NSAIDs for pain relief

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

NSAIDs

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

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

 

 

Image courtesy of anekoho/FreeDigitalPhotos.net

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Case Study: Low Level Laser Therapy

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

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

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

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

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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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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.

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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.

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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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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.

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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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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.

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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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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.

 

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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.

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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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Thoughts on pain management and the cost of care

John Bonica, M.D. a world renowned anesthesiologist at the University of Washington in Seattle was the individual most responsible for the creation of a new specialty, Pain Medicine. In 1977 The American Pain Society was founded and became the United States national chapter in the International Association for the Study of Pain. Complicated difficult to treat pain patients were usually not successfully treated by a physician representing one medical discipline and thus the multi-disciplinary pain treatment model was created.

It was understood that belief systems about the patients’ pain such as –“having pain means I am harming myself “ resulting in the avoidance of activities that produce discomfort and eventually eliminating many important activities in the patients life with resulting deconditioning, depression, pain drug use, dollars spent and ultimately disability. Pain becomes the focus of life and the more it is pondered the worse it feels. Multi-disciplinary teams composed of a pain management physician, psychiatrist, psychologist, social worker, occupational therapist, physical therapist and pain team nurses provide weeks of intensive full day treatment programs with remarkable success in restoring function to patients disabled with persistent pain.

There is an organization called Cochrane Collaborations that reviews various medical treatments to determine if they have been adequately studied and the results of the studies indicate that they are effective, ineffective or undetermined. Almost all of the treatments for back pain have been found to be neither ineffective or effective, meaning the evidence is out and more and better studies are needed- but multi-disciplinary pain centers have consistently been found to be effective for the treatment of chronic back pain. In the early 1990s there were more than a hundred pain centers certified by the Commission on Accreditation of Rehabilitation Facilities and despite the success of multi-disciplinary programs , close to half of them are no longer operating.

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.

Please refer back to the past two blogs to find the background material for todays blog. 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.

Although many patients could be helped with one or both of these approaches, many patients in need of physical therapy and psychological services that were integrated with the overall 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 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 . Some of the increased cost is because of more numerous and complicated surgeries  . The bottom line is that we are spending more money each year on neck and back pain in the US, approximately the same as we spend on Cancer, and not getting good results.

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Through the ages various explanations have been offered to explain the cause and how to treat it.  But it wasn’t until the 19th century that the spine and the nervous system were seen as the fundamental source of back pain. The idea that the cause of back pain was some injury or irritation in the bones and nerves of the spine was adopted by the medical community and this notion has persisted up to the present. With this in mind, recommending bed rest made sense-so bed rest became a standard treatment through most of the 20th century.  Some savvy physicians recommended staying active, but their opinion was drowned out by the bed rest proponents. If you have an injury it can take weeks to heal, and therefore it was common to have patients with back pain lie in bed, often in a hospital, sometimes without even getting up to go to the bathroom, for two or more weeks. It was only at the end of the 20th century, that the medical community recognized two facts:1. Back pain was usually not from any obvious injury. 2. Prolonged bed rest was not only not helpful, it was damaging. So patients with typical back pain began to be encouraged to remain active and to return to work as quickly as possible.

When x-rays were introduced, doctors could see the joints in the spine and the pelvis, and began to suggest that this is where the pain originated.  New phrases, such as “my sacroiliac is out” and I have a “bout of lumbago”, creeped into our conversations.  In the 1920s and 30s a variety of new creative surgeries were tried including fusing the sacroiliac joint, fusing the joint between the lumbar section of the spine and the sacrum and cutting out parts of the spinal column, all of which didn’t solve the problem and rapidly became unpopular. Some bad ideas with dreadful consequences don’t go away easily, and some physicians have reintroduced sacroiliac fusion. The joints that don’t look pretty on x-ray or now with MRI/CT scanning, although not undergoing surgery, still remain as targets for injections in pain centers.

The first report of spine surgery to remove a herniated disc to treat pain radiating down the leg (sciatica) was in 1934 and in 1935 the same operation was suggested as a treatment for back pain as well. The disc pressing on a nerve to cause pain shooting down the leg and the surgery to remove the part of the disc and bone in the spine to relieve the pressure on the nerve made sense and surgery for sciatica sometimes is indicated and successful. But looking to the disc as the cause of back without leg pain proved to be the foundation of the mistaken notion that the disc was the fundamental cause of most low back pain. This concept has led to needless surgeries, exorbitant costs and tragic suffering. Over the next twenty years surgery on the disc became one of the most common operations done by neurosurgeons.

The disc was not the reason for most back pain and many of the surgeries that were done were failures with patients experiencing no change or even worse back pain. The number of unsuccessful back surgeries was so high that a new diagnosis was created, something unique in all of medicine, “Failed Back Surgery Syndrome” , also known as “Post-laminectomy Syndrome”, referring to the part of the vertebra, the lamina, that is cut away to remove pressure from the disc. The surgeon was no longer the unquestioned authority as the answer to back pain. Many clinicians, including orthopedic and neurosurgeons, recognized that the problem of back pain was more complex than a problem in the discs and that many factors including emotions, job issues and physical conditioning, all contributed to the experience of back pain.

In the 1970s a new movement to understand pain in general, with back pain as a major focus, was spawned through the efforts of John Bonica, M.D. and his colleagues. More on Pain Treatment Centers next time.

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Opioid Induced Hyperalgesia (OIH)

Patients who receive high, escalating doses of opioids (for example: morphine or oxycodone) may experience an increase in pain as a result of their medication.  This phenomenon, called Opioid Induced Hyperalgesia (OIH), is different than developing a tolerance to medication in several waysPain pills blog-Norman Marcus Pain Institute-blog

  • The nature of the pain is different than the pain for which the opioid was originally prescribed.  Often, pain becomes more diffuse, or widespread.
  • The location of the pain is different than the pain for which the opioid was originally prescribed, and often extends to more locations.
  • The quality of the pain is different than the original pain.  For example, the patient may experience allodynia, a condition in which normal sensation, such as touch, becomes painful.
  • Pain sensitivity can increase
  • Pain tolerance decreases
  • Whereas patients who have developed opioid tolerance may have transient relief from additional opioids, patients with OIH will have an increase in pain from additional opioids.[1]

Theoretical explanations for OIH include the roles of microglia and mast cells.  Though the mechanism by which this occurs isn’t fully understood yet, use of ultra low-dose Naltrexone has been reported to be effective in decreasing opioid side effects and facilitating reductions in dose. It is clear that long-term maintenance on opioids can do more harm than good for some patients.  Therefore, it may be wise to periodically attempt to decrease the amount of opioids to see if this either results in no increase or an actual decrease in pain.


[1] Lee, Marion, Sanford Silverman, Hans Hansen, Vikram Patel, and Laxmaiah Manchikanti. “A Comprehensive Review of Opioid-Induced Hyperalgesia.” Pain Physician Journal (2011): n. pag. Print.

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Pain relief following a motor vehicle accident

Dean was a 41-year-old, married executive when he was involved in a motor vehicle accident where his car was totally wrecked. X-rays revealed no fractures. Over the next five years he experienced progressively increasing aching and tightness in his low back which sometimes radiated into his buttocks and down into both legs to the soles of his feet. He also reported pain in his neck and shoulders, which was made worse by bending over.

Therapeutic exercises, medications, psychotherapy, epidural steroids and nerve blocks were given without success. Radiofrequency lesioning of nerves innervating the facet joints in his cervical and lumbar spines provided six months of minor relief.

His pain became unbearable and he attempted suicide twice. When he consulted me five years after the accident, he was no longer working and rarely left his house. Physical examination revealed 16 muscles that appeared to be a source of pain. He lived out of state so his treatment was not continuous. Over the course of 4 months, he received muscle-tendon injections to each muscle identified followed by 3 days of a physical therapy protocol after each injection which included teaching Dean an exercise program that had been given at the YMCA . No muscle was re-injected. His pain was eliminated. Four years later, he continues to contact us to let us know he is still pain free and working as a corporate executive.

 

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The Cinderella Hypothesis

Cinderella syndrome-Norman Marcus Pain Institute-blogThe Cinderella Hypothesis postulates that damage to the muscles can occur when the muscle fibers which are activated first are also the last to deactivate. Like Cinderella, they are always working, and not given adequate amounts of time to recover. These damaged muscle fibers can be a source of pain.

Low intensity, continuous activation of the fibers can be initiated consciously, for example while typing, or subconsciously, due to tension. Some studies have found that damage to the muscles can occur in as little as 30 minutes during continuous typing.

Though continuous activation without release does not happen for all patients during low intensity, sustained activity, the Cinderella Hypothesis presents a compelling case for taking breaks throughout the work day to participate in some brief stretching, which may help relax and lengthen the muscles.

 

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