Articles - Ask Dr. P - The Pain Doc

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.

Effective Exercise to Maintain Posture

by Pain Doc | Mar 15, 2011 | Uncategorized

Most people are aware that sitting at a desk in front of a computer can be hazardous to your health. The body simply isn’t designed to be placed in such an uncomfortable position for such a long period of time, and will rebel if forced to do so.

The universal desk job has the following ill-effects on the body:

Increases pressure to the lumbar discs by over 50% than standing which can accelerate degenerative disc disease
Inactivates the erector spinae muscles of the back, which has been shown to increase bad cholesterol levels in the bloodstream, contributing to cardiovascular disease
Increases pressure to the sciatic nerves, which can lead to sciatica
Makes it more difficult for blood in the lower extremities to return to the heart
Reduces the natural curvatures of the spine in the neck, mid back and lower back (referred to as the cervical and lumbar lordosis and thoracic kyphosis), which are needed for the spine to support body weight more efficiently
When typing, can lead to strain of the shoulder, arm, wrist and hands due to the unnatural and biomechanically disadvantaged position of the upper extremities during this activity

Of course, we need to work, and if our jobs require sitting at a desk… well, there’s no getting around it. The solution then is to condition your body so that it can better withstand these physical onslaughts.

One of the ways is to do a posture-improving exercise called wall angels. To do this simple exercise, find a wall that is free from obstructions.

Stand back against the wall, heels touching and back of head touching.

Lift both arms and touch the back of your arms, wrists and hands to the wall remembering to keep your wrist straight at all times.

Raise your arms as high as you can, keeping them in contact with the wall at all times. You will feel the urge to bend your wrist and break contact with the wall as your chest muscles tighten; do not let this happen (in the video above, the patient is unwittingly doing this with her left hand. Watch, and try not to do this).

When you can’t go any higher, lower your arms in the same way, as low as you can go without letting your arms break contact with the wall. In fact, exert mild pressure against the wall with the back of your arms, wrists and hands (actively push against the wall during the exercise).

Those are the basic motions, do them at a fairly moderate pace (not too slow, not too fast– one cycle up and down should take about 2 seconds); about 50-100 repetitions per exercises session. Do 3-4 sessions throughout your day.

The exercise will activate the upper back muscles, which tend to be inactivated when sitting at a desk, and stretch the chest and anterior (front) neck muscles, which tend to be overactive and gradually shorten over time, causing the familiar rounded shoulders and stooping head posture. This exercise sort of “equalizes” muscle activity of the chest and back, improving your posture.

Back Pain as a Result of Brain-Muscle Miscommunication

by Pain Doc | Mar 13, 2011 | Low Back Pain

Most people who have general back pain and stiffness don’t question it enough; i.e. wonder why they have it. All they want is for it to go away in the quickest amount of time. A person suffering from back pain will first wait and see if it goes away with rest and time, and if it’s really bad, over the counter medications. If this doesn’t work, he will make an appointment with his primary care physician, who will usually prescribe pain medication and muscle relaxants to address the symptom (not the cause). The patient may be referred for physical therapy, which typically consists of modality application (heat, ice, lumbar traction, electric muscle stimulation and possibly low level laser) and exercises. Some people with lower back pain consult a chiropractor, who will address the problem usually be employing some form of spinal manipulation; and some will seek an acupuncturist.

But what if all these treatment forms are on the wrong track; i.e, they are based on errant assumptions? What if there is more to the back pain than sore muscles and stiff joints?

If you suffer from back pain; particularly lower back pain, it may be the result of dysfunctional nerve signals coming from the brain. The brain controls voluntary and involuntary contraction of your muscles, like a finely tuned machine run by a super fast computer. It’s analogous to a world-class conductor conducting a symphony so that every note, tempo, and timing is perfect.

If the nerve impulses (millions of them occur just standing) are dysfunctional, it can cause certain muscle groups to contract when they aren’t supposed to, forcing joint surfaces together and limiting their movement. It can cause one side to be inactive, resulting in unbalanced muscle tone. Abnormally functioning nerve signals to the muscles can throw off the synchronization of muscle contraction, which would be a big problem right in the middle of moving a heavy piece of furniture.

I believe that most cases of gradually occurring lower back pain are the result of degraded communication between the brain (cerebral cortex and cerebellum) and the musculoskeletal system. Even if the onset of pain was a specific incident such as bending forward to pick something up, it is secondary to a malfunctioning brain-muscle communication.

So, what does one do? Realize that for lower back pain, one shouldn’t simply focus on external means to reduce the pain; whether it be pharmacological (drugs) or manual (physical therapy, chiropractic). These methods can help reduce the pain and make you feel better, but if they don’t address the true problem, the pain is guaranteed to return.

Somatics is a form of therapy that treats muscular conditions by attempting to remove emotional or subconscious factors that may be contributing to the problem. The idea here is that the brain’s ability to properly regulate the body’s muscular function has been compromised by an old injury; inactivity, or harmful thought patterns. Somatic therapy addresses the problem by attempting to restore the connection using specific exercises, concentration, and breathing techniques.

If you have lower back pain that just won’t respond permanently to physical therapy or chiropractic, consider Hanna somatic exercises. This technique seeks to restore proper brain-muscle function using deliberate, specific targeted exercises (not your typical strengthening and stretching exercises). The system is taught by Lawrence Gold, a certified Hanna Somatics practitioner and is available on DVD or internet download. A sample of one of the exercises can be found here.

Relieving Foot Pain from a Morton’s Neuroma

by Pain Doc | Mar 11, 2011 | Foot and Ankle Pain

If you notice a gradually developing pain in your forefoot (just past your instep) between the tarsal bones of the 3rd and 4th toes that is worse when you press it between your thumb and index finger, you most likely have what’s called a Morton’s Neuroma.

Despite it’s name, it is not a true tumor. It is a buildup of fibrous tissue that surrounds the sheath of one of the nerves that innervate the foot. The nerve lies between the muscles that connect the tarsal bones and due to the fibrous buildup gets compressed within this narrow confine. It is worse when standing and walking.

Morton’s neuromas are usually treated with orthotics (custom shoe inserts to help counter flat arches, over pronation, or other abnormalities of the foot) and cortisone injections to the painful nerve. Sometimes surgical removal of the excess fibrous tissue is done if the condition does not resolve.

A simple remedy that can provide welcome relief, and perhaps allow the nerve to heal faster is inserting rolled up gauze or cotton between the 3rd and 4th toes. This spreads apart the tarsal bones and creates more room for the nerve. Sometimes simple things make for effective remedies, and this is one of them.

Tension Headache Remedy

by Pain Doc | Mar 10, 2011 | Headaches

Tension headaches are those thought to be triggered by prolonged muscle contraction in the neck, jaw and head. This can be voluntary and subconscious (nervous or habitual), or involuntary in response to stressful situations.

Oftentimes when I take a history from a patient complaining of frequent tension headaches, I discover that the patient also has jaw pain. This could be a sign that the patient is grinding his/her teeth either during sleep or throughout the day. Worn down tooth surfaces in the molars are also a sign of grinding teeth.

When one grinds or clenches the jaw, two bilateral (both sides of the head) muscle groups are engaged: the masseter, which is the thick muscle you can palpate right over the angle of the jaw; and the temporalis, which anchors to the side of the head and attaches to the mandibular notch. These two muscles elevate the mandible (lower jaw).

When a muscle is under tension (also referred to as hypertonic or hyperactive) it is basically malfunctioning. Muscles control joint movement, and if the muscle is not working properly it can activate tiny nerves called mechanoreceptors and nociceptors embedded around the joint, causing pain.

When the temporalis muscle is under tension, it can affect blood flow around the scalp, which can also develop into a headache.

So, what can one do? Here’s a simple remedy that has anecdotal evidence to support it: open your jaw and relax it. To make it easier, insert a pencil or pen in between your teeth (but don’t bite down on it!) and hold it in place for a few minutes. This action inactivates the masseter and temporails muscles somewhat by activating their agonist pair, the pterygoid muscles.

Give it a try next time you feel a tension headache coming on. But better yet, focus on eliminating the environmental or emotional triggers that cause you to clench your teeth or tense up your neck and head muscles.

Back Pain or Arthritis? Try Curcumin and Boswellia Extract

by Pain Doc | Feb 27, 2011 | Uncategorized

Image via Wikipedia

Curcumin is the yellow spice derived from the plant Curcuma longa, commonly called turmeric. Extensive research over the last 50 years indicates that curcumin can both prevent and treat cancer and inhibit inflammation. The anti-cancer potential of curcumin stems from its ability to suppress proliferation of a wide variety of tumor cells and down-regulate or inhibit various enzymes and biochemical pathways involved in cancerous activity and tumor growth.

Curcumin has been described as a potent antioxidant and anti-inflammatory agent. Pharmacologically, curcumin has been found to be safe. Human clinical trials indicated no dose-limiting toxicity when administered at doses up to 10 g/day. All of these studies suggest that curcumin has enormous potential in the prevention and therapy of cancer.

Boswellia frereana (known as Frankincense) comes from a tree native to Somalia. Clinical studies have shown its benefits for both osteo- and rheumatoid arthritis. Its anti-inflammatory properties have also been shown to make frankincense a safe and effective treatment for asthma, inflammatory bowel diseases, such as colitis, Crohn’s disease and ileitis.

A 2010 study on boswellia’s potential to reduce cartilage degeneration showed that it inhibited the breakdown of the collagenous matrix; reduced potency of various metalloproteinases, which are enzymes that break down protein molecules; and significantly reduced the production of inflammatory agents like prostaglandins and cyclooxygenase 2 (COX2). Epi-lupeol was identified as the principal constituent of B. frereana.

This was the first report on the observed anti-inflammatory properties of Boswellia frereana in an in vitro model of cartilage degradation. The researchers demonstrated that B. frereana prevents collagen degradation and inhibits the production of pro-inflammatory mediators and MMPs and therefore should be examined further as a potential therapeutic agent for treating inflammatory symptoms associated with arthritis.

So if you are experiencing chronic, inflammatory pain, it wouldn’t hurt to try increasing your intake of these two herbs.