Dr. Marcus and his colleagues just published a 2 part long-term muscle treatment outcome study of lower back pain patients who were originally diagnosed as having pain in the spine and nerves exiting the spine (i.e. herniated disc, facet arthropathy, spinal stenosis, lumbar radiculopathy). The first large group of patients had been treated unsuccessfully with one or more of the following: spine surgery, facet blocks, radiofrequency ablation, trigger point injections and prolotherapy. The second small group were scheduled for back surgery. Both groups responded to a muscle treatment protocol with significant reductions in pain intensity and improvements in level of activity. Three of seven pre-surgery patients, identified with painful muscles, had their surgeries cancelled. Results were maintained at > 14 months follow-up. This second published study of his muscle evaluation and treatment protocol suggests that improved treatment and cost of care could result if muscles were routinely evaluated and treated in all patients with lower back pain. Click here to read the study document.
pain management Archives
Where to begin? In the first two chapters of my book, End Back Pain Forever, I explore a variety of issues related to the difficulties in evaluating and treating patients with back pain. I am posting these chapters as a means to share my perspective which developed over more than 40 years as a pain medicine physician in the US and the UK. I encourage the members of my LinkedIn Group, Let’s Talk About Pain to agree, disagree, or share your own experience as a patient, family member of a patient, or clinician.
The cost of evaluating and treating lower back pain and neck pain is rising. From 1997-2005 it went up from $54 to $86 billion/year. Unfortunately, advances in spine surgery techniques, nerve blocks, and pain medication have not translated into more successful treatment – from 1997-2005, 25% more patients reported difficulties functioning because of neck pain or back pain.
Although 70-80% of back pain is diagnosed as non-specific lower back pain, referring to sprains and strains of muscles, ligaments and tendons, the current guidelines do not mention muscle as a possible source of persistent back pain. This leads to an overemphasis on the spine and the nerves leaving the spine.
We need a treatment model (step-care) that addresses the most common reason for back pain first. Protocols that provide soft tissue treatments that are least costly with minimal chance of harm, should produce better, more cost-effective outcomes.
Spending more money to do the same kinds of treatment is not working. This discussion group will explore possible reasons for sub-optimal pain treatment outcomes. How can we change the way we evaluate and treat persistent pain to improve our results and lower the costs of care?
A search for back pain on the internet finds almost 600 million sites. With so many different ideas on how to address this problem, we will attempt to narrow the discussion to concepts that have been studied and published in scientific journals. One obvious issue is the absence of a muscle evaluation and treatment protocol.
The tragic occurrence of meningitis, stroke and death following use of infected steroids used for spine injections should make us more aware that this very common treatment for back pain may not be worth the risks. The use of epidural steroid injections (ESIs) to shrink an inflamed nerve thought to be causing back pain has not been shown to consistently reduce pain and even when it does the benefit is frequently short-lived. Aside from infection, other rare but serious side effects include bleeding that can cause nerve damage with possble weakness and paralysis, and additional pain. Steroids themselves have been the cause of bone (aseptic necrosis) and tendon damage.
Multiple medical professional organizations have suggested that ESIs should not be used for long standing back or neck pain or for pain in the back or neck that does not radiate to the arms or legs. Despite the evidence that even when ESIs reduce or eliminate pain, at best they are useful for 3 months or less. Other countries i.e. Denmark, rarely use ESIs.
As long as a thorough physical examination does not take place with all patients complaining of back or neck pain, with the purpose of determining if muscles are a source of pain, we will continue to rely on imaging studies that lead us to mistakenly believe that all back pain comes from the spine and the nerves leaving the spine. Continuing to provide unnecessary and ineffective treatments not only squanders our limited resources but could cause irreparable harm.
“Thank you for treating me as someone struggling with pain and not as a former drug addict who could not be trusted with strong pain medication” – a note I recently received from one of my patients.
A patient with a history of drug abuse may be fearful that their past will prevent adequate treatment for a serious painful condition. My patient imagined that I would not be respectful of his suffering and his commitment to sober living. He received the pain medication that allowed him to go through a series of medical and dental procedures without suffering. He was grateful.
Concerns about opioid misuse have made physicians wary of prescribing potentially habit-forming pain medication. Illicit prescription drug use is a growing problem in the USA and is actually the preferred street drug aside from marijuana. However in treating patients in pain, two basic American traditions should be the guiding principles with patients who have a history, or who test positive on a written test to determine the risk, of drug abuse:
1. Innocent until proven guilty; and
2. in the words of Ronald Reagan, Trust but verify. Those patients who have problems properly using pain medication need extra attention, not condemnation. They may be more difficult to treat, but that is why there are specialists to deal with complex pain problems.
In this next segment, I take Hans up on his offer to examine one of my patients. Read what happens next!
Click here for the Part 4 segment.
You Are Not Alone: The Back Pain Epidemic (Part 5)
Dr. Kraus and I met a week later at Lenox Hill. I had chosen a patient whom I shall call Beth. She was a forty-five year-old woman so defeated by pain after three unsuccessful spinal operations that she could no longer hold a job. Her life had revolved around her work, which was at the core of her sense of self. She was devastated. No one had found a truly successful treatment for her, and I did not believe that anyone could. She was on high doses of morphine, 60 milligrams orally five to six times a day, to relieve her pain.
After reviewing her case history, Dr. Kraus gave her a comprehensive and thoughtful mental and physical examination. Starting with her neck, he used his fingertips to palpate her muscles to distinguish between those that were supple and pain free and those that were stiff and painful. He found five pairs of painful muscles on both sides of the lower back, buttocks, and thighs. “If these muscles are treated properly,” he told me, “it should reduce or eliminate her pain.” Read the rest of this entry
This excerpt from my book End Back Pain Forever, is about my mentor and friend, Dr. Hans Kraus. He changed the way I viewed pain and the treatment of pain, and enhanced my life and ultimately my patients’ lives for the better.
You Are Not Alone: The Back Pain Epidemic (Part 4)
Then, in 1993, I met Dr. Hans Kraus. He was to transform my life and the life of my patients. He was eighty-five years old and had just retired from his practice as a specialist in physical medicine and rehabilitation. He had also given up mountaineering and rock climbing. In all those pursuits, he had won international acclaim. Originally trained as an orthopedic surgeon at the University of Vienna, Dr. Kraus was well known for having successfully treated President John F. Kennedy’s back after all prior treatments had failed. Yet his nonsurgical approach to treating patients with muscle pain, especially low back pain, was not accepted by other doctors, including some of the very doctors who referred their own patients to him for what proved to be successful treatment.
For example, one prominent orthopedic surgeon at the Columbia University School of Medicine, Dr. Frank Stinchfield, who routinely sent many of his back pain patients to Dr. Kraus, underwent spinal surgery rather than consult him for his own back pain after a herniated disk was diagnosed. The surgery failed, and Dr. Stinchfield was never able to work again because of unrelenting pain.
Another disappointing example was that of Dr. Jonas Salk, best known for developing the first safe and effective polio vaccine. Dr. Salk did consult Dr. Kraus for back pain, and the treatment was successful. It eliminated Dr. Salk’s pain and allowed him to avoid surgery. Yet when Dr. Kraus needed Dr. Salk’s help to obtain research support, the famed medical researcher declined. He said that muscle pain didn’t have a “scientific foundation.” That has since changed, and we will look at the basic research explaining the mechanisms of muscle pain in Chapter 4.
In our first meeting, Dr. Kraus asked what I did. I told him that I treated patients with chronic pain.
“How do you do that?” he asked.
“I teach them how to manage their pain, how to deal with it, live with it.”
“Why not get rid of their pain?”
“Because it’s chronic pain,” I said. “You can sometimes reduce it, but you can’t get rid of it.”
He persisted. “Have you treated the muscles?”
“We treat the muscles with aerobic exercises.”
“Aerobic exercises? Really? Muscle pain caused by muscle spasm, tension, stiffness, and trigger points does not respond to aerobics. But it will respond to other types of exercises: prescribed exercises designed to treat the specific source of pain. That’s what I’ve done.”
“Low-impact aerobics are the standard way,” I said.
“They may be the standard way,” he replied. “But they are sure to make many of your patients feel worse.”
He asked if I had “very difficult cases,” and I told him that I did. “Some,” I added, “are impossible to treat.”
“Would you mind if I were to examine one of them?”
This excerpt from my book End Back Pain Forever, provides a small summary of my early involvement in pain medicine.
You Are Not Alone: The Back Pain Epidemic (Part 3)
In 1975, I became a staff physician in the Montefiore Department of Neurology’s Headache Unit, founded by Dr. Arnold Friedman. Two years later, with Dr. Edith Kepes, an anesthesiologist at the hospital, we started the first outpatient pain center in New York City, effectively following the lead of Dr. John J. Bonica, a medical giant to whom we owe the study of pain as a recognized discipline. As a young army anesthesiologist during World War II, he pioneered pain-relieving techniques and treated ten thousand wounded soldiers. Dr. Bonica went on to write a 1,500-page medical classic, The Management of Pain, Dr. Kepes and I began a team approach with practitioners from different fields – including colleagues from anesthesiology, neurology, orthopedic surgery, neurosurgery, physiatry, psychiatry, and psychology – all of whom were interested in what could be done for patients tormented by chronic pain.
I subsequently expanded on this concept by starting the New York Pain Treatment Program at Lenox Hill Hospital in 1983. It was considered a state-of-the-art treatment center in a hospital setting, with an integrated team that involved not only doctors but also physical and occupational therapists, psychologists, and pain rehabilitation nurses. We used a variety of treatments: biofeedback and relaxation training; physical therapy to increase strength, mobility, and endurance; hypnosis to help control pain; stress management to provide coping skills for handling daily upsets that may increase muscle tension; occupational therapy to teach patients how to complete their routine tasks effectively through proper time management; individual, family, and group psychotherapy to resolve personal difficulties related to living with chronic pain; and medication management to eliminate many ineffective drugs that patients were taking in their journeys from doctor to doctor.
But our program had a basic flaw. We were convinced that teaching people how to live with their pain was usually the best we could do. We didn’t believe that we could eliminate their pain. Many of our patients remained on strong medication indefinitely. If a patient had a 35 percent decrease in pain, I considered that good. If we got it down to 50 percent, it was considered a success.
Along with the vast majority of physicians, I was committed to the fallacy that most chronic pain couldn’t be cured. Then, in 1993, I met Dr. Hans Kraus. He was to transform my life and the life of my patients.
The NY Times on 4/9/2012 ran a story about the overuse and unintended negative consequences of strong (opioid) pain medication. They mentioned opposing views concerning the liberal use of opioids. I participated in a debate in 1995 about the inappropriate use of the diagnosis “Chronic Pain Syndrome”(CPS) in patients whose muscles had not been assessed as a cause of their persistent pain, which resulted in the justification to put some of these patients on opioids for the rest of their lives.
Since then one of the largest growth industries in medicine is the evaluation and treatment of back and neck pain, currently accounting for ~$100 billion in direct medical costs. The pain juggernaut is fueled in part by ignoring muscles which are the most common reason for pain complaints. Addressing the incorrect causes of pain leads to inappropriate, expensive and potentially harmful treatments with poor outcomes, persisitent pain, and overuse of opioids. CPS is a license to prescribe life-long medication. Chronic use of opioids has not been studied for its overall impact on patients with CPS but neither have any of the other medications that we are now using. Does the marginal reduction in pain in many of the patients taking these medications justify their costs and side effects? As the Times reports, for some patients the treatment is actually making them worse.
Imagine if some of these patients had pain that could be eliminated. Many do; it’s from muscles that are not evaluated or treated in a systematic way. My new book, End Back Pain Forever, to be released by Atria on June 5, 2012 is a wakeup call to change the way we are treating common pain problems.
There may be more to your pain than you think. Pain affects how you feel and how you move your body. More often than not, these changes happen without you even realizing it. Consider a concept known as kinesiophobia, defined as a 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.
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. Read the rest of this entry
Two days ago I reported on a study that showed we are frequently doing a disservice to patients in inappropriately ordering imaging studies such as MRIs. Yesterday I saw a patient who could be the poster person for the study. This patient had a back injury one year ago when a fall onto the buttock produced lasting severe low back pain. The pain doesn’t radiate-it is only in a discrete area on the buttock. She felt a tender sensation when the area was pressed.
Despite the obvious findings suggesting the cause of her pain was muscle and not spine and nerves coming from the spine, an MRI was ordered and it showed a bulging disc and she was told this was the cause of her back pain. She has had a variety of physical therapy interventions and injections without relief.
Her physical examination showed that she could touch her toes and her straight leg raising was 90 degrees, rarely if ever seen with a patient whose pain was the result of a disc. She did have two muscles, the Gluteus Maximus and Piriformis, which were tender when stimulated by the Muscle Pain Detection Device. This showed that these muscles were the probable cause of her pain. A ketamine based cream was applied to the skin over these muscles and her pain was gone, further supporting the connection between the muscles identified and her long-standing back pain.
Read the rest of this entry
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
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.
Read the rest of this entry
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”
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.
Read the rest of this entry
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.
Read the rest of this entry
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.”
Read the rest of this entry
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?
Read the rest of this entry
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.
Read the rest of this entry
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.”
Read the rest of this entry
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.
Read the rest of this entry