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.


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.


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.


Marijuana and its effect on pain

For the first time ever, the New York State Assembly’s one-house budget proposal included more expansive plans to approve the use of  medical marijuana.  In a recent poll 88% of New Yorkers felt that medical marijuana should be legalized, and both republican and democrat senators are listening.

Marijuana leaf

In order to make a decision on whether a drug should be available, we look to the science (peer-reviewed research) to help us decide whether the benefits of the drug are worth the risks.  Some studies show marijuana is effective for pain relief (especially the neuropathic pain which accompanies disorders like Multiple Sclerosis[1]) and for improving sleep for those with painful disorders.[2]  Other studies also found that smoking marijuana helped to increase pain tolerance, with a greater effect observed for those who were not novice users.[3]

In a study in which individuals smoked marijuana cigarettes containing different amounts of THC (one of the active components that is responsible for many of Marijuana’s effects), they found that too small a dose did not provide any analgesic benefit, and too large a dose actually increased pain.  In this study, cigarettes containing 4% THC experienced the most pain relief.  This suggests that there is an optimal dosage of marijuana to relieve pain.4

Despite the apparent benefits, there are short and long-term adverse effects.  Marijuana can cause anxiety and panic, and, at very high doses, psychotic symptoms.  Patients using marijuana should not drive while taking it.  Long-term users can show signs of dependence and subtle cognitive impairment.[4]

Marijuana may be useful in a variety of painful conditions, but most studies currently available are not large enough to draw useful conclusions.  Legalization will allow larger scale studies to be done so that we can be more confident about both the positive and negative effects.  Like any other potent drug, it needs to be carefully regulated and only used when appropriate.

Image courtesy of Paul / FreeDigitalPhotos.net

[1] Hosking, R. D., and J. P. Zajicek. “Therapeutic Potential of Cannabis in Pain Medicine.” British Journal of Anaesthesia 101.1 (2008): 59-68. Oxford Journals. 29 May 2008. Web. 14 Mar. 2014.

[2] Rog, David J., Turo J. Nurmikko, Tim Friede, and Carolyn A. Young. “Randomized, Controlled Trial of Cannabis-based Medicine in Central Pain in Multiple Sclerosis.” The Official Journal of the American Acadmey of Neurology 65 (2005): 812-19. Neurology. 27 Sept. 2005. Web.

[3] Milstein, S. L., K. MacCannell, G. Karr, and S. Clark. “Marijuana-produced Changes in Pain Tolerance. Experienced and Non-experienced Subjects.” International Pharmacopsychiatry 10.3 (1975): 177-82. PubMed. Web.

[4] Kondrad, Elin. “Medical Marijuana for Chronic Pain.” North Carolina Medical Journal 74.3 (2013): n. pag. NC Medical Journal. Web.


Antiepileptic medications

Anti-seizure, or anti-epileptic, medications have commonly been used to treat pain, especially nerve-related pain. Examples include pregabalin (Lyrica), gabapentin (Neurontin), topiramate (Topamax), and carbamazepine (Tegretol/Carbatrol). The exact mechanism in which these medications work is not completely clear. Anti-seizure medications help decrease hyperactivity of the nerves that cause seizures; therefore, it is thought that these medications can have a similar effect with decreasing the activity of the nerves that cause pain.

As with all medications, there are side effects – most common side effects are dizziness, drowsiness, nausea, vomiting,  blurred or double vision, and weight gain. Therefore, if you are not having reasonable pain relief with one of these medications, it shouldn’t be continued. It is generally a good idea to stop these medications slowly, since abruptly stopping in someone who is seizure prone could cause a seizure.


NSAIDs for pain relief

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


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


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.


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.


Statins may cause muscle pain

Do you have or used to have high cholesterol? Statins are a class of drug used to lower the amount of cholesterol produced by the liver.  You might recognize some of the more common brands like Lipitor (Atorvastatin Calcium) or Crestor (Rosuvastatin Calcium).  They are commonly used for patients with high cholesterol, diabetes, or those with a family history of heart attacks.  Recent data shows that approximately 5% of patients maintained on statins experience muscle pain and weakness.  Muscle pain is one of the top reasons patients choose to stop taking statins[1].  If you are taking a statin and are experiencing muscle pain or weakness, you may want to talk with your doctor about adjusting your dose or finding an alternative treatment.

[1] Jacobson, Terry A. “Toward “Pain-Free” Statin Prescribing: Clinical Algorithm for Diagnosis and Management of Myalgia.” Mayo Clinic Proceedings 83.6 (2008): 687-700. Science Direct. Web.


Hypothyroidism and muscle pain – are they related?

You can experience muscle pain for many reasons. We discussed trigger points in an earlier blog (see www.normanmarcuspaininstitute.com/what-are-trigger-points/ to recap your memories).  A common medical problem, abnormal activity of the thyroid gland, can cause muscle pain.

Hypothyroidism is a condition in which your thyroid gland doesn’t make enough hormone.  (Hyperthyroidism, which is not as common, is when the thyroid gland produces too much hormone and that can also produce muscle pain.)  When you don’t have enough thyroid hormone, many systems in your body are affected and you may notice the following signs and symptoms:

-brittle nails

-hair loss

-fatigue (feeling tired)

-dry skin

-memory problems

-having trouble thinking clearly

-weight gain

Muscle symptoms associated with hypothyroidism are often described as a cramping, stiffness or weakness.

Hypothyroidism is generally treated with hormone replacement therapy, which means you’re taking synthetic (man-made) hormones to replace the ones that the body isn’t producing.  In one study, almost 20% of patients complained of joint and/or muscle pain, of which 50% had relief in symptoms after starting thyroid replacement therapy[1].

So if you have been diagnosed with hypothyroidism or have symptoms of hypothyroidism and also complain of muscle pain, it’s very possible that the two are related. Ask your doctor to check it out.

[1] Carette, S., Lefrancois, L. Fibrositis and primary hypothyroidism. J Rheumatol. 1988; 15(9):1418-21.


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


-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.


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.


One way in which muscles can cause pain

Nerves connect muscles to the spinal cord.  When something stimulates your muscles, for example, if someone were to press on your arm, the muscle sends a message via the nerves first into the spinal cord, and then up to the brain.  Once the brain receives the message (in this case, that there is pressure on your arm), then your body is able to perceive sensation.  This all happens in a split second, so that your brain receives the message immediately after the stimulus appears.  When the sensation is strong enough it no longer feels like pressure or a simple touch; it is experienced, rather, as pain.    Once the brain processes the message, then you become aware of pain in your muscle.

Read the rest of this entry


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.


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.


Primary Care Physicians (PCPs) vs. Pain


We have always encouraged a step-care model for treating our patients in pain. Start with the least expensive, least invasive procedures before trying the more expensive, complicated, and invasive procedures.  So when you first experience pain, your primary care physician, or PCP, would be your first stop.

The Institute of Medicine (IOM) made the following key recommendations[1]:

  1. Use non-steroidal anti-inflammatory medications (NSAIDs) and acetaminophen (Tylenol) as first line pain medication.
  2. Referral from primary care physicians (PCPs) to specialists for back pain was not recommended. Referral  to physical therapists was recommended.
  3. Use of imaging, such as MRI, CT scan, or x-ray, were not recommended.

This may be easier said than done.

Read the rest of this entry


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.


Conditioned Pain Modulation

Have you ever noticed that pain in one area took your attention away from pain in another spot?  For example, you were feeling back pain and then jammed your toe, and your back pain diminished or went away.  As the toe pain reduced, the back pain reappeared.  Conditioned Pain Modulation (CPM), formerly known as DNIC (diffuse noxious inhibitory control), is the phenomenon where pain in one area inhibits pain in a different area of the body.

Another example is seen in patients who have pain that is noticeably worse on one side of the body than the other.  Once pain is treated on their “bad” side, their “good” side seems to get much worse.  In this case, pain on the “good” side was always present, but becomes more noticeable once the worst pain was addressed.

In fibromyalgia syndrome patients, there appears to be impaired CPM. [i]  CPM is one reason why understanding a patient’s pain complaint is challenging.

[i] Davis, Mellar P. “The Clinical Importance of Conditioning Pain Modulation: A Review and Clinical Implications.” Research and Development of Opioid-Related Ligands (2013): n. pag. Print.



Muscles in the shoulder girdle were the cause of pain

A study in Clinical Orthopaedics & Related Research [468(10):2678-89], reports that over time the function of the shoulder deteriorates in a significant number of patients who underwent rotator cuff repair, despite continued pain relief in many of the same patients.  The study found that even if greater function was achieved in the months directly following surgery, both strength and range of motion decreased to less than preoperative values even though pain was alleviated.shoulder pain blog-Norman Marcus Pain Institute

I treated a 60 year old man with a diagnosis of rotator cuff tear. Because of severe shoulder pain and restriction of movement in his shoulder, he was unable to brush his teeth, hold utensils to eat, or comb his hair. He was scheduled for surgery to repair his rotator cuff. He was found on examination to have six muscles in his shoulder girdle that were causing his pain.

These muscles were injected over the course of 3 weeks and following each injection a physical therapy protocol was used that restored his range of motion. His pain was eliminated. His surgery was cancelled. He remained pain free for the two years that he was followed.

In view of the findings reported in the paper and my results with this patient and others diagnosed with shoulder pain from rotator cuff tear or impingement syndrome, it is important to evaluate muscles as a source of pain and function impairment prior to performing surgical repair.


Headaches are the most commonly reported pain problem

headache blog from Dr. Norman MarcusA recent study of office workers who complained of weekly headaches examined the effect of a simple resistance exercise program for the neck and shoulders, and found an approximately 50% reduction in headache frequency.

Headaches are the most commonly reported pain problem. If brief exercise can have such a dramatic effect on headache frequency, it should be considered as a standard intervention for all office workers who appear to have muscle tension type headaches. One possible reason brief exercise is so effective is that it may help relax tense muscles which can become stiff from repetitive strain, for example bending your head and neck over a desk for hours at a time.  Simply performing an action to address headaches on a daily basis may also 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 can reduce headache frequency.

Even though self-awareness can help, knowing what you are thinking and feeling is not as easy to achieve as one might imagine. Many of my patients report becoming aware of unsettling feelings and sometimes divulge situations that have been troubling to them while doing their prescribed exercises. There are many thoughts and feelings that are upsetting for us to acknowledge. It may be difficult to admit that you are angry or resentful towards someone you love or someone on whom you depend for your livelihood. We may be uncomfortable or ashamed to admit to feelings of fear or envy. Repressing or denying thoughts and feelings can lead to increases in muscle tension with resultant headaches, and to symptoms of anxiety.

If it’s all about repressed feelings why don’t all the headaches or anxiety symptoms disappear when we become more conscious? H.L. Menken said that “there is always a simple solution for a complex problem, and it is usually wrong.” Exercise addresses a different reason for your neck pain than struggling with uncomfortable emotions. When it comes to persistent pain problems, a multi-faceted approach which addresses multiple sources of discomfort may provide the most relief.

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