NMPI Blog - Norman Marcus Pain Institute

A patient with widespread pain is a challenge to understand and treat

Monday, October 14th, 2013 at 3:04 PM

We see that in some patients who have central sensitization, treating the peripheral pain generators may results in a decrease or elimination of the widespread pain.

Widespread pain is often addressed with medication. It is common for a patient to be given an anticonvulsant, such as pregabalin (Lyrica) or gabapentin (Neurontin), or a serotonin-norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta) or venlafaxine (Effexor). These drugs affect the neurons transmitting pain-related signals in the central nervous system. nerve bundle-Norman Marcus Pain Institute blog

Another possible target in the nervous system is the glial cells. The glia are non-neuronal cells that provide support and protection for the neurons. 90% of the central nervous system (spine and brain) are made up of glial cells.

Two cells types, microglia and astrocytes, recently have been found to play a role in pain processing. These two types of cells are stimulated in response to damaged or dying cells. Astrocytes produce inflammation, while microglia initiate both inflammatory and anti-inflammatory activity. An inflammatory response in the microglia results in pain-producing chemicals, adding to the patient’s overall pain. Chronic pain and opioids, such as morphine and oxycodone, can also stimulate the microglia to produce these same pain-producing chemicals.

This may be one of the reasons why opioids are ineffective in patients with long-standing pain, as with fibromyalgia (FMS). Interestingly, drugs that block opioids, such as naltrexone, in very small doses have been found to be effective in decreasing pain in FMS (http://www.ncbi.nlm.nih.gov/pubmed/23359310). The mechanism appears to be blocking the pain producing effect of the microglia. Since the doses are so small (~4mg/day), the typical blocking of the mu receptor (the receptor that is known to be typically stimulated by opioids) doesn’t occur. What we often find as a result is pain relief and a decreasing need for opioids.

Since microglia also play an anti-inflammatory role, in our search for drugs to affect the microglia, we need to find a balance in which we can maintain their protective anti-inflammatory roles while also reducing their inflammatory pain producing effects. (http://www.nature.com/nrn/journal/v10/n1/abs/nrn2533.html)

Treating widespread pain vs. the original pain generator

Monday, October 14th, 2013 at 3:01 PM

hip joint-Norman Marcus Pain Institute blog Considering the possible effects of central sensitization may affect the treatment plan (and in turn the outcome) for a patient in pain.

For example, take someone who injured a joint – let’s say a hip – which led to osteoarthritis and in addition diffuse, widespread hyperalgesia (increased sensitivity to pain). Sometimes when a patient is in pain for a long period of time, we concentrate on the widespread pain rather than the original pain generator, the hip. These patients may be diagnosed with fibromyalgia because of their widespread pain, with treatment concentrated on that diagnosis. If the hip is treated (for example, a hip replacement), the widespread pain may resolve. This was demonstrated in a recent article, published in May 2013, that studied 40 patients. Patients who received hip replacements had normalization of their increased sensitivity and elimination of their widespread pain. (http://www.ncbi.nlm.nih.gov/pubmed/23400951)

Let’s take a look at a contrasting scenario in my next blog.

More on Fibromyalgia Syndrome (FMS)

Wednesday, October 9th, 2013 at 1:07 PM

I reread my blog on misleading diagnoses and central sensitization, and it confused me, so it must have confused some of you. The point was that if so many of us have different interpretations of pain and how to treat it, we can’t all be right. Nonspecific Low Back Pain-10-8-13

I want to discuss specific pain syndromes where it is unclear what causes the pain. We have batted around some causes and possible explanations for Nonspecific Low Back Pain. I want to explore Fibromyalgia Syndrome (FMS), a condition characterized by widespread, diffuse pain on both sides of the body, above and below the waist. In order to be diagnosed with FMS, patients must experience pain at a minimum of 11 out of 18 specified tender points, stiffness in joints, extreme fatigue, and difficulty sleeping. Due to the diffuse nature of FMS, it is often difficult to pinpoint a specific pain generator.

In order to understand why we have problems identifying a significant source of pain, I am suggesting that we explore and understand central sensitization – the phenomenon of increased sensitivity of the central nervous system to all stimuli because of tissue damage somewhere in the periphery. This means that an injury at a peripheral site – for example, the hip or shoulder – can cause sensitivity in the central nervous system, which controls how we perceive and respond to stimuli. This causes too much response for the amount of input – which means someone who is sensitized will experience pain in response to a stimulus that normally would not cause pain.

Apparent diagnoses sometimes lead us astray …

Monday, October 7th, 2013 at 11:29 AM

When treating chronic back pain, over-reliance on imaging studies frequently suggest arthritis, disc herniations, spinal stenosis, degenerative disc disease, and spondylolisthesis as the underlying diagnoses. Unsuccessful treatment often results if muscles, tendons, and fascia are not considered in the differential diagnosis.

Widespread pain is often diagnosed as Fibromyalgia Syndrome (FMS). In 1990 the American College of Rheumatology (ACR) presented classification criteria for the diagnosis of FMS [http://bit.ly/1bCzlC4.] 11 of 18 specified tender points as well as widespread pain defined as pain experienced on the left and right side, in the upper and lower body, and axially. Most patients are diagnosed with FMS by their primary care physician. However, most primary care physicians do not perform a physical examination of tender points. Because of this the ACR in 2010 proposed an additional set of diagnostic criteria for FMS that did not rely on a physical examination (http://bit.ly/1bCzlC4).

Three conditions must be met to satisfy the criteria:

Threshold scores on two new indices created by the ACR- the widespread pain index and the symptom severity scale score based on the presence of fatigue, waking un-refreshed and cognitive symptoms.
Patients must have similar symptoms at approximately the same intensity for at least three months.
No other disorder would reasonably explain the pain.

Although there is reasonable correlation between patients diagnosed with the 1990 criteria and the 2010 criteria, the absence of the physical examination may lead to overlooking patients whose diffuse pain can be successfully treated by addressing peripheral pain generators. Painful tissue peripherally (for example muscle or joint) can sensitize muscles diffusely [Woolf CJ, Central Sensitization: Implications for the diagnosis and treatment of pain. Pain 152 (2011) S2-S 15].

I welcome your comments on the complexities of diagnosing and treating FMS; more on central sensitization in my next post.

Back Pain: Opinion vs. Evidence

Monday, September 23rd, 2013 at 10:38 AM

I Googled back pain and got 649,000,000 hits. I am sure that the opinions of all those who posted their successful approaches were in there.

Overall I would say the consensus, based on cost and outcomes analysis, is that we do too much treatment of low back pain. Back pain is a symptom that may be caused by a variety of factors.

Deconditioning, muscles, tendons, operable lesions of the skeleton and neuraxis, are all possible causes. It is important to recognize that all the clinicians who posted their very different theoretical models and treatment approaches, believed they were achieving success with a majority of their patients. How could this be true unless each clinician was treating a unique subgroup of back pain patients? A recent article (http://bit.ly/1fjuCUT) demonstrated that pain clinicians publishing their outcomes reported an approximately 300% greater success rate than non-pain clinicians reporting on the outcomes of the same procedures. We are invested in believing that what we do works.

I try to consult the Cochrane Library of Systematic Reviews (www.thecochranelibrary.com) to get a sense of the validity of various approaches for the treatment of back pain. The literature on prolotherapy, trigger point injections, nerve blocks and surgery for chronic low back pain uniformly is found to be inadequate to make a case for the routine use of these approaches.

We need randomized controlled studies that report on function as well as pain intensity and with adequately long follow up data to improve our ability to know what works and for whom.

Opinion vs. Evidence on Long Acting Opioids

Wednesday, September 18th, 2013 at 2:40 PM

Do you believe that long acting opioids should be used routinely when patients are taking round the clock meds? A recently published study http://bit.ly/18y6RXL concluded that long acting but not short acting opioids were associated with hypogonadism in men. Boxed warnings on long acting opioids now read that if short acting opioids are effective they should continue to be used rather than switching to long acting.

Without large studies to prove a concept and insure the absence of unwanted effects, the standard of care has been that more expensive long acting opioids were preferable because they were assumed to be less likely to lead to abuse and addiction. I experienced this opinion as a mandate when a mail- in pharmacy my patient was using, said that if I didn’t write for long acting opioids they would no longer dispense meds to him. Opinion based guidelines, rather than evidence based guidelines, unfortunately is driving much of the practice of pain medicine.

It is important to understand what any diagnosis means in relationship to your back or leg pain.

Thursday, September 12th, 2013 at 10:37 AM

I have heard from a number of group members who have been diagnosed with spinal stenosis. The diagnosis is often made based on what is found on a CT scan or MRI without the expected corresponding signs and symptoms. It is important to understand what any diagnosis means in relationship to your back or leg pain.

Spinal stenosis is a narrowing of the space formed by the bony segments that together make up the vertebra (the bones of the spine). The space in each vertebra is connected to the vertebra above and below to form the spinal canal, through which the spinal cord passes. Narrowing of the canal in the lumbar region, called lumbar spinal stenosis, could squeeze the spinal cord. When you are standing up, the curve in the spine makes the narrowing worse and may cause pain radiating to the leg. Many patients found to have narrowing don’t have the signs and symptoms that would indicate that their back and leg pain was caused by the narrowing. Bending over when you walk, having more pain if you straighten up, and having to wait a few minutes when you sit down for the pain to go away, are all symptoms that suggest the spinal stenosis was truly the cause of the pain; just finding narrowing with imaging isn’t enough.

Other imaging diagnoses such as degenerative disc disease, degenerative osteoarthritis, bulging or herniated disc, and facet arthropathy, may also be misleading. Just because there is an anatomic finding on an image doesn’t mean it is the cause of the pain. If some form of exercise relieved the pain, the most reasonable explanation would be that much of the pain was related to soft tissue, such as muscle and tendon and not to the imaging diagnoses.

The importance of a multi-disciplinary approach to persistent pain

Thursday, August 29th, 2013 at 9:30 AM

An example of the importance of a multi-disciplinary approach to persistent pain is the patient with Kinesiophobia (fear of movement associated with anxiety related to an injury). Just as stress and anxiety can make pain worse, kinesiophobia can prevent a patient from recovering to their full extent and achieving relief from muscle pain.

An example….

Consider the case of a 50-year-old woman who was visiting the Norman Marcus Pain Institute for the treatment of her foot and ankle pain. The pain started two weeks after a fall, and had plagued her for five months. Because she felt that she was unable to walk without support, she used a walker or a cane. She complained of pain in her heel and ankle and in her Achilles tendon. Her foot was cold and clammy. Attempting to move her foot up and down and applying pressure to the painful areas caused the pain to become much worse.

She was overwhelmed with her pain and fearful that she would never get better. With her continued pain, tenderness, stiffness, and cold and clammy feet, her doctor told her she had RSD and needed to see a pain doctor for medications and possibly nerve block injections.

When she came in to consult with Dr. Marcus, he wanted to see if he could help increase the range of motion in her ankle. He used Ethyl Chloride spray to briefly make the area cold and numb. She moved her ankle and her pain was gone! Once she felt relief from her original pain, Dr. Marcus asked her to stand. However, she couldn’t because she was too weak. Five months without walking had weakened her muscles and made her unable to walk. She needed strengthening exercises, so she was referred to a physical therapist that helped her re-learn her walking technique while strengthening her muscles. She is now without pain because she no longer holds her ankle stiffly.

Kinesiophobia created more problems than necessary

Her fear of pain and her belief that not walking or moving her ankle would protect her caused her to become disabled, relying on her walker or cane. This could have easily been mistaken for RSD and lead to unnecessary, expensive and painful treatments. She had kinesiophobia, or fear of movement. This is an important factor when a patient is trying to overcome the effects of a painful injury.

The emphasis on procedures vs. cognitive and non-interventional approaches is producing unsustainable costs of care

Monday, August 26th, 2013 at 6:51 PM

The emphasis on procedures vs. cognitive and non-interventional approaches is a driving force in producing unsustainable costs of care in all areas of American Medicine. A recent study in JAMA Internal Medicine revealed that some procedures are reimbursed 3-5X more than cognitive services. The insurance industry appears to have inadvertently affected the delivery of care for patients in pain by incentivizing expensive interventional procedures and shortchanging all others.

In the past 40 years the field of Pain Medicine has shifted dramatically. A Thermidorian Reaction has occurred in the pain treatment community. The failure of surgical interventions for many chronic pain problems was the foundation for the original mission of clinicians treating these patients. We were aware that focusing on a putative pain generator in the periphery or relying on opioids to minimize pain and suffering, often produced sub-optimal results. We have reverted to the position against which we originally revolted. The platinum standard of care, the multi-disciplinary pain treatment center has been supplanted by high tech expensive interventions, often of questionable value (cost divided by effectiveness).

How can we take advantage of technological innovation in Medicine whilst at the same time continue to value what is simple and works well? This will require a shift in how we pay for medical services. As we have seen when there is a large disparity between pay scales in different medical disciplines, human nature will oblige many new graduates to avoid the least reimbursed fields. Ultimately society suffers. If exercise can eliminate back pain in some patients who appear to have an operable lesion how can we improve the chances that it will be tried first? If we do not collectively come up with an effective solution, someone else will. What are your thoughts?

The cost of services for the treatment of back and neck pain has continued to rise

Monday, August 19th, 2013 at 10:14 PM

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:

Medication management
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.

Multi-disciplinary pain centers consistently found to be effective for the treatment of chronic back pain

Monday, August 19th, 2013 at 10:01 PM

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.

Clinicians observed that patients with persistent pain had misconceptions about their condition that inhibited their ability to recover. Patient would frequently say “ if I have pain it means I am harming myself “ resulting in the avoidance of activities that produce discomfort and eventually eliminating many important activities in their life with resulting deconditioning, depression, 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 were created to address all of the factors associated with perpetuating the patient’s inability to function. Multidisciplinary pain centers provided 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 commonly provided treatments for various medical conditions to determine if the treatment is effective, ineffective or undetermined. Almost all of the treatments for chronic back pain have been found to be neither ineffective or effective, meaning the evidence is inconclusive 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 their success, close to half of them are no longer operating. “So what’s up with that?”

Back and neck pain that starts in one specific area often spreads locally and sometimes to other regions

Saturday, August 3rd, 2013 at 3:47 PM

A number of my patients who have been struggling with pain management for more than a year may report that although their pain began in one specific spot, over time, it began to spread. Sometimes, over time, neck pain would involve the lower back pain as well. Many of these patients were thought to possibly have fibromyalgia syndrome and were given anticonvulsant or serotonin-norepinephrine reuptake inhibitors (SNRIs). The spread of pain may be from central sensitization (CS) (http://bit.ly/1aVsdg0, http://bit.ly/1bHgSDU). With some of these patients when the worst pain was treated and resolved from one area it could appear in another and muscles not recognized on the initial examination would now be found to be causing discomfort. This could be a function of diffuse noxious inhibitory control (DNIC) http://bit.ly/14Ac4GL,

These confounding problems appear to represent two opposing and confusing phenomenon: CS and DNIC [currently referred to as conditioned pain modulation (CPM)] (http://bit.ly/1aVuish). Do these issues enter into your evaluation and treatment protocols?

Flouting guidelines: Worsening Trends in The Management and Treatment of Back Pain

Saturday, August 3rd, 2013 at 3:45 PM

The study published in JAMA today demonstrated that from 1999-2010 in 3 key areas, guidelines for the treatment of back pain are being ignored:

Use of recommended NSAIDs and APAP as first line drugs decreased by ~35% whilst not recommended opioid use increased by ~50%.
Not recommended referral from PCPs to specialists for back pain increased by ~106%.
Not recommended use of imaging increased ~50% for MRI and CT and for x-ray remained the same.

Is this a problem? If so, how should it be addressed?

Spine surgery and exercise

Tuesday, July 23rd, 2013 at 8:42 AM

I was interviewed, on Doctor Radio on Sirius XM. One of the callers told us that after she had spine fusion her pain was eliminated but if she didn’t do exercises at least every other day her muscles above and below the surgical site would tighten up and pain would begin to return. Even when surgery is indicated for back pain, proper conditioning of the postural muscles is still important.

If she didn’t have a good physical therapist and she wasn’t motivated to doing her exercises her surgery might have been considered a failure, another Failed Back Syndrome. Too often the need to address muscle health is overlooked in the treatment of persistent pain problems. As I emphasize in End Back Pain Forever, exercise and physical conditioning should be taught in grade school and encouraged throughout our life.

Many Back Surgeries Unnecessary

Monday, July 1st, 2013 at 11:05 AM

In the United States we are faced with the highest per capita health costs in the world. One would think that massive expenditures could provide the best care and treatment outcomes, but this is not the case. In many aspects the US is worse or no better than countries spending 50% of what we do on health care. One reason is that we often inappropriately provide costly evaluation and treatment interventions. We provide surgery too frequently on conditions that could be treated more cost-effectively. Having a step- care model (using the least invasive and potentially harmful, and most cost-effective approaches first) for various conditions would offer models of care for the majority of problems whilst still allowing for modifications in unusual circumstances. —Dr. Norman Marcus

By Ryan Sabalow

Some doctors estimate the national rates of unnecessary hysterectomies and back surgeries are even higher than the 25 percent cited by state health officials questioning the Redding area’s high rates of the procedures.

Dr. Ernst Bartsich, a clinical associate professor of obstetrics and gynecology at Weill Cornell Medical College in Manhattan, N.Y., said as many as one in three women in the U.S. has had her uterus removed by the time she’s 60. That number increases to one in two by 65.

Bartsich, an outspoken critic of what he calls the overuse of hysterectomies, said he believes that 85 percent of such procedures could have been avoided through less invasive methods, such as removing painful fibroid tumors from the uterine wall or through medication.
Read the rest of this entry

How can we know what back pain treatments make sense?

Monday, July 1st, 2013 at 10:32 AM

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

Bedside Manner and the power of suggestion in back pain

Sunday, June 30th, 2013 at 6:30 PM

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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Obesity, poverty, and community influence- back pain

Sunday, June 30th, 2013 at 6:28 PM

Obesity is more prevalent in neighborhoods with a high incidence of poverty. A study in the New England Journal of Medicine showed that encouraging families to relocate to higher income neighborhoods could lower the rate of obesity and signs of diabetes. This finding may lead to a better understanding of how we can combat the obesity epidemic. Read the rest of this entry

“Doctor, My Back is Killing Me!” – Chapter 1, Part 3 (#endbackpain)

Wednesday, June 26th, 2013 at 2:23 PM

In the last part of Chapter 1 from End Back Pain Forever, we turn to the story of “Stephanie”. Please review this blog for the complete chapters 1 and 2 from my book.

“Doctor, My Back is Killing Me!”, Part 3

Take the case of a patient whom I shall call Stephanie. She is a married attorney who in 2004 began to experience stiffness whenever she she got up out of a chair. She also had problems straightening up if she bent over. This was bothersome, but it was nothing compared to her first attack of spasms in her low back, on the right side. The spasms were incapacitating. She couldn’t walk and had to lie in bed for four days, taking painkillers and muscle relaxants. When the spasms broke, she still felt an inkling of discomfort that would frequently and unexpectedly morph into repeat episodes of painful spasms.

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“Doctor, My Back is Killing Me!” – Chapter 1, Part 2 (#endbackpain)

Wednesday, June 26th, 2013 at 2:21 PM

Here is Part 2 of Chapter 1 from my book, End Back Pain Forever. Click here for Part 1.

Chapter 1

“Doctor, My Back is Killing Me!”, Part 2

“I can put you on strong medication to dull the pain,” says the doctor. “It may be that your spine is the problem.”

“Does that mean surgery?”

“It could. Surgeons do a million spinal operations a year.”

Surgery on your spine is the last thing you want to do, but your back pain is horrendous. And, of course, you want to get better. So you say, “Can’t we do an MRI or a CT scan to see if there’s anything wrong with the spine?” MRI, or Magnetic Resonance Imaging, is a picture generated by magnetic fields, while a CT (computed tomography) scan is a picture generated by X-rays.

When you are shown the test results, the doctor points out that the images of your spine show that you have, say, a herniated disc (in which the cushion between two bony vertebrae is either protruding or has ruptured) or spinal stenosis (narrowing of the spinal column that houses your spinal cord), or some other spinal anomaly–and that, apparently, is the cause of your pain.

But if it were true that the abnormality on the MRI or CT scan was indeed the cause of your pain, I wouldn’t have written this book–because almost no one has a “normal” MRI or CT scan of the lower spine, and what is read as abnormal is frequently not the cause of your pain.

Read the rest of this entry

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