Pain Doc - Ask Dr. P - The Pain Doc

An Often Neglected Approach to Self-Treat Disc Bulging

by Pain Doc | Aug 27, 2013 | Uncategorized

Disc bulges, or herniations, come in a variety of presentations. They usually are limited to the lower lumbar spine (L3/4 to L5/S1) and the neck (C4/5-C7/T1). In taking the medical history of patients suffering from disc bulges, there is usually a history of a sedentary office job that requires sitting long hours; a previous injury like a sports, work, or car accident injury; and in rare cases, no significant event or habit that could explain how the disc bulge occurred. In fact, there are studies that indicate that degenerative disc disease, which can include varying degrees of disc bulging, can be hereditary.

A common theoretical model for degenerative discs goes like this: something happens that causes the disc to bear excessive weight, which over time forces fluid out of the disc causing it to dessicate. The outer fibers responsible for keeping the disc intact and the nucleus in place weaken, allowing the center nucleus to bulge outwards. Chiropractors often attribute this scenario to subtle misalignments in the vertebrae caused by minor trauma, prolonged sitting and insufficient support from the abdominal muscles and lumbar muscles. Normally the disc should support 80% of the weight above it and the facet joints (the smaller joints behind the disc) about 20%. But if a physical event changes the orientation of the vertebra, it can force the disc to support 90-100% of the weight, accelerating its demise.

Other models reference calcification of the vertebral end plates,the surfaces of the vertebrae above and below the disc, which then prohibits capillaries from feeding nutrients to the disc causing it to die. Bone calcifies in response to trauma; vertebral end plates can sustain “micro-compression” injuries from activities that place a heavy, axial load (perpendicular) to the disc. Examples include basketball, gymnastics, running, and parachuting.

An acute herniated disc can be extremely debilitating, as it tends to last a lot longer than a typical sprain/strain injury. It hurts, limits movement, can make sleep difficult and restricts you from work and physical activity. If it presses on a nerve root it can send shooting pains down the buttock and leg and cause numbness and weakness. The general recommendation for most cases of non-emergency disc herniations is to manage the pain using physiotherapy (ice, heat, muscle stim, laser), do physical therapy including stretching and strengthening exercises and wait for the disc bulge to self-resolve in 2-3 weeks. Once it heals and the inflammation goes down, the pain usually goes down as well.

If your disc herniation is pressing on a nerve root, the disc may shrink as it heals, removing pressure from the nerve. This is the best scenario obviously, as you avoid surgery and get your life back. At this point, it is prudent to avoid activity that risks re-injury (heavy lifting while turning torso) and do everything you can to strengthen your core muscles and spinal muscles to guard against re-injury. Functional exercises should be emphasized, for this purpose.

The thing that can dramatically increase the chances of full recovery without surgery is healing your insides– reduce systemic inflammation by getting down to a healthy weight and maintaining it; stop smoking, avoid alcohol as best you can, reduce stress, reduce insulin levels, maintain normal blood glucose levels, ensure that your gut micro flora is in balance, and get adequate sleep every day. Eat healthy, decrease your portions, and drink enough water to stay hydrated throughout the day. Exercise consistently, 20-40 minutes each time. This is what a healthy lifestyle routine is made of.

People who are in pain usually are concerned about knocking down the pain first, and ignore the health of the rest of their body. Remember, your entire body is essentially a colony of specialized cells that are interconnected via the bloodstream, nerves, and hormones. When one area is injured, the rest can come to its aid.

If you suffer from disc herniations, joint pain or other musculoskeletal form of pain and are overweight, pay more attention to getting yourself healthy inside; it’s the often ignored self-help method to treat pain.

How Insufficient Sleep Can Increase Your Pain

by Pain Doc | Aug 21, 2013 | Uncategorized

If you are suffering from pain, insufficient sleep can delay your recovery and even make your pain worse.

Eight-nine hours of sleep is considered ideal for most adults. Anything less than this, especially if your body is already compromised with obesity, diabetes, heart disease, high blood pressure, arthritis, or other systemic disease will make matters worse.

Insufficient sleep raises cortisol levels. Cortisol is the hormone secreted by your adrenal glands (above kidneys) and is involved in a number of physiological functions including stress response, mood, and metabolism. When cortisol levels remain abnormally high, it drives blood glucose levels up and suppresses insulin sensitivity of cells prolonging the high glucose levels. This is how sleep deprivation promotes obesity.

Insufficient sleep also abnormally lowers the satiety hormone leptin and raises the hunger hormone ghrelin. This combination leads to overeating. In one study involving rats, sleep deprivation delayed healing of burn injuries in the sleep-deprived rats.

But perhaps the most dangerous thing sleep deprivation can cause is increased systemic inflammation. Inflammation is your body’s way of quarantining an injury site and healing injured tissue. But if it is ongoing and present throughout the body in small amounts, it can damage blood vessels, nerves and other tissues.

On June 22, 2002, researchers at the annual meeting of the Endocrine Society held in San Francisco reported that sleep deprivation markedly increases inflammatory cytokines. This finding helps explain why pain flare-up occurs in response to lack of sleep in a variety of disorders. According to the researchers, even modest sleep restriction adversely affects hormone and cytokine levels. In a carefully controlled study, sleep deprivation caused a 40% to 60% average increase in the inflammatory marker IL-6 in men and women, while men alone showed a 20% to 30% increase in TNF-a. Both IL-6 and TNF are potent pro-inflammatory cytokines that induce systemic inflammation (Vgontzas et al. 1999; Vgontzas et al. 2001).

Interleukin-6, Tumor necrosing factor alpha, and C-reactive protein– these are the inflammatory markers that can be measured by a blood test. Get yours checked if you haven’t done so. Studies show that high levels are associated with heart disease, diabetes, stroke and early death. TNF-a especially attacks cartilage and bone and is found in high quantities in persons suffering from arthritis.

Life Extension provides the following nutritional interventions that one can use to counteract systemic inflammation:

The docosahexaenoic acid (DHA) fraction of fish oil may be the most effective nonprescription nutrient to suppress pro-inflammatory cytokines (it’s best to get concentrated EPA-DHA fish oil for this purpose).
Gamma-linolenic acid (GLA) is a precursor of PGE1, a potent anti-inflammatory agent.
DHEA is a hormone that decreases with age. DHEA has been shown to suppress IL-6, an inflammatory cytokine that often increases as people age. Typical doses of DHEA are 25-50 mg daily, although some people take 100 mg daily.
Nettle leaf has been shown to suppress the pro-inflammatory cytokine TNF-a. Take 1000 mg daily.
Vitamin E and N-acetyl-cysteine (NAC) are protective antioxidants with anti-inflammatory properties. Vitamin E that contains gamma-tocopherol and tocotrienols provides the most broad-spectrum protection. NAC is an amino acid with antiviral and liver protectant properties. Six hundred milligrams daily is recommended.
Vitamin K helps reduce levels of IL-6, a pro-inflammatory messenger. Vitamin K also helps in the treatment of osteoporosis by regulating calcium and promoting bone calcification. If you are taking Coumadin or other anticoagulant medicine, consult your physician before taking vitamin K.
Consuming at least 1000 mg per day of carnosine and/or 300 mg of the European drug aminoguanidine can inhibit pathological glycation reactions in the body.

Also, avoid eating foods that are cooked at high temperatures, as they tend to form advanced glycated end-products, or AGE. These are basically denatured proteins that can accumulate in your tissues and promote inflammation. Food that this pertains to are deep fried foods, junk foods/ chips cooked at high temperature, and charred foods from barbecuing.

Back to the point– make sure you get at least eight hours of sleep daily, especially if you suffer from back pain, neck pain, herniated discs, and post-surgical pain. Insufficient sleep can interfere with healing by raising inflammatory cytokines in your bloodstream, which may also increase pain levels.

If you have difficulty sleeping, here are some suggestions:

Avoid watching and reading emotional content (news on TV, newspaper, internet, emails). Better yet, unplug everything electronic 2-3 hours before bedtime.
Take a walk in nature frequently where there is no noise pollution
If you’re hungry around bed time, avoid eating anything with carbs or sugar; stick with protein (whey smoothie, plain Greek yogurt, boiled egg).
Read a book or listen to relaxing music.
Practice deep breathing and meditating
Do high intensity interval training 3-4 hours before bed time
Practice present-time consciousness (turn off stray thoughts, focus on the present moment)
If you have trouble sleeping, keep your eyes open and let yourself get drowsy
Make sure your room is completely dark, with no ambient light entering; make sure you have fresh air ventilating through
Move all electrical devices (alarm clock, cell phone, etc.) far away from your head
If you always have to get up to go to the bathroom, avoid drinking water 2 hours before bed (drink an adequate amount before then to get hydrated).
Try listening to hypnosis sleep recordings

That’s it, happy dreams and less pain!

Muscle Atrophy from Kenalog (Cortisone) Injection

by Pain Doc | Aug 10, 2013 | Uncategorized

If you are considering getting a cortisone shot for pain or allergies, I highly recommend that you do your due diligence in researching the safety of cortisone injections before you do it.

What exactly is cortisone? It is a type of corticosteroid. Corticosteroids are a class of chemicals naturally produced in the adrenal cortex (adrenal glands above the kidneys) that are used to regulate multiple body functions. The cortisone in cortisone shots are analogues (molecularly identical) of these hormones that are synthesized in laboratories.

According to Medicinenet,

Corticosteroids can be taken by mouth, inhaled, applied to the skin, given intravenously (into a vein), or injected into the tissues of the body. Examples of corticosteroids include prednisone and prednisolone (given by mouth), methylprednisolone sodium succinate injection (Solu-Medrol) (given intravenously), as well as triamcinolone, Kenalog, Celestone, methylprednisolone (Depo-Medrol), and others (given by injection into body tissues).

Corticosteroids affect a number of physiological responses including inflammation modulation, immune response, carbohydrate metabolism, protein catabolism (breakdown), stress response, immune response, and behavior/mood.

Cortisone shots for pain reduction have powerful anti-inflammatory capabilities, which is why they are a popular with orthopedic doctors in the treatment of injuries and joint pain. Cortisone shots, when they work, act almost instantaneously. They reduce pain by reducing the inflammatory response around the localized injection. Cortisone shots also usually include an anesthetic drug such as lidocaine.

Side effects can include redness and temporary increase in pain, and dermatological effects like skin discoloration (especially in dark-pigmented patients).

Severe side effects from prolonged steroid use or large doses can include hyperglycemia, insulin resistance, diabetes mellitus, osteoporosis, cataract, anxiety depression, colitis, hypertension, seizures, fainting, peptic ulcers, erectile dysfunction, hypogonadism, hypothyroidism, increased menses, and retinal damage.

Kenalog (Triamcinolone) is a type of corticosteroid that is used to treat inflammation; particularly inflammatory skin diseases like lupus; allergies, rhinitis, and bronchospasm. It is known to cause plenty of undesirable side effects especially dimpling/pitting at the injection site. Women especially are known to get terrible side effects from Kenalog injections, notably prolonged/ painful menstrual cycles.

Previously I related a personal experience where, due to the urgency of the situation, I decided to get a cortisone shot for severe neck pain and spasm (which I found out later was hyperkalemic muscle paralysis and did not involve inflammation). I had three Kenalog injections along my left upper trapezius muscle, about a 5 mL dose. Normally I avoid taking medications and injections for pain as much as possible, but I was scheduled to drive a 400 mile trip the next day and needed immediate relief.

Well, it turned out to be a very bad experience. The shot atrophied the muscle, and now I am unable to raise it above shoulder level from the side. The doctors I consulted with were uncertain of the long term prognosis. I was advised to get physical therapy (which I have been doing myself) to encourage the muscle to regain its functionality. However, it doesn’t appear to be changing. An ominous fact I learned during my research of corticosteroids is that protein catabolism (breakdown of protein into its amino acids components) is one of the functions of natural corticosteroids. Could it be that the Kenalog shot “dissolved” some muscle tissue? I certainly hope that is not the case. If it were, it is not possible to rebuild that muscle tissue through weight lifting, as muscle hypertrophy from weight lifting works for existing muscle tissue only.

The experience was so bothersome that I decided to make a case study out of it for readers of this blog, and hopefully save someone from going through this awful experience. Before you get a Kenalog injection, make sure you know what you are getting into. My advice, skip it— the problems it causes appear to outweigh the benefits (see this internet message board on muscle atrophy from Kenalog injection). Instead, try less invasive procedures appropriate for your condition such as massage, chiropractic, acupuncture/cupping, botanicals/herbs, laser treatment, ultrasound, traditional Chinese medicine, gluten-free diet, ketogenic diet, fasting, juicing, and detox/cleanses.

Severe Neck Muscle Spasm of Unknown Cause

by Pain Doc | Aug 3, 2013 | Myofascial Pain

It’s been a while since I posted my last entry, as I have been busy launching a new authority site, painandinjurydoctor.com. This particular post, as luck would have it, is a case study in a rare condition that I only recently became aware of.

Last June, I experienced a severe case of cervical (neck) muscle spasm. It had a prodrome characterized by soreness around the left side of my left neck; the type that typically is associated with “sleeping in a funny position” or using a bad pillow. That’s what I attributed it to, so I was not concerned, thinking it would be gone in a day or two.

Boy was I wrong. The following day, the soreness quickly turned into unusually severe pain and muscle spasm. Unusual in the sense that I could not think of anything physical I did to trigger it. I certainly did not get injured in the days leading up to the prodrome. The neck spasm and pain took a life of its own.

The pain got so bad that it caused my neck to laterally flex to the left about 25 degrees, and rotated it downward about 10 degrees. The tilt caused mild nausea, as my vestibular system became affected. I was able to walk around gingerly, with head tilt and rotation firmly fixed. Lying down was the only thing that reduced the pain, but I had to use my hand for support when lifting/moving my head on the pillow, as recruitment of the neck muscles was excruciating. When I went to bed that night, I thought to myself “one long night’s sleep should reduce the pain to 50%.” I was still hopeful that my neck spasm was just an ordinary muscle contraction that would resolve on its own.

Wrong again. As I woke up the next morning, I realized to my dismay that the pain was even worse. Normally I would ice and rest it and do passive stretches, but I had a trip planned for the family that involved driving in just two days. I needed to be able to turn my head fully; I needed to be out of pain, and fast.

I drove myself to the emergency room, hoping that prescription medications (which I avoid unless it’s an emergency like this) would be able to calm the muscle. I was prescribed a muscle relaxant and anti-inflammatory, which had no effect. I iced, tried a TENS unit I happened to have at home; and tried a phototherapy (infrared, near infrared therapeutic light) unit; all of which had no effect. I saw an acupuncturist, which did not help.

Determined to knock down the pain, I went to a dentist I knew and had some anaesthetic injections directly into the posterior neck muscles (I originally thought of getting Botox, which he did not recommend). By this time, the pain was so severe that it created referred myofascial pain in the left hemisphere of my scalp, especially the occiput region. The anaesthetic shots did nothing. That evening, I consulted with my colleague, and we decided to try a kenalog (cortisone) injection the next day.

I received three kenalog injections (about 5 cc) along my left upper trapezius. I felt nearly immediate relief (but partial). This was the first thing that seemed to dampen some of the pain. I estimate that it reduced the pain by about 33%.

In the coming days, the pain gradually reduced, and I was able to turn my neck better. But there was more reason for concern. I noticed that my left sternocleidomastoid muscle was flaccid. I could not get it to respond with neck movement, and even resistance exercise. It was as if it weren’t there. I was still able to rotate my neck to the right, because other muscles that are used for this were normal.

What could cause it? My first thought was the Spinal Accessory Nerve, a cranial nerve that controls the sternocleidomastoid muscle and part of the trapezius muscle. I wondered if it was possible that I somehow injured it and snapped it off my neck muscle (I lift heavy weights regularly). But this was not likely, as significant force is required to detach a nerve from a muscle, and I did not sustain any traumatic injury that would explain my symptoms. Then I thought of possible brain lesions. A tumor could affect the neurons that form the spinal accessory nerve. However, a brain MRI ruled that out.

I spoke to three MDs, including an experienced orthopedic surgeon, who were basically stumped by this presentation.

So, let’s go over the facts: severe neck spasm with no apparent physical etiology; no response to medications and electrotherapy; no response to anesthetic; some response to kenalog; negative findings on brain MRI, and flaccid left sternocleidomastoid muscle but normal neck range of motion (active and passive).

I spent the next couple of days researching the internet, trying to find information that would explain my condition. And, I believe I found the answer to this perplexing problem.

My research led me to a rare condition known as hyperkalemic periodic paralysis. You can read more about it by clicking the link, but basically it is a condition caused by a faulty gene that makes a protein that plays an important role in muscle contraction. In order for a muscle to contract, the electroytes sodium (Na+) and potassium (K+) flow along channels within the muscle. The faulty protein in hyperkalemic periodic paralysis plays a role in the structure of these channels. If you want detailed information on mechanism of this condition, this article does a good job.

Some people with HPP have high levels of potassium (K+) in their blood during a spasm attack and shortly thereafter; some have normal levels. Factors that can trigger attacks include rest after exercise, potassium-rich foods, stress, fatigue, and periods without food (fasting). Muscle strength improves between attacks, although many affected people continue to experience mild stiffness (myotonia), particularly in muscles of the face and hands.

Why it would be very specific to one muscle and not affect other muscles is unknown. At least I could not find any information that would explain this.

One month after the attack, my left SCM is showing early signs of making a comeback. There is slight definition of the distal portion that attaches to the collarbone when doing active resistance (stressing the muscle). Hopefully, it will return to normal, and this nightmare will not happen again.

So, lesson learned: if you have a severe muscle spasm and notice that it is flaccid after the pain is gone, you might have hyperkalemic muscle paralysis. The current medical advice is to determine if you have the hyper or hypo kalemic variant. If you have hyperkalemia, the recommendation is to avoid foods high in potassium. Avoid fasting, and make sure to eat carbohydrates. Also, avoid strenuous exercise (this is one I have to ignore, until I am proven otherwise). Apparently, rest after strenuous exercise is a trigger for this condition.

P.S. There is more to the story to this (that involves the Kenalog injection). More on this later.

The Dangers of Using Opioid Drugs to Treat Pain

by Pain Doc | Sep 25, 2012 | Uncategorized

Opioids are strong drugs that are typically prescribed for cases of acute pain such as that from major trauma or post-surgery, and also for patients experiencing severe, chronic, debilitating pain; primarily from terminal cancer and rheumatoid arthritis. Opioids chemically bind to receptors in the central and peripheral nervous system and produce an analgesic effect via decreased pain perception, decreased reaction to pain, and increased pain tolerance.

Morphine and codeine are opioid drugs derived from natural opiates of the opium poppy plant; hydromorphone, hydrocodone, oxycodone, oxymorphone, ethylmorphine and buprenorphine are semi-synthetic and created from either natural opiates or from morphine esters; fentanyl, pethidine, levorphanol, methadone, tramadol and dextropropoxyphene are fully synthetic opioids.

Doctors usually prescribe opioids with caution because of their side effects and propensity of addiction. Known side effects include nausea and vomiting, drowsiness, itching, dry mouth, miosis, and constipation. More potent doses can result in respiratory depression, confusion, hallucinations, itching, hypothermia, bradycardia/tachycardia (abnormally slow/fast heart rate), orthostatic hypotension, dizziness, headaches, urinary retention, ureteric or biliary spasm, muscle rigidity, myoclonus (involuntary muscle twitches) and flushing of the skin. If the dose is not closely monitored and adjusted appropriately to the patient, side effects can often lead to serious consequences. There is a troubling trend where

opioid drugs are increasingly being prescribed for less serious forms of pain such as back pain. Not surprisingly, the number of documented cases of adverse drug reactions has risen accordingly.

When patients are not properly informed about how to take opioid painkillers or are prescribed too high a dose of these drugs, or too long a course of treatment, serious and potentially fatal side effects may result, including respiratory depression (reduced respiration or breathing). If left untreated, patients who develop respiratory depression as a result of a painkiller overdose may die from a lack of oxygen due to shallow breathing caused by the medication.

Thousands of patients die each year as a result of a prescription painkiller overdose.

The CDC reports that prescription painkiller overdoses were responsible for more than 15,500 deaths in 2009. While all prescription painkillers have contributed to an increase in overdose deaths over the last decade, methadone has played a central role in the epidemic. More than 30% of prescription painkiller deaths involve methadone, even though only 2% of painkiller prescriptions are for this drug. Six times as many people died of methadone overdoses in 2009 than a decade before.

When these deaths are the result of patients who were given excessive doses of pain medications, improperly warned about the side effects of the drug, or prescribed more potent drugs than were necessary, the doctors or hospital that prescribed these medications may be at fault. The law firm of Heygood, Orr & Pearson is one of many in the country that offer legal assistance to those injured or damaged by taking prescription drugs. The firm recently launched a website, Painkiller Overdose Lawyers . The site will serve as a resource with the latest news and legal information for patients who believe they were injured after using a prescription opioid painkiller.