Articles - Ask Dr. P - The Pain Doc

When NOT getting pain relief can be a good thing.

by Pain Doc | Mar 27, 2014 | Uncategorized

Musculoskeletal pain sufferers are one of the most difficult types of patients for doctors to treat. An informal survey of MDs and chiropractors indicated that chronic pain patients “are not their favorite” to treat, and it’s not hard to understand why.

When drugs, surgery, physical therapy or chiropractic adjustments fail to resolve pain, the patient keeps coming back, reporting the bad news to the provider. The office visit becomes an emotional outlet for the patient as the patient speaks at length of where it hurts, how it feels, and so on; sometimes getting emotional. And the doctor has to absorb all of this outpouring, which wears him/her down emotionally and physically. It makes the provider feel as though he or she has failed; or feel powerless and ineffective. Without admitting it, the doctors just want these pain patient to “go away.” They do their best to say something, anything to hopefully appease the patient until that dreaded next appointment. By this time, the patient has already gone through prescription meds and did all the things the doctor said to do, so the doctor doesn’t have much left to offer. It leads to frustration for both the patient and doctor.

Some doctors go so far as to discharge (get rid of) the patient against his asking, passing him on to another doctor.

It’s one of those things that is not well known to pain sufferers, but is a reality in hospitals and clinics across the world.

But consider this: when something happens in your life that you initially perceive as “bad,” it can actually be a good thing in disguise. It happens a lot. Such jolting, pivotal moments like being discharged by your doctor are like re-setting a frozen computer: it takes you out of a non-productive cycle and forces you re-assess your situation. It removes the dependency factor and makes you look elsewhere for answers, increasing your chances of finding the right one for you.

So, if you suffer from back pain and haven’t gotten results from medications, it could be a good thing. Explore other avenues that might give you better results, without the toxicity.

I am currently investing a lot of time reviewing the case histories of the thousands of pain patients I have seen over the years and taking note of commonalities; some of which I mentioned in the previous post. While many of them did have degenerative changes in their spine which were not reversible, many also were not at that point yet, but were on their way. I noticed that many lacked knowledge on how to keep their spine flexible and healthy, and/or were of a mindset that ignored the importance of staying active. They believed that work (their job) was a top priority in their life and allowed it to consume most of their waking hours, pushing aside other important, vital things like exercising, removing stressors, resting and relaxation, and eating a healthy diet.

I understand that life is full of difficulties and challenges– we all have them. We convince ourselves that we will get fired if we don’t put in x-amount of hours per day at the job. We convince ourselves that exercising isn’t all that important, and that it feels really uncomfortable and is something to avoid. We convince ourselves that it’s too much effort to research healthy foods and supplements, and that eating the same junk food or highly processed food won’t hurt our health. These are all being generated in the subconscious mind, considered the main driver of behavior and decision-making.

Well, this is a mindset that is common to, in my estimation, over 80% of all the back pain sufferers I have treated. Mindset— your set attitudes and beliefs– is what drives your actions; and much too often it drives actions that are “the path of least resistance.” Yes, it’s human nature, but it’s also the thing that is keeping your body from healing itself.

You may be thinking, “I tried to cure my back pain with exercises but I still have the pain.”

For pain resolution, I believe that it’s not just the exercises themselves that are important; it’s the specific ones and knowing what they do; the sequence in which you do them, the frequency in which you do them and concurrent activities involving nutrition, sleep, meditation, breathing and others that altogether will produce the best results.

This concept describes the upcoming, comprehensive pain relief program I am designing that will help people conquer their pain once and for all, without harmful drugs or surgery. It will be a multi-media course based on video demonstrations of numerous powerful healthy lifestyle strategies, as though you were in my office. I’m really excited about it, because I know that it is going to help millions of people manage and even eradicate their chronic pain problem.

If you wish to get notified when it is released and take advantage of the special launch price, just opt in on the site’s sign up page in the upper right.

Chronic Back Pain – Here Are Your Options

by Pain Doc | Mar 26, 2014 | Low Back Pain

From my casual observation as a clinician, about 80% of people suffering from back pain fit a certain demographic profile:

Male
Age 35-60
10-20+ pounds overweight
Works in manual labor or;
White collar- prolonged sitting
Sedentary or moderate physical activity

Of secondary association, there are these traits:

History of past injury
History of contact sports or sports involving jumping (i.e. gymnastics)
Familial history of back pain
Smoker
Stressed
Insufficient sleep
Unbalanced diet: junk food, excess carbs, insufficient vegetables

Now of course there are people who have back pain who don’t have any of these characteristics, but those individuals are a very small minority.

If half of these factors apply to you, there is a good chance you have back pain in some form.

The problem with “non-specific” chronic back pain that is not associated with a single-event trauma like lifting something heavy is that, by the time you feel the pain, the internal structures that are causing it have degenerated to a point where it is difficult to completely resolve. And, males in general usually defer seeing a doctor or specialist when they feel the first signs of something wrong; they are more likely to ignore it until it gets to a level where it interferes with their activities in some way.

Non-specific low back pain is often difficult to diagnose because there are usually multiple things happening simultaneously:

spondylosis (bony projections indicative of joint degeneration)
stenosis (narrowing of spaces where nerves pass through)
arthritis (inflammation within the joint surfaces)
vertebral slippage (spondylolisthesis; retrolisthesis)
disc degeneration
ligament calcification
sometimes osteopenia (loss of bone mass)
sometimes paraspinal muscle spasms/ hypertonicity
sometimes spontaneous fracture

There is a lot of debate among physical therapists, chiropractors and orthopedic specialists regarding how far can a degenerated disc and associated spondylosis recover, and if it is even possible at all. Is it “once you have it, you have it for life?” or is there still a miraculous chance that your body can repair degenerated areas in the spine if you just give it the right conditions?

The answer has big ramifications; after all, getting diagnosed with chronic pain due to lumbar degenerative disc disease at age 40 can be devastating if it means that you have to live the rest of your life with low back pain. We all want not just to live, but to live with vitality; right? We don’t want to go through life sitting down, watching everybody else have fun; we want to engage life and live it to its fullest.

What we do know is that once you develop osteophytes (spondylosis)– those bony spikes that protrude from the edges of vertebral structures– they do not resorb, no matter what. Thankfully, they are “slow growing,” and it is possible to stem that growth by doing things like losing weight if you’re overweight, eating healthy, exercising and strengthening your back and core muscles to improve support. But once they reach a certain point and obstruct nerve passageways, you’re looking at surgical intervention (spinal decompression surgery), which often works but also often causes new problems, or provides temporary results as the osteophytes resume growing.

But with discs, there is more hope. Discs are mostly water. If you can re-hydrate your discs and get them healthy, they will increase in thickness and in the process create more space between your vertebrae, potentially relieving pressure from pinched nerves and impacted facet joint surfaces. However, some people have passed the point of no return where the disc is functionally “dead” (looks solid black on MRI). In these situations, the vertebrae eventually fuse together which accelerates stenosis, requiring surgical decompression.

So, if you have chronic back pain, your alternatives are to engage in lifestyle modification habits that strengthen the body and promote healing; work with a chiropractor, physiatrist or other rehab specialist to see if improving joint movement and muscle balance are enough to resolve the problem; or consult with an orthopedic MD and see if you are a candidate for surgery.

Stay tuned, as I will soon be coming out with a Healthy Lifestyle Education instructional course designed to help those with chronic pain.

If you wish to be notified of it when it launches and receive a preview, submit your name and email to this form below:

Notify me when the Get Rid of Chronic Pain Healthy Lifestyle Education course launches!

Study Shows Benefit to Stratified Care for Low Back Pain

by Pain Doc | Mar 19, 2014 | Low Back Pain

A recent study (ImPact Back Study) published in the Annals of Internal Medicine demonstrated that low back pain sufferers had statistically significant improved treatment outcomes, at a lower cost when the case was classified as either low, medium or high “risk” for persistent disability and received a standardized treatment method for that level.

Specifically, low-risk patients received a single session of intervention comprising assessment, education and support for self-management.

Medium-risk patients receive physical therapy interventions that focus on reducing pain and disability, encouraging physical exercise and facilitating early return to work.

Meanwhile, high-risk patients receive “psychologically informed” physical therapy that integrates cognitive behavioral techniques with traditional physical therapy to reduce pain and disability, improve psychological functioning and facilitate self-management.

Other benefits associated with stratified care as compared with usual care included significantly more risk-appropriate referrals to physical therapy, a 39% relative reduction in sickness certifications, a 50% relative reduction in time off work sick, a decrease in use of non-opioid medications and concurrent increase in use of mild opioids.

This study was done in the U.K., so there are likely differences in the protocols for treating low back pain compared to the U.S. It is interesting that common procedures in the U.S. for “high risk” low back pain such as facet injection and decompression surgery were not mentioned. Perhaps it is their experience that such procedures have not demonstrated efficacy in resolving low back pain, and that psychotherapy combined with traditional physical therapy is more effective.

The bottom line is that, if you have low back pain, an accurate diagnosis is obviously very important. Granted, in many cases the origin is difficult to pin down, it is prudent to take into consideration the possible role of the patient’s psychology and use appropriate interventions like CBT. Defaulting to opioid and non-opioid drugs may be counterproductive, as addiction and liver and kidney toxicity is always a risk.

The Origins of Musculoskeletal Pain – Which Describes Yours?

by Pain Doc | Mar 7, 2014 | Hand and Wrist Pain, Low Back Pain, Myofascial Pain

Musculoskeletal pain refers to pain affecting the muscles, ligaments, tendons, joints and sometimes bones. Sometimes it is straight-forward; other times it is not. Before you convince yourself that you know the origin/cause of your musculoskeletal pain, consider the following:

Pain can be due to trauma/injury where the tissue itself is generating the pain due to ruptured cells and the effects of inflammation. This is the most unambiguous case because it is connected to an identifiable event. This pain can be acute, meaning relatively recent onset; sub-acute, referring to a state where the injury still is healing but pain and some swelling is still present; and chronic, which basically means symptoms that remain after the body has done all it can at the moment to heal the injury.

Pain can manifest in one area of your body due to abnormal movement in a distal location. The abnormal movement might be caused by a previous trauma event like a car accident or sports injury, it can be congenital (developed at birth) and it can be from repetitive movements required by a certain occupation or hobby/sport. Abnormal movement (called dyskinesia) can also arise from muscle imbalances, where one muscle loses strength due to inactivity, decreasing joint stability and facilitating excessive, restricted, or other abnormal movement of that joint, forcing distal joints to make up the difference in lost movement or compensate to create more stabilization. The distal muscle(s)/joint(s) then work in a fashion that they were not designed for, leading to strain, spasm and even injury to the muscle or joint.

This is the most tricky type of pain manifestation because it is often mis-diagnosed resulting in the wrong treatment approach and lack of resolution. An example of this is sciatica (pain in the buttock) from a spasmed piriformis muscle scissoring the sciatic nerve due to an unlevel pelvis coming from hyperactive same-side erector spinae musculature. If the back muscle and pelvic imbalance is not corrected and the patient simply gets massage to the piriformis muscle, you can see how this pain will never go away with this type of treatment.

Pain can be referred pain. In referred pain, the brain senses the pain to be in one area of the body when the abnormal site is actually in another area. Despite an increasing amount of literature on the subject, the mechanism of referred pain is still unknown. Going back to the heart attack example, myocardial infarction can cause referred pain to the left jaw and left arm. The image below illustrates commonly observed types of referred pain and their true source (credit to Wikipedia).

Pain can arise from hypoxia (insufficient oxygen to the tissues). An extreme example of this kind of pain is a myocardial infarction, or “heart attack” where a major artery to the heart muscle is blocked, preventing oxygen from reaching a section of the heart. Biochemical reactions take place when this happens, which generate pain.

Thoracic outlet syndrome is a condition where the nerves and blood vessels supplying the arm get compressed in the neck region by tight scalene muscles or the collar bone. The resulting hypoxia can contribute to pain in the arms and hands.

Pain can come from trigger points, also known as trigger sites or muscle knots, are described as “hyper-irritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers.” Trigger points are usually only a few centimeters in diameter.

Clinical textbooks on the subject establish the following requirements to meet the definition of trigger points:

Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection.
The painful point can be felt as a nodule or band in the muscle, and a twitch response can be elicited on stimulation of the trigger point.
Palpation of the trigger point reproduces the patient’s complaint of pain, and the pain radiates in a distribution typical of the specific muscle harboring the trigger point.
The pain cannot be explained by findings on neurological examination.

As in referred pain, the mechanism of trigger points is still being debated. Trigger point tissues have been biopsied, and findings indicate the presence of hyperactive muscle spindles, special cells whose function is to detect the rate of lengthening in a contracting skeletal muscle and initiating the firing of complementary muscles to complete the desired goal.

Wikipedia gives a nice summary of what causes trigger points to form:

Activation of trigger points may be caused by a number of factors, including acute or chronic muscle overload, activation by other trigger points (key/satellite, primary/secondary), disease, psychological distress (via systemic inflammation), homeostatic imbalances, direct trauma to the region, collision trauma (such as a car crash which stresses many muscles and causes instant trigger points) radiculopathy, infections and health issues such as smoking.

Finally, there are more highly-complex causes of pain related to dysfunction of the central nervous system, sympathetic nerves, biochemical and hormonal issues, and even psychosomatic. These types of cases are difficult to diagnose and are often treated using pharmacological agents, and on the other side of the spectrum, holistic approaches with mixed results.

NO MATTER what pain you may be experiencing, know that it always, always helps to detoxify your body as best you can via a nutritionally-dense diet centered on naturally-occurring, non-GMO, organic unprocessed food sources; reducing your processed sugar and grain intake; regular exercise, getting enough sunshine to your body; targeted supplementation, meditation or other relaxation methods, and even nurturing social support. This is the theme of this blog, because there is no shortage of treatment methods for pain and not enough emphasis coming from doctors or the government on prevention, wellness and health optimization; i.e. Healthy Lifestyle Education.

In the next couple of blog posts, I will talk about real, practical ways you can reduce your pain without the help of your doctor by making strategic lifestyle modifications. Your body has a potent array of disease-fighting systems and has an innate ability to repair and regenerate itself. The problem is that in many pain sufferers, these systems are burdened by unhealthy habits and are not running at their full potential. Imagine what can happen if those systems were brought back on line, constantly doing what they are naturally programmed to do– protect you and keep you alive; fighting germs, cancer cells and developing diseases; and repairing injured sites so that you can function better. Isn’t this a goal worthy of your efforts?

More to come, stay tuned!

Dr. Perez

The Bad Health Effects of Frequent, Prolonged Sitting

by Pain Doc | Sep 25, 2013 | Uncategorized

I’ve been saying for many years that one of the best things you can do to improve your health is to be more active. And one of the ways to do it that is low tech and doesn’t require a heck of a lot of thought is making a conscious effort to stand more than you usually do throughout your day; especially for those who have sedentary desk jobs.

When you stand, you burn more calories because you engage your erector spinae muscles, gluteal muscles and of course leg muscles. You can burn at least 100 more calories a day simply by standing for two hours more. It’s also better for your posture. And get this, other research says that sitting can cause your bad cholesterol levels to rise because it deactivates spinal muscles that prefer to burn fatty acids for energy.

A study just a few years ago revealed a positive correlation between hours spent sitting and premature death. The American Cancer Society study found that women who sit for more than six hours a day were about 40% more likely to die during the course of the study than those who sat fewer than three hours per day. Men were about 20% more likely to die. Now that is a risk factor that can easily be avoided.

If you have a desk job that requires sitting two or more hours straight, or is such that it is easy to get caught up in your work and sit for that amount of time or longer (common for software programmers, researchers, accountants and attorneys to name a few) you need to find a way to remind yourself to stand periodically and ideally do some simple exercises while you are at it, like squats, lunges or doing a couple of laps in your building’s staircase or stair well. Incorporating such a simple routine can have a huge impact on your health, now and in the future.

Lastly, check out this modern concept office workstation by Focus. It is much better for your back than traditional workstations that place max pressure on your lumbar discs, potentially increasing your chances of developing degenerative disc disease. The unique design of the Focus workstation results in much less pressure on your lower back and engages the spinal muscles and leg muscles more than a traditional chair with a back rest. This will allow you to work longer hours without as much risk. But still, it’s better to get off your butt every 20-30 minutes and walk to prevent the bad stuff from happening.

Spinal Stenosis – What it Is, and What to Do

by Pain Doc | Sep 14, 2013 | Leg Pain, Sciatica

Spinal Stenosis

Recently, Carrie Ann Inaba, one of the judges of the show Dancing With the Stars publicly announced that she has been suffering for quite some time from cervical spinal stenosis– a condition in which the canal that encases the spinal cord in the neck narrows and obstructs nerve tissue. She explained how her condition impacts her life, limiting her from doing the things she loves to do. To Carrie Ann’s dismay, she no longer dances with a partner for fear of getting whiplash and paralysis. That’s quite unfortunate for someone whose entire career revolved around dancing.

Although spinal stenosis is a generalized term for narrowing of the spinal canal by any cause, the most common type, which will be discussed here, is the type caused by osteophytes— growth of bony projections that narrow the openings where nerves pass through. Advanced osteophytic activity is also referred to as spondylosis. When it is severe enough to narrow the spinal canal (foramen) it then creates the condition known as spinal stenosis. For your information, other forms of spinal stenosis are those caused by herniated discs, spondylolisthesis, tumors or any mass that encroaches into the spinal canal.

In her article, Carrie Ann mentioned that spinal stenosis is a form of arthritis and that she is anxious to find a cure for it. Unfortunately spinal stenosis is not one of those conditions that can resolve on its own with rest, exercise and time and other non- invasive measures. And since the inflammation from spinal stenosis is secondary to irritation of nerves, it is technically not a type of arthritis. That is why anti-inflammatory medications have minimal effect on the pain associated with spinal stenosis, which is typically deep, sharp and radiating in nature.

Spinal stenosis occurs when vertebrae, the bones that comprise the spinal column gradually morph in a way that constricts the spinal foramen (canal), or space where the spinal cord resides. When there is less space for the spinal cord to move, it is subject to more abrasion with spinal movement; i.e. bending and turning your neck. The cord (actually, meninges or covering of the cord) rubs against sharp edges of the bony projections into the foramen with movement causing inflammation and injury to the nerve tissue, sometimes causing sclerosis (hardening). In advanced cases, especially cases of lumbar spinal stenosis (due to the more significant weight burden) the narrowing gets so advanced that there is constant pressure on the nerve roots. At this point, it is an emergency situation as renal function and sensation to the legs are affected.

Signs of advanced spinal stenosis include paresthesias, sharp pain with movement, weakness in the extremities, and muscle atrophy in legs and/or arms. Symptoms can be permanent if not treated early.

And what is the treatment for spinal stenosis? First of all, doctors will usually order MRI and x-ray to determine extent of narrowing. If it is caught early, physical therapy and lifestyle modification is recommended. The goal is to slow down or stop the progression of the narrowing.

Surgery is the only option for advanced cases. Since spinal stenosis involves physical structures compressing nerve tissue, there are surgical procedures that can enlarge the spinal canal by scraping off the encroaching bone material and buy the patient more time. Since bone is comprised of live cells, the movement of bony projections (called osteophytes) into the spinal canal is still likely after surgery and many who have had such spinal decompression surgeries develop the same problem several years later.

It’s not quite evident why some people suffer from spinal stenos more than others. But those who have a history of physical trauma to the spine like car accidents, sports injuries and falls are at a higher risk. The theory is that the injury event disrupts the normal alignment of the spinal segments resulting in accelerated wear and tear over time; much like how a loose screw in a machine accelerates mechanical failure. Some orthopedists hypothesize that the appearance of bony projections is the body’s attempt to fuse and stabilize adjacent vertebrae so they can no longer move separately; thus reducing the probability of injury. However, the nerves that share the space with the vertebrae get damaged in the process. If this theory holds true, then it is an inherent design flaw of the body’s self-healing mechanisms.

Also, heavy smoking and obesity, and general poor health can increase your chances of developing spinal stenosis.

I’m sure more than one doctor broke the news to Ms. Inaba that there basically is no “cure” for spinal stenosis once it is in its advanced stages, which appears to be her case based on her own description of her symptoms. It is a mechanical condition that mandates mechanical intervention. No amount of drugs will cure spinal stenosis from advanced osteophyte formatioin. Her only option at this point is spinal decompression surgery to widen the spinal canal and hope that the nerve tissue did not sustain permanent damage.

The best strategy for dealing with spinal stenosis is prevention. If you sustained injury to your spine from a car accident (even a low impact one that did not require medical treatment), a sports injury (including repetitious trauma like that related to gymnastics and football) or slip and fall, realize that “the seed” for spinal stenosis may have been planted in you already. If your injury event was over five years ago, get an x-ray to identify any levels where osteophytes are present; these are the sentinels of potential areas of spinal stenosis as they identify areas of biomechanical weakness. If there are some, the first course of action is to not worsen things. Avoid or reduce activities that regularly place trauma to your spine. Engage in specific exercises that strengthen the neck and lower back to offer more stability. Stretch often (yoga is a great choice) and take care of the insides of your body as well with proper diet, nutrition, hydration and adequate rest.

Lastly, the Cervical and Lumbar Posture Pump is a home rehabilitation device that tractions and separates vertebrae to hydrate the discs and increase nutrient absorption which can slow down the progression of spinal stenosis if done diligently on a regular basis. I have personally used them in my practice, and patients reported positive results.

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.