Category: Adam Sewell MD

MOTOR VEHICLE INJURIES

A migraine is characterized by intense, throbbing pain, that is often experienced at the temples, the front or back of one or both sides of the head, and there is sometimes eye involvement. Women are far more likely to experience migraines, but they are found in any gender and all age groups. One culture or ethnicity is not more likely to experience them than any other.

The severe pain, and associated neurological symptoms, are often described as debilitating with migraines. The head pain may be either unilateral (one-sided) or bilateral (both sides), and the entire experience usually lasts from one-to-four hours. Sometimes, however, a migraine can linger for several days, or return several times a week as a “chronic migraine”. With some migraines, there is nausea and vomiting.

Migraines are categorized as “Classical” and “Common.”
The Classical Migraine produces one-sided pain, and many people see an aura about 30 minutes to an hour before a migraine. Auras can include flickering lights or other visual disturbances. In a common migraine the pain is felt on both sides of the head, and there are, typically, no visual disturbances. Some other sensory manifestations include: smells, blurry vision, numbness or tingling in the face, unsteadiness and weakness.

Although the exact cause of migraines is unknown, it’s thought to be a combination of environment and genetics. Some common environmental triggers are: bright lights, loud noises, certain foods (chocolate, peanut butter, avocado, banana, citrus, dairy products, and fermented/ pickled foods, MSG), alcohol drinks (red wine), certain medications (birth control pills), menstrual cycle fluctuations, exertion activities; as well as mental health disorders, such as depression.

Mechanism

In the past, it was believed that blood vessel changes caused migraines. However, recent research reveals that migraines aren’t just caused by blood vessel changes in the brain, but also, the various brain nerve pathways and neurotransmitters. Migraines are thought to have a genetic link or predisposition, as they often run in families. The theory is those with a family history of Migraines, may have a gene that predisposes them to migraine HA’s (2007 Goadsby).

Diagnosis

Severe headaches are one of the most common reasons people visit an emergency room or see a physician. However, because most headaches are chronic in nature, it is important to seek your general practitioner’s advice in managing headache symptoms. Additionally, most headaches, even severe migraines, are not dangerous or life threatening. There are some instances where headaches are associated with other diseases or conditions, so it is important to always seek treatment for a headache that does not go away or that is sudden and severe or described as “the worst headache of your life”.

There are many medical conditions that cause secondary headaches. A physician evaluation is critical to determine an accurate diagnosis of any chronic headache conditions.

Some of the more serious conditions that require immediate medical attention are: intracranial hemorrhages/ hematomas, meningeal infections (viral, bacterial, and fungal), strokes, and malignant hypertension. Again, if there seems to be anything unusual about the headache(s) that you are experiencing, seeking medical attention is of utmost importance. In order to accurately find the source of a headache, a physician may order a series of tests and studies including: radiological scans (MRI, CT), neurological exam, blood work, or an eye/vision assessment.

Treatment

There are two pharmacological treatment categories for primary headaches, and are classified as “abortive” or “preventive.”

Abortive therapy

Abortive therapy’s goal is to stop head pain immediately. These medicines may provide pain relief; but they don’t promise a decrease frequency or intensity, and they will not prevent reoccurrences of pain. In addition, the effectiveness varies from person to person, and depending on the cause and type of headache, these medications may not work for some people at all. Over-the-counter medications don’t usually work for cluster headaches, and they only work for some people with certain kinds of migraines. Also, they rarely effects cases of intense head pain.

Common abortive therapies for Primary HA’s:

Oxygen – most commonly used for a Cluster HA.
Ergots
Triptans
NSAID’s
Anti-emetics
Opiates
Butalbital with aspirin or acetaminophen

Many patients have pain relief with abortive treatments, but there is serious concern about overuse and medication dependency, especially when the medications cause secondary concerns. In May 2007, the National Neurological Institute in Milan Italy published an article stating “Most patients with frequent headaches eventually overuse their medications, and when this happens, the diagnosis of medication-overuse headache is clinically important, because patients rarely respond to preventive medications whilst overusing acute medications” (2007 Grazzi).

Additionally, overuse of abortive headache medications, may eventually cause a resistance to such medications in the future. This can cause the attacks to become more frequent and severe.

Preventive therapy

Preventive therapies are directed at reducing frequency and severity of headaches. Most of these medications don’t work to alleviate acute pain symptoms. As a result, they are often used in conjunction with abortive therapy medications.

Some common preventive medications for headaches:

Cardiovascular drugs (Beta blockers, Calcium channel blockers)
Antiseizure medications
Antihistamines
Antidepressants

Antidepressant medications may help where there is a relationship between a Depression/Anxiety Disorder or sleep disturbance and migraines.

Addressing both the physical and mental health of a patient who experiences chronic headaches, will improve their quality of life and headache symptoms (2007 Frediani F). Mental health disorder treatments can be both medication and/or behavioral therapy.

Another aspect of successful headache treatments, are behavioral interventions and modifications. Behavioral modifications, include: biofeedback training, mind and body relaxation (yoga, acupuncture, massage), and cognitive behavior therapy. All of these treatments have proven quite successful for migraine prevention (2006 Holroyd).

Behavioral and supplemental treatment options:

Acupuncture
Cognitive Behavioral Therapy
Group Therapy
Massage
Exercise and Nutrition Counseling, Vitamin Supplements
Prayer
Biofeedback
Chiropractic Manipulations
Hormone Supplements

Recent studies have proven the effectiveness of Botulinum A toxin (Botox) injections as a migraine treatment option. Some of those who have received Botox injections for facial wrinkles, also, noted headache relief. The Botox injection is offered in the same area for headaches, as it is for wrinkles in cosmetic procedures.

In 2007, The Chicago Medical School at Rosalind Franklin University of Medicine and Science, compared the efficacy of Botox for migraines and tension headaches and reported positive findings using Botox as a headache treatment (2007 Freitag).

A 2006 publication stated that 75% of patients who received Botox injections for the preventative migraine treatments, reported eventual compete pain relief from headaches. No adverse effects have been reported, as “Botox (BTX-A) showed good efficacy and tolerability as a prophylactic agent” (2006 Anand). Trained pain physicians can safely offer Botox injections as a migraine treatment option.

Proven treatment options for reducing migraine frequency:

Botox Injections
Occipital Nerve Stimulation
Cervical Facet Injections
Cervical Epidural Steroid Injections
Sphenopalatine Nerve Blocks
Occipital Nerve Blocks
Supratrochlear Nerve Blocks
Supra/ Infraorbital Nerve Blocks

There has been a tremendous amount of research on the effectiveness of treatments for headache relief, and research has, generally, shown that conventional and conservative therapies are often not effective in treating the associated facial pain and peripheral/ central desensitization. Both are common in migraines.

One migraine study, conducted by the Department of Anesthesiology, Intensive Care and Pain Management in Italy reported, 85% of patients responded favorably to supraorbital and greater occipital nerves blocks (1997 Caputi).

Transnasal sphenopalatine ganglion (SPG) block injections can be helpful for migraines as well. .

The combinations of therapies above have been proven to reduce painful symptoms for all types of headaches.

Headache Journal

Lastly, a headache journal can be a helpful way to monitor headache triggers and symptoms and can be an excellent personal resource that you can share with your physician. Often, just realizing the environmental or physical triggers of your headaches, can have tremendously positive results and give you a sense of control over the pain you are experiencing. It can be a written record of detailed symptoms and notes on food, sleep routines and other important information, revealing possible headache triggers. Additionally, pain management can be noted. What treatments work? Which ones don’t? These things can all be recorded in your headache journal.

For more information or questions about headaches, treatments, and other items mentioned, please see your pain physician.

Resources/Journal Articles

Adam Sewell MD

MIGRAINES HEADACHES

Mechanism

Diagnosis

There are many medical conditions that cause secondary headaches. A physician evaluation is critical to determine an accurate diagnosis of any chronic headache conditions.

Treatment

There are two pharmacological treatment categories for primary headaches, and are classified as “abortive” or “preventive.”

Abortive therapy

Common abortive therapies for Primary HA’s:

Oxygen – most commonly used for a Cluster HA.
Ergots
Triptans
NSAID’s
Anti-emetics
Opiates
Butalbital with aspirin or acetaminophen

Additionally, overuse of abortive headache medications, may eventually cause a resistance to such medications in the future. This can cause the attacks to become more frequent and severe.

Preventive therapy

Some common preventive medications for headaches:

Cardiovascular drugs (Beta blockers, Calcium channel blockers)
Antiseizure medications
Antihistamines
Antidepressants

Antidepressant medications may help where there is a relationship between a Depression/Anxiety Disorder or sleep disturbance and migraines.

Behavioral and supplemental treatment options:

Acupuncture
Cognitive Behavioral Therapy
Group Therapy
Massage
Exercise and Nutrition Counseling, Vitamin Supplements
Prayer
Biofeedback
Chiropractic Manipulations
Hormone Supplements

Proven treatment options for reducing migraine frequency:

Botox Injections
Occipital Nerve Stimulation
Cervical Facet Injections
Cervical Epidural Steroid Injections
Sphenopalatine Nerve Blocks
Occipital Nerve Blocks
Supratrochlear Nerve Blocks
Supra/ Infraorbital Nerve Blocks

Transnasal sphenopalatine ganglion (SPG) block injections can be helpful for migraines as well. .

The combinations of therapies above have been proven to reduce painful symptoms for all types of headaches.

Headache Journal

For more information or questions about headaches, treatments, and other items mentioned, please see your pain physician.

Resources/Journal Articles

Adam Sewell MD

LOW BACK PAIN

Low back pain (LBP) is a common and frequent complaint. Pain may be either acute or chronic and can be due to injury, trauma, overuse, or from lifting heavy objects. If the inflammation or irritation results in significant damage to the back structures, the pain result in a chronic pain disorder. Structural damage to the lower back (lumbar spine) may include injury to the vertebrae, facet joints, vertebral discs, vertebral ligaments, lower back muscles, spinal cord and peripheral nerves, as well as internal organs in the pelvis (spleen, kidney, pancreas, and liver). Most of the time, LBP is acute and resolves within four weeks, however, depending on the pain cause. LBP can be a recurring condition and is very common among the American population.

Though unlikely, there are serious conditions that cause back pain as well. Seek medical attention if your back pain is severe and is accompanied by a high fever.

Back Anatomy

Bony Structures

The bony structures of the back, the vertebrae, connect together. At the top and bottom of each vertebra are facet joints, connection points, for the vertebrae to attach to one another. The five lumbar spine vertebrae provide a flexible, movable support structure, which also protects the spinal cord.

Spinal bone conditions that can cause chronic LBP include:

Facet Joint Osteoarthritis
Spinal Stenosis(narrowing of the spinal canal)
Vertebral Body Fractures
Osteoporosis
Spondylolisthesis
Neoplasms (Primary vs. metastatic lesions)
Infections

Disc Conditions that can produce chronic LBP include:

Degenerative Disc Disease
Disc Protrusion
Disc Herniation
Disc Extrusion
Facet Joint Osteoarthritis
Spinal Stenosis(narrowing of the spinal canal)
Sciatica(Nerve Root Irritation or Compression)
Disc Infection.

Spinal Ligaments and Muscles

There are three major spinal ligaments that attach, support and protect each vertebra. The many muscles, also, provide the same support and are responsible for movement. The spine has a complex spinal nerve system. Each nerve has two roots attached to the spinal cord. They exit the spine to innervate the skin, muscles, and surrounding structures of the back and lower extremities (legs and feet).

Spinal ligaments and muscles have a tendency to become strained from excessive lifting, exercise, or improper body mechanics. This can cause local nerve irritation, resulting in LBP, and myofascial (muscle and connective tissue) and ligament injury account for the majority of this kind of back pain.

Conditions that can produce chronic pain from ligaments and musculature include:

Myofascial Pain Syndrome
Muscular Strain
Torn Muscle
Ligamentous Strain
Ligamentous Tear

Referred pain

Referred pain is any pain that has its source in one area but is felt in a completely different location in the body. Organs in the abdomen and pelvis can cause referred back pain. Specifically, the kidney, pancreas, spleen, and liver are known to cause LBP due to: enlargement, infection, inflammation, obstruction, decreased blood supply and sometimes cancer. All the nerves in the body connect to the spine and may travel into the spinal cord at the same level as other structures in the lower back. This can cause pain perception in the back, instead of the organs.

Pathology

Common causes of LBP include: Herniated Discs, Spinal Stenosis, Strained Muscles Sciatica, Arthritis (auto-immune vs. non-auto-immune), Fibromyalgia, Vertebral Body Fractures, and Osteoporosis. Far less common causes are infections, Ankylosing Spondylitis, Psychological causes and Metastatic Cancer. There are several different risk factors for malignancy (cancer), but some are: an age greater than 50, pain not improved by lying down, symptoms worsen at night, and pain for longer than four weeks.

Acute Lower-Back Pain

Acute LBP comes on quickly, and occurs either during or after, a specific activity. This kind of injury is often caused by overuse, excessive exercise, heavy lifting, sports injuries, motor vehicle accidents, or any trauma to the lower back. Acute pain of this kind is usually the result of inflammation from strain or sprain to muscles and surrounding ligaments. Acute pain from ligament and muscle irritation responds well to anti-inflammatory drugs (Ibuprofen).

Vertebral body fractures, ruptured discs, and spinal cord compressions can also cause acute pain. This is, especially, true if there are pre-existing conditions, like osteoporosis, cancer, or spinal stenosis.

Acute back pain should be evaluated by a physician to rule out other causes like: kidney stones, kidney infection, and acute pancreatitis. In some cases of acute back pain, a specialist and proper imaging is required for immediate evaluation.

These causes and symptoms might include:

Acute Vertebral Compression Fractures
Acute Disc Herniation
Fever/Chills
Weakness or Paralysis
Loss of Bowel or Bladder Control
Spinal Cord Compression

Chronic Lower Back Pain

Chronic LBP is any persistent pain that lasts, at least, three months. Usually this kind of pain manifests gradually and worsens over time. A person with chronic LBP may experience additional pain down either leg. This is called sciatica.

Causes of chronic LBP are numerous and include:

Arthritis, Facet Joint
Sacroiliac Joint Disease
Spinal Stenosis (narrowing of the spinal canal)
Fibromyalgia
Degenerative Disc Disease
Disc Protrusion
Disc Herniation
Disc Extrusion
Facet Joint Osteoarthritis
Nerve Root Irritation or Compression (Sciatica)
Central Sensitization
Excessive Breast Size
Poor Posture
Psychological and Emotional Factors
Vertebral Body Fractures
Osteoporosis
Spondylolisthesis
Ankylosing Spondylitis
Neoplasms
Infections

Central Sensitization is common with any chronic pain syndrome and involves, both, the peripheral nervous system (PNS) and the central nervous system (CNS). Tissue injury and inflammation activate the PNS, which sends pain signals through the spinal cord to the brain.

Central sensitization is when neuron over-activity occurs within the CNS, (brain and spinal cord). Normal responses from the PNS begin to produce abnormally high responses, so that a sensory reaction that once normally produced a harmless normal sensation, now produces significant pain. This is often seen in patients suffering from chronic LBP.

Sacroiliac Joint (SIJ) Disease

SIJ is another chronic pain cause that is centered in the sacroiliac joint disease. Many strong ligaments and muscles support these joints, which are located on both sides of the lower back. The main function of these joints is for weight support and weight transfer, which makes them susceptible to injury.

The SIJ is innervated by multiple nerves and spinal nerve roots, and inflammation in this joint causes severe pain. SIJ pain can worsen with prolonged sitting, twisting motions, or other sudden movements. The pain often starts spontaneously; or as the result of specific injury or trauma.

Conservative treatment options, such as anti-inflammatory drugs and physical therapy, are often effective. A 2007 report found that the effectiveness of a lidocaine injection into the SIJ resulted in a 96% pain improvement in patients with SIJ (2007 Murakami).

Diagnosis

Making a LBP diagnosis can be difficult, because so many different conditions can cause similar symptoms. After a physical exam and detailed history, he or she will most likely order one or more visual tests, like, an X-ray, Computerized tomography (CT) scan, Magnetic resonance imaging (MRI) or Bone scan. All of these depend on clinical suspicions and findings during the exam.

Treatment Options

Spinal bone conditions

A 2007 report stated that lumbar facet joint nerve blocks, with local anesthetics, may be effective for treating chronic lower back pain, especially, of facet joint origin. Physical therapy, cognitive behavioral therapy, biofeedback, diet and exercise have also proven to be effective (Manchikanti 2007).

Procedures like, facet injections/denervation, vertebroplasty, SI joint injection/denervation, lysis of adhesions, spinal cord stimulation, intrathecal pumps and other treatments may provide pain relief for many spinal bone conditions.

Disc treatments

Facet injections, epidural steroid injections, lysis of adhesions, epidural infusions, spinal cord stimulation, intrathecal pumps and other treatments can be a beneficial pain management option for many disc injuries and conditions.

Spinal Ligaments and Muscles treatments

Trigger point injections have proven successful for pain relief for musculoskeletal pain. Prolotherapy is an alternative therapy that specifically targets ligaments. This sort of therapy, also called Regenerative Injection Therapy, is beneficial for many sufferers of chronic pain. Physical therapy, acupuncture, massage, yoga, diet, and exercise, and other alternative therapies, can beneficial pain management options for myofascial pain and other ligament and muscle pain.

Individuals with LBP pain lasting longer than four weeks or who are experiencing uncontrollable pain should see a pain specialist for treatment options.

Recent research shows that early treatment lowers the risk of developing a chronic pain syndrome. Contrary to some belief, bed rest generally doesn’t help LBP. Staying active and physical therapy are suggested instead. There are many pain relief options for those with severe LBP.

Pain Relief Option Overview

Pharmacotherapy – NSAIDs (Ibuprofen like drugs), Acetaminophen (Tylenol), muscle relaxants, and membrane stabilizing medications can offer significant relief from LBP.

Minimally-Invasive Procedures

Epidural Steroidal Injections are commonly used for chronic back pain syndromes, like degenerative disc disease. Medications are injected into the epidural space (area outside the spinal cord) and in the area where the pain originates. ESI’s are used to alleviate symptoms for a range of back-pain conditions. The medications spread to other areas and portions of the spine to reduce inflammation and irritation.

Medial Branch Blocks (MBBs) are often used to treat neck and back pain related to arthritis. Medial branches are spinal nerves that branch out from the vertebra and connect to the facet joints. The procedure is an injection of medications that reduce inflammation and irritation of the facet joint.

Lysis of adhesions is a type of ESI that removes excessive scar tissue from the epidural space. It’s typically performed when other more conservative treatments have failed to provide adequate pain relief.

Infusions Techniques involves inserting a small catheter into the epidural space or next to the affected nerves. A local anesthetic, and other medications, are administered through the catheter. The continuous infusion of medicines and anesthetic has the potential to result in long-lasting pain relief.

Spinal cord stimulation is typically used for individuals with chronic and severe LBP. A small electrical pulse generator is implanted under the skin, decreasing pain to the spinal cord and brain pain processing centers. An initial trial period is done to see if it will help with longer-term pain relief. If the trial period offers pain relief, than a permanent SCS device is implanted.

Peripheral Nerve Stimulation is typically used for individuals with chronic and severe LBP. Tiny electrodes are placed close to the affected nerves, and low-level electrical impulses block pain perception originating from the nerve. An initial trial period is done to see if it will help with longer-term pain relief. It may offer significant pain relief from chronic LBP as well.

Kyphoplasty and vertebroplasty are two procedures that treat compression fractures, which are often related to osteoporosis. Acrylic bone cement is injected into compressed or fractured vertebrae, strengthening the vertebrae, restoring vertebral height, and reversing spinal deformities.

Intrathecal pump implants allow delivery of pain medications (opiates, local anesthetics, and/or muscle relaxants) to affected area. Sixty-six percent of cancer patients, who use intrathecal pumps, experience pain reduction (Becker 2000).

Percutaneous discectomy, is a procedure for herniated or bulging discs, where a needle is inserted through the skin into the bulging disc. The extra material is suctioned out of the disc, relieving pressure on the disc and on other nearby structures.

Disc denervation uses heat to deaden or dull a nerve. Needles are placed along the vertebral bodies, close to the discs, and when the appropriate nerve placement is located, the nerves are anesthetized and destroyed using heat, generated from radio frequency.

Cryotherapy utilizes freezing temperatures to deaden or dull a nerve. A probe is placed through a needle, near the irritated and painful nerves, and electrical stimulation is used to pinpoint the proper location, and nerves are anesthetized. Several freezing cycles are initiated over the painful nerves.

Peripheral nerve blocks and ablation is a nerve block that uses injected medications on, or near, irritated nerves. Peripheral nerves are often are sources of LBP. Once the painful sensations are blocked with a local anesthetic, then ablation or destruction of the nerves can be performed.

Trigger points are specific muscle areas that cause pain, and trigger point injections involve injecting a local anesthetic and steroid, onto a “Trigger Point.” Often this procedure can offer significant pain relief from muscle spasms.

The use of Botox for LBP is a relatively new and innovative treatment option. In 2005 “Botulinum toxin Type A” (BtA) became the first line therapy for the treatment for cervical dystonia. Although a single injection of BtA is effective, multiple injections often work better for patients (Costa 2005). Along with pain reductions, many patients have had an improved range of motion ((Juan 2004). Not everyone can receive Botox injections, so it is important to speak with your doctor about all your medical conditions before proceeding.

Transcutaneous Electrical Nerve Stimulation (TENS) – TENs uses a small, battery-operated device that delivers low-voltage electrical current through the skin via electrode patches. The electric impulses interfere with pain sensations and replace pain perceptions with different stimuli.

Alternative/Complimentary Treatment Options

Always consult a physician before beginning any alternative or complimentary therapy. There are many different alternative therapies that are very helpful in relieving LBP including, acupuncture, biofeedback, physical therapy, exercise, nutrition, therapeutic massage, chiropractic manipulations, nutrition, and prolotherapy.

Surgical Options

Surgical procedures are typically performed conservative pain management options have failed, or when the spinal cord nerves are severely compressed. Serious compressions are characterized by bladder and/or bowel incontinence, lower extremity weakness, spasticity, and/or loss of sensation.

Invasive Surgical Procedures Include:

Discectomy
Laminectomy
Spinal Fusion
Spinal Instrumentation

For long-term pain relief, surgical fusion or discectomy may not be successful. In addition, these procedures have greater risks for serious complications, including: bleeding, nerve damage, epidural scarring, and prolonged recovery times.

Surgery is generally the last resort, when pain specialists have exhausted other avenues of treatments; or when life-threatening complications have developed, or neurological symptoms like weakness, bowel or bladder changes, and/or loss of sensation are experienced. Surgical fusion or surgery for the chronic pain treatment is not usually routine.

For more information about lower back pain causes, conditions, procedures, treatments or other items mentioned, please consult your pain physician.

Resources/Journal Article

Adam Sewell MD

KNEE PAIN

The knee is one of the largest, most complex joints in the body. It is made up of four bones: The femur, the tibia, the fibula, and the patella. The muscles that support the knee are the quadriceps, in the front of the knee, and the hamstrings, in the back. These structures are connected through a collection of ligaments and cartilage. The anterior cruciate ligament (ACL) prevents the femur from moving backwards onto the tibia, and the posterior cruciate ligament (PCL) prevents the femur from sliding forwards. There are two collateral ligaments, medial and lateral, that also help to provide support. The meniscus (lateral and medial) is tissue that sits between the femur and the tibia, providing ease of movement between the two bones. There is also articular cartilage that sits behind the patella. The knee is surrounded by bursae, fluid filled sacs which help to cushion the knee joint.

Types of Knee Pain

The main movement of the knee is bending and straightening. Because the knee is, also, capable of twisting, many traumatic injuries to the ligaments can occur. Some symptoms of this type of injury include a “popping” sound, immediate inability to bear weight on the affected limb, or the sense of the knee “giving way.” These types of injuries, sometimes, require surgical repair. Twisting can cause injury to the tendons or the meniscus as well. Both of types of injuries can cause pain, swelling, and difficulty straightening the leg.

Another main cause of knee pain is degeneration. This is called “osteoarthritis”, and it is the “wear and tear” of the cartilage of the knee, which degenerates as we age. When the condition becomes severe, there is no more (or very little) cartilage left between the knee bones, and this can cause significant pain. Chondromalacia patella is also a type of degeneration, and it means that there is damage to the cartilage beneath the kneecap.

Treatment

Establishing a correct diagnosis for knee pain is the first, and most important, aspect of treating knee pain. An MRI is usually used to make this determination. Also, there are several injections that may help knee pain. One of the most common is a corticosteroid, which is injected directly into the knee joint. This type of injection reduces inflammation and pain. Viscosupplementation (Orthovisc, Synvisc) provides lubrication to the knee joint for persons with degenerative conditions such as osteoarthritis. There are several nerve blocks that may be beneficial as well.

The most common type of nerve block for knee pain is called a saphenous nerve block. A saphenous block provides relief for many types of knee pain, including the pain that sometimes accompanies total knee replacement. Other treatments for knee pain are – chiropractic therapy, gait analysis, bracing, and TENS unit application. Physical therapy can, also, help to strengthen the muscles surrounding the knee joint, improving its stability. Icing the knee can help decrease pain and swelling, as well, and anti-inflammatory medications (ibuprofen, naproxen sodium, Celebrex) are helpful mainstays of treatment for people with knee pain. However, other types of medication may be helpful as well.

Neuropathic medications (gabapentin, Lyrica) are beneficial for persons that have neuropathic pain (burning, numbness, ‘pins and needles’), and opioid medications (hydrocodone, oxycodone) are beneficial for people with acute knee injuries. If a person is experiencing an acute-type injury of the knee, an orthopedic surgery referral is may be immediately made by a primary physician.

If the patient does not respond to more conservative treatments, neuromodulation through spinal cord stimulation may be a consideration. Spinal cord stimulation involves placing a small electrode within the epidural space of the spine. The stimulation of the large nerve fibers will inhibit the small nerve fibers, blocking the sensation of pain. Peripheral nerve stimulation (PNS) is very similar, but the electrodes are placed along the peripheral nerves instead, typically close to the area of pain. Both are completed under a local anesthetic and minimal sedation. The trial stimulator is typically worn for 5-7 days and connected to a stimulating device. If the trial successfully relieves your pain, it may be beneficial to undergo a permanent SCS/PNS.

Knee pain can be quite disabling. Arkansas Pain provides a comprehensive and multidisciplinary approach to your pain. If you suffer from chronic knee pain, please call us to schedule an appointment today!

References:

Adam Sewell MD

JOINT PAIN

Joint pain can range from mild to severe, and it can make moving the joint impossible. A joint is anywhere two bones or more connect together.

Joint pain may be acute, sharp or sudden, and arise from an injury or trauma. It can, also, be chronic, coming on gradually, and related to an underlying condition. An injury or trauma may turn into a chronic pain condition as well, however. If pain starts as an injury and doesn’t begin to alleviate within 48 hours to a few weeks, there may be an underlying condition.

There are different types of joints, and most are related to movement. The back and neck have spinal bones (vertebra), and each vertebra has two facet joints, which connect the vertebrae together. They allow for limited spine movement. The majority of joints in the human body are synovial joints, meaning that they are filled with synovial fluid.

Acute joint pain often occurs in the synovial joints, such as the knees, hips, shoulders and hands, because these joints allow for the most movement. Back and neck pain are, also, a common source of joint pain.

Most acute joint pain, occurring from injuries, can be treated at home with anti-inflammatory drugs (Ibuprofen) and by applying ice, periodically, to the injured joint.

Joint pain occurring from an injury or trauma that results in intense pain, excessive swelling, joint deformity, or inability to use the joint, needs immediate medical attention.

There are many causes of joint pain. Some Common Causes include:

Osteoarthritis
Rheumatoid Arthritis
bursitis
gout
Sacroiliac joint disease
Injury or trauma

Pathology

Osteoarthritis

Osteoarthritis is most common cause of joint pain in the United States. Known as the “wear and tear” arthritis, it occurs over time and is often attributed to the aging process. It is a chronic and progressive condition caused by the thinning of bone cartilage and the formation of bony spurs (osteophyte) in the joint spaces. Most individuals have some level of osteoarthritis by the age of 70 (Brasington). The specific cause of Osteoarthritis is unknown, and it is not just a disease of aging. It is, instead, the result of a combination of factors including genetics, joint degeneration, and other mechanical processes (Kalunian).

Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a form of arthritis caused by an auto-immune disorder that causes the body to attack its own joint tissues. The subsequent continuous attack causes joint degeneration and pain. This disease can be severe, but there are many treatments today.

Bursitis

Bursitis is related to the bursa. These are the small sacs of fluid that cushion the area between a tendon and a bone. The most common places where bursitis is felt, are in the elbow, shoulder, and hip. Bursitis can, also, appear in the knee, heel and the base of the big toe, but the aforementioned locations are the most common. Bursitis occurs in joints that perform frequent repetitive motion.

Gout

Gout is characterized by sudden, severe pain (usually experienced at night), redness and tenderness in joints of the knees, legs, or the base of the big toe. This condition occurs when urate crystals build up in a joint, causing the inflammation and intense pain of a gout attack.

Sacroiliac Joint Disease

Lower back pain often is related to the Sacroiliac joint, which links the lower spine and the pelvis together. There are several ligaments and muscles that support these joints, and they are located on both sides of the lower back. As we age, the joint will sometimes fuse together, and in some cases, arthritis develops in the joint.

Injury or Trauma

Injuries from sports, falls, and auto accidents are common causes of joint pain and/or injury. An acute injury may occur during the activity; or it may build gradually after the injury worsens over time. This turns the initial injury into a common condition.

Diagnosis

If you have any of the following, seek medical attention:

Severe pain
Redness, swelling and tenderness
Heat in the joint area
Any Pain that doesn’t resolve or alleviate in 48 hours to four weeks.

At the time of the appointment, your physician will take a medical history and perform a physical assessment of the painful joint. Additional questions about when the pain started, where it is located, and what, if any, injuries have occurred, will all be valuable information f or an accurate diagnosis. After the initial visit, your doctor may order one or more visual tests. These may include an X-ray, Computerized tomography (CT) scan, Magnetic resonance imaging (MRI) or a Bone scan. MRIs are especially useful before any procedures are performed.

Treatments

Please see a physician before beginning any treatment plan.

Medications

Medications are the recommended and first treatment choice for managing most joint pain. Over-the-counter non-steroidal anti-inflammatory medications, known as NSAIDs, (Ibuprofen, and Aleve) are tried first. Prescription NSAIDs, like Celebrex, ma, also, help arthritis-related joint pain. Anti-inflammatory medications reduce the inflammation, which is often the root cause of pain in joint injuries.

“NSAIDs are effective against mild to moderate pain, and are important for the Management of both acute and chronic pain” (Brennan).

Exercise

Some exercises can be beneficial for those with joint pain. Swimming, walking, and yoga are all examples of exercises that are low-impact, and that add minimal stress on the joints and help maintain motion.

Physical Therapy

A course of physical therapy may help with joint pain by improving, and sustaining, range of motion. A physical therapist can create an exercise program catered to an individual patient’s abilities, limitations, and goals.

Joint Injections

There are many types of joint injection procedures. Some are common and minimally invasive non-surgical procedures used to treat joint pain, in many joints in the body. They are, especially, effective in the hips, knees, shoulder, back, and neck.

Joint injections are sometimes useful as a diagnostic tool. If an injection produces pain reduction, then the location and source of the pain can be more easily deduced.

Many patients with joint pain experience relief through these injections. Injections are combined with cortisone (steroid) and a short-term local anesthetic (lidocaine, bupivacaine). The local anesthetic works to interrupt the pain cycle, and the corticosteroid reduces inflammation in the joint and is more long term. Multiple joint injections may be ordered to improve a patient’s range of motion and quality of life.

Medial Branch Blocks (MBBs) are a type of joint injection for chronic neck and back pain. Radiofrequency ablation (deadening the nerve) may be part of the procedure. The process is an injection of medications that reduce inflammation and irritation of the facet joint and the related nerves.

Evidence suggests that therapeutic lumbar MBBs with local anesthetic and steroids, may be effective in the treatment of chronic low back pain within the facet joints (Manchikanti 2007).

Replacement Surgery

Joint replacement surgery is considered the last option and used when other treatment options have failed. The most common kinds of replacements are for the hips and knees. The replacement may be total or partial replacement and is aimed at relieving severe and painful joints. The recovery time after surgery is often long, and there is a higher potential for complications and risks than with less invasive treatment options.

For more information about joint pain or other items mentioned, please see your pain physician.

Resources/Journal Articles

Adam Sewell MD

HIP PAIN

The hip joint is a large weight bearing joint that attaches the leg bone (femur) to the pelvis, allowing the body to walk, run, and sit. The hip is a very strong structure, but, like all bones and joints, is not immune to damage. Sports-related injuries, motor vehicle accidents (MVA), and falls in the elderly are cause some of the worst hip injuries. However, arthritis is usually the culprit in severe chronic hip pain.

In 2007 the Centers for Disease Control (CDC) stated, “Arthritis continues to burden the U.S. population as the leading cause of physical disability and affects women disproportionately: women with arthritis report greater prevalence of activity and work limitations, psychological distress, and severe joint pain than their male counterparts” (Theiss 2007).

Anatomy

As stated before, the hip joint is a ball and socket joint, where the femur (large thigh bone) connects to the pelvis. The top of the femur is a round ball, which fits into the socket (acetabulum) formed by the pelvic bone, and the ball is allowed to glide and rotate within the acetabulum because a group of ligaments and muscles support the joint and inhibit over extension. Within the joint is, also, a synovial lining, which provides lubricating fluid to decrease friction.

Pathology

Hip dislocations and femur fractures are often acute injuries and are treated as such. There are other conditions that can produce chronic progressive hip pain, however, and these are more common.

Diseases, besides trauma, that can cause chronic hip pain:

Osteoarthritis (OA)- also known as degenerative arthritis or degenerative joint disease. OA is the most common cause of arthritis in the United States. It is most common in women, people over the age of 55, obese people, and those with a history of previous joint trauma or disease. OA results from repetitive wear and tear of the joint. OA can cause a chronic, non-inflammatory arthritis of any moveable joint. The most common joints involved in OA are the DIP joints (small joints closest to your fingernails) of the fingers and the knees. Typically the joint involvement is one-sided and asymmetric. Patients typically experience crepitus, which is a crackling or popping sound and sensation. This is created when the cartilage has broken down and two rough edges are coming into contact with each other. This can also cause a decrease in range of motion, pain that worsens with activity, and improves with rest. There is typically no localized swelling or redness seen with this cause of arthritis.
Rheumatoid Arthritis (RA)- Unlike OA, RA is a chronic, systemic, destructive, inflammatory arthritis. It is commonly seen in younger aged women 35-50, although can be seen in anyone. Infections by viruses, and bacteria and genetic factors (HLA-DR4) are thought to possibly trigger the destructive inflammation.RA is characterized by symmetric involvement of the large and small joints. The originating cause is by a nonspecific inflammation which then produces T-cell activation (cell of your immune system) and a pannus (flap of tissue) is formed. The pannus erodes into the surrounding cartilage, tendons, and even bones.
Avascular Femoral Head Necrosis- Results from incomplete blood supply to the bone. The bone then typically develops necrosis or destruction of normal tissue. A fracture of the femoral neck or dislocation of the femoral head may damage the blood vessels that supply the femoral head. Other causes can be from arthritis syndromes, local or systemic steroids, infection, radiation, or unknown causes. When there is necrosis in the femoral head, the bone typically cannot support the body weight and the femoral head can eventually collapse and fracture causing pain and further complications.
Labral Tears- The hip socket or acetabulum is lined by cartilage. This cartilage is called your labrum and allows for smooth movements of the femur ball in your hip joint. A labral tear can result from injury or wear and tear arthritis. Labral tears can often be painful and those affected often complain of a “catching” or “locking” sensation with certain movements. Treatment often involves medications, injections, physical therapy, and sometimes surgery.
Lumbar Radiculitis- Spinal nerve in the low back can become irritated and aggravated by various conditions. If a nerve root becomes irritated it can cause painful radiation into the lower extremity. The pain is called referred because it is felt in the hip, but the pathology is in the low back. Typically radiculitis can be diagnosed with a physical exam and relevant spinal imaging.

Diagnosis

Diagnosing patients with hip pain can be difficult, as many of the symptoms are similar those of other conditions. The first step in evaluating a patient with hip pain is to get a comprehensive history and physical exam. Some questions that a doctor may ask a patient suffering from hip pain are –

Where is the pain located?
How long has the pain been there?
What were you doing when you first noticed the pain?
Is there anything you can do that alleviates the pain?
Are you currently taking any medications for the pain? Do they work?
Is there any family history of arthritis or other autoimmune disease?

After conducting a full history and physical exam your physician may want additional studies. These might include radiological films and blood work. Imaging techniques, like MRIs, CT scans, or Xrays, are useful because the help your doctor see directly into the effected joint.

Common imaging techniques to evaluate arthritis include:

X-Ray – a diagnostic test which uses an electromagnetic energy ray to produce images of internal tissues. Bones are well visualized.
CT Scan – a diagnostic test that combines x-rays with computer technology to produce cross sectional views of the body. This is helpful because it helps to visualize detailed images of the body, including the bones, muscles, and organs.
MRI Scan – a diagnostic image that uses large magnets and a computer to produce detailed images of the structures within the body. This is even more detailed than the CT Scan and X-Ray.

Common laboratory tests that your physician may want to check are complete blood count (CBC), complement, antinuclear antibody (ANA) for rheumatalogical conditions, creatinine, erythrocyte sedimentation rate, rheumatoid factor, urinalysis, and a white blood cell count (WBC). Additionally, your physician may want to perform an arthrocentesis to look at the fluid in the joint. This is especially crucial when gouty arthritis or a septic arthritis is suspected. Another method in evaluating the joint is called an arthroscope. This procedure involves placing a small, optic tube (arthroscope) into the joint, so that your doctor can get an inside view of your joint.

Treatment

There are many treatment options for arthritis and joint pain. The most common and recommended methods are conservative. Staying active and engaging in physical therapy, taking NSAIDs and Acetaminophen (Tylenol), have all proven to be quite helpful to most arthritis sufferers. Physical therapy has been noted to significantly improve the postural stability in hip OA patients (Giemza 2007). Also, intra-articular joint injections have gained popularity, because they are successful, minimally invasive, and long-lasting.

A joint injection may be considered for patients who have not found relief with other methods. The injection can help relieve pain by reducing the inflammation and numbing the joint. It can, also, help to diagnose the source of the pain. Joint injections offer rapid relief of symptoms, which allow the patient to quickly resume regular activity. Often times, this method is superior to oral medications for many arthritis sufferers.

There are many treatments available to those suffering from arthritis, and Arkansas Pain Specialists can answer any of your questions.

Articles

Adam Sewell MD

HEEL SPUR

A heel spur is a hook of bone that protrudes from the bottom of the foot at the place where the plantar fascia connects to the heel bone. Pain associated with heel spurs is usually pain from plantar fasciitis and not the actual bone. Heel spurs are most often diagnosed when a patient is receiving treatment for pain to plantar fasciitis. Spurs are diagnosed via X-ray.

Heel spurs are most commonly found in middle age and effect men and women evenly. As already noted, plantar fasciitis is, generally, the root cause of bone spurs, and it occurs when the fascia, a thick connective tissue that connects the heel bone and ball of the foot, becomes inflamed. It is estimated that up to 70 percent of plantar fasciitis patients have a bone spur.

Bone spurs are soft calcium deposits caused from tension in the plantar fascia. When they are discovered on an X-ray, they are also used to diagnose plantar fasciitis, which is caused by repetitive stress. Walking, running and dancing can all exacerbate this condition.

Treatments for bone spurs and plantar fasciitis include:

Stretching the calf muscles several times daily is critical in providing tension relief for the plantar fascia. Some physicians may recommend using a step to stretch, while others may encourage yoga or pushing against a wall to stretch.
Icing after activity. A frozen tennis ball can provide specific relief. Rolling the tennis ball under the arch of the foot after exercise can lessen pain in the area.
Taping is also recommended at times. Several manufacturers of sports tape have plantar fascia specific lines.
Orthotics are a good idea for those on their feet during the day. They can provide cushioning and relief.
Cortisone shots in the fascia can provide temporary anti-inflammatory relief.
Losing weight is perhaps the most effective method of improving heel and foot pain. Those overweight are far more likely to report these syndromes.

Causes for heel spurs (and plantar fasciitis) are: a sudden increase in activity, lack of arch support or poor shoe choice, injury, inflexibility in Achilles tendon and calf muscles and spending too many hours on the feet for several days in a row. Also, arthritis from aging is often a common cause of bone loss and natural cushioning under the heel. Tarsal tunnel syndrome can also be a culprit in bone spurs. In the United States, the cause is usually obesity. With more than 60 percent of the nation obese or morbidly obese, foot pain related to excessive weight, is quite common. Dietary changes can help with long-term relief for bone spurs and plantar fasciitis.

Heel Spur – PainDoctor.com

Adam Sewell MD

HEADACHES

Millions of people suffer from chronic headaches, some of which, cause intense pain and debilitating symptoms that interfere with, and even completely halt, a person’s daily activities. Headaches that occur, at least, two times a week over a three month period are considered chronic. There are many causes for chronic headache including, environmental causes and triggers, genetic history, trauma to the neck or head, and or other injuries. Headaches (Has) are more common in women than men and have been characterized as “generalized” or “localized”. Generalized headaches occur in more than one area of the head. Localized pain is more specific. Headaches may originate from other areas of the body, such as the neck or shoulders, as well. The vast majority of headaches are not life threatening or serious. They are, also, not usually related to any serious disease or condition. Their pain can be sudden, chronic, or severe however.

Pathology

There are two main types of headaches – “Primary” or “Secondary.” Primary headaches are far more common, and are not caused by a disease. Primary headaches are subdivided into separate categories and are caused by another disease or condition. Secondary headaches stem from several medical issues, such as high blood pressure, or in extremely rare cases, a brain tumor.

Common Primary HA Types

Tension Headaches

Tensions, or stress, headaches are very common, beginning in adolescence. Patients often describe the pain as a dull pressure. They can, also, be likened to a tight band wrapping in increasing tension around the head. It comes on slowly and can be caused, or worsened, by stress, fatigue, hunger and neck or eye strain.

Tension headaches are more common at the end of the day. Pain is usually felt in the upper neck or back of head, and it can spread to the front of the head. Tight neck muscles are often the root cause of this kind of headache. They are also more common in people with depression and sleep disturbance.

Cluster Headaches

With a cluster headache, there is sudden severe pain on one-side of the head that lasts from 15 minutes to an hour. They reoccur in cycles, or “clusters”. There is, also, a definite pattern with these kinds of headaches. Symptoms occur in same area, around the same time of day, and, often, during the same time of year.

Women are far more likely to experience all other kinds of headaches, except, cluster headaches. Men have a higher incidence of these. Some symptoms that can be experienced are – sudden severe, one-sided pain, pulsing or throbbing pain, and pain behind the eyes.

A cluster headache is more intense than in other types of headaches, and people who take high-blood pressure medications, consume alcohol, or take illegal drugs, are more likely to experience this type of headache. In addition to the symptoms listed above, people who experience cluster headaches may, also, notice one-sided redness, tearing from one eye nasal discharge, or stuffiness. In rare cases, neurological conditions like, Horner’s syndrome or ptosis, may be related to this type of headache. Emotions and foods are not triggers for cluster headaches.

Migraine Headaches

A migraine is characterized by intense, throbbing pain, which is often experienced at the temples, the front or back of one or both sides of the head, and there is sometimes eye involvement. Women are far more likely to experience migraines, but they are found in any gender and all age groups. One culture or ethnicity is not more likely to experience them than any other.

Mechanism

Cluster Headaches are caused by the sudden opening of blood vessels in the brain, causing severe head pain, from compression and irritation on Cranial Nerve V (Trigeminal), which supplies sensory and some motor functions to the face.

The causes of Tension Headaches are less understood. However, there is some belief that their causation is due to brain neurotransmitter or chemical changes, related to stress and emotional factors. Another theory is that chronic musculoskeletal, muscle irritations (myofascial) may cause Tension Headaches (2007 Ashina). Myofascial irritation can be caused by jaw clenching, teeth grinding and poor neck and back posture.

Migraines are thought to have a genetic link or predisposition, as they often run in families. The theory is those with a family history of Migraines, may have a gene that predisposes them to migraine HA’s (2007 Goadsby).

Diagnosis

There are many medical conditions that cause secondary headaches. A physician evaluation is critical to determine an accurate diagnosis of any chronic headache conditions.

Some of the more serious conditions that require immediate medical attention are: intracranial hemorrhages/ hematomas, meningeal infections (viral, bacterial, fungal), strokes, and malignant hypertension. Again, if there seems to be anything unusual about the headache(s) that you are experiencing, seeking medical attention is of utmost importance. In order to accurately find the source of a headache, a physician may order a series of tests and studies including: radiological scans (MRI, CT), neurological exam, blood work, or an eye/vision assessment.

Treatment

There are two pharmacological treatment categories for primary headaches, and are classified as “abortive” or “preventive.”

Abortive therapy

Common abortive therapies for Primary HA’s:

Oxygen – most commonly used for a Cluster HA.
Ergots
Triptans
NSAID’s
Anti-emetics
Opiates
Butalbital with aspirin or acetaminophen

Additionally, overuse of abortive headache medications, may eventually cause a resistance to such medications in the future. This can cause the attacks to become more frequent and severe.

Preventive therapy

Some common preventive medications for headaches:

Cardiovascular drugs (Beta blockers, Calcium channel blockers)
Antiseizure medications
Antihistamines
Antidepressants

Antidepressant medications may help where there is a relationship between a Depression/Anxiety Disorder or sleep disturbance and migraines.

Behavioral and supplemental treatment options:

Acupuncture
Cognitive Behavioral Therapy
Group Therapy
Massage
Exercise and Nutrition Counseling, Vitamin Supplements
Prayer
Biofeedback
Chiropractic Manipulations
Hormone Supplements

Proven treatment options for reducing migraine frequency:

Botox Injections
Occipital Nerve Stimulation
Cervical Facet Injections
Cervical Epidural Steroid Injections
Sphenopalatine Nerve Blocks
Occipital Nerve Blocks
Supratrochlear Nerve Blocks
Supra/ Infraorbital Nerve Blocks

Transnasal sphenopalatine ganglion (SPG) block injections can be helpful for migraines as well. This procedure has been used as a cluster headache treatment, too, after medications proved unsuccessful. Cluster headache can become pharmacologically resistant, but there are many other treatments that can assist in limiting or stopping their pain. SPG blockade has been shown to have the most successful pain relief outcomes.

The combinations of therapies above have been proven to reduce painful symptoms for all types of headaches.

Headache Journal

For more information or questions about headaches, treatments, and other items mentioned, please see your pain physician.

Resources/Journal Articles

Adam Sewell MD

FOOT PAIN

Foot pain is a very common complaint. Because the foot is comprised of so many tiny and intersecting bones and ligaments (26 bones and 33 joints, and hundreds of ligaments, muscles, and nerves), there are many places where injury can occur. Bone spurs, stress fractures, Achilles tendinitis, bursitis, neuropathy,

osteoarthritis, neuromas, and tarsal tunnel are all frequent causes of foot pain and they can be divided into two categories, structural, or neuropathic.

Structural Foot Pain

Structural abnormalities of the foot include bone spurs, Achilles tendinitis, osteoarthritis, rheumatoid arthritis, and stress fractures. Bone spurs, or osteophytes, are bony projections that can develop along the edges of the bones in the feet, and they are typically the result of arthritis. They can be highly irritating to surrounding nerves, and cause a significant amount of pain. Just above the heel, is the Achilles tendon, which can become inflamed, resulting in tendinitis. Achilles tendinitis is usually the result of a sports injury, where the ankles and calf muscles are significantly overused. Osteoarthritis is caused by the breakdown and loss of cartilage in the joints. It is most often seen in older adults. Rheumatoid arthritis is a severe autoimmune disease. In RA, the body’s immune system attacks normal joint tissues and organs, resulting in severe pain and deformities. Stress fractures are tiny fractures that occur in the bones of the feet. They are typically caused by overuse, or improper physical training. Some treatments for structural foot pain include:

Non-steroidal anti-inflammatories (NSAIDS)
Opioid medications
Physical therapy
Splinting/casting
Steroid injections
Surgical intervention
Neuropathic Foot Pain

Foot pain can, also, have a neuropathic source, and stem from Morton’s neuroma, peripheral neuropathy, RSD, and lumbar radiculitis. A Morton’s neuroma is a swelling and nerve irritation between the third and fourth toes. Peripheral neuropathy is an inflammation of the peripheral nerves in the lower extremities, and can stem from multiple things. Some of these conditions are: Diabetes Mellitus, infections, and vitamin deficiencies. RSD is an abnormal neuropathic response to injury and is characterized by redness, swelling, and temperature changes. Foot pain can also be caused by nerve root impingement at the lumbar spinal level. Some treatments for neuropathic foot pain include:

Medications like Lyrica (pregabalin), Neurontin (gabapentin) and Cymbalta (duloxetine)
Lumbar epidural steroid injections
Lumbar sympathetic blockade
Physical therapy
Neuromodulation via TENS unit or spinal cord stimulation

Spinal Cord Stimulation (SCS) is often described as a “pacemaker for pain”. It works by introducing an electrical current into the epidural space near the source of chronic pain impulses. Under a local anesthetic, and some minor sedation, your doctor will place the trial SCS leads into the epidural space. The trial stimulator is typically worn for 5-7 days and connected to a stimulating device, which is taped to your skin. If the trial successfully relieves your pain you can decide to undergo a permanent SCS if desired. With both neuropathic and structural foot pain, the utilization of multiple treatments increases the chance of improvement in pain and quality of life

References:

Adam Sewell MD

FIBROMYALGIA

The cause of fibromyalgia is uknown and characterized by widespread pain and decreased pain threshold (Nugraha et al, 2011, and CDC, 2009). It affects an estimated 2% of the general U.S. population (Traynor et al 2011), or 5 million Americans age 18 or older (CDC, 2009), and it’s more likely to be found in women (Bartels et al, 2009).

The term is derived from the Latin “fibro-”, which refers to the fibrous connective tissues, the Greek “myo-,” or “muscle”, and Greek “algos-”, meaning “pain”. “Fibromyalgia” means “connective tissue and muscle pain”. This pain manifests as generalized tenderness, specific tender points, as well as a range of somatic symptoms.

According to the American College of Rheumatology, the diagnostic criteria for fibromyalgia is: widespread pain, and presence of 11 or more tender points among a possible 18 sites throughout the body. Fibromyalgia, also, includes sleep disturbances, fatigue, stiffness, hypersensitivity to physical and psychological environmental stimuli, depression and anxiety. In addition, fibromyalgia may coexist with other conditions such as headache, irritable bowel syndrome, chronic fatigue syndrome, temporomandibular joint disorder (TMJ), rheumatoid arthritis, lupus erythematosus, painful menstrual periods, and other pain and autoimmune syndromes (CDC, 2009; Weir et al, 2006; Calandre & Rico-Villademoros, 2012). The diagnosis of fibromyalgia is considered one of exclusion.

Some patients with fibromyalgia may develop central sensitization, or the overreaction of pain receptors to normal physical sensations. Central sensitization is thought to be a consequence of prolonged pain from any long-term painful condition like fibromyalgia. In central sensitization, low-threshold sensory fibers activated by light touch of the skin trigger neurons in the spinal cord to respond only to painful stimuli. Eventually, even harmless stimuli provoke feelings of pain. This phenomenon is known as allodynia.

Those with fibromyalgia may also experience hyperalgesia, or increased sensitivity to pain. Although its cause is not yet fully understood, it is thought that both genetic and environmental factors are involved in the development of fibromyalgia (Calandre & Rico-Villademoros, 2012). Additional research may lead to development of more effective treatments or new preventative measures for chronic pain syndromes like fibromyalgia (Henry et al, 2011).

The NEJM review acknowledges that, for patients experiencing the pain and symptoms of fibromyalgia, there is little doubt that the condition is real, as is the need for relief, and many fibromyalgia patients express dissatisfaction with their quality of life.

Treatment

Although there is no cure for fibromyalgia, symptoms may be lessened, or go through periods of remission, as time passes. It is important to remember that fibromyalgia is not a progressive or life-threatening condition, and that certain treatments can significantly improve the issues, especially the pain and fatigue, associated with the disorder.

There is no cure, so treatment focuses on managing symptoms and improving overall quality of life. Therapies including medications, physical exercise, and psychological treatment can all be effective approaches (Calandre & Rico-Villademoros, 2012).

First-line drugs used to treat fibromyalgia include, pregabalin used for neuropathic pain, and the serotonin- and norepinephrine-reuptake inhibitors duloxetine and milnacipran for disturbed sleep and depression. These medications were designed, principally, to address pain that stems from the spinal cord and the brain (Crofford, 2008). Evidence from clinical trials indicate these three drugs can have a significant impact on fibromyalgia-related pain, reduce sleep disturbances and fatigue, and improve quality of life and mood (Traynor et al, 2011).

A combination of medications is often necessary to mitigate the symptoms of fibromyalgia, particularly as symptom profiles vary between patients. These include: antidepressants, non-steroidal anti-inflammatory drugs (NSAIDs), sedatives, muscle relaxants, analgesics, sedatives, anticonvulsants, sleep aids, and corticosteroids, depending on each patient’s clinical history, target symptoms, and functional impairments (Han et al, 2011; Moldofsky et al, 2010; Russell et al, 2009; Di Franco et al, 2010). In addition, other therapies may be prescribed to treat specific symptoms like sleep-disturbance, irritable bowel syndrome, and rheumatoid arthritis (Mease et al, 2011).

Opioids (e.g., OxyContin, Vicodin, Percocet), are typically not recommended for the treatment of fibromyalgia, because they have not been shown to provide a long-term benefit for most patients. Though the information is limited, all current guidelines discourage opioid use, because they are habit forming and may not be of benefit to most people with fibromyalgia. They can, in fact, cause greater pain sensitivity, persistence of chronic pain (Ngian et al, 2011), and other long-term effects.

Newer research suggests fibromyalgia patients may have low magnesium levels, and supplementation with magnesium citrate may reduce symptoms of the disorder. It is thought to lower the intensity of fibromyalgia pain, particularly across tender points (Bagis et al, 2012). The same study, also, reported that a combined therapy of amitriptyline plus magnesium citrate not only reduced pain, but improved depression among patients.

Medications are not the only way to treat the symptoms of fibromyalgia. Self-management treatments like, scheduling daily relaxation time, establishing a regular sleeping pattern, getting regular exercise, and educating oneself on fibromyalgia, can all be helpful. ACR also advocates deep-breathing exercises and meditation to help curb stress that can exacerbate symptoms.

Another therapeutic option recommended by ACR is cognitive behavioral therapy (CBR), which can help redefine a person’s perceptions and opinions about illness, teach symptom reduction skills, and help alter a person’s behavioral response to pain. A 2012 randomized controlled trial was conducted to assess the efficacy of an individually administered form of CBR for fibromyalgia (Woolfolk et al, 2012). The study indicated that the patients receiving the experimental treatment reported less pain and overall better functioning than control patients, both at post-treatment and at follow-up.

Several physical treatments have, also, shown tremendous benefit. These include, exercise, yoga, physical therapy, massage therapy and Tai Chi. Strength training and aerobic exercise have beneficial effects on pain in adults with fibromyalgia, as well. One study found that fibromyalgia patients assigned to a yoga program showed significantly greater improvements of symptoms and functioning, including pain, fatigue, and mood and revealed more acceptance, and other coping strategies (Carson et al, 2010).

A growing body of research suggests that Tai Chi produces numerous benefits in the treatment of fibromyalgia, including improved balance and muscle strength, better attentiveness and sleep, and lowered anxiety (Field, 2011). Tai Chi, which consists of gentle, meditative, flowing movements, balance and weight shifting, breathing techniques, and cognitive tools, also promotes positive cardiovascular changes (Field, 2011).

The ACR commonly, also, recommends acupuncture (Itoh & Kitakoji, 2010), transcutaneous electrical nerve stimulation (TENS) (Löfgren & Norrbrink, 2009), massage therapy (Sunshine et al, 1996), and nutritional strategies (Lamb et al, 2011; Dykman et al, 1998). In many cases, these treatments can help individuals with fibromyalgia improve their quality of life. Trigger point injections, membrane-stabilizing infusions and Botox injections have also shown benefit and may decrease pain long enough for patients to resume more conservative therapy (Smith et al, 2002).

Chronic pain causes changes throughout the nervous system that often worsen over time. It has significant psychological and cognitive consequences and can actually cause a separate disease entity (Pizzo & Clark, 2012). Fibromyalgia can be debilitating, causing social and economic impairment and effect the ability of people to work and maintain relationships with family and friends (Firestone et al, 2012). Treatment from an experienced pain management specialist can help fibromyalgia patients obtain the treatment necessary to regain their quality of life.