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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.

Do this simple thing to add years to your life

by Pain Doc | Aug 18, 2012 | Uncategorized

No, it’s not quit smoking, exercising more, or eating a healthy diet I’m talking about; although these things can add years to your life.

You know what it is? Answer: stop sitting too much!

We are living in a society that encourages sitting, thanks to computers. Many jobs require it. Using the computer at home to surf the web, check bank accounts, shop, etc. require it. School requires it. Going to restaurants and coffee shops require sitting. Evidence is showing that prolonged sitting promotes disease, malady and death in epidemic proportions.

The latest study examining the relationship to prolonged sitting and morbidity tracked over 50,000 men and 69,000 women over the course of 13 years. Study participants indicated if they sat less than 3 hours per day total or over six hours per day, total. The results showed that women who sat the most were 37% likely to die, and for men who sat the most, they were 18% more likely to die than the rest of the study participants. The association remained virtually unchanged after adjusting for physical activity level; meaning, a woman who sat for more than six hours a day who exercised regularly still had the same chance of dying than a woman who sat for more than six hours per day and did not exercise regularly.

Numerous other studies done in the past show that prolonged time spent sitting, independent of physical activity, affects metabolism and may influence things like triglycerides, high density lipoprotein (HDL cholesterol, the good cholesterol) fasting plasma glucose, resting blood pressure, and leptin, which are biomarkers of obesity and cardiovascular and other chronic diseases.

It is clear by now that prolonged sitting, which can be defined as over four hours per day, is a threat to your health. There needs to be more public health announcements on this. Imagine the billions of dollars in health care costs that we as a country can realize if everyone knew not to sit too long, as well as all the lives that can be saved.

If you are in a job that requires prolonged sitting, I suggest that you print out the study (link below) and show it to your supervisor. Tell him or her that you take this seriously, and you must be allowed to stand up and walk at least once an hour, for 15 minutes. Or, stand up and walk every 15 minutes of sitting, for about five minutes.

Reference: “Leisure Time Spent Sitting in Relation to Total Mortality in a Prospective Cohort of US Adults.” Alpa V. Patel, et al.

New Study Shows Qigong Helps Relieve Fibromyalgia

by Pain Doc | Aug 13, 2012 | Fibromyalgia

Qigong, sometimes spelled Chi gung, is a form of exercise that originated in China some 4,000 years ago. Literally translated to “life energy cultivation” it involves aligning breath, movement, and awareness for exercise, healing, and meditation for the purpose of balancing the body’s energy meridians and enhancing the intrinsic capacity of the body to heal. Qigong is considered a part of Traditional Chinese Medicine, or TCM, along with acupuncture and Chinese herbology.

Basically, in TCM it is believed that there are “energy meridians” or lines that cover the body from head to toe. Health is dependent on the “flow” of this energy, or chi. Whenever there is an “obstruction” in one or several meridians, the body experiences disease. Qigong works to improve this energy flow by focused breathing, meditation, and gentle movements. Whether the benefits of Qigong are derived from improved energy flow, or by better breathing and exercise is uncertain.

Fibromyalgia is a condition that involves diffuse, muscular pain in multiple parts of the body. It is more of a syndrome; meaning, it is described in terms of symptoms rather than objective findings such as offered by an X-ray or MRI. Fibromyalgia is also often associated with chronic fatigue syndrome. It is a difficult musculoskeletal disorder to diagnose and treat because it usually lacks a causative event. Some believe that it may be related to a virus, or abnormal central nervous system response.

A recent study investigating the effectiveness of qigong on fibromyalgia was published August 3rd. The randomized, controlled study involved 100 fibromyalgia patients, divided into a control group and test group. Outcomes were pain, impact, sleep, physical function and mental function, and these were recorded at baseline, 8 weeks, 4 months and 6 months using standardized pain questionnaires (10 point and 100 point). The test group participated in a one-hour practice session once weekly for 8 weeks and were asked to practice the movements and exercises at home every day for six months for 45 to 60 minutes. After the first 8 weeks of practice, the investigators reported the following results:

Based on a 10-point scale, patients in the qigong group had a 1.55 point reduction in pain compared with only 0.02 points in controls
Based on the 100-point Fibromyalgia Impact Questionnaire, individuals who participated in qigong reported a decrease of 18.45 points compared with 0.93 points in controls. This questionnaire rates pain, sleep, function, and psychological distress
Quality of sleep also improved during the 8-week treatment period based on a sleep quality index of 3.29 points
Psychologically, patients in the 8-week treatment group showed an improvement of 5.29 points on a questionnaire

Following the initial 8-week treatment period, the patients said they practiced for a mean of 4.9 hours per week, which declined to 2.9 and 2.7 hours by months 4 and 6, respectively. However, the 52% of patients who practiced at home the most (5 hours per week) enjoyed the most benefits in a number of areas.

Individuals who participated in the delayed treatment also showed improvements similar to those in patients who took part in the immediate qigong sessions and practice in all areas. When the authors combined the results of the two groups, the results revealed sustained effect of qigong on pain at both 4 and 6 months, and benefits persisted through 6 months for impact scores, sleep, and physical and mental well-being.

Bottom line: this is one of several studies that suggest the Chinese system of qigong exercise can be helpful in reducing, or at least managing chronic pain. If you have FM and have not tried it yet, it is worth investigating.

Functional Exercises to Strengthen the Core and Back

by Pain Doc | Aug 12, 2012 | Uncategorized

Functional exercises, in my opinion, are the “best” kind of exercises in that you get the most “overall benefit” per unit time doing them. This is especially true for those who don’t have that much time to dedicate to exercise.

Basically, functional exercises are those that engage the whole body rather than one section at a time. They improve strength, coordination, and muscle stamina; and have cardiovascular benefits as well. For example, arm curls, bench pressing, and leg pressing are not considered functional exercises because they target just one area. An example of a functional exercise would be carrying a 30# sandbag on your shoulder and walking up a hill.

Most people group exercise as either cardio or strength. But coordination is often forgotten. You see, muscle groups need to have good coordination between them in order for your body to function at its peak and be the most resistant to injury. Muscle coordination is a neurological function as much as it is a muscular contraction function. The proper “firing sequence” of neurons to each muscle fiber must be fine tuned in order to have optimum muscle performance, and this is done by repetitious, combined movements of multiple groups. Functional exercises do just that. Do them often, and you will notice that common movements will be easier to do, such as walking up a long flight of stairs, or lifting something heavy and placing it on a higher level.