back pain posts Archives

The Start of Baseball Season

The baseball season just opened and already players are calling off their first few games due to “tweaked knees” and “sore backs”. As the sun is starting to come out, and the snow is (FINALLY!) melting, many of us are anxious to get outside and start playing sports again. However, this is also a time where pain can start rearing its ugly head. Many people forget to limber and stretch properly before AND after playing sports, causing strains and sprains of muscles.baseball

So keep in mind these important tips to get moving again this spring:

  1. Do gentle limbering stretches every day to help maintain flexibility of your muscles.
  2. Stretch before and after any exercise.
  3. Start slowly – if you haven’t moved all winter, start with simple exercises, like walking, before starting anything more difficult.
  4. If you’re feeling extremely sore the following day, it means you may have done too much. Cut back on the difficulty and amount of time the next time you exercise. Slowly increase the difficulty and the length of the session. A safe rule of thumb is to start out after a long layoff at 50% of your prior routine and then increase 15-20% every 5-7 days as long as you feel okay at any level before going to the next.
  5. Drink lots of water!
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Acetaminophen

The BMJ (what used to be called the British Medical Journal) just published an article stating that acetaminophen (ie Tylenol) has been found to provide no relief in low back pain (compared to a placebo). Acetaminophen was also related to a risk of having an abnormal liver test. The article included data from 13 randomized controlled trials (RCTs).

An RCT to evaluate a drug is a research study where one group of people receives the actual drug (in this case, acetaminophen) and the other group receives a placebo (a pill with no active ingredient, generally a sugar pill). Then, data is collected from both groups to see if either achieved any painTylenol relief. In this analysis, it shows that whether you receive acetaminophen or a sugar pill, you had the same amount of pain relief – meaning that active drug had no real pain relief effect.

Although most of the patients I see find no relief from acetaminophen, a small percentage of patients do, so don’t completely dismiss this drug when it comes to helping your pain. However, if you do take acetaminophen, make sure that you’re not taking too much. The FDA recommends taking less than 3000mg a day. This means if you’re taking Extra Strength Tylenol (500mg), you can only take 6 pills a day, or regular strength, 300mg, 10 pills a day. Higher amounts can lead to liver damage that could even be life-threatening.

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Smoking and Back Pain – is it related?

We all know that smoking is bad for you. In fact, since 1965, the Surgeon General’s Warning posted on every package of cigarettes says: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy. But did you know that in addition to the myriad of illnesses that are related to tobacco and smoking, recent studies show that smokers have a higher prevalence of back pain than non-smokers? It’s true.

Several studies in the 1980s and 1990s have shown a correlation between smoking and increased back pain.  More recently, a smokingmeta-analysis was done in 2010, which basically means a large number of studies (in this case, 40) were put together, and the results were compared to see what pattern, if any, existed between back pain and smoking. This meta-analysis concluded that current and former smokers have a higher prevalence of back pain. It even made the comparison between adult smokers to adolescent smokers; adolescents showed a higher prevalence of back pain. Therefore, we can conclude, the earlier one smokes, the greater risk to your back.

Is there a technical or medical reason behind this connection? Indeed. Smoking causes constriction of blood vessels, which reduces the amount of blood going to your muscles. Decreased blood results in decreased oxygen, which is one of the most important factors in initiating muscle pain. Some smokers actually had parts of their arms and legs amputated because of dead tissue caused by too little oxygen.

Do you want be free of back pain? Put out that cigarette and quit smoking!

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Spinal Surgery for Lumbar Stenosis

A recent study was published in the Journal of the American Medical Association, analyzing spinal surgeries done on Medicare patients who were diagnosed with lumbar stenosis.

Let’s rewind – what is lumbar stenosis? Lumbar refers to the lower part of the spine, where we would normally identify as low back. Stenosis refers to the narrowing of the bones in the spine, often pushing or compressing the nerves that being in the spinal cord and extend into your legs. Spinal stenosis is often associated with pain and numbness in the leg.

When a patient is diagnosed with lumbar spinal stenosis, a wide variety of treatments are offered. If the spinal stenosis is actually causing pain and difficulties functioning, such as walking, you would imagine that exercise and physical therapy would have little or no effect. However, pBack Painhysical therapy and exercise are frequently prescribed and may reduce symptoms. This means that at least some of the pain is from muscles and that the picture seen with the CT or MRI showing the nerves being compressed wasn’t accurately showing the reason for all the pain. Without a thorough examination of the muscles in the lower body, we may overlook an easily treated source of pain.

Overreliance on imaging studies can lead to unnecessary, costly, and sometimes damaging treatments, which may include various pain medications, injections (such as epidural injections), and surgery. When surgery is recommended, there are different complexities of surgeries that can be performed.

In this recent study, the surgeries were divided into three categories: 1. Decompression by itself (removing a small piece of bone from the spine to relieve pressure on the spinal cord or nerves), 2. Simple (only 1-2 levels) fusion (fusing the bones in the spine using metal and or bone that may be harvested from the hip or provided by a bone bank), or 3. Complex Fusion (more than 2 levels and/or anterior [front] and posterior [back] approach). From the years 2002 to 2007, the number of decompression and simple fusion surgeries decreased while the number of complex fusion surgeries increased 15-fold. With increasing complexity of the surgery, the odds for complications and rehospitalization significantly increase without a significant demonstrated improvement in outcomes.

We should all be concerned that the number of complex surgeries is increasing, causing more severe side effects and death. Hospital charges alone for a less complex surgery can cost around $23,000 while the complex surgeries may cost over $80,000.

 

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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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What To Do When Back Pain Causes Overdose?

“We don’t appreciate what we have until it’s gone.” If only we had a dime for every time we heard this. Perhaps the reason it is such a common expression is the simple truth in it. This certainly applies to our health, but specifically our backs. We probably all take our good health in vain, until something goes wrong. By the time we are in our forties over twenty percent of us experience some form of back pain. And what do we do when we experience pain? Well, unfortunately many people will turn to strong painkillers. This means opioids, morphine-like painkillers. And, while we have written about this topic in the past, there is something new on the horizon. Evzio, the brand name of injectable Naloxone, is a prescription medicine that can block the effects of morphine and related painkillers. Approved by the FDA in April 2014, it allows a patient to quickly treat themselves or be treated by a family member if the patient has overdosed on opioids.Evzio

In the past, Evzio was difficult to obtain due to its high cost. However, recently The Clinton Foundation announced that it has negotiated a lower price for Evzio (see NYT article). This will allow municipalities to more easily purchase this medication, making it more available to those who need it.

It is a sad reality that many people will turn, in desperation, to painkillers as an answer to their aching backs. We, at the Norman Marcus Pain Institute, only use opioids as a last resort. Our method of finding the source of the pain and treating it has eliminated back pain for thousands of patients.. Nevertheless, with the rise of overdoses each year, the increased availability of naloxone to non-medical personnel will allow lives to be saved.

 

 

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Why Health Insurances Carriers Should Not Be For Profit Enterprises

In November, I read this article in The New York Times on How Medical Care Is Being Corrupted. In a nutshell — Insurance carriers have been incentivizing care for more than 20 years by selectively paying for some services whilst denying others.

To successfully address a complicated problem, such as long-standing pain, more than one approach is often most effective albeit initially more expensive. As a Pain Medicine physician, I have witnessed the defunding of the only approach that has been found to be consistently successful (by the Cochrane database for systematic reviews) in addressing patients disabled by chronic back pain: comprehensive multidisciplinary pain treatment centers.

While cost should be a consideration in choosing treatment – it should not be the primary deciding factor. For-profit insurance companies can be effective in helping policyholders fund their medical care but they are constrained by conflicting interests

  1. A moral and ethical obligation to care for policyholders who have purchased a policy to protect their health.
  2.  Shareholders who have invested in the company and expect each quarter to produce a reasonable profit.

If you believe, as I do, that health insurance not be allowed to be a for profit enterprise, join in a national discussion to legislate that all health insurance be not-for-profit. Insurance companies should only exist for the protection of the individual patient.

 

 

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Earlier in November, Rafael Nadal, the 14-time Grand Slam winner, announced he would receive stem cell treatment to help heal his ailing back, the same type of treatment he received for his knee. His doctor in Barcelona, Dr. Angel Ruiz-Cotorro, who has been treating Nadal for 14 years, said, “Nadal’s back pain is ‘typical of tennis’ players in that the treatment is meant to help repair his cartilage.” Stem cells were recently extracted from Nadal for a cultivation process to “produce the necessary quantities,” said Ruiz-Cotorro. Once cultivated, the stem cells will be placed into the joints of his spine with the goal of regeneration of cartilage as well as for an anti-inflammatory effect. Dr. Ruiz-Cotorro predicts that Nadal can return to training in early December.

Will stem cell treatment work for Nadal’s Back Pain?

Stem cell treatment may seem logical in certain situations – for example, if you have a mechanical problem where a knee has worn out cartilage, causing bone to rub against bone, it makes sense to use stem cells to grow new cartilage to have a cushion to protect the bone and cause the knee to be less painful. As much as we may want to see him back on the courts tennisgrabbing more grand slam titles, if Nadal’s stem cell treatment is being used to eliminate his pain by repairing his joints or discs, the actual cause of his back pain may not be addressed.

Where does back pain originate?

The number one reason for back pain is muscular and other soft tissue, yet muscles are rarely evaluated as the cause of back pain. The only way to determine if Nadal’s back pain is from soft tissue and similar to most people with back pain would be a physical examination of Nadal’s back that included identifying possible muscles as the cause of his pain.

Some doctors believe that the disc, the cushion between the bones of the spine (the vertebra), is a major cause of back pain. They believe that surgeries to correct the flattening or herniation of the disc will decrease or eliminate back pain. Sometimes they are right, but they are just as likely to be wrong. The truth is that there is as high as a 50% failure rate for spine surgeries that were done to eliminate back pain thought to be related to disc problems. There are other joints in the spine that are thought to cause pain; one of them is the facet joint, which could also be a target for stem cell treatments.

When doctors rely on an MRI or CT scan to determine the source of the pain, the information obtained is often confusing. If a surgeon sees an abnormality on an MRI, he will often point to that abnormality as the cause of the pain; in my experience the abnormality found on an MRI or CT scan frequently is not the cause. In fact, if you randomly selected 100 people off the street, and perform an imaging scan, 40 may present with a herniated disc and have no pain and absolutely no awareness of their herniated disc; 70 may have degenerated (worn) discs with no pain, and a large number will have facet joint abnormalities. Therefore, finding an “abnormality” is more common than not. One, then, can deduce that the abnormality is more likely NOT the source of the pain. So treating the abnormality (with steroid injections, surgery, or stem cells) may therefore not relieve the pain.

Stem Cell Treatment and Sports Stars

Nadal, currently ranked as the number 3 professional tennis player in the world, is not the first sports star to chase after a “miracle cure.” The Denver Bronco quarterback Payton Manning and Yankees pitcher Bartolo Colon both went abroad to seek out stem cell treatment as a quick fix to get back in the game. (They both seem to be doing better overall, but it is inconclusive if the stem cell treatment was the cause of their recovery).

Will it work?

In the laboratory, it has been possible to demonstrate the ability of stem cells (most commonly found in the developing embryo and newborn) to grow new tissue. These cells are like silly putty; they can turn into, or adapt, to become any type of tissue. For example, a stem cell in the right environment in the body could become bone, cartilage or some organ (for example, liver or pancreas). But, it hasn’t been as easy to grow tissue in an actual person. There are some early studies that show that stem cells “may” relieve back pain, but both the doctors who are testing the technique and outside experts say much more research is needed before they can say whether the treatment offers real relief.

The use of stem cell therapies continues to be a hot topic for debate in the sports medicine and orthopedic surgery worlds. There is no current evidence-based research to prove that it works.

Sir William Osler, a famous physician, once said: “Use every new treatment as quickly as possible before it stops working.” Stem cell treatment needs to be further investigated to determine if stem cell treatments indeed work, and if so, for what conditions?

 

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Men:
Where do you keep your wallet? Many of you probably answered, “your back pocket.” Did you know that this could be causing your back pain?

When you sit down with your wallet in your back pocket, it presses into your muscles, which can cause pain in your low back and buttock. The squeezed muscle can press your sciatic nerve causing the pain to travel down your leg.

If you’re suffering from back pain, try keeping your wallet in an external bag or a front pocket. Or simply decrease the thickness of your wallet by taking out any extraneous items, such as old receipts or credit cards that you no longer need or use.

 

Women:

Those fashionable Jimmy Choos or Manolo Blahnik’s, which are known for their height, may actually be increasing your low back pain. But don’t switch out those high heels for the increasingly popular ballet flats or stylish sandals because flats can stretch and strain the muscles in the calves and thighs causing pain in the buttock and low back.

You don’t have to forgo fashion for comfort. Wearing low, comfortable heels can save your back from unnecessary pain. Remember to wear shoes that fit properly as well – ill-fitting shoes can cause you to tighten your leg and buttock muscles causing low back, buttock, and leg pain.

 

Children:

Now that school is back in session, many kids are carrying heavy books in their backpacks. Often, the heavy, incorrectly worn backpacks can cause poor posture and strain on muscles. Parents, have your child(ren) pack their backpacks so that the heaviest books are placed towards the back of the bag. This way, the heaviest part of the bag is closer to the back of the child. (see picture) Also, remind your child(ren) to use both straps on both shoulders. This helps distribute the weight evenly, as opposed to placing strain on one shoulder. Another option is using backpacks with rolling capabilities.

Similarly, all you ladies who stuff your shoulder bags with everything from lipstick to workout weights, carrying a heavy bag on your shoulder every day can be the source of your aching neck and back. While those oversize totes conveniently contain everything you might possibly need in a day, the accumulated stress on your neck and spine from “pocketbook overload” can lead to serious strain on your muscles, tendons, nerves, and ligaments, causing serious body aches. So what does a fashionable woman on the go do?

  • If you absolutely must carry a tote, lighten the load – try to take out the items you don’t really use or need.
  • Switch the bag from one shoulder to the other often, minimizing the amount of time you strain the shoulder and neck muscles.
  • Try using two lighter bags instead of one big one. Splitting the load and carrying them on both sides distributes the weight evenly.

And don’t forget; no matter what you carry, having good posture helps reduce back pain.

children backpack

Parents:

Lifting your baby 50 times per day, or bending and lifting up to get your active toddler out of his/her sibling’s hair, are innocent movements that can indeed cause low back pain. Good posture and proper lifting techniques can help parents avoid the increased risk for low back pain. Some key pointers:

  • Keep your feet (shoulder width) apart, your back straight and bend your knees to reach for your child.
  • Use your leg muscles, which are bigger and stronger than your back muscles, to lift your child. After you bend over, bring your child to your chest, bring your back to the upright position, and then straighten your legs. If you straighten your legs before bringing your body upright, you’re using your low back muscles to lift your child. However, if you straighten your legs last, then you’re using your leg muscles.

Keep in mind; this is a good tip for lifting anything heavy!

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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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Epidural steroids are not effective for spinal stenosis

I have been suggesting for many years that there is an overuse of spinal injections and surgeries for low back and leg pain, so it was no surprise when I read an article in The New York Times (NYT) that reported on a study recently published in the New England Journal of Medicine[1] about patients with spinal stenosis who are frequently treated with a procedure that has been shown to be ineffective. Epidural steroid and lidocaine injections for patients found to have spinal stenosis were no better than epidural injections of lidocaine alone. In chapter 4 of my book End Back Pain Forever I discuss the many reasons for back pain. MRIs and CT scans of the low back will almost always find something such as spinal stenosis or a degenerated or herniated disc even in patients without pain. Therefore the US Institute of Medicine suggests that these imaging studies should not be done routinely since what you find in the study is frequently not the cause of your pain. The most common cause of back pain is muscles and other soft tissue. If you treat the diagnosis you got from the MRI or CT and the actual reason for the pain is muscle, it makes sense that the treatment will frequently fail, which it does!

The NYT report of this relatively large, randomized, double blind, controlled study clearly demonstrates the ineffectiveness of the use of steroids for symptoms attributable to spinal stenosis (narrowing of the canal in the spine which contains the spinal cord) which occurs frequently as we age. The treatments most often provided are epidural steroids to theoretically reduce the inflammation of the nerves being squeezed by the narrow canal, and surgery to widen the canal. Both approaches have a significant failure rate.

At the Norman Marcus Pain Institute we have shown in multiple published articles that one reason why these approaches are ineffective is that the pain in the back and leg may not be the result of the narrowing or other supposed abnormalities seen on the MRI or CT scan. It is well known that very few (in one published article- less than 10%) scans of the low back in adults are read as normal; as many as 40% of adults with no back pain have herniated discs, and 70% have degenerated discs. So it is “normal” to find an abnormality.

B_vertebrae_function_01

Our unique physical examination, utilizes an instrument I developed, reveals that many patients with back and leg pains have areas of muscle tenderness that are the source of their pain yet are overlooked. One study of more than 23,000 patients[2] found that 70-80% of patients with back pain were diagnosed with sprains and strains of muscle and other soft tissue. It’s hard to believe then, armed with this knowledge, that muscle examination and treatment is not part of the typical standard of care for back pain in the USA[3]. If we are to properly address the cause of most back pain, the evaluation and treatment of its muscular causes must be addressed.

 


 

[1] Friedly JL, Comstock BA, Turner JA, et al. A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis. New England Journal of Medicine. 2014:374:11-21.

[2] Deyo RA, Weinstein JN. Primary care – low back pain. New England Journal of Medicine. 2001:5:363-70.

[3] Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

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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

One lesser-known but valuable tool for multiple painful conditions is the low-level laser.  The laser is a source of extremely pure, organized light, as opposed to something like a regular light bulb, which emits a scattered, disorganized light.  We can liken organized light to the sound of a flute playing a single note, and disorganized light to the sound of a stone rolling around in a tin can.  The laser is a non-painful treatment option that affects the local (near the area being treated) immune system, blood circulation, and the release of different chemicals that affect how we experience pain.

While it isn’t clear exactly how the laser helps a variety of painful conditions, there are two proposed means by which the laser improves pain:

  1. The light energy (called photons) is absorbed in the injured area and stimulates the production of Cytochrome C.  Cytochrome C is a protein involved in cell metabolism and energy.  When Cytochrome C is stimulated, it revs up the cell’s metabolism, and gives the cells more energy to heal the injured area.
  2. The light energy from the laser leads to the production of small amounts of singlet oxygen.  Singlet oxygen is a reactive form of oxygen, which means that it is very easy for this type of oxygen to take part in chemical reactions.  At high doses, singlet oxygen can be destructive, and has been used in cancer treatment to destroy cancerous cells.  At very low doses, singlet oxygen can increase the number of cells.  This may be one way the laser helps promote tissue repair.

The laser in a non-invasive, non-painful treatment option that can, in some cases, produce results immediately.  For pain that has been around for a long time, more than one treatment session is usually needed for best results.

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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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How we perceive pain – nociceptors

We generally don’t think of muscles as a cause of pain. Sure, we know that after exercise or playing ball we can have muscle soreness, but when pain persists we often think it is coming from nerves, joints or the spine.  Believe it or not, muscles (and other soft tissue) are the most common reason for pains such as lower back pain, neck pain and shoulder pain.  The brain gets information from the body about pain from specialized nerves called nociceptors that respond to tissue damage. Trauma, overwork, and over-exercising cause low oxygen and too much acidity in the muscle. These changes, along with other chemicals that are produced when the muscle is damaged in any way, stimulate the nociceptor.  When a stimulus as strong enough it causes the nerve cell to produce an electrical impulse that is sent into the spinal cord and then up to the cortex, the part of the brain where we perceive pain.

There are actually more nociceptors in the muscle attachment sites (the ends of the muscle where it attaches to the tendon and the tendon attaches to the bone) than in the muscle tissue. That is why if you have pain originating in muscles you may be more aware of the pain close to a bone than in the middle of the muscle.

Any kind of injury releases substances from damaged muscle and surrounding tissue that stimulates the nociceptor. If the nociceptor gets enough stimulation it creates an electrical discharge which travels down the nerve and ends up in the spinal cord. Muscle nerves that have been stimulated repeatedly become more sensitive to additional stimulation. They are called sensitized nerves and they will more easily produce electrical activity with even non painful events such as any contraction to move the muscle. That is why when an injured muscle is used it may cause pain.  That is why if you have strained muscles for any reason you may feel pain from every day movement.  Nociceptors are key structures in the perception of pain.

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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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Will my back pain go away?

Although Low Back Pain (LBP) is thought to affect around 80% of individuals, it is also thought to be self limited and get better quickly (within weeks). Studies of patient populations however suggest that it is actually a more serious problem. Although most patients who experience back pain do not see a doctor, 60-80% of those that do are still reporting pain one year later and in those whose pain has disappeared, 20% will have a recurrence within months.

A large number of patients (40-50%) will not see a medical physician for their pain preferring to receive alternative treatment, in large part due to the inability of our current model to help many of the patients suffering with lower back pain and neck pain. If there were a test to determine who was at risk not to have their pain eliminated and to be become a chronic sufferer, this could alert the clinician to employ more than one approach to ease the pain.  Published predictive studies are too different to compare outcomes although  the following factors are consistently found to predict poor outcome in the reviewed studies: older age, poor general health, increased psychological or psychosocial stress, poor relations with colleagues, physically heavy work, worse baseline functional disability, sciatica, and the presence of compensation.

Complimentary and alternative medicine (CAM) is used by 40-60% of patients in the US to deal with their back pain . The mechanism for effectiveness of the various CAM approaches deserves study as does the role of muscles in low back pain. The absence of a standardized routine examination of muscles’ strength, flexibility, and tenderness in patients with back pain ignores an important variable especially in light of the fact that the most common diagnosis for acute back pain is Non-specific Low Back Pain,  referring to sprains and strains of muscles and other soft tissue.

The bottom line is that our current system of care for lower back pain is sorely in need of review and revision.

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