Monday, April 21st, 2014 at
Low level laser therapy (LLLT) is a promising new treatment for a variety of painful conditions which is believed to reduce inflammation and stimulate healing of wounds. Interest in the laser first developed when Endre Mester at Semmelweis University noticed that applying the laser to the backs of shaven mice caused hair to regrow faster than those who did not receive laser treatment. This observation prompted further study into the regenerative effects of the laser first in rats, and then later in humans.
Currently, there aren’t many large-scale studies evaluating the effectiveness of the laser, but smaller studies of the laser for painful conditions show promising results.
A study of 50 patients with knee osteoarthritis reported that the laser was significantly more effective at providing pain relief than transcutaneous electric nerve stimulation (TENS)**. Similarly, a separate study of 125 patients with knee osteoarthritis reported both an improvement in pain and an increase in function after LLLT.
In a study of patients with temporomandibular disorders, the laser improved pain within 24 hours, with relief lasting at the 180 day follow-up.
Current studies show that the laser is an up and coming, non-invasive, non-painful treatment option, but larger studies are needed to determine the correct dosing, and for which conditions the laser will be most useful.
**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.
 Chung, Hoon, Tianhong Dai, Sulbha K. Sharma, Ying-Ying Huang, James D. Carroll, and Michael R. Hamblin. “The Nuts and Bolts of Low-level Laser (Light) Therapy.” Annals of Biomedical Engineering 40.2 (2012): 516-33. Print.
 Kędzierski, Tomasz, Katarzyna Stańczak, Kamila Gworys, Jowita Gasztych, Marcin Sibiński, and Jolanta Kujawa. “Comparative Evaluation of the Direct Analgesic Efficacy of Selected Physiotherapeutic Methods in Subjects with Knee Joint Degenerative Disease – Preliminary Report.” Ortopedia Traumatologia Rehabilitacja 14.6 (2012): 1-10. Print.
 Gworys, Kamila, Jowita Gasztych, Anna Puzder, Przemysław Gworys, and Jolanta Kujawa. “Influence of Various Laser Therapy Methods on Knee Joint Pain and Function in Patients with Knee Osteoarthritis.” Ortopedia Traumatologia Rehabilitacja 14.3 (2012): 269-77. Print.
 Pereira, T. S., O. D. Flecha, R. C. Guimaraes, A. M. Botelho, JC Ramos Gloria, and K. T. Aguiar Tavano. “Efficacy of Red and Infrared Lasers in Treatment of Temporomandibular Disorders–a Double-blind, Randomized, Parallel Clinical Trial.” Cranio : The Journal of Craniomandibular Practice 32.1 (2014): n. pag. Ovid. Web.
Wednesday, April 2nd, 2014 at
There has been an increase in the number of hours we sit in front of a computer for leisure and work. Does your job require you to stare at a computer for hours at a time? One study found that workers sitting for 95% of the day, and/or worked with their neck at 20˚ or more in flexion for more than 70% of their working time, had a significantly increased risk of neck pain.
An ergonomically designed workstation would help reduce the strain on your muscles. Here are a few suggestions:
- Place your monitor so you are looking at it straight ahead or down at no more than a 15˚ angle.
- The monitor should be 18-24 inches away.
- The angle of your elbows when typing on the keyboard should be > 90 degrees.
- An ergonomic mouse or keyboard may also help.
- A laptop is always non-ergonomic; because the monitor and keyboard cannot be separated one or the other is in the wrong position. If you always use a laptop think about getting an auxiliary keyboard.
- Footrests should be used if your feet do not rest flat on the floor.
- If you use a phone frequently get a headset so you will not have to hold the handset to your ear.
Aside from these changes, you may also consider doing limbering activities such as small stretches throughout the day – shrug your shoulders a few times, move your arms above your head, or get up and walk around your chair.
 Ariens, G. AM, P. M. Bongers, M. Douwes, M. C. Miedema, W. E. Hoogendoorn, G. Van Der Wal, L. M. Bouter, and W. Van Mechelen. “Are Neck Flexion, Neck Rotation, and Sitting at Work Risk Factors for Neck Pain? Results of a Prospective Cohort Study.” Occupational and Environmental Medicine 58 (2001): 200-07. BMJ Group. Web.
Wednesday, March 26th, 2014 at
Many patients with chronic pain become depressed; therefore it is not surprising that many of these patients will receive antidepressant medications. What is very interesting is that these antidepressants not only can decrease depression associated with pain, but they can also decrease pain itself. They are frequently used to treat persistent pain associated with problems in nerves. The reason that antidepressants are effective for pain is that the chemicals in the nervous system that are associated with depression also are associated with pain.
Antidepressants increase the available amounts of chemicals which affect your mood. These chemicals include serotonin, norepinephrine, and dopamine. The two most common types of antidepressants are:
- SSRIs (Serotonin Specific Reuptake Inhibitors) – Antidepressants which only increases the amount of serotonin available. Examples of SSRIs are escitalopram (Lexapro), fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft).
- SNRIs (Serotonin/Norepinephrine Reuptake Inhibitors) – Antidepressants which increase the amount of serotonin and norepinephrine available. Examples of SNRIs are venlafaxine (Effexor) and duloxetine (Cymbalta). Examples of Tricyclic Antidepressants (a type of SNRI) are amitriptyline (Elavil), and nortriptyline (Pamelor).
SSRIs are not as effective for pain relief as SNRIs.
Even though the antidepressants may help diminish pain, their side effects can be unacceptable. A recent review found that although approximately 1/3 of patients who took antidepressants for neuropathic pain experienced moderate pain relief or better, 1/5 discontinued use due to adverse side effects.
Common side effects of antidepressants are nausea, dizziness, insomnia, weight gain/loss, dry mouth and diminished interest in sex (decreased libido). If you’re not having reasonable pain relief with one of these medications, it should not be continued.
 Saarto, T., and P. J. Wiffen. “Antidepressants for Neuropathic Pain: A Cochrane Review.” Journal of Neurology, Neurosurgery & Psychiatry 81.12 (2010): 1372-373. Print.
Friday, March 14th, 2014 at
The next series of blogs is a brief discussion of different types of medications used for pain.
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).
Although 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
Wednesday, March 12th, 2014 at
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.
Monday, February 17th, 2014 at
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, 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; 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
-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. (This article can be accessed here.
 Mense, Siegfried, and Robert Gerwin. Muscle Pain: Diagnosis and Treatment. Heidelberg: Springer, 2010
 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.
 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.
Wednesday, February 12th, 2014 at
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.
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.
Monday, February 3rd, 2014 at
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).
70% of lower back pain is diagnosed as idiopathic or non-specific, 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%.
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. 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.
 Deyo, RA., et al. Low Back Pain. NEJM. 2001; 344(5):363-370
 Martin, B., et al. Expenditures and health status among adults with back and neck problems. JAMA. 299(6):656-64, Feb 2008.
 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.