neck pain posts Archives

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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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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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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Sometimes the pain isn’t coming from where you think

 

I recently saw Fred, a 30 year old male, who complained of significant neck pain and shoulder pain. The pain on his left side was much greater than on the right. He tried several chiropractic treatments, massage, physical therapy, acupuncture, and exercises without relief of his pain.

neckpain

When I first examined Fred, I found two muscles that were painful, his anterior and medial scalenes on both sides. The scalenes are muscles that go from the side of the neck down to the 1st rib as it sits under the clavicle (collarbone). Since he complained mostly of pain on his left neck and shoulder, I injected his left scalenes, followed by 3 days of physical therapy (which included neuromuscular electrical stimulation and gentle, limbering exercises). Fred claimed that the pain on the left subsided, but he noticed that the right side was now more painful. So, the following week, he had his right scalenes treated (with injections into the muscle, followed by 3 days of physical therapy). Fred reported a significant decrease in his overall pain, and reported only soreness at the injection sites.

I followed up with Fred approximately one month later. He reported to me that his overall pain level continued to stay low, but he noticed that when he looked up, he felt tightness on the left side of his neck.  When I examined him, I found two muscles to be contributing to his pain, the Serratus Anterior and the Subscapularis. These muscles are in his shoulder. He was very shocked to learn that tightness in his neck was caused by muscles in his shoulder!!

Once these muscles were treated, he reported that the tightness in his neck was released. Sometimes we have to look for muscles contributing to pain in areas other than where you may be feeling it. This is called referred pain. If I had continued to treat muscles in Fred’s neck, he may never have had relief!

 

 

 

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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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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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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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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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One reason for the closing of many centers was the pull back by insurance carriers for payments for non-interventional pain treatment services. Doing a procedure seemed to be considered more valid and worthy of payment than a non-invasive service even if it was effective in reducing pain, improving function and lowering future cost of care. Today some of the best pain centers cannot survive by depending on insurance payments and are forced to charge their patients large out of pocket sums in order to remain in operation. Some of these insurance carriers that will not pay for comprehensive pain centers will routinely pay for procedures of questionable effectiveness. Although the number of CARF approved pain centers in the US halved, the number of outpatient pain centers mushroomed. The services provided however focused on two areas:

  1. Medication management
  2. Nerve blocks and other invasive procedures.

Some patients could be helped with one or both of these approaches, but many patients in need of physical therapy and psychological services that had been integrated in a comprehensive treatment plan, would no longer receive optimal treatment. Reimbursement would be the driver of care rather than the needs of the patient. Centers could not stay in business and provide care that insurance companies would not cover. The shift toward procedures became an accepted standard of care and new organizations of pain physicians were formed whose membership focused predominantly on invasive procedures.

The emphasis on medication management was in part fueled by the belief that most patients with persistent pain could be treated successfully and safely with strong pain medications, such as opioids like morphine and oxycodone. We have a better understanding now of problems encountered when we freely offered potent pain medications to too many patients. Strong pain medications not only treat pain but also affect mood. Many patients with or without pain have anxiety and/or depression. Pain medications can provide emotional relief and patients would take them consciously or inadvertently for psychological rather than pain relief. Prescribed pain medication have become more popular than street drugs such as heroin for people who were drug abusers and some patients feigned pain and sold the prescribed pills for a handsome profit.

The cost of services for the treatment of back and neck pain, now with many less comprehensive multi-disciplinary centers, has nonetheless continued to rise at an alarming rate. Next time let’s look at the phenomenon of unintended consequences.

 

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How can we know what back pain treatments make sense?

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

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Bedside Manner and the power of suggestion in back pain

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.

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A discussion about back pain

Back PainWhere to begin? In the first two chapters of my book, End Back Pain Forever,  I explore a variety of issues related to the difficulties in evaluating and treating patients with back pain. I am posting these chapters as a means to share my perspective which developed over more than 40 years as a pain medicine physician in the US and the UK. I encourage the members of my LinkedIn Group, Let’s Talk About Pain to agree, disagree, or share your own experience as a patient, family member of a patient, or clinician.

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The cost of evaluating and treating lower back pain and neck pain is rising. From 1997-2005 it went up from $54 to $86 billion/year. Unfortunately, advances in spine surgery techniques, nerve blocks, and pain medication have not translated into more successful treatment – from 1997-2005, 25% more patients reported difficulties functioning because of neck pain or back pain.

Although 70-80% of back pain is diagnosed as non-specific lower back pain, referring to sprains and strains of muscles, ligaments and tendons, the current guidelines do not mention muscle as a possible source of persistent back pain. This leads to an overemphasis on the spine and the nerves leaving the spine.

We need a treatment model (step-care) that addresses the most common reason for back pain first. Protocols that provide soft tissue treatments that are least costly with minimal chance of harm, should produce better, more cost-effective outcomes.

Spending more money to do the same kinds of treatment is not working. This discussion group will explore possible reasons for sub-optimal pain treatment outcomes. How can we change the way we evaluate and treat persistent pain to improve our results and lower the costs of care?

A search for back pain on the internet finds almost 600 million sites. With so many different ideas on how to address this problem, we will attempt to narrow the discussion to concepts that have been studied and published in scientific journals. One obvious issue is the absence of a muscle evaluation and treatment protocol.

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Epidural Steroids- Are they worth the downside risk?

The tragic occurrence of meningitis, stroke and death following use of infected steroids used for spine injections should make us more aware that this very common treatment for back pain may not be worth the risks. The use of epidural steroid injections (ESIs) to shrink an inflamed nerve thought to be causing back pain has not been shown to consistently reduce pain and even when it does the benefit is frequently short-lived. Aside from infection, other rare but serious side effects include bleeding that can cause  nerve damage with possble weakness and paralysis, and additional pain. Steroids themselves have been the cause of bone  (aseptic necrosis) and tendon  damage.

Multiple medical professional organizations have suggested that ESIs should not be used for long standing back or neck pain or for pain in the back or neck that does not radiate to the arms or legs. Despite the evidence that even when ESIs reduce or eliminate pain, at best they are useful for 3 months or less. Other countries i.e. Denmark, rarely use ESIs. 

As long as a thorough physical examination does not take place with all patients complaining of back or neck pain, with the purpose of determining if muscles are a source of pain, we will continue to rely on imaging studies that lead us to mistakenly believe that all back pain comes from the spine and the nerves leaving the spine. Continuing to provide unnecessary and ineffective treatments not only squanders our limited resources but could cause irreparable harm.

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End Back Pain Forever: Chapter 2, part 5 #endbackpain

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

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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.

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Why do we over-prescribe strong pain medication?

The NY Times on 4/9/2012 ran a story about the overuse and unintended negative consequences of strong (opioid) pain medication. They mentioned opposing views concerning the liberal use of opioids. I participated in a debate in 1995 about the inappropriate use of the diagnosis “Chronic Pain Syndrome”(CPS) in patients whose muscles had not been assessed as a cause of their persistent pain, which resulted in the justification to put some of these patients on opioids for the rest of their lives.   

Since then one of the largest growth industries in medicine is the evaluation and treatment of back and neck pain, currently accounting for ~$100 billion in direct medical costs. The pain juggernaut is fueled in part by ignoring muscles which are the most common reason for pain complaints. Addressing the incorrect causes of pain leads to inappropriate, expensive and potentially harmful treatments with poor outcomes, persisitent pain, and overuse of opioids. CPS is a license to prescribe life-long medication. Chronic use of opioids has not been studied for its overall impact on patients with CPS but neither have any of the other medications that we are now using. Does the marginal reduction in pain in many of the patients taking these medications justify their costs and side effects? As the Times reports, for some patients the treatment is actually making them worse.

Imagine if some of these patients had pain that could be eliminated. Many do; it’s from muscles that are not evaluated or treated in a systematic way.  My new book, End Back Pain Forever, to be released by Atria on June 5, 2012 is a wakeup call to change the way we are treating common pain problems.

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How to decrease headache frequency

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.
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