Reurink G, Goudswaard GJ, et al. Platelet-Rich Plasma Injections in Acute Muscle Injury. N Engl J Med. 2014:370:2546-2547.

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Stiffness is an important aspect of muscle pain

I recently saw George, a 48-year-old man, who suffered from pain, described as soreness in the thighs, neck, shoulders and arms, and tingling in his calves and shin. Sitting for more than two hours or sitting for more than 20 minutes would cause an increase in his pain.  Bending over also brought on his pain.

George had tried physical therapy on multiple occasions, and saw two neurologists, who could not find anything that would explain his pain.

When I examined him, I found him to be strong but very stiff. When he bent over, he was able to reach within 14 inches of the floor. When he lied on his back and lifted one leg up at a time, he was able to reach only 57 degrees (85 75 degrees is normal). Because he was so stiff, I decided to start a course of exercises that would help increase his range of motion.

Over the next few weeks, George learned all 21 of the Kraus-Marcus exercises, which he was advised to do every day. As he did the exercises, he noticed that his pain level was decreasing and wasn’t occurring as often as usual. When he was taught the last 7 exercises, he was able to bend over to within 9 inches of the floor, and could lift each leg to 80 degrees.

A month later, George reports a 90% decrease in his overall pain.  Sometimes we find that starting with the most conservative of treatments can prevent us from performing more costly and dangerous treatments. Very often, stiffness is an important aspect of one’s pain that can easily be found and treated!

 

 

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Low Level Laser Therapy as promising treatment

Low level laser therapy (LLLT) is a promising new treatment for a variety of painful conditions which is believed to reduce inflammation and stimulate healing of wounds.  Interest in the laser first developed when Endre Mester at Semmelweis University noticed that applying the laser to the backs of shaven mice caused hair to regrow faster than those who did not receive laser treatment.[1]  This observation prompted further study into the regenerative effects of the laser first in rats, and then later in humans.

Currently, there aren’t many large-scale studies evaluating the effectiveness of the laser, but smaller studies of the laser for painful conditions show promising results.

A study of 50 patients with knee osteoarthritis reported that the laser was significantly more effective at providing pain relief than transcutaneous electric nerve stimulation (TENS)**.[2]  Similarly, a separate study of 125 patients with knee osteoarthritis reported both an improvement in pain and an increase in function after LLLT.[3]

In a study of patients with temporomandibular disorders, the laser improved pain within 24 hours, with relief lasting at the 180 day follow-up.[4]

Current studies show that the laser is an up and coming, non-invasive, non-painful treatment option, but larger studies are needed to determine the correct dosing, and for which conditions the laser will be most useful.

 

 

 

**TENS (transcutaneous electrical stimulation) – electrodes are applied to the skin, sending an electric current to the nerves in the skin. The nerves then transmit a signal to the brain. This signal is competing with the signal coming from your painful area. So, instead of feeling your normal pain, you’ll feel a buzzing sensation where the electrodes are attached.



[1] Chung, Hoon, Tianhong Dai, Sulbha K. Sharma, Ying-Ying Huang, James D. Carroll, and Michael R. Hamblin. “The Nuts and Bolts of Low-level Laser (Light) Therapy.” Annals of Biomedical Engineering 40.2 (2012): 516-33. Print.

[2] Kędzierski, Tomasz, Katarzyna Stańczak, Kamila Gworys, Jowita Gasztych, Marcin Sibiński, and Jolanta Kujawa. “Comparative Evaluation of the Direct Analgesic Efficacy of Selected Physiotherapeutic Methods in Subjects with Knee Joint Degenerative Disease – Preliminary Report.” Ortopedia Traumatologia Rehabilitacja 14.6 (2012): 1-10. Print.

[3] Gworys, Kamila, Jowita Gasztych, Anna Puzder, Przemysław Gworys, and Jolanta Kujawa. “Influence of Various Laser Therapy Methods on Knee Joint Pain and Function in Patients with Knee Osteoarthritis.” Ortopedia Traumatologia Rehabilitacja 14.3 (2012): 269-77. Print.

[4] Pereira, T. S., O. D. Flecha, R. C. Guimaraes, A. M. Botelho, JC Ramos Gloria, and K. T. Aguiar Tavano. “Efficacy of Red and Infrared Lasers in Treatment of Temporomandibular Disorders–a Double-blind, Randomized, Parallel Clinical Trial.” Cranio : The Journal of Craniomandibular Practice 32.1 (2014): n. pag. Ovid. Web.

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Small changes may make a big difference to your neck pain

There has been an increase in the number of hours we sit in front of a computer for leisure and work. Does your job require you to stare at a computer for hours at a time? One study found that workers sitting for 95% of the day, and/or worked with their neck at 20˚ or more in flexion for more than 70% of their working time, had a significantly increased risk of neck pain[1].

An ergonomically designed workstation would help reduce the strain on your muscles. Here are a few suggestions:

  • Place your monitor so you are looking at it straight ahead or down at no more than a 15˚ angle.
  • The monitor should be 18-24 inches away.
  • The angle of your elbows when typing on the keyboard should be > 90 degrees.
  • An ergonomic mouse or keyboard may also help.
  • A laptop is always non-ergonomic; because the monitor and keyboard cannot be separated one or the other is in the wrong position.  If you always use a laptop think about getting an auxiliary keyboard.
  • Footrests should be used if your feet do not rest flat on the floor.
  • If you use a phone frequently get a headset so you will not have to hold the handset to your ear.

Aside from these changes, you may also consider doing limbering activities such as small stretches throughout the day – shrug your shoulders a few times, move your arms above your head, or get up and walk around your chair.



[1] Ariens, G. AM, P. M. Bongers, M. Douwes, M. C. Miedema, W. E. Hoogendoorn, G. Van Der Wal, L. M. Bouter, and W. Van Mechelen. “Are Neck Flexion, Neck Rotation, and Sitting at Work Risk Factors for Neck Pain? Results of a Prospective Cohort Study.” Occupational and Environmental Medicine 58 (2001): 200-07. BMJ Group. Web.

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How antidepressant medication can affect your pain

Many patients with chronic pain become depressed; therefore it is not surprising that many of these patients will receive antidepressant medications. What is very interesting is that these antidepressants not only can decrease depression associated with pain, but they can also decrease pain itself. They are frequently used to treat persistent pain associated with problems in nerves. The reason that antidepressants are effective for pain is that the chemicals in the nervous system that are associated with depression also are associated with pain.

Pain pills blog-Norman Marcus Pain Institute-blog

Antidepressants increase the available amounts of chemicals which affect your mood.  These chemicals include serotonin, norepinephrine, and dopamine.  The two most common types of antidepressants are:

  1. SSRIs (Serotonin Specific Reuptake Inhibitors) – Antidepressants which only increases the amount of serotonin available.  Examples of SSRIs are escitalopram (Lexapro), fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft).
  2. SNRIs (Serotonin/Norepinephrine Reuptake Inhibitors) – Antidepressants which increase the amount of serotonin and norepinephrine available.  Examples of SNRIs are venlafaxine (Effexor) and duloxetine (Cymbalta).  Examples of Tricyclic Antidepressants (a type of SNRI) are amitriptyline (Elavil), and nortriptyline (Pamelor).

SSRIs are not as effective for pain relief as SNRIs.

Even though the antidepressants may help diminish pain, their side effects can be unacceptable.  A recent review found that although approximately 1/3 of patients who took antidepressants for neuropathic pain experienced moderate pain relief or better, 1/5 discontinued use due to adverse side effects.[1]

Common side effects of antidepressants are nausea, dizziness, insomnia, weight gain/loss, dry mouth and diminished interest in sex (decreased libido). If you’re not having reasonable pain relief with one of these medications, it should not be continued.



[1] Saarto, T., and P. J. Wiffen. “Antidepressants for Neuropathic Pain: A Cochrane Review.” Journal of Neurology, Neurosurgery & Psychiatry 81.12 (2010): 1372-373. Print.

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NSAIDs for pain relief

The next series of blogs is a brief discussion of different types of medications used for pain.

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) are generally one of the first line of medications used in the initial treatment of pain. They are exactly what their name means – they are not steroid medications (like cortisone or prednisone) and they reduce inflammation which is the body’s response to any damage from any cause. When inflammation occurs there is pain along with redness, swelling and heat, which are collectively known as the cardinal signs of inflammation. Examples of NSAIDs are ibuprofen (Advil/Motrin), naproxen (Naprosyn), meloxicam (Mobic), and diclofenac (Voltaren). Aspirin is similar to the NSAIDs in almost every way but curiously it helps prevent heart attacks whereas NSAIDs may cause them (see below).

PillsAlthough NSAIDs have a number of side effects, the two most common are stomach irritation and an increased tendency to bleed. That’s why you are advised to eat when taking NSAIDs and why you have to stop taking NSAIDS before any type of intervention that may cause bleeding (such as injections or surgery).  In order to decrease the side effect of stomach irritation, many have switched to a topical NSAID, most commonly diclofenac which is offered as a patch (Flector-patch) or gel (such as diclofenac or Voltaren gel). Other potentially serious side effects include kidney failure – if your kidneys are not working properly the NSAID can cause them to stop functioning, asthmatic episodes if you are prone to having asthma, and heart attacks if you have cardiovascular disease (heart disease, high blood pressure, history of stroke).

 

 

Image courtesy of anekoho/FreeDigitalPhotos.net

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Case Study: Low Level Laser Therapy

Gregory is a 29 year old manager whose job requires that he travel often.  He came to see me for pain at the back of the left side of his neck which he often felt upon waking up, and during or after jogging over the past 4-5 years.  An MRI showed that his neck did not have any significant spinal abnormalities that might be causing his pain, but a physical examination revealed three muscles that were likely the source of his pain.

I began treating Gregory with a 15 watt class 4 laser.  On his second day of treatment, he reported that he felt no pain in the left side of his neck when he woke up, but that the pain had moved to the right side of the neck and shoulder.  I continued treating the left side of his neck, and also began to treat the right side with the laser.

When he returned for the third day of treatment, the pain in the left side of his neck was completely gone, and the right side’s discomfort was significantly reduced.  At a two month follow-up, his pain was gone.

He is now able to go jogging without any pain in his shoulders or neck.  By starting with a conservative treatment approach, Gregory was able to avoid invasive or costly procedures, and regain function.

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Treating trigger points in muscles

The most common method in treating trigger points is with trigger point injections. Simply put, trigger point injections are needles being placed into the taut, tender points of the muscle. However, there are different techniques in injecting the muscle fibers.

There are two major types of needles used in injecting the muscle. With dry needling, it is common to use acupuncture needles[1], which are small, thin and flexible. When a liquid is injected in the muscle (such as saline or lidocaine), hypodermic needles are used, which is a hollow needle that is generally thicker and is not flexible.

Different fluids (injectates) can be used in trigger point injections. Lidocaine or bupivacaine are commonly used, which are numbing agents. Corticosteroids and botulinum toxin (better known as Botox) are also used, in hopes that the injectate would reverse the changes in the trigger point rather than just the needle causing minor damage and inflammation which is thought to lead to regrowth of normal muscle fibers. Still others have used saline. Studies have shown that it didn’t matter what was injected into the muscle[2]; there was not a noticeable difference in pain relief between the different injected substances. Also, dry needling injections seem to be just as effective as injections with any substance, suggesting that what is injected is not what causes relief but rather the physical needling of the muscle.

Other treatments used for trigger points include:

-TENS (transcutaneous electrical stimulation) – electrodes are applied to the skin, sending an electric current to the nerves in the skin. The nerves then transmit a signal to the brain. This signal is competing with the signal coming from your painful area. So, instead of feeling your normal pain, you’ll feel a buzzing sensation where the electrodes are attached.

-“spray and stretch” – a technique in which ethyl chloride spray (or a comparable cold) is used to numb a painful area, followed by gentle stretching

-ultrasound

-low level laser

The fact that so many different approaches claim to be effective indicates that there is confusion concerning the understanding and treatment of pain thought to be coming from trigger points.  All muscle pain is not caused by trigger points.  My associates and I discuss the need for a comprehensive approach to muscle pain in a study published in Pain Medicine[3]. (This article can be accessed here.

 


 


[1] Mense, Siegfried, and Robert Gerwin. Muscle Pain: Diagnosis and Treatment. Heidelberg: Springer, 2010

[2] Cummings, T.Michael, and Adrian R. White. “Needling Therapies in the Management of Myofascial Trigger Point Pain: A Systematic Review.” Archives of Physical Medicine and Rehabilitation 82.7 (2001): 986-92.

[3] Marcus, Norman J., Edward J. Gracely, and Kelly O. Keefe. “A Comprehensive Protocol to Diagnose and Treat Pain of Muscular Origin May Successfully and Reliably Decrease or Eliminate Pain in a Chronic Pain Population.” Pain Medicine 11.1 (2010): 25-34.

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What are trigger points?

Have you ever felt a painful tightness that just won’t go away no matter how much you stretch? Even if the pain subsides or goes away temporarily, when it recurs you still feel a tender knot that’s always in the same area. This may be due to trigger points (TrPs).  TrPs are tender nodules which can cause pain and are found in a taut band of muscle tissue.  This taut band is formed from a small group of contracted muscle fibers which will make that region of your muscle feel hard and tender.  TrPs are sensitive to pressure and movement. Pressing on a trigger point will cause pain.

Muscle Fiber

TrPs can be classified as either active or latent.  A latent TrP is one that causes pain when palpated, or pressed on, but not spontaneously while resting.  An active TrP can cause spontaneous pain – either at rest, in use, or while being pressed.  If there is enough stress – for example, from too much exercise, a latent TrP can transform into an active TrP.

The cause of TrPs is still being studied, however, there is speculation that the taut band appears in the muscle first without any tenderness or irritation.  With additional stress, the hardened area becomes tender to the touch (a latent TrP), and finally, may progress to producing spontaneous pain as an active TrP.  The initial hardness in a band of muscle fibers can be caused my multiple factors:  injury, overstretching, or over-exercising.

TrPs can be a debilitating source of pain. They can cause weakness and lack of coordination in the muscles where they are found. Next blog, we will discuss common treatment options for trigger points.

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Muscles as the source of pain

Muscles are the largest organ system in the body, accounting for approximately 50% of our body weight.  We have different ways of categorizing muscles: how they look, how they move, and where they’re located. We are going to focus on muscles that move voluntarily, which means we tell the muscles to move, as opposed to involuntary muscles, which automatically move on their own (like our heart and blood vessels). There are 641 muscles in the body – 340 pairs (meaning we have one on the right, and one on the left), and one unpaired (which is the transverse arytenoid for those who must know).

Back Pain

70% of lower back pain is diagnosed as idiopathic or non-specific[1], which means we are not sure what caused the pain. However, most investigators believe that sprains and strains of the soft tissue are the source of pain. Soft tissue refers to muscles, tendons, and ligaments. So it may be surprising that the emphasis in evaluating and treating lower back pain, neck pain, and shoulder pain, is on the spine and the nerves coming out of the spine. In fact, from 1997 to 2005, the prevalence of the diagnosis of spine-related issues has increased 100% while the diagnosis of strains and sprains of soft tissue has gone down by 40%[2].

This is generally attributed to the increase in the use of high-tech imaging studies, such as MRI and CT scans.  However, just because we have a clearer image of what’s going on inside of your body doesn’t mean that we have a clearer understanding of what’s causing your pain. More than 90% of lower spine MRIs exams in adults are abnormal[3]. Studies have found that up to 40% of people have herniated discs and as many as 70% have degenerated discs with no pain. If people can walk around with abnormal spines without pain, then this means that abnormalities in the spine aren’t always the cause of pain. Your diagnosis of a herniated disc, spinal stenosis, or spondylosisthesis may actually be unrelated to your source of pain.

Muscles are often ignored when it comes to diagnosing pain. I believe the reason is that we rarely evaluate muscles as a source of pain. We generally don’t learn about or understand how they work, what chemical changes take place inside, and how they produce pain (the pathophysiology). I would like to take the next few blogs to discuss how muscles contribute to your chronic pain.



[1] Deyo, RA., et al. Low Back Pain. NEJM. 2001; 344(5):363-370

[2] Martin, B., et al. Expenditures and health status among adults with back and neck problems. JAMA. 299(6):656-64, Feb 2008.

[3] Zimmerman, Robert D. “A Review of Utilization of Diagnostic Imaging in the Evaluation of Patients with Back Pain: The When and What of Back Pain Imaging.” Journal of Back and Musculoskeletal Rehabilitation 8 (1997): 125-33.

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