Hip pain and surgery

A bony abnormality of the hip called Femoral Acetabular Impingement Syndrome (FAIS), where the head of the femur (the thigh bone) is found to be irregularly shaped rather than its “normal” spherical shape, is sometimes treated with a surgical procedure to shave the head of the femur. FAIS can affect young individuals in contrast to osteoarthritis (OA) of the hip which usually occurs in older patients. It is thought that FAIS can cause pain in the hip, and can in addition if left untreated, result in OA. Read the rest of this entry

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Osteoporosis Prevention and Treatment

Osteoporosis in women is a growing public health challenge with an aging population. New approaches are needed to prevent and treat decreases in bone density and strength. Two recent articles present different and potentially complementary approaches.

Diet: Lanou reviews the studies on soy diets for the prevention of osteoporosis and bone fractures. Although the results are not consistent, soy based diets that are part of a diet rich in fruits and vegetables appear to be effective. Other studies have suggested that such a diet has a wide range of health promoting effects. Although there is not yet strong enough evidence to suggest that everyone become a vegetarian, at least for women, increasing the amount of fruits and vegetables and having soy in your diet, is a good idea.
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How to decrease headache frequency

A recent study of a simple resistance exercise program for the neck and shoulders, in office workers who complained of weekly headaches (HAs), showed an approximately 50% reduction in HA frequency vs. a weekly health education control group. The exercise groups were 2 minutes or 12 minutes of daily exercise. The remaining HAs were no different in terms of intensity or duration of pain.

HAs are the most commonly reported pain problem. If brief exercise could have such a dramatic effect on HA frequency, it should be considered as a standard intervention for all office workers who appear to have muscle tension type headaches. However it is not clear why neck and shoulder exercise reduce HA frequency. It is understandable that exercising muscles that are tense and stiff from repetitive strain, for example bending your head and neck over a desk for hours at a time, could help relax stiff and tense muscles. which can cause back and neck pain.  But just performing an action to address HAs on a daily basis may make you more aware of the circumstances surrounding a headache episode. Since headaches are frequently brought on with emotional stress, being more aware of and addressing stress has been shown to reduce HA frequency through various interventions.
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New possibilities for painful knees

The body can sometimes heal itself in painful conditions. A study of patients with painful osteoarthritis of the knee showed that by mechanically separating the bones in the knee that were touching and causing pain, cartilage regrew and pain and function improved. No other treatment is available that can produce structural change in an existing osteoarthritic joint. This is a potentially revolutionary discovery, and if shown to be effective in larger studies, may help patients with knee pain avoid or forestall knee replacement surgery. And give at least some temporary pain relief.

~ Norman Marcus, MD
Norman Marcus Pain Institute, New York NY
 
“Your New York City Pain Relief Doctor”

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Above all else, do no harm!

In our desperate wish for pain relief, we sometimes receive treatment that is harmful. One of those treatments may be botulinum toxin, frequently provided as Botox injections to tender muscles. A recent article showed how Botox could produce permanent damage in muscles with normal muscle fibers being replaced with fat cells.
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Knee pain, back pain, and muscles

A large study of army recruits demonstrated the protective effect of exercise on the development of knee pain. Male and female recruits who performed 4 stretching and 4 strengthening exercises for 7 weeks, were 75% less likely to develop anterior knee pain.
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Follow-up to recent Failed Spinal Fusion post:

The patient mentioned in the blog posted in March, 2011 copied me on an email he sent:

“I’ve been waiting for clearance from my surgeon who finally declared my fusion as failed (FBSS) in early March and offered no additional hope for pain reduction. At one-year post surgery I could be evaluated for an implanted morphine pump or spinal cord stim. Pain management started experimenting with oxymorphone and hydromorphone, which both had bad side effects and were less effective than the oxycodone. I’ve had the first two weeks of treatments with Dr. Marcus. The first week he did my left side lower back and leg, this Monday he did the right side lower and mid back. Pain reduction is at least 90%! I have much more energy, am more active and I’m beginning to feel flexible. He is also working on my mid-back and legs. I’ve been able to reduce oxycodone from ~180mg+/day to 60-80mg/day.”
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MRI, CT, and X-rays may mistake the cause of your back pain

MRI, CT and X-rays may fool us. A recent article concluded that the amount of constriction of the nerves exiting the lower spine thought to be the reason for back and leg pain was not correlated with the amount of relief a patient experienced with steroid injections around that nerve(s).

Beautiful clear pictures of the spine and nerves seduce us into believing we can see the reason for the pain. Focusing too much on imaging and not enough on the physical examination, results in many patients receiving surgery and nerve blocks that were assumed to be the right treatment but didn’t relieve the pain. Did that happen to you?
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Obesity and Understanding BMI with back pain

People in all industrialized countries are being harmed by a world-wide obesity epidemic. We generally determine if we are the proper weight by calculating the BMI (Body Mass Index): dividing your weight in pounds x 703 by your height in inches squared. If you weigh 140 pounds and are 5 feet, 8 inches, your BMI would be 21.28-
(140 x 703/68 x 68). Normal is 18.5-24.9, overweight is 25-29.9 and obese is over 30. A study of patients in 30 European countries found that over 70,000 new cancer cases were attributable to excess BMI in 2002. Obesity is also associated with an increased incidence of diabetes, hypertension, arthritis, coronary artery disease and dementia.
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Painless back and muscle injections

Pain is a deterrent to many patients when offered a therapeutic injection. There is some encouraging news on ways to make injections more comfortable.

A Cochrane review found that adjusting the pH, with bicarbonate, of a lidocaine injectate for local anesthesia, reduced the discomfort for patients without reducing analgesic effectiveness. The burning sensation produced by the acidic pH of lidocaine injectable is diminished by adjusting the pH upwards from the 3.5 -7.0 usually found in commercial preparations, to approximately 7.4.
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Misinformed medical advice may be harmful

A word in the mouth of a physician is as dangerous as a scalpel in the hand of the surgeon, Eugene Bauer, M.D. 1931

Women who have had breast surgery for cancer do not have more lymphedema with exercise according to a new study published in JAMA. This is an important finding because the myth has been that exercise could cause edema in women who had lymph node excision during surgery. The study showed that not only were the women who exercised stronger, but that they had a lower incidence of edema.
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Spinal Cord Stimulators- How well do they work?

Results of a 2 year study on Spinal Cord Stimulation (SCS), sponsored by St Jude’s Medical, Inc., found that 70 % of patients reported 50% or better pain relief at their final two-year visit. In addition 88% of these patients reported that their quality of life was improved or greatly improved. No specifics were reported concerning measures of success aside from reduction of back pain.

These results are much better than the previously reported SCS studies, A systematic review of SCS for failed back surgery syndrome and complex regional pain syndrome showed ~ 50% of patients achieved ~50% pain relief. The devil is in the details and without them, which should include how many patients had to have surgical revision of the SCS because of complications, the number of patients able to return to work, and the reduction in use of pain medications, it is difficult to come to any conclusions about the claims of extraordinary success.

~ Norman Marcus, MD
Norman Marcus Pain Institute, New York NY
 
“Your New York City Pain Relief Doctor”
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Darvon banned by FDA- Methadone spared

The painkilling drug Darvon (propoxyphene) was banned this week by the FDA because it can cause potentially fatal arrhythmias (abnormal heart rhythms). But other pain medications, like methadone, can also cause dangerous arrhythmias. I have been asked a few times why was Darvon banned, but not methadone?
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An important 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 conclusions published in the abstract are found in the next paragraph:
“The early high functional scores after primary rotator cuff repair or reconstruction of the types we performed in the 1980s did not persist. The function achieved postoperatively was lost, as ROM and strength decreased to less than preoperative values. However, alleviation of pain was long-standing in most patients. Based on our data, we should warn patients to expect less
than permanent relief with those repairs. We cannot say whether the same will apply to currently performed types of repairs.”
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Golfers with back pain

A golfing patient I treated originally came to me with low back pain and later with shoulder pain and neck pain- all preventing his inner champion from blossoming. Like so many golfers he had come to accept the suffering as part of the game. He was amazed to find that he could get rid of the back pain that had plagued him for years. He wrote about it in his blog today bit.ly/9aluAt

Thank you for the mention in your blog.

~ Norman Marcus, MD
Norman Marcus Pain Institute, New York NY
 
Your New York City Pain Relief Doctor”
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Source of your back, shoulder and neck pain

A 35 year old executive complained of neck and shoulder pain radiating into his fingers along with difficulty using his fingers. His MRI showed bone spurs in his neck which were causing compression of the nerves going into his arm. A neurosurgeon had suggested that he have surgery to remove the spurs and to fuse the vertebra in his neck.

He was given cervical spine epidural steroids and after the 2nd injection his pain and difficulties in his hand were eliminated, but the pain in the region of his shoulder blade persisted. He felt that it was time to revisit the neurosurgeon, but I told him that pain only in the shoulder isn’t typical for a problem in the spine.
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Measuring Low Back Pain Treatment Outcomes

The article in the European Spine Journal highlights a major difficulty in assessing the effectiveness of various back pain treatments. No two studies used the same criteria to measure improvement. The lack of uniformity appears to be present in every aspect of the enigma of low back pain. Recent studies demonstrated that the tests a family physician uses to establish probability of a disc herniation may not be valid. There are inconsistent criteria for fusion vs. a simple laminectomy or foraminotomy for back pain. Injection techniques vary widely for back pain thought to be from nerve or muscle.
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Is chronic back pain adequately treated?

I just read an article on the under treatment of chronic pain with the most common associated disease states listed as osteoarthritis, rheumatoid arthritis, fibromyalgia, and sickle–cell anemia. Since physical deconditioning is fraught with many serious negative consequences, such as obesity, high blood pressure, stroke, heart disease and diabetes in addition to be being a cause of most common pain problems, it should probably rank as a form of disease.
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Activity and quality of life

A recent article showed that even gentle but regular physical activity in middle aged women reduced the incidence of hip fractures. Lack of exercise contributes to many of the health problems with which we are confronted- obesity, heart disease, diabetes, hypertension, dementia, arthritis, and osteoporosis. At a time when the cost of health care is so important to each of us as Americans, awareness of inexpensive interventions and self responsibility for our well being should be foremost in our minds.

Proper exercise should take into account your level of conditioning before you begin any program. Many new exercisers will strain their weak or stiff muscles causing pain and disillusionment with their new found passion and quit. Remember the most important thing about your exercise plan is that you are able to and actually return for your next scheduled session.
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If I get back pain will it go away?

Although Low Back Pain (LBP) is thought to affect around 80% of individuals, it is also thought to be self limiting 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.
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