Uncategorized - Ask Dr. P - The Pain Doc

Pain With No Apparent Cause

by Pain Doc | Jul 2, 2012 | Uncategorized

It’s strange, but you would think that for someone experiencing neck, back, shoulder or any other type of musculoskeletal pain in his body, he would know exactly when it started, and how.

But surprisingly, this is not the case for a majority of patients I have seen over the years. Most cases of pain I see are idiopathic; meaning, “with no apparent cause (at least in the eyes of the patient).”

A typical history of such a patient goes something like this:

Me: “Ok Sue, I understand you are experiencing pain in your upper back, right side. When did it start, and how, to your knowledge?”

Patient: “At least the past five or so years. I don’t know what started it; it just seemed to have appeared gradually. It is good some days, then bad, and lately it has been getting worse, so I decided to get it checked.”

At this point, I continue with the history by asking questions related to the patient’s occupational, social/recreational, and past medical history. Usually there is something in the history that can be linked to the complaint, like a past car accident, a particular sports activity during college, or something about the physical requirements of her occupation. But in some cases, there still is nothing in the history that can explain the pain.

But where there is a problem, there is an answer. It’s just that sometimes the answer requires some smart detective work.

If you suffer from pain that can’t seem to be traced to a specific cause, realize that musculoskeletal pain, aside from systemic related disorders such as rheumatoid arthritis, lupus, bone disease, and others, develops from some kind of mechanical breakdown in the musculoskeletal system. It can be something obvious like a hard fall that injures and misaligns a joint; something seemingly innocuous like sleeping on your right side for most of your adult life; or something very subtle, like a subluxated heel bone that does its damage via a drip effect.

So, your best bet is to find a practitioner who is very experienced in human biomechanics. Chiropractors or physical therapists such as Craig Liebenson, DC who emphasize body kinematics and targeted exercise rehabilitation will typically have a keen eye for abnormal or dysfunctional movement. The course of treatment will involve identifying and acknowledging the problem; aggressive rehabilitative exercise regimen, and lifestyle modifications. Manual therapies may be employed, such as spinal manipulation; and orthotics may be required, at least during the initial phase of treatment.

This applies to conditions including unilateral hip or knee pain, TMJ pain, neck pain with right or left rotation, rib or sternum pain, and many others. Oftentimes the condition is secondary to a primary cause, so the doctor should not jump to conclusions and direct all treatment to the site of pain. A thorough investigation and inspection is required.

Hamstring muscle strain from running

by Pain Doc | Jun 29, 2012 | Uncategorized

I have a patient who complains of acute pain right under the right butt cheek, and inner part of the thigh. It is a persistent pain that has been bothering him for weeks and also feels stiff. He is in his mid 50s, professional, and in good health other than “high” cholesterol, for which he takes Lipitor.

The pertinent history for this patient is that he is an avid runner, and has been running regularly since his 20s. He is one of those folks who enjoys the feeling of running, during and after. It is a form of stress relief for him. He also does Pilates using the reformer, and enjoys 3-4 glasses of wine on most nights.

The area in question is the biceps femoris tendon, which is part of the “hamstrings” of the leg. It functions as the major knee flexor of the leg (its agonist, opposing muscle is the quadriceps group). The biceps femoris muscle inserts into the ischial tuberosity, which is the bony part of the ischium (half of the pelvis) that we use to sit.

Without the benefit of an MRI or CT scan, and based mostly on the history and lack of other findings that would cause me to think otherwise, I diagnosed myofascial strain of the biceps femoris tendon, with possible tendinopathy (degradation of the tendon from overuse). Basically, something has happened to the muscle and tendon that is resulting in unrelenting pain.

Running is the repetitive, alternating contraction and relaxation of opposing muscles. The most stress occurs at the tendinous attachments to the anchor points on the bone. However, the spot where the tendon attaches to bone is stronger than the breaking point of the tendon itself, so when it is stressed, the body of the tendon will experience tearing (strain) first. It is rare for a tendon to separate from bone at the attachment site. This is the case for this patient, as his pain is described as about 2-3 inches from the attachment point on the ischial tuberosity.

I am treating his injury with a LiteCure deep tissue laser and have given him a nutritional prescription consisting of whey protein to provide the building blocks for repair; high potency fish oil and capsaicin to help reduce the inflammation, and bromelain supplements to serve as an enzyme to soften scar tissue formation. Today, I advised him to drink distilled water for 2-3 weeks. Distilled water may have a chelating-type of effect (binding) on dissolved, inorganic toxins or debris in tissues, which could help with the situation; it is often used for detox programs because of this quality. He was advised to rest, ice and compress the area for 3 days to help suppress the inflammatory reaction.

The case is a very interesting one that will hopefully have a good outcome. We should realize that a muscle is very much like an organ of the body, although it is rarely referred to as one. It has its own unique type of cells, blood supply, and plays an important function. As in all cases of disease of the body, a good strategy is to give it an edge in repairing itself. Diet modification, concentrated, high potency supplements, and non-pharmacological, manual therapy, when used in the right manner can oftentimes hasten recovery.

Laser Therapy for Chronic and Acute Musculoskeletal Pain

by Pain Doc | Sep 20, 2011 | Uncategorized

Low level laser therapy, or LLLT is the application of low-powered lasers or light emitting diodes for the purpose of pain relief and/or injury repair. The therapy is typically done transdermal; meaning through the skin into the target tissue, such as a sore shoulder joint (no surgical incisions). While some research studies show that LLLT can result in immediate pain reduction in rheumatoid arthritis, osteoarthritis, tendinopathies, acute and chronic neck pain, temporomandibular joint (TMJ) pain and other joint disorders there is currently a lack of consensus on the best parameters to use; i.e. power, dosage, time, pulsing, and type of laser. The therapeutic wavelength appears to be between 800-1,000 nm; and dose to be around 6-10 joules/cm2.

LLLT may reduce pain related to inflammation by lowering levels of COX-2 and tumor necrosis factor-alpha (enzymes associated with inflammation); oxidative stress, edema, and bleeding. It is also believed to cause cellular mitochondria to produce more ATP– a cell’s basic energy unit, resulting in increased metabolic activity.

Low level laser therapy is offered by some chiropractors, sports physicians, and acupuncturists. Lasers are classified according to how much damage they can do to the eye, which basically means how powerful they are in terms of wattage. The wattage rating of a laser determines how long it takes to deliver a dose, and how deep the light penetrates tissue (important if you are treating thick areas of the body such as the hip or knee joint). At 10 watts max output, the LiteCure and K-Laser are two of the strongest lasers in the market for this purpose. Lasers with output of 500mW or less will not penetrate as deeply, and will require a longer treatment time to administer a therapeutic dose.

A typical treatment regimen will be 10-15 minutes of laser; six to eight sessions. Sometimes that is all it takes to take care of an acute or chronic problem. Many practitioners including myself incorporate soft tissue therapy, joint mobilization and rehab exercises to fully deal with the painful condition.

So if you are experiencing a recent injury such as a sports injury; or have chronic pain such as tendinitis, sciatica, plantar fascitis, rotator cuff tear, or knee pain, consider trying low level laser therapy. It is generally safe, and faster-acting than manual therapies alone (chiropractic, PT, occupational therapy). Be cautious and tell your practitioner if you are taking photosensitive medications, or have light sensitive skin, as the treatment can be uncomfortable and may even cause pigmentation.

UPDATE ON THIS TOPIC: Can Red Light Heal Injuries and Lessen Pain?

Dr. Dan

Chronic Pain Affects Approximately 116 Million Americans

by Pain Doc | Aug 2, 2011 | Uncategorized

Woman with hip pain

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

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

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

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

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

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

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

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

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

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

——

My comments:

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

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

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

References:

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

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

Article on Laser Spine Institute

by Pain Doc | Jul 12, 2011 | Uncategorized

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

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

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

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

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

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

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

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

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

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

Whiplash Injuries and How to Treat One

by Pain Doc | May 28, 2011 | Uncategorized

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

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

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

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

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

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

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

You can find more information on whiplash on my website.