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Depression Can Make Knee Pain Worse – Study

by Pain Doc | Mar 25, 2011 | Uncategorized

A recent study in The Journal of Bone and Joint Surgery showed that people who had mild to moderate knee osteoarthritis and were depressed rated their pain as severe, the level which others in the study who had x-ray documented advanced osteoarthritis reported.

I’ve always believed that there is a “mind-body” connection, and this is yet another study that supports this. The thoughts that you allow to enter your mind can have a definite effect on your physiology, whether it be blood pressure, heart rate, respiration rate, digestion, strength, immune response, or pain. Check out this cancer treatment center’s use of visual and music therapy to help with treatment.

Jon T. Giles, MD, an assistant professor of medicine at Columbia University and rheumatologist at New York Presbyterian Hospital in New York City, says this study adds further weight to the existing medical literature highlighting the effect of psychosocial issues on pain responses.

“Painful sensations are relayed through the brain in a very complex way, and can be modulated up or down,” he says. With stress, poor sleep, anxiety and depression, which are known to influence pain levels, “stimuli feel more painful than they would in someone without the adverse psychosocial factors. This probably explains in part why the largest effect of depression in the study was seen in those without much OA to see on X-rays.”

The study recommends that patients fitting this profile get psychiatric evaluation and treatment, including anti-depressant drugs, in order to help alleviate their pain.

The study does not outright say that only “clinical” depression can make pain worse. If you have pain, persistent negative thoughts are more likely to make it appear worse than it actually is. Remember, the perception of pain is a complex neurological pathway that is not entirely understood.

I can sympathize with those experiencing chronic pain– it can be a terrible cycle, where the pain itself can push the patient to negative thoughts and depression, embedding it further and further into the body’s central nervous system. Speaking as a human being, and not just a health care provider, I can offer the following suggestions to break the cycle. And I’m sure it’s not all new, but worth repeating here:

1. Don’t hang around negative people. Their negative energy will bring you down. Instead, hang around those with “positive buoyancy,” the ones who can lift you up emotionally. Most small children fit in this group.

2. Similar to #1, avoid negative stimuli in your environment– crime shows, news, reality TV, newspaper headliners, internet news, etc.

3. Find something to keep your mind occupied; something that requires active brain usage (not passive, like watching TV). Social activities that involve interacting and working with other people is a good choice; especially if it is for a good cause. Arts and crafts is another good choice.

4. Get a pet. There’s nothing like a dog who exhibits unconditional, total loyalty to you.

5. Eat only those foods that nourish the body. The nutrient dense foods that occur naturally; i.e. plants and animals are the best for a body experiencing pain: fruits, green leaf plants, sardines, lean meat, nuts. Definitely avoid cigarette smoke, alcohol, corn syrup, sugar, and food preservatives.

6. Get out in the sun. Take of your shirt, expose your trunk to the sun several times throughout the day.

7. Stay active, as much as your pain will allow. Tai chi and yoga are good if your body can’t handle the forces of running , jumping, and lifting weights. Walking briskly is good, too.

8. Get fresh air. Drive to your nearest nature preserve, far enough away from the city and suburbs and get some negative ions (the only good, negative thing if you’re in pain!) and clean oxygen in your lungs.

Knee Pain, Roosters and Osteoarthritis?

by Pain Doc | Mar 22, 2011 | Knee Pain

Osteoarthritis occurs when the cartilage lining the articulating (contacting) surfaces of a joint gets damaged or wears out, exposing nerve endings inside and leading to inflammation. Since a joint is a precision, biological mechanism the slightest change in any of its components will eventually lead to breakdown, much like car engine.

As the cartilage thins, bone on bone contact occurs. Since bone is living tissue, it will respond to this irritation by forming osteophytes, better known as bone spurs. The osteophytes compound the problem by disrupting proper joint movement and irritating surrounding ligaments. And to make matters worse, the joint fluid, called synovial fluid gradually loses its ability to cushion the joint. Synovial fluid to a joint is like motor oil to a car engine’s cylinder: it enables “near frictionless” movement. It forms a thin, lubricating buffer between the ends of the two bones that make up a joint; for example in the knee, the tibia (lower leg) and femur (upper leg).

The knee is perhaps the most common joint to experience osteoarthritis. It is a large, primary weight bearing joint that takes a lot of punishment in the course of a day. Basic activities like walking, running, going up stairs, stepping down from a curb, exercising, and sports really put the knees to task. Those who have advanced osteoarthritis in the knees realize how important they are to a normal life.

I ran across this treatment for knee osteoarthritis that involves a single injection that can last for six months. It is called Synvisc-One, and it’s made from the combs of roosters. Apparently, the substance found in rooster combs is similar in biochemical make up to that of synovial fluid. If you’ve ever pressed or bent a rooster’s comb, you can see why– it is soft, cushiony, and rebounds quickly to its original shape.

synvisc injection into the knee joint

The procedure is a relatively quick outpatient procedure. After filling out the necessary forms to ensure you have no contraindications, especially any known allergies to birds, the doctor injects the Synvisc into your knee joint using a large caliber needle. There, it occupies the capsular space just like motor oil occupies a car engine’s cylinder. The substance cushions the knee joint surfaces (distal femur-proximal tibia articulation) and lubricates the space to minimize abrasion of these surfaces.

Synvisc is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics, e.g., acetaminophen. It can be an option for total knee replacement for some people.

The drawback is that you have to keep getting them. But for those who have severe osteoarthritis in both knees and can’t afford or do not desire knee replacement surgery, six months of less pain is a pretty big deal. As with all forms of treatment options, a lot of it is personal choice. Not everyone’s situation is the same.

Check out our Self Treatment for Knee Pain video for non-drug, non-surgical therapies to manage osteoarthritis of the knee.

Whole Body Vibration for Back Pain

by Pain Doc | Mar 21, 2011 | Low Back Pain

Whole body vibration, or WBV is popular in the fitness, health, and beauty industries. It involves standing stationary or doing exercises on a motorized platform that vibrates at different frequencies and amplitudes (basically, different speeds and intensities).

Research on the benefits of whole body vibration are mixed, but a significant number of studies point to definite benefits including increased muscle strength, increased blood circulation to the leg muscles and skin, increased bone density, reduced muscle atrophy following bed rest and in space, improved postural control in older individuals, and reduced chronic lower back pain. However, at least one study warns of potential adverse health effects of “excessive” whole body vibration training.

The WBV machine consists of a platform, handle grips and control panel. You do exercises like squats with both feet on the platform, or alternating lunges with the front foot placed on the platform while it vibrates at a set frequency. Depending on the model, a WBV machine can vibrate in the z-axis (or straight up and down direction– most intense), x and y axis (front to back, side to side), or teeter-totter (like a seesaw action). Amplitude (height differential of the platform in one vibrational cycle) and frequency (number of cycles per second).

Two popular models are the durable, commercial-grade PowerFit VB588 Whole Body Vibration Machine and the less expensive but lower quality home use model, PowerFit PFM002. If money is not an option, you can get the Power Plate – Pro5 – Model 565273 which is the brand that is found in exclusive fitness centers throughout the world.

There are generally three classifications of whole body vibration machines: High Energy Lineal, found mostly in commercial vibration training studios and gyms. The vibration direction is lineal/upward eliciting a strong stretch-reflex contraction in muscle fibres targeted by the positions of training program. 2. Premium Speed Pivotal, (teeter-totter movement) used for physiotherapy work at lower speeds and exercise workouts at “premium” speed, up to 27 Hz. Both commercial and home units are available. 3. Medium Energy Lineal, the majority of lineal platforms produced. These are usually made of plastic; some have 3-D vibration which is low quality. They give slower and less consistent results. 4. Low Speed Pivotal units. These can give “therapy” benefits. Other machine types are low Energy/Low amplitude lineal and Low energy/High amplitude lineal with varying uses from osteoporosis prevention, therapy for improved blood circulation and flexibility and limited fitness training. I am not certain if this classification system is used by the various manufacturers of WBV machines.

So, should you try whole body vibration if you have chronic back pain? My advice is to check with your doctor first. If you are cleared by your doctor, start conservatively– low amplitude, and only for a minute or two; standing only. Take note of how you feel. Most of the studies done thus far on these machines involved fairly extensive time periods, like 6-12 weeks of daily usage, so if you plan to use WBV to reduce back pain your body needs to be able to take it. If you are able to work up to 5-10 minutes on the machine without feeling nauseous, more pain, dizzy or any other adverse symptom, do it for a week and re-evaluate. If all is OK, try exercises like simple squats on the platform. If you feel improvement in your lower back pain, then congratulations, your particular situation responds to whole body vibration. However, there are no studies that I am aware of that track the long-term effects of WBV therapy on chronic lower back pain. So, a good rule of thumb is to do it daily for at least two weeks, symptoms permitting; and then do it less periodically for maintenance. Obviously, at the first onset of any adverse reaction from using WBV, stop immediately and report it to your doctor.

Some of the possible ways whole body vibration resistance exercises can help reduce back pain is by increasing blood flow to the muscles, exercising the muscles, and bombarding sensory input to the back muscles thereby breaking any “learned” abnormal neurological patterns to the muscles.

Even if you don’t have back pain, whole body vibration offers other proven health benefits like improved blood circulation, decreased muscle weakness from body inactivity, and improved postural balance. It would therefore make a nice addition to your home exercise equipment.

Treating Chronic Repetitive Strain Syndromes

by Pain Doc | Mar 19, 2011 | Sprains and Strains

If your job, hobby, or recreational activities involve repetitive movement patterns you may develop a repetitive strain injury, or RSI. Also known as overuse injuries, cumulative trauma disorders, and musculoskeletal disorders these types of conditions are characterized by pain, inflammation, swelling, and reduced joint movement.

Some of the more well-know causes of RSIs include:

typing/data entry (wrist tendonitis, epicondylitis)
hair styling (wrist tendonitis)
using vibrational tools (wrist, hand tendonitis)
carrying small children (deQuervain’s syndrome)
tennis (lateral epicondylitis; i.e. tennis elbow)
golf (medial epicondylitis; i.e. golfer’s elbow)
running (achilles tendonitis)
bowling (medial epicondylitis, wrist tendonitis)

RSIs mostly affect tendons, ligaments, bursae, and neural sheaths but they can affect muscle fibers as well. What happens is the offending activity places unusually high demand on these structures resulting in microscopic tears to the tissues. A very gradual inflammatory response follows, which then takes a life of its own. At this point the patient notices that the pain is more frequent and doesn’t go away with rest, and he/she may reach for an over the counter non-steroidal anti-inflammatory like Motrin.

What makes repetitive strain injuries so persistent is that they are caused by an activity the individual needs ( job) or loves (favorite sport) to do, and essentially he/ she “re-injures” the condition with the activity until it gets to an advanced stage.

Most of the time a repetitive strain injury is transient; i.e. it appears for several weeks then disappears. The patient resorts to icing, rest, temporary discontinuation of the offending activity, over the counter meds, massage therapy, bracing, and in some cases, cortisone shots.

In some people, the pain turns chronic; i.e. doesn’t entirely go away even after weeks and months since the onset. If you are experiencing this, it can be due to improperly healed microtears causing abnormal muscle and tendon performance; and perhaps trigger points which are believed to be concentrations of nerve endings at an old injury site.

When the condition is chronic, you can attempt to do the therapy in the video above. You use a flat edged massage instrument to “strip” the muscle close to where it attaches to the joint. This can help loosen any fibrous adhesions (“stickiness”) that may be interfering with muscle and tendon movement. It also mildly agitates the area (be careful not to overdo it) and increases blood flow, which can stimulate repair by fibroblasts, special cells that synthesize collagen.

This therapy is not to be done when the condition is acute (recent onset, hot, red, swelling). Doing so will make it worse. Try it only when it has reached a chronic stage and inflammation is absent. If it causes an unusual increase in pain, discontinue and apply ice.

Thoracic Outlet Syndrome Exercise

by Pain Doc | Mar 15, 2011 | Hand and Wrist Pain

Thoracic outlet syndrome is a condition where the neurovascular (nerves, blood) structures that service the arm get compressed outside of the spine (a peripheral neuropathy). The compression can come the collarbone, the scalene muscles at the base of the neck, an apical tumor or other mass. Thoracic outlet syndrome can be unilateral (one side) or bilateral (both sides).

The brachial plexus is a bundle of nerves that eventually form the major nerves of the arm: median, radial, and ulnar. It passes directly underneath the center of the collarbone. The subclavian artery, which becomes the brachial artery, is right next to it and supplies blood to the arm. The collarbone (clavicle) connects your shoulder blade (scapula) to your breastbone (sternum). There is only a few millimeters clearance between the bottom of the collarbone and the ribcage, so proper alignment of these structures is absolutely critical for the nerves and blood vessels to work unobstructed.

Trauma to the shoulder complex, repetitive shoulder movements (like a baseball pitch), a long history of sleeping on your side, and a habit of carrying a heavy bag with a strap over your shoulder, or a history of carrying any other heavy objects on the shoulder such as a 5-gallon water bottle are some of the things that can cause the collarbone to close down on the neurovascular bundle. Symptoms can include numbness down the arm; hand numbness, arm and hand weakness, pins and needles sensation in the fingertips, and poor circulation in the arms (feeling of swelling or fullness).

A cervical rib can predispose one to thoracic outlet syndrome. A cervical rib is a congenital anomaly where a small rib branches from the lower neck vertebrae. A cervical rib can easily obstruct the brachial plexus on that side.

A syringomyelia or syrinx is a slowly expanding fluid filled sac in the spinal cord, usually at the neck level, that places dangerous pressure to the cord; enough to cause muscle atrophy (wasting) of the areas served by the affected neurons. Although syringomyelias are rare, they must be ruled out first.

If you are experiencing upper extremity numbness, see your doctor. You should get referred to an orthopedic specialist who can do some tests to properly diagnose your condition. If thoracic outlet syndrome is suspected, your doctor may order a nerve conduction or needle electromyograph (EMG) study to determine if the nerve is compromised. Typically, physical therapy is prescribed for several weeks. If there is no improvement, surgery may be recommended.

The exercise below can be helpful for some sufferers of thoracic outlet syndrome, especially the type that involves the collarbone pressing down on the neurovascular bundle. It is simple to do, and generally safe. This exercise attempts to lift the collarbone repeatedly off the ribcage, creating more space for the brachial plexus and subclavian artery. Do at least 100 per day for a week; if relief is felt, continue doing as needed. If at any point your symptoms feel worse, stop immediately.