NMPI Blog - Norman Marcus Pain Institute

Morphine: Friend or Enemy?

Wednesday, July 23rd, 2014 at 5:26 PM

You may have read several articles in the news lately about opioids and pain medications. Earlier in July, The New York Times printed two separate articles on the dangers and abuse of prescriptions drugs in the States. On July 1^st, Sabrina Tavernise’s Prescription Overdose Deaths in Florida Plunge After Tough Measures, Report Says, appeared in the Health section and on July 3^rd, The Op-Ed editors wrote a piece entitled States and Painkiller Overdoses.

Obviously, the media is very concerned regarding the large number of pain medications being prescribed, the amount of medications being misused and/or diverted, and the adverse effects of the medication, particularly addiction. Pills

Back in the day, alcohol was used as anesthesia for surgeries – patients were given a bottle of bourbon and told to bite the bullet. Modern medicine introduced Ether and chloroform for surgical procedures and morphine to control the pain after the surgery. Morphine was thought to only be effective by injection, but then we found that morphine tablets and liquid taken by mouth could be just as effective in relieving pain. Morphine was then used for patients with terminal cancer pain. Why not make a dying patient comfortable?

The availability of oral instead of injectable morphine allowed doctors caring for cancer patients to more easily relieve the suffering that many dying cancer patients experienced. If it was good for cancer pain, why not use it for back pain and neck pain? Short acting and long acting morphine-like drugs were developed and a new approach to pain control became the standard of care. Use morphine and other related drugs, such as oxycodone, Oxycontin, Dilaudid, and hydrocodone, and if the patient has more pain, raise the dose of pain medication.

Although overdose could interfere with breathing and cause death, the most troublesome side effect with careful use was thought to be constipation. Other adverse effects of these medications began to be observed, such as addiction and opioid-induced hyperalgesia (when the morphine-like pain medication actually causes more pain).

In addition, people who had been using mind-altering drugs like heroin recognized that they could get the same effect from prescribed medications, which could be cleaner and cheaper. The illicit use of prescription pain drugs is a growing problem in the USA, and are actually the preferred street drug after marijuana.

At NMPI, we only use prescription drugs like oxycodone, Oxycontin, Dilaudid, and hydrocodone to relieve severe pain when patients are unresponsive to our usual therapies. We take a holistic approach to the treatment of pain. Our treatments include:

Exercises
Muscle/tendon injections (no cortisone or any other steroids are ever injected into the muscle tissue)
Low-level laser therapy, which can aide in the healing of damaged muscle tissue and sensitized fibers found in the muscle attachments.
Traditional and novel medications, relaxation therapy, and counseling

In the next few blogs, I will discuss the problems arising with prescription drugs for pain relief and what steps are being taken to try to manage this problem.

Tennis Elbow Causing You Pain? PRP is NOT the Solution Study Shows

Friday, July 18th, 2014 at 2:31 PM

At NMPI, we frequently see patients in our office with pain in their elbow. Most often it’s tennis players who complain of persistent pain in the forearm as the result of overuse from racquet sports but other sports and non-athletic activities can also put you at risk for this condition known as Tennis Elbow (TE), or lateral epicondylitis. Strain related changes in the tendons that join the forearm muscles to the outside of the elbow can be very painful.

I was not surprised to read in the British Journal of Sports Medicine, that a recent study (Strong Evidence Against Platelet-rich Plasma Injections for Chronic Lateral Epicondylar Tendinopathy: A Systematic Review) reported that PRP, which I recently reported as not being effective for hamstring injuries, is now found to be ineffective for persistent Tennis Elbow as well. PRP has been increasingly used for many painful conditions that athletes experience. This is based on the finding that in laboratory animals healing can be induced in damaged tissue if platelets are injected into the injured area. The popularity of PRP for TE has grown despite no strong evidence that it actually works. Sir William Osler, a renowned physician once said “use every new treatment as quickly as possible before it stops working.” At NMPI, we do not rush to use a “new” approach just because it is new. We are committed to eliminating our patients’ pain and preventing its recurrence.

TE is commonly diagnosed by producing pain when pressing on the tendons that attach to the lateral epicondyle along with pain when the wrist is pulled upward (dorsiflexion) against resistance. TE is generally self-limiting but in some patients it may take more than a year to get better with no treatment. When the pain and tenderness persist various treatments have been tried.

Here’s what works:

In a 2010 paper, an exercise treatment was found to be very effective in relieving TE pain and tenderness.
At NMPI, we treat these tender muscles successfully with a laser or with muscle injections.

Here’s what doesn’t work:

Steroids are not recommended since there is no inflammation in TE and steroids can actually damage the tendon.
PRP for tennis elbow has been found to not be effective

Newer treatments are often not better. It is always best to first treat any lasting pain problem with the least invasive, safest, and least expensive interventions. This is called the step-care model and the approach you will receive at the Norman Marcus Pain Institute.

Platelet Rich Plasma Injections (PRP) are not effective for Hamstring injuries

Tuesday, July 15th, 2014 at 3:43 PM

PRP injections have become a frequently used treatment for painful muscle and tendon injuries despite there being no rigorous studies of its effectiveness[1]. PRP involves the drawing of blood from the injured patient, spinning it down to collect the platelets and then injecting the platelets into the injured tissue. The rationale is that platelets will provide growth factors that will make you heal faster.

A study[2] reported on in a letter to the New England Journal of Medicine found that athletes with hamstring injuries recovered no better with PRP than with placebo (a salt water injection). In a randomized double blind controlled study (RCT), in which 80 recreational and professional athletes with hamstring injuries received either PRP or placebo injections, there was no difference in the average amount of time it took for each group to return to normal activities. In other words, in this study, injections with salt water were as effective as the $1600 injection of platelets. It is often difficult to treat pain related to muscles and tendons. For anyone in pain, a suggested treatment that can get you better faster and is offered by respected physicians is hard to resist. The problem is that without carefully studying a new procedure, compared to a similar control treatment, it is not possible to be sure that the new treatment actually works better. This first RCT of PRP for hamstring injuries suggests that it may not be a reasonable approach to painful muscle injuries.

If the assessme Fusion x64 TIFF File nt of muscle pain was a routine part of the physical examination, time, money and suffering could be minimized. At the Norman Marcus Pain Institute, our approach to painful muscles following injury is based on the work of my mentor, Hans Kraus, M.D., President JFK’s physician for the treatment of his back pain. Painful muscles are frequently the result of tension, weakness, stiffness, spasm or altered muscle tissue (usually referred to as trigger points).

At the Norman Marcus Pain Institute, our physical examination tests for all these causes of pain so that the simplest cost effective treatments can be provided prior to using any invasive procedures. Sometimes severe pain is quickly eliminated with our exercise, electrical stimulation and laser protocols that are described in detail in my book End Back Pain Forever. Your pain may require medication and injections, because one size does not fit all.

[1] Moraes VY, Lenza M, Tamoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2013.

[2] Reurink G, Goudswaard GJ, et al. Platelet-Rich Plasma Injections in Acute Muscle Injury. N Engl J Med. 2014:370:2546-2547.

Epidural steroids are not effective for spinal stenosis

Thursday, July 10th, 2014 at 1:44 PM

I have been suggesting for many years that there is an overuse of spinal injections and surgeries for low back and leg pain, so it was no surprise when I read an article in The New York Times (NYT) that reported on a study recently published in the New England Journal of Medicine[1] about patients with spinal stenosis who are frequently treated with a procedure that has been shown to be ineffective. Epidural steroid and lidocaine injections for patients found to have spinal stenosis were no better than epidural injections of lidocaine alone. In chapter 4 of my book End Back Pain Forever I discuss the many reasons for back pain. MRIs and CT scans of the low back will almost always find something such as spinal stenosis or a degenerated or herniated disc even in patients without pain. Therefore the US Institute of Medicine suggests that these imaging studies should not be done routinely since what you find in the study is frequently not the cause of your pain. The most common cause of back pain is muscles and other soft tissue. If you treat the diagnosis you got from the MRI or CT and the actual reason for the pain is muscle, it makes sense that the treatment will frequently fail, which it does!

The NYT report of this relatively large, randomized, double blind, controlled study clearly demonstrates the ineffectiveness of the use of steroids for symptoms attributable to spinal stenosis (narrowing of the canal in the spine which contains the spinal cord) which occurs frequently as we age. The treatments most often provided are epidural steroids to theoretically reduce the inflammation of the nerves being squeezed by the narrow canal, and surgery to widen the canal. Both approaches have a significant failure rate.

At the Norman Marcus Pain Institute we have shown in multiple published articles that one reason why these approaches are ineffective is that the pain in the back and leg may not be the result of the narrowing or other supposed abnormalities seen on the MRI or CT scan. It is well known that very few (in one published article- less than 10%) scans of the low back in adults are read as normal; as many as 40% of adults with no back pain have herniated discs, and 70% have degenerated discs. So it is “normal” to find an abnormality.

Our unique physical examination, utilizes an instrument I developed, reveals that many patients with back and leg pains have areas of muscle tenderness that are the source of their pain yet are overlooked. One study of more than 23,000 patients[2] found that 70-80% of patients with back pain were diagnosed with sprains and strains of muscle and other soft tissue. It’s hard to believe then, armed with this knowledge, that muscle examination and treatment is not part of the typical standard of care for back pain in the USA[3]. If we are to properly address the cause of most back pain, the evaluation and treatment of its muscular causes must be addressed.

[1] Friedly JL, Comstock BA, Turner JA, et al. A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis. New England Journal of Medicine. 2014:374:11-21.

[2] Deyo RA, Weinstein JN. Primary care – low back pain. New England Journal of Medicine. 2001:5:363-70.

[3] Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

Sometimes the pain isn’t coming from where you think

Monday, June 16th, 2014 at 9:30 AM

I recently saw Fred, a 30 year old male, who complained of significant neck pain and shoulder pain. The pain on his left side was much greater than on the right. He tried several chiropractic treatments, massage, physical therapy, acupuncture, and exercises without relief of his pain.

When I first examined Fred, I found two muscles that were painful, his anterior and medial scalenes on both sides. The scalenes are muscles that go from the side of the neck down to the 1st rib as it sits under the clavicle (collarbone). Since he complained mostly of pain on his left neck and shoulder, I injected his left scalenes, followed by 3 days of physical therapy (which included neuromuscular electrical stimulation and gentle, limbering exercises). Fred claimed that the pain on the left subsided, but he noticed that the right side was now more painful. So, the following week, he had his right scalenes treated (with injections into the muscle, followed by 3 days of physical therapy). Fred reported a significant decrease in his overall pain, and reported only soreness at the injection sites.

I followed up with Fred approximately one month later. He reported to me that his overall pain level continued to stay low, but he noticed that when he looked up, he felt tightness on the left side of his neck. When I examined him, I found two muscles to be contributing to his pain, the Serratus Anterior and the Subscapularis. These muscles are in his shoulder. He was very shocked to learn that tightness in his neck was caused by muscles in his shoulder!!

Once these muscles were treated, he reported that the tightness in his neck was released. Sometimes we have to look for muscles contributing to pain in areas other than where you may be feeling it. This is called referred pain. If I had continued to treat muscles in Fred’s neck, he may never have had relief!

Stiffness is an important aspect of muscle pain

Friday, May 30th, 2014 at 1:20 PM

I recently saw George, a 48-year-old man, who suffered from pain, described as soreness in the thighs, neck, shoulders and arms, and tingling in his calves and shin. Sitting for more than two hours or sitting for more than 20 minutes would cause an increase in his pain. Bending over also brought on his pain.

George had tried physical therapy on multiple occasions, and saw two neurologists, who could not find anything that would explain his pain.

When I examined him, I found him to be strong but very stiff. When he bent over, he was able to reach within 14 inches of the floor. When he lied on his back and lifted one leg up at a time, he was able to reach only 57 degrees (85 75 degrees is normal). Because he was so stiff, I decided to start a course of exercises that would help increase his range of motion.

Over the next few weeks, George learned all 21 of the Kraus-Marcus exercises, which he was advised to do every day. As he did the exercises, he noticed that his pain level was decreasing and wasn’t occurring as often as usual. When he was taught the last 7 exercises, he was able to bend over to within 9 inches of the floor, and could lift each leg to 80 degrees.

A month later, George reports a 90% decrease in his overall pain. Sometimes we find that starting with the most conservative of treatments can prevent us from performing more costly and dangerous treatments. Very often, stiffness is an important aspect of one’s pain that can easily be found and treated!

Low Level Laser Therapy as promising treatment

Monday, April 21st, 2014 at 9:10 AM

Low level laser therapy (LLLT) is a promising new treatment for a variety of painful conditions which is believed to reduce inflammation and stimulate healing of wounds. Interest in the laser first developed when Endre Mester at Semmelweis University noticed that applying the laser to the backs of shaven mice caused hair to regrow faster than those who did not receive laser treatment.[1] This observation prompted further study into the regenerative effects of the laser first in rats, and then later in humans.

Currently, there aren’t many large-scale studies evaluating the effectiveness of the laser, but smaller studies of the laser for painful conditions show promising results.

A study of 50 patients with knee osteoarthritis reported that the laser was significantly more effective at providing pain relief than transcutaneous electric nerve stimulation (TENS)**.[2] Similarly, a separate study of 125 patients with knee osteoarthritis reported both an improvement in pain and an increase in function after LLLT.[3]

In a study of patients with temporomandibular disorders, the laser improved pain within 24 hours, with relief lasting at the 180 day follow-up.[4]

Current studies show that the laser is an up and coming, non-invasive, non-painful treatment option, but larger studies are needed to determine the correct dosing, and for which conditions the laser will be most useful.

**TENS (transcutaneous electrical stimulation) – electrodes are applied to the skin, sending an electric current to the nerves in the skin. The nerves then transmit a signal to the brain. This signal is competing with the signal coming from your painful area. So, instead of feeling your normal pain, you’ll feel a buzzing sensation where the electrodes are attached.

[1] Chung, Hoon, Tianhong Dai, Sulbha K. Sharma, Ying-Ying Huang, James D. Carroll, and Michael R. Hamblin. “The Nuts and Bolts of Low-level Laser (Light) Therapy.” Annals of Biomedical Engineering 40.2 (2012): 516-33. Print.

[2] Kędzierski, Tomasz, Katarzyna Stańczak, Kamila Gworys, Jowita Gasztych, Marcin Sibiński, and Jolanta Kujawa. “Comparative Evaluation of the Direct Analgesic Efficacy of Selected Physiotherapeutic Methods in Subjects with Knee Joint Degenerative Disease – Preliminary Report.” Ortopedia Traumatologia Rehabilitacja 14.6 (2012): 1-10. Print.

[3] Gworys, Kamila, Jowita Gasztych, Anna Puzder, Przemysław Gworys, and Jolanta Kujawa. “Influence of Various Laser Therapy Methods on Knee Joint Pain and Function in Patients with Knee Osteoarthritis.” Ortopedia Traumatologia Rehabilitacja 14.3 (2012): 269-77. Print.

[4] Pereira, T. S., O. D. Flecha, R. C. Guimaraes, A. M. Botelho, JC Ramos Gloria, and K. T. Aguiar Tavano. “Efficacy of Red and Infrared Lasers in Treatment of Temporomandibular Disorders–a Double-blind, Randomized, Parallel Clinical Trial.” Cranio : The Journal of Craniomandibular Practice 32.1 (2014): n. pag. Ovid. Web.

Small changes may make a big difference to your neck pain

Wednesday, April 2nd, 2014 at 2:36 PM

There has been an increase in the number of hours we sit in front of a computer for leisure and work. Does your job require you to stare at a computer for hours at a time? One study found that workers sitting for 95% of the day, and/or worked with their neck at 20˚ or more in flexion for more than 70% of their working time, had a significantly increased risk of neck pain [1].

An ergonomically designed workstation would help reduce the strain on your muscles. Here are a few suggestions:

Place your monitor so you are looking at it straight ahead or down at no more than a 15˚ angle.
The monitor should be 18-24 inches away.
The angle of your elbows when typing on the keyboard should be > 90 degrees.
An ergonomic mouse or keyboard may also help.
A laptop is always non-ergonomic; because the monitor and keyboard cannot be separated one or the other is in the wrong position. If you always use a laptop think about getting an auxiliary keyboard.
Footrests should be used if your feet do not rest flat on the floor.
If you use a phone frequently get a headset so you will not have to hold the handset to your ear.

Aside from these changes, you may also consider doing limbering activities such as small stretches throughout the day – shrug your shoulders a few times, move your arms above your head, or get up and walk around your chair.

[1] Ariens, G. AM, P. M. Bongers, M. Douwes, M. C. Miedema, W. E. Hoogendoorn, G. Van Der Wal, L. M. Bouter, and W. Van Mechelen. “Are Neck Flexion, Neck Rotation, and Sitting at Work Risk Factors for Neck Pain? Results of a Prospective Cohort Study.” Occupational and Environmental Medicine 58 (2001): 200-07. BMJ Group. Web.

How antidepressant medication can affect your pain

Wednesday, March 26th, 2014 at 10:36 AM

Many patients with chronic pain become depressed; therefore it is not surprising that many of these patients will receive antidepressant medications. What is very interesting is that these antidepressants not only can decrease depression associated with pain, but they can also decrease pain itself. They are frequently used to treat persistent pain associated with problems in nerves. The reason that antidepressants are effective for pain is that the chemicals in the nervous system that are associated with depression also are associated with pain.

Antidepressants increase the available amounts of chemicals which affect your mood. These chemicals include serotonin, norepinephrine, and dopamine. The two most common types of antidepressants are:

SSRIs (Serotonin Specific Reuptake Inhibitors) – Antidepressants which only increases the amount of serotonin available. Examples of SSRIs are escitalopram (Lexapro), fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft).
SNRIs (Serotonin/Norepinephrine Reuptake Inhibitors) – Antidepressants which increase the amount of serotonin and norepinephrine available. Examples of SNRIs are venlafaxine (Effexor) and duloxetine (Cymbalta). Examples of Tricyclic Antidepressants (a type of SNRI) are amitriptyline (Elavil), and nortriptyline (Pamelor).

SSRIs are not as effective for pain relief as SNRIs.

Even though the antidepressants may help diminish pain, their side effects can be unacceptable. A recent review found that although approximately 1/3 of patients who took antidepressants for neuropathic pain experienced moderate pain relief or better, 1/5 discontinued use due to adverse side effects.[1]

Common side effects of antidepressants are nausea, dizziness, insomnia, weight gain/loss, dry mouth and diminished interest in sex (decreased libido). If you’re not having reasonable pain relief with one of these medications, it should not be continued.

[1] Saarto, T., and P. J. Wiffen. “Antidepressants for Neuropathic Pain: A Cochrane Review.” Journal of Neurology, Neurosurgery & Psychiatry 81.12 (2010): 1372-373. Print.

Marijuana and its effect on pain

Wednesday, March 19th, 2014 at 9:00 AM

For the first time ever, the New York State Assembly’s one-house budget proposal included more expansive plans to approve the use of medical marijuana. In a recent poll 88% of New Yorkers felt that medical marijuana should be legalized, and both republican and democrat senators are listening.

In order to make a decision on whether a drug should be available, we look to the science (peer-reviewed research) to help us decide whether the benefits of the drug are worth the risks. Some studies show marijuana is effective for pain relief (especially the neuropathic pain which accompanies disorders like Multiple Sclerosis[1]) and for improving sleep for those with painful disorders.[2] Other studies also found that smoking marijuana helped to increase pain tolerance, with a greater effect observed for those who were not novice users.[3]

In a study in which individuals smoked marijuana cigarettes containing different amounts of THC (one of the active components that is responsible for many of Marijuana’s effects), they found that too small a dose did not provide any analgesic benefit, and too large a dose actually increased pain. In this study, cigarettes containing 4% THC experienced the most pain relief. This suggests that there is an optimal dosage of marijuana to relieve pain.4

Despite the apparent benefits, there are short and long-term adverse effects. Marijuana can cause anxiety and panic, and, at very high doses, psychotic symptoms. Patients using marijuana should not drive while taking it. Long-term users can show signs of dependence and subtle cognitive impairment.[4]

Marijuana may be useful in a variety of painful conditions, but most studies currently available are not large enough to draw useful conclusions. Legalization will allow larger scale studies to be done so that we can be more confident about both the positive and negative effects. Like any other potent drug, it needs to be carefully regulated and only used when appropriate.

Image courtesy of Paul / FreeDigitalPhotos.net

[1] Hosking, R. D., and J. P. Zajicek. “Therapeutic Potential of Cannabis in Pain Medicine.” British Journal of Anaesthesia 101.1 (2008): 59-68. Oxford Journals. 29 May 2008. Web. 14 Mar. 2014.

[2] Rog, David J., Turo J. Nurmikko, Tim Friede, and Carolyn A. Young. “Randomized, Controlled Trial of Cannabis-based Medicine in Central Pain in Multiple Sclerosis.” The Official Journal of the American Acadmey of Neurology 65 (2005): 812-19. Neurology. 27 Sept. 2005. Web.

[3] Milstein, S. L., K. MacCannell, G. Karr, and S. Clark. “Marijuana-produced Changes in Pain Tolerance. Experienced and Non-experienced Subjects.” International Pharmacopsychiatry 10.3 (1975): 177-82. PubMed. Web.

[4] Kondrad, Elin. “Medical Marijuana for Chronic Pain.” North Carolina Medical Journal 74.3 (2013): n. pag. NC Medical Journal. Web.

Antiepileptic medications

Monday, March 17th, 2014 at 9:30 AM

Anti-seizure, or anti-epileptic, medications have commonly been used to treat pain, especially nerve-related pain. Examples include pregabalin (Lyrica), gabapentin (Neurontin), topiramate (Topamax), and carbamazepine (Tegretol/Carbatrol). The exact mechanism in which these medications work is not completely clear. Anti-seizure medications help decrease hyperactivity of the nerves that cause seizures; therefore, it is thought that these medications can have a similar effect with decreasing the activity of the nerves that cause pain.

As with all medications, there are side effects – most common side effects are dizziness, drowsiness, nausea, vomiting, blurred or double vision, and weight gain. Therefore, if you are not having reasonable pain relief with one of these medications, it shouldn’t be continued. It is generally a good idea to stop these medications slowly, since abruptly stopping in someone who is seizure prone could cause a seizure.

NSAIDs for pain relief

Friday, March 14th, 2014 at 9:43 AM

The next series of blogs is a brief discussion of different types of medications used for pain.

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) are generally one of the first line of medications used in the initial treatment of pain. They are exactly what their name means – they are not steroid medications (like cortisone or prednisone) and they reduce inflammation which is the body’s response to any damage from any cause. When inflammation occurs there is pain along with redness, swelling and heat, which are collectively known as the cardinal signs of inflammation. Examples of NSAIDs are ibuprofen (Advil/Motrin), naproxen (Naprosyn), meloxicam (Mobic), and diclofenac (Voltaren). Aspirin is similar to the NSAIDs in almost every way but curiously it helps prevent heart attacks whereas NSAIDs may cause them (see below).

Although NSAIDs have a number of side effects, the two most common are stomach irritation and an increased tendency to bleed. That’s why you are advised to eat when taking NSAIDs and why you have to stop taking NSAIDS before any type of intervention that may cause bleeding (such as injections or surgery). In order to decrease the side effect of stomach irritation, many have switched to a topical NSAID, most commonly diclofenac which is offered as a patch (Flector-patch) or gel (such as diclofenac or Voltaren gel). Other potentially serious side effects include kidney failure – if your kidneys are not working properly the NSAID can cause them to stop functioning, asthmatic episodes if you are prone to having asthma, and heart attacks if you have cardiovascular disease (heart disease, high blood pressure, history of stroke).

Image courtesy of anekoho/FreeDigitalPhotos.net

Case Study: Low Level Laser Therapy

Wednesday, March 12th, 2014 at 10:35 AM

Gregory is a 29 year old manager whose job requires that he travel often. He came to see me for pain at the back of the left side of his neck which he often felt upon waking up, and during or after jogging over the past 4-5 years. An MRI showed that his neck did not have any significant spinal abnormalities that might be causing his pain, but a physical examination revealed three muscles that were likely the source of his pain.

I began treating Gregory with a 15 watt class 4 laser. On his second day of treatment, he reported that he felt no pain in the left side of his neck when he woke up, but that the pain had moved to the right side of the neck and shoulder. I continued treating the left side of his neck, and also began to treat the right side with the laser.

When he returned for the third day of treatment, the pain in the left side of his neck was completely gone, and the right side’s discomfort was significantly reduced. At a two month follow-up, his pain was gone.

He is now able to go jogging without any pain in his shoulders or neck. By starting with a conservative treatment approach, Gregory was able to avoid invasive or costly procedures, and regain function.

Low-Level Laser Therapy

Thursday, February 27th, 2014 at 9:00 AM

One lesser-known but valuable tool for multiple painful conditions is the low-level laser. The laser is a source of extremely pure, organized light, as opposed to something like a regular light bulb, which emits a scattered, disorganized light. We can liken organized light to the sound of a flute playing a single note, and disorganized light to the sound of a stone rolling around in a tin can. The laser is a non-painful treatment option that affects the local (near the area being treated) immune system, blood circulation, and the release of different chemicals that affect how we experience pain.

While it isn’t clear exactly how the laser helps a variety of painful conditions, there are two proposed means by which the laser improves pain:

The light energy (called photons) is absorbed in the injured area and stimulates the production of Cytochrome C. Cytochrome C is a protein involved in cell metabolism and energy. When Cytochrome C is stimulated, it revs up the cell’s metabolism, and gives the cells more energy to heal the injured area.
The light energy from the laser leads to the production of small amounts of singlet oxygen. Singlet oxygen is a reactive form of oxygen, which means that it is very easy for this type of oxygen to take part in chemical reactions. At high doses, singlet oxygen can be destructive, and has been used in cancer treatment to destroy cancerous cells. At very low doses, singlet oxygen can increase the number of cells. This may be one way the laser helps promote tissue repair.

The laser in a non-invasive, non-painful treatment option that can, in some cases, produce results immediately. For pain that has been around for a long time, more than one treatment session is usually needed for best results.

Statins may cause muscle pain

Monday, February 24th, 2014 at 9:30 AM

Do you have or used to have high cholesterol? Statins are a class of drug used to lower the amount of cholesterol produced by the liver. You might recognize some of the more common brands like Lipitor (Atorvastatin Calcium) or Crestor (Rosuvastatin Calcium). They are commonly used for patients with high cholesterol, diabetes, or those with a family history of heart attacks. Recent data shows that approximately 5% of patients maintained on statins experience muscle pain and weakness. Muscle pain is one of the top reasons patients choose to stop taking statins[1]. If you are taking a statin and are experiencing muscle pain or weakness, you may want to talk with your doctor about adjusting your dose or finding an alternative treatment.

[1] Jacobson, Terry A. “Toward “Pain-Free” Statin Prescribing: Clinical Algorithm for Diagnosis and Management of Myalgia.” Mayo Clinic Proceedings 83.6 (2008): 687-700. Science Direct. Web.

Hypothyroidism and muscle pain – are they related?

Wednesday, February 19th, 2014 at 9:30 AM

You can experience muscle pain for many reasons. We discussed trigger points in an earlier blog (see www.normanmarcuspaininstitute.com/what-are-trigger-points/ to recap your memories). A common medical problem, abnormal activity of the thyroid gland, can cause muscle pain.

Hypothyroidism is a condition in which your thyroid gland doesn’t make enough hormone. (Hyperthyroidism, which is not as common, is when the thyroid gland produces too much hormone and that can also produce muscle pain.) When you don’t have enough thyroid hormone, many systems in your body are affected and you may notice the following signs and symptoms:

-brittle nails

-hair loss

-fatigue (feeling tired)

-dry skin

-memory problems

-having trouble thinking clearly

-weight gain

Muscle symptoms associated with hypothyroidism are often described as a cramping, stiffness or weakness.

Hypothyroidism is generally treated with hormone replacement therapy, which means you’re taking synthetic (man-made) hormones to replace the ones that the body isn’t producing. In one study, almost 20% of patients complained of joint and/or muscle pain, of which 50% had relief in symptoms after starting thyroid replacement therapy[1].

So if you have been diagnosed with hypothyroidism or have symptoms of hypothyroidism and also complain of muscle pain, it’s very possible that the two are related. Ask your doctor to check it out.

[1] Carette, S., Lefrancois, L. Fibrositis and primary hypothyroidism. J Rheumatol. 1988; 15(9):1418-21.

Treating trigger points in muscles

Monday, February 17th, 2014 at 9:30 AM

The most common method in treating trigger points is with trigger point injections. Simply put, trigger point injections are needles being placed into the taut, tender points of the muscle. However, there are different techniques in injecting the muscle fibers.

There are two major types of needles used in injecting the muscle. With dry needling, it is common to use acupuncture needles[1], which are small, thin and flexible. When a liquid is injected in the muscle (such as saline or lidocaine), hypodermic needles are used, which is a hollow needle that is generally thicker and is not flexible.

Different fluids (injectates) can be used in trigger point injections. Lidocaine or bupivacaine are commonly used, which are numbing agents. Corticosteroids and botulinum toxin (better known as Botox) are also used, in hopes that the injectate would reverse the changes in the trigger point rather than just the needle causing minor damage and inflammation which is thought to lead to regrowth of normal muscle fibers. Still others have used saline. Studies have shown that it didn’t matter what was injected into the muscle[2]; there was not a noticeable difference in pain relief between the different injected substances. Also, dry needling injections seem to be just as effective as injections with any substance, suggesting that what is injected is not what causes relief but rather the physical needling of the muscle.

Other treatments used for trigger points include:

-TENS (transcutaneous electrical stimulation) – electrodes are applied to the skin, sending an electric current to the nerves in the skin. The nerves then transmit a signal to the brain. This signal is competing with the signal coming from your painful area. So, instead of feeling your normal pain, you’ll feel a buzzing sensation where the electrodes are attached.

-“spray and stretch” – a technique in which ethyl chloride spray (or a comparable cold) is used to numb a painful area, followed by gentle stretching

-ultrasound

-low level laser

The fact that so many different approaches claim to be effective indicates that there is confusion concerning the understanding and treatment of pain thought to be coming from trigger points. All muscle pain is not caused by trigger points. My associates and I discuss the need for a comprehensive approach to muscle pain in a study published in Pain Medicine[3]. (This article can be accessed here.

[1] Mense, Siegfried, and Robert Gerwin. Muscle Pain: Diagnosis and Treatment. Heidelberg: Springer, 2010

[2] Cummings, T.Michael, and Adrian R. White. “Needling Therapies in the Management of Myofascial Trigger Point Pain: A Systematic Review.” Archives of Physical Medicine and Rehabilitation 82.7 (2001): 986-92.

[3] Marcus, Norman J., Edward J. Gracely, and Kelly O. Keefe. “A Comprehensive Protocol to Diagnose and Treat Pain of Muscular Origin May Successfully and Reliably Decrease or Eliminate Pain in a Chronic Pain Population.” Pain Medicine 11.1 (2010): 25-34.

What are trigger points?

Wednesday, February 12th, 2014 at 9:39 AM

Have you ever felt a painful tightness that just won’t go away no matter how much you stretch? Even if the pain subsides or goes away temporarily, when it recurs you still feel a tender knot that’s always in the same area. This may be due to trigger points (TrPs). TrPs are tender nodules which can cause pain and are found in a taut band of muscle tissue. This taut band is formed from a small group of contracted muscle fibers which will make that region of your muscle feel hard and tender. TrPs are sensitive to pressure and movement. Pressing on a trigger point will cause pain.

TrPs can be classified as either active or latent. A latent TrP is one that causes pain when palpated, or pressed on, but not spontaneously while resting. An active TrP can cause spontaneous pain – either at rest, in use, or while being pressed. If there is enough stress – for example, from too much exercise, a latent TrP can transform into an active TrP.

The cause of TrPs is still being studied, however, there is speculation that the taut band appears in the muscle first without any tenderness or irritation. With additional stress, the hardened area becomes tender to the touch (a latent TrP), and finally, may progress to producing spontaneous pain as an active TrP. The initial hardness in a band of muscle fibers can be caused my multiple factors: injury, overstretching, or over-exercising.

TrPs can be a debilitating source of pain. They can cause weakness and lack of coordination in the muscles where they are found. Next blog, we will discuss common treatment options for trigger points.

One way in which muscles can cause pain

Monday, February 10th, 2014 at 9:29 AM

Nerves connect muscles to the spinal cord. When something stimulates your muscles, for example, if someone were to press on your arm, the muscle sends a message via the nerves first into the spinal cord, and then up to the brain. Once the brain receives the message (in this case, that there is pressure on your arm), then your body is able to perceive sensation. This all happens in a split second, so that your brain receives the message immediately after the stimulus appears. When the sensation is strong enough it no longer feels like pressure or a simple touch; it is experienced, rather, as pain. Once the brain processes the message, then you become aware of pain in your muscle.

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How we perceive pain – nociceptors

Wednesday, February 5th, 2014 at 10:34 AM

We generally don’t think of muscles as a cause of pain. Sure, we know that after exercise or playing ball we can have muscle soreness, but when pain persists we often think it is coming from nerves, joints or the spine. Believe it or not, muscles (and other soft tissue) are the most common reason for pains such as lower back pain, neck pain and shoulder pain. The brain gets information from the body about pain from specialized nerves called nociceptors that respond to tissue damage. Trauma, overwork, and over-exercising cause low oxygen and too much acidity in the muscle. These changes, along with other chemicals that are produced when the muscle is damaged in any way, stimulate the nociceptor. When a stimulus as strong enough it causes the nerve cell to produce an electrical impulse that is sent into the spinal cord and then up to the cortex, the part of the brain where we perceive pain.

There are actually more nociceptors in the muscle attachment sites (the ends of the muscle where it attaches to the tendon and the tendon attaches to the bone) than in the muscle tissue. That is why if you have pain originating in muscles you may be more aware of the pain close to a bone than in the middle of the muscle.

Any kind of injury releases substances from damaged muscle and surrounding tissue that stimulates the nociceptor. If the nociceptor gets enough stimulation it creates an electrical discharge which travels down the nerve and ends up in the spinal cord. Muscle nerves that have been stimulated repeatedly become more sensitive to additional stimulation. They are called sensitized nerves and they will more easily produce electrical activity with even non painful events such as any contraction to move the muscle. That is why when an injured muscle is used it may cause pain. That is why if you have strained muscles for any reason you may feel pain from every day movement. Nociceptors are key structures in the perception of pain.

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