NMPI Blog - Norman Marcus Pain Institute

Misinformed medical advice may be harmful

Thursday, December 9th, 2010 at 7:05 PM

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?

Monday, December 6th, 2010 at 7:06 PM

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”

Darvon banned by FDA- Methadone spared

Wednesday, November 24th, 2010 at 7:08 PM

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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Pain relief, motion, and function after rotator cuff repair may not last

Friday, October 15th, 2010 at 7:10 PM

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

Tuesday, September 28th, 2010 at 7:11 PM

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”

Source of your back, shoulder and neck pain

Thursday, August 12th, 2010 at 7:12 PM

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

Thursday, June 24th, 2010 at 7:14 PM

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?

Tuesday, May 25th, 2010 at 7:15 PM

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

Tuesday, May 18th, 2010 at 7:18 PM

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?

Tuesday, May 11th, 2010 at 7:22 PM

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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Chronic Low Back Pain and Fibromayalgia

Friday, April 23rd, 2010 at 7:25 PM

A recent article discussed the number of patients with Chronic Low Back Pain (CLBP) who also had Fibromyalgia syndrome (FMS). This article is an example of the confusion in medicine about both conditions. Believe it or not although the most common diagnosis for low back pain is non-specific low back pain, referring to sprains and strains of muscles and other soft tissue, there is no agreed method to look for and treat muscle generated low back pain. Patients with
Fibromyalgia on the other hand, although complaining of pain in muscles, are for the most part not considered to have muscles as the cause of their pain but rather problems in their nerves that are experienced as pain in muscles.
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Back Pain Treatment

Thursday, April 22nd, 2010 at 7:27 PM

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:

Medication management
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.
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Multi-disciplinary Pain Centers rise and fall

Wednesday, April 21st, 2010 at 7:28 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.

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.
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History of the concept of the spine as the cause of back pain

Tuesday, April 13th, 2010 at 7:30 PM

Back pain can be found in the medical literature as far back as 1500 B.C. in Egypt.
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.
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History of Back Pain- Don’t believe that the newest approach is the best!

Sunday, April 11th, 2010 at 7:31 PM

Spinal fusion surgery for back pain was reviewed in three articles in the Journal of the American Medical Association this week http://cot.ag/bjDgWW . The sobering conclusions were that we are spending up to 10 times more for complicated new surgical procedures and frequently getting worse outcomes and up to twice as many complications.

Unfortunately, this is nothing new in the history of back pain treatment. An article in Spine http://cot.ag/dASfWh analyzed the cost of the treatment of back and low back pain in the United States. It found that the cost of care from 1997 to 2005 went up from $62 billion to $86 billion and at the same time the number of patients reporting difficulty in functioning because of their pain also went up by 25%. Spending 65% more ($34 billion) resulted in worse outcomes.
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History of Muscle Pain

Monday, March 22nd, 2010 at 7:34 PM

A review of comprehensive pain treatment textbooks finds no chapters dealing with muscle pain aside from sections on “Myofascial Pain Syndrome” discussing “trigger points” as the defining characteristic of syndromes with painful muscles. This points up a fundamental problem in discussing and understanding clinical muscle pain- the lack of agreed terminology to describe what is found when a painful muscle is examined. All muscle pain logically cannot be the result of trigger points. Treating every patient with tender muscles with injections will frequently result in failure to eliminate the pain. To better appreciate this lack of understanding, the history of muscle pain should be reviewed.
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Pain Medications in the News

Wednesday, July 8th, 2009 at 12:52 AM

Back pain that never goes away completely can undermine your quality of life. It can prevent you from participating in activities that bring you pleasure and security. The medications that we use to deal with the pain, while being life-savers in terms of providing relief from the suffering, expose us to potential harm.

Tylenol (acetaminophen) has been found to result in more than 40,000 cases of liver damge each year in the US. Some of these patients have died. Because of the misuse of this generally well tolerated drug, the FDA will limit its availability in combination drug products such as Percocet and Vicodin. The recommended upper limit has been 4000 mgms but will probably be reduced in the near future . A regular dose Tylenol tablet is 325 mgms, making twelve the maximum number of tablets/day. When you take the combinaton drug you may not be aware that you are ingesting the same drug as in Tylenol and inadvertently take a harmful overdose.
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What causes my back pain?

Sunday, May 3rd, 2009 at 12:49 AM

With severe back pain we frequently worry about having a herniated disc. If you have back pain and get an MRI chances are you’ll find something. At NY Hospital/Weill-Cornell, 90% of the MRIs of the low back are read as abnormal. But most back pain is diagnosed as “Idiopathic /Non-specific”, referring to sprains and strains of soft tissue such as muscle. But common soft tissue problems are not seen on the MRI so we often incorrectly assume that what we see on the image, such as disc herniaton/bulge, degenerated discs, spinal stenosis, facet arthritis, spondylolisthesis, is the cause of the pain. When we treat these “causes” we have many failures. Actually in some studies more than 50% of the back surgeries are unsuccessful leading to a new diagnosis, Failed Back Surgery Syndrome. Some clinicians recognize that muscles could be a source of the back pain and have attempted to treat the muscle that they have identified by applying pressure (palpation) to the suspected painful muscle. There are a variety of treatments that are offered. I will discuss some of them next time.

~Norman J. Marcus, MD

Norman Marcus Pain Institute, New York NY

“Your New York City Pain Relief Doctor”

The Blog to Illuminate and Eliminate Chronic Pain

Monday, April 27th, 2009 at 11:55 PM

It is my wish to inform patients and colleagues about the possibilities of eliminating pain even when it is thought to be permanent (chronic) or require an invasive proceedure such as surgery, nerve injections, spinal cord stimulation or a morphine pump to achieve any relief.

Our story begins with the recogniton that the current standard of care doesn’t work very well. An article in the Jouranl of the American Medical Association (JAMA), in February, 2008, by Martin, Deyo, et al.. reported that even though the cost of neck and low back pain in the USA increased from $26 billion in 1997 to $86 billion in 2005, there was no improvement in treatment outcome. $86 billion is also the amount we spend on cancer.

Actually patients were reporting that they were more impaired by neck and back pain in 2005 than in 1997. It appears that the reasons that we frequently offer to explain low back pain such as herniated discs, degenerated discs, arthritis, and spinal stenosis, are frequently wrong since treating these so called causes results in no, or partial, temporary improvement. What is missing from the published diagnosis and treatment guidelines for common pain problems such as low back, neck and shoulder pain, is any approach which addresses muscles as the primary source of pain.

In future postings we will look at some reasons why muscles are ignored and what you can do about it.

~ Norman Marcus, MD
Norman Marcus Pain Institute, New York NY

“Your New York City Pain Relief Doctor”

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