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Chronic Pain Affects Approximately 116 Million Americans

by Pain Doc | Aug 2, 2011 | Uncategorized

Woman with hip pain

The Institute of Medicine (the medical branch of the US National Academies of Science) released a report brief on June 29, 2011 on the state of chronic pain in America, entitled Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The purpose was to assess how pain affects people of different socioeconomic backgrounds, and what can be done on the national level to improve awareness and treatment.

Chronic pain affects at least 116 million American adults—more than the total affected by heart disease, cancer, and diabetes combined. Pain also costs the nation up to $635 billion each year in medical treatment and lost productivity. It is a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. Given the burden of pain in human lives, dollars, and social consequences, relieving pain should be a national priority.

The toll documented in the report is staggering. Childbirth, for example, is a common source of chronic pain. The institute found that 18 per cent of women who have Caesarean deliveries and ten per cent who have vaginal deliveries report still being in pain a year later.

Ten per cent to 50 per cent of surgical patients who have pain after surgery go on to develop chronic pain, depending on the procedure, and for as many as ten per cent of those patients, the chronic postoperative pain is severe.

The risk of suicide is high among chronic pain patients. Two studies found that about 5 per cent of those with musculoskeletal pain had tried to kill themselves; among patients with chronic abdominal pain, the number was 14 per cent.

For patients, acknowledgement of the problem from the prestigious Institute of Medicine is a seminal event. Chronic pain often goes untreated because most doctors haven’t been trained to understand it. And it is isolating: family members and friends may lose patience with the constant complaints of pain sufferers. Doctors tend to throw up their hands, referring patients for psychotherapy or dismissing them as drug seekers trying to get opioids. “Most people with chronic pain are still being treated as if pain is a symptom of an underlying problem,” said Melanie Thernstrom, a chronic pain sufferer from Vancouver, Washington, who wrote The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing and the Science of Suffering (Farrar, Straus & Giroux, 2010) and was a patient representative on the committee. “If the doctor can’t figure out what the underlying problem is,” she went on, “then the pain is not treated, it’s dismissed and the patient falls down the rabbit hole.”Among the important findings in the Institute of Medicine report is that chronic pain often outlasts the original illness or injury, causing changes in the nervous system that worsen over time. Doctors often cannot find an underlying cause because there isn’t one. Chronic pain becomes its own disease.

“Having pain that is not treated is like having diabetes that’s not treated,” said Ms. Thernstrom, who suffers from spinal stenosis and a form of arthritis in the neck. “It gets worse over time.”

Ms. Thernstrom compared the effect of chronic pain on the body to the rushing waters of a river carving out a new tributary. Pain, she says, also changes the body’s landscape.

“My pain is at the level where it’s manageable,” she said. “I do wish I had gotten aggressive treatment in the first year. There is a window of time to intervene, because pain changes your nervous system and pain pathways develop.”

“When pain becomes chronic, when it becomes persistent even after the tissue and injury have healed, then people are suffering from chronic pain,:” Mackey said. “We’re finding that there are significant changes in the central nervous system and spinal cord that cause pain to become amplified and persistent even after the injury has gone away.” The pain report is only a first step for the community of medical professionals who treat pain. It will be up to medical schools to begin better education of doctors in the treatment of pain, and the National Institutes of Health to decide whether to promote research into chronic pain.

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My comments:

This report is an important milestone in creating a national awareness of the “epidemic of pain” in this country. Chronic pain is a very difficult problem to treat, because in most cases, there is nothing left for the doctor to do. It truly frustrates doctors to see patients not getting any better over time. Many primary care doctors dread having to see their chronic pain patients come in, because of the reasons stated in the article– suspicions of exaggerated symptoms, assumptions of pain reliever drug addiction, psychological problems, etc.

More attention is needed in formulating a strategy to prevent chronic pain from happening, and ways to better manage it. This study is a good first step towards that direction.

If you have chronic pain, it still is a good idea to do the things that make the body healthier overall: give it the building blocks to regenerate and repair tissue (high nutrient density foods); avoid ingesting toxins such as smoke, alcohol, preservatives, and pesticides; drink pure, clean water; get a good dose of Vitamin D every day by going outside in the sun; do short workouts that engage all body parts in unison every day, avoid negative people, negative media, and negative thoughts as best you can; engage in activities that require concentration; socialize with positive people; laugh to your heart’s desire, and get enough rest each and every day. These activities may not cure chronic pain, but can make it more manageable.

References:

The New York Times, Giving Chronic Pain a Platform of Its Own

The Institute of Medicine, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research

Article on Laser Spine Institute

by Pain Doc | Jul 12, 2011 | Uncategorized

For many individuals searching the internet for solutions to their lower back pain, Laser Spine Institute, or LSI is a familiar name. This is a network of physician-owned spinal surgery centers that rely heavily on Google and other internet search engines to obtain their clients. Their chosen niche is minimally invasive laser surgery, where the physician makes a tiny incision in the patients back and inserts a fiber optic laser and tiny camera to ablate, or burn off nerve endings around an offending spinal disc. Then, they may burn off part of the disc that is compressing nerve tissue. Through their marketing, LSI suggests that patients can be back on their feet within hours of the surgery.

However, the center is attracting a lot of attention in the malpractice arena. And, respected spinal surgeons not affiliated with LSI say that such a methodology is already available through standard medical care for spinal disc problems and cost much less; although instead of lasers, radiofrequency devices are used.

According to an article in the May 2011 edition of Bloomberg magazine, author David Armstrong reports:

Laser Spine and its competitors, part of a boom in outpatient clinics operated by entrepreneurial physicians, sell a high-tech version of procedures that have been around for years — despite a lack of independent research to show that their variations lead to better outcomes. The company commands higher prices than laser-less rivals, driving up the cost of health care. Its number of malpractice claims per 1,000 surgeries is several times the rate for all U.S. outpatient surgery centers, based on insurance industry data.

…There’s little government oversight regarding which doctors can do spine surgery — all they need is a medical license, whether their training is in orthopedics, foot surgery or pediatrics…

…Doctor-investors may lower their standards for deciding when to operate, according to researchers from the University of Michigan in a study in the journal Health Affairs last year. Looking at five common procedures at Florida surgery centers, they found that once doctors became investors, the number of surgeries they performed increased by 87 percent.

So, if you are considering spinal surgery and run across LSI, make sure to do your due diligence. Being in acute pain can make one vulnerable to lofty marketing, as there is an urgency to make a fast decision. Based on this article, it seems that there are three main problems with Laser Spine Institute:

1. There is a conflict of interest, as some doctors are investors in the parent company. Thus, there is an incentive for performing unnecessary procedures.

2. There is little if any respected research that suggests that laser surgery is superior to traditional spinal surgery methods.

3. The centers use a high volume model and rely heavily on advertising instead of professional referral. Not a good indicator for quality of service.

Whiplash Injuries and How to Treat One

by Pain Doc | May 28, 2011 | Uncategorized

Whiplash is the colloquial term for a neck sprain strain injury that comes about from the head and neck being “whipped” back and forth as the result of a short-lived acceleration and deceleration of the body. Perhaps the most common event that can create this is a car collision; specifically a rear end car collision. Other things that can cause it are roller coaster rides and other amusement park rides; bungee jumping; horsing around and similar types of accidents.

Let’s discuss whiplash from a car accident. You’re sitting in traffic, and all of a sudden you hear a loud screech and feel something powerful crash into the back of your car. You hear crunching metal, and maybe even shattered glass. Your back sinks into your car seat as your car is thrust forward from the impact, and your body suddenly stops and reverses direction. You instinctively grip your steering wheel and stiffen your arms to protect yourself, which braces your torso somewhat but because of the flexibility of your neck and the weight of your head, your neck bends back sharply and recoils violently forward, then back again until it rests. In that split second, your neck muscles, not having enough time to react do not protect your cervical (neck) spine and suffer microtears. Swelling sets in; then soon after, neck stiffness. Depending on the force of the impact and other factors such as the speed and mass of the car that struck you; the amount of denting/deformation of your car, and your body type other areas can experience injury as well. This includes the upper shoulders, mid and lower back, jaw, wrists, knees and ankles. Most pain in a whiplash, however, is centered in the neck, upper shoulders and upper back.

I made a video on what to do for whiplash that illustrates a good home care procedure to alleviate the pain and rehab the neck. If you’ve suffered a whiplash injury to your neck, and were cleared by the emergency room of any red flags, the goals will be:

Reduce pain and swelling
Reduce scar tissue build up by doing gentle, active stretches, even during the pain period
Restore joint (verbebral) biomechanics and neck range of motion
Strengthen surrounding muscles in the neck
Restore proper neck curvature

You’ll also want to get enough protein (whey protein is the best, followed by eggs and fish), foods high in anti oxidants, and drink enough fluids during your injury rehabilitation. Taking 2000 mg Vitamin C is also a good idea, as it has shown to be helpful in wound regeneration. Lastly, get out in the sun and expose your neck and back for about 20 minutes. Sunlight stimulates Vitamin D synthesis and may have other beneficial effects on the cellular level.

If you were in a car accident and want extra reassurance, find a chiropractor who has experience treating soft tissue injuries. Don’t just go with the office that has the loudest advertising– make sure you are comfortable with the office and the doctor first after asking a lot of questions. I have treated whiplash injuries in San Francisco for over 15 years and have had great success. One of my most useful pieces of equipment for treating acute sprains and strains such as whiplash is the Solaris phototherapy unit, which uses therapeutic light between 660-800 nm wavelength. Light at this frequency actually speeds up wound healing at the cellular level by increasing ATP production (basically, increasing cellular metabolism, which includes waste removal). Once the pain and swelling is down, I initiate manual therapies to restore joint biomechanics and to rehabilitate the surrounding soft tissues to reduce the risk of chronic pain.

If you happen to live or work near San Francisco and were injured in a car accident, you can contact my office at (415) 627-9077.

You can find more information on whiplash on my website.

Prolotherapy: A Controversial Remedy for Muscle and Ligament Pain

by Pain Doc | May 28, 2011 | Uncategorized

Prolotherapy, short for proliferation therapy is a controversial technique that involves a series of injections of an inactive irritant substance into a painful joint, or area where ligaments or tendons insert into bone. The injected substance can be dextrose, phenol, saline solution, glycerol, lidocaine, or even cod liver oil extract. Prolotherapy injections are intended to artificially initiate the natural healing process by causing an influx of fibroblasts that synthesize collagen at the injection site, leading to the formation of new ligament and tendon tissue.

Some of the signs that might benefit from prolotherapy include:

Joint laxity, such as in the shoulder, that does not resolve with standard treatment
Distinct tender points at tendons or ligaments as they attach to the bones
Unresolved, intermittent swelling or fullness involving a joint or muscle
Popping, clicking, grinding, or catching sensations in joints
Temporary benefit from chiropractic manipulation or manual mobilization
Aching or burning pain that is referred into an upper or lower extremity
Recurrent headache, face pain, jaw pain, ear pain
Chest wall pain with tenderness along the rib attachments on the spine or along the sternum
Spine pain that does not respond to surgery, or where there is no definitive diagnosis despite X-rays, MRIs and other tests.

So why is prolotherapy considered “controversial?” Because, according to the federal government (Health Care Financing Administration) there is currently no strong, compelling study that proves prolotherapy can cure cases of soft tissue pain. A “strong” study is one that has at least several hundred test subjects; has a control group (who get a placebo, or fake treatment) and is done in a “double-blind” methodology where the test subject and the administering doctor do not know if the injection is a prolotherapy agent (only a third member of the research study knows). However, there are numerous studies in the literature using smaller test populations (less than a hundred) that support prolotherapy as an effective treatment for pain.

A 2005 study entitled A systematic review of prolotherapy for chronic musculoskeletal pain (Clin J Sport Med. 2005 Sep;15(5):376-80) analyzed major studies on prolotherapy and reached the following conclusion:

Two RCTs (randomized controlled trials) on osteoarthritis reported decreased pain, increased range of motion, and increased patellofemoral cartilage thickness after prolotherapy
Two RCTs on low back pain reported significant improvements in pain and disability compared with control subjects, whereas 2 did not. All studies had significant methodological limitations.

There is a research project at the University of Wisconsin involving prolotherapy to treat knee osteoarthritis that is due to publish its results soon.

So, if you have chronic musculoskeletal / joint pain, especially related to trauma, that has not resolved with cortisone injections, chiropractic, physical therapy, personal training, surgery, and time, prolotherapy may be worth investigating. The good thing about it is that it is generally safe.

Are Inversion Tables Good for Back Pain?

by Pain Doc | May 25, 2011 | Uncategorized

Inversion therapy tables are see-saw like contraptions designed to use gravity to decompress the spine. They have been around for more than twenty years already, so today’s models offer more in terms of comfort and ease of use. But the principle is the same: use a platform balanced on a horizontal rod, with a mechanism to offer some controlled resistance. You lie face up on the platform (more expensive models allow you to be face down), lock your feet into the foot carriage either by hooking your insteps onto rollers, or wearing gravity boots strapped to the carriage; and raise your arms in varying angles to control the amount of tilt. Arms extended straight above your head result in the maximum angle, usually around 45 degrees. The weight of your torso pulls gently on your spine, and you get some degree of stretch to your back.

So is inversion therapy good for your back? Can it relieve lower back pain? The answer is “yes” for some cases of low back pain. I wrote about how low back pain can come from bulging discs, an acute or chronic low back strain, and even abnormal communication between the brain and the postural muscles. Low back stiffness is usually caused by inactivity, carrying too much abdominal weight, which places too much pressure on the small facet joints in the back of the spine; and basically “turned off” muscles; i.e. poorly conditioned, inactive erector spinae and multifidi muscles that surround the spine. This is common in people who sit more than four hours a day on a regular basis and don’t exercise.

Inversion table therapy should be helpful for some cases of disc bulges and back stiffness. Do not do it for an acute lumbar strain. And if your problem is due to miscommunication between the brain and postural muscles, inversion therapy may offer some relief, but the symptoms will quickly return, as this type of back problem originates in the motor neurons of the brain, not the back muscles.

Before you go out and buy one, realize that you must be able to physically handle being inverted. Although you shouldn’t stay inverted for more than 30 seconds or so, for some people, just a few seconds of being inverted (upside down) can be unpleasant, and dangerous. If you have the following conditions, you should not use inversion therapy for back pain:

metal plates, hardware in spine or lower extremities
history of migraine headaches
eye diseases (especially glaucoma)
history of vertigo, tinnitus, Meniere’s disease
recent surgery to ankles, knees, hips, spine
cardiovascular disease; heart problems
risk factors for stroke
aortic aneuyism
osteoporosis

Basically, aside from back pain, you need to be in fairly good physical shape to do inversion therapy; otherwise the risks exceed the benefit. Ask your doctor if it is OK for you to do it.

Now, for those who meet the physical criteria. As in anything new, start slowly. Get used to your machine– how it feels, how responsive it is to your movements. Know how long you can be inverted before you start feeling dizzy. The proper way to do it is to start with small angles first, maintaining the position for a minute or so. Attempt steeper angles, but in small increments. You will find that the steeper you go, the less time you are able to hold the position, due to blood pressure increasing in the head from the effects of gravity. Take your time. Do not attempt a 45 degree incline your first day. You don’t even have to go that far, ever, as long as you can get a good stretch to your low back.

As you get comfortable with your inversion therapy table, you can do some gentle and slow spinal twists as you are inverted. Just rock your upper torso and shoulders from side to side. You may hear some pops as some vertebral facet joints decompress. The popping sound is just air pockets shifting in the joint capsules as the space increases from the stretching.

Lastly, adhere to this tip, which most people forget when doing inversion therapy: concentrate on relaxing your spinal muscles. In fact, before you start your inversion therapy session, close your eyes and take three, deep breaths through your nose, and slowly exhale through your mouth. Focus on your diaphragm expanding, drawing in the air, then relaxing it as you exhale. If you are tensed up, your back muscles will NOT allow the table to decompress your spinal joints. Back muscles are strong and can easily prevent the spine from elongating if they are under contraction. Remember, the goal of inversion therapy is to target the spinal discs and facet joints, not the back muscles themselves. The spine is where most of the symptoms of back pain and stiffness originate.

There are many brands of inversion tables, and varying degrees of quality. The basic ones are rated to about 250 pounds max (person’s weight). The Teeter Power VI Inversion Table with Gravity Lock Ratchet table is a higher-end table that doesn’t require you to raise your arms in order to tilt the table. A motorized inversion table may offer better traction to the lumbar spine, as the act of raising the arms contracts the back muscles which is definitely undesired when attempting to stretch the spine. And if money is not an issue, you may consider the Teeter DFM – Decompression and Functional Movement Table, a commercial-grade table designed with input from doctors and therapists. This table can be used in the prone (face down) OR supine (face up) position, and offers progressive decompression therapy.

My advice is if you are a chronic back pain sufferer, go with a higher end machine because you will be using it a lot. That way, you can rest assured that you’ll be getting a sturdier machine with better construction that will last longer. The cheaper models still can do a decent job, but they are made of weaker material and tend to be more “rickety” as they are held together by bolts and thinner metal tubing.