Wednesday, January 12, 2011

Chronic pain: The enemy within

Mary Vargas spent her last pain-free moments driving down a country road to visit a Connecticut flower farm. She was 23 and newly married, a law student about to start a summer job. It was the day after Independence Day, 1996.
It also was the day her independence from doctors and hospitals would end. Vargas stopped to make a left into the parking lot. A driver who was admiring the scenery plowed into the rear of her car. Vargas' head whipped back and forth like a ball on a spring, damaging her spine. The injury transformed her into one of millions of Americans tormented by chronic pain.
"My husband describes pain as almost being a third person in our marriage," she says.
As many as 40 million people may share Vargas' plight. A new USA TODAY/ABC News/Stanford University Medical Center poll indicates that 19% of American adults — almost 1 in 5 — say they suffer from chronic pain; 44% have acute, or short-term, pain. Half of the 1,204 respondents cite the source of their discomfort as a medical injury or condition such as joint pain, heart disease or cancer. (The poll's margin of error is plus or minus 3 percentage points.)
"The problem is absolutely enormous," says Russell Portenoy, chairman of pain medicine at New York's Beth Israel Medical Center. "It rivals every serious public-health issue, whether you're talking about heart disease, cancer, obesity or anything else."
Still, the burden of pain will grow as the population ages. More than half of patients reporting chronic pain were older than 55.
A study of pain's effect on worker productivity reported in The Journal of the American Medical Association in November 2003 calculated the cost in the USA at more than $62 billion a year from reduced performance alone. Add in the cost of treatment and lost workdays and the total climbs to an estimated $100 billion, according to the American Pain Foundation.
The psychological effects of pain amplify the trauma, contributing to depression, anxiety, sleeplessness and suicide. "Many people in severe pain from terminal illness fear their pain more than they fear death," says Scott Fishman, chief of pain medicine at the University of California-Davis.
Despite the burden that pain imposes on society, pain relief has long been a stepchild of medicine. Many pain medications derive from aspirin and opium, whose origins date back 2,000 years.
Pain medicine isn't recognized by the American Board of Medical Specialties as a primary medical specialty on par with cardiology, oncology or anesthesiology.
The American Board of Pain Medicine has taken the lead in educating and credentialing pain medicine specialists. So far, the board has certified just 1,700 doctors as pain specialists. That's about one pain specialist for every 23,500 people who need care.
With specialists so rare, many pain patients are cared for by doctors who lack training and experience in the appropriate use of a range of pain therapies, among them drugs, spine stimulators and implanted pumps, and alternative therapies, including acupuncture.
From doctor to doctor
Patients hopscotch from doctor to doctor for years before they're given an accurate diagnosis, pain specialists say, and it may take even longer to find appropriate care.
"I always ask my incoming patients, 'How many physicians have you gone to with this complaint?' " says B. Todd Sitzman, medical director of the Center for Pain Medicine in Hattiesburg, Miss. "It's unusual to see someone who hasn't gone to at least three other physicians looking for answers."
The upshot, doctors say, is that patients suffer. The survey bears this out. Of those surveyed who sought care, 90% reported that the doctor understood their pain problem well, but just 30% reported getting a "great deal" of relief.
Vargas, of Emmitsburg, Md., now a health discrimination lawyer, suffers from overwhelming pain, possibly because doctors who weren't trained in pain medicine told her to wait six months to see whether her injuries would heal. By then, it was too late. Fishman and other experts say it is critical to intervene immediately and break the pain cycle before the nervous system loses its ability to turn the pain off.
After a year of waiting, Vargas began an agonizing odyssey from doctor to doctor, hospital to hospital. Finally, one of her three physical therapists referred her to a pain specialist. He recommended that she allow surgeons to implant a spinal cord stimulator, an electrical device that sends a signal to electrodes at a point above the damaged nerve and interferes with transmission of the pain signal.
"I was on a number of medications, but after we got the stimulator working, I was able to drop all but one," says Vargas, who still takes a narcotic called fentanyl. "I was able to have a baby and do all kinds of things I couldn't imagine doing without the stimulator." The couple's son, William, is 2½ .
"The pain of childbirth has a beginning and an end and a positive result. With chronic pain, there is no end," Vargas says.
The science of pain
The more researchers delve into the nature of pain, the more they realize how complex the pain network is. "There's more to pain than we ever dreamed of," Fishman says. "Whenever we think we've found an answer to the puzzle, we realize there are more questions."
In someone with a healthy nervous system, pain can be a lifesaver — a sentinel on duty to warn of potential risks and prompt protective responses.
Gabrielle "Gabby" Gingras, 4, of Elk River, Minn., illustrates how important pain can be.
The playful little girl is one of very few children in the world with a genetic defect called congenital insensitivity to pain. She lacks the nerves to warn her that the knife is sharp or the glowing coil on the stove is burning her hand.
The first inkling of this came the day after Gabby was born, when a nurse pricked her heel for a blood test and she slept through it. Then, when she began teething, she chewed her tongue and knuckles to a pulp. Rubbing her eyes has left her blind in one and with 20/300 vision in the other. When she broke her jaw, which had been weakened by an infection, it took a month for her parents to realize it.
"We're trying to teach her to blink her eyes and bend her knees when she jumps," says her dad, Steve, 40. "We're trying to teach her to tell when water's too hot."
People with congenital insensitivity to pain often don't survive past middle age, doctors say. They are often crippled, their lives cut short by injuries and infections.
Gabby's mom, Trisha, 39, says she finds herself envying mothers of children with cancer. "If they go five years and beat it, they're done. With Gabby, it's never going away."
The couple, who also have a healthy daughter named Katie, created a foundation to be a networking tool for families whose children have similar conditions. Its name: "The Gift of Pain."
The pain-sensing nerves that Gabby lacks are the tiniest and most vulnerable, because they have the least insulation. The nerve endings are called nociceptors. The highest concentrations are in the areas needed for survival, especially the head, mouth, hands and feet. When they encounter a stimulus, such as a pinprick, they send a message through trunk cables to a part of the spinal cord called the dorsal horn. This is the switchboard that relays pain signals to the brain. It uses a second nerve network to relay everyday sensations.
If you prick your finger on a rosebush, nerves carry signals to the brain, the brain pinpoints the location of the injury and sounds an alarm to pull back to prevent further damage. It sensitizes a wide area around the injury to expand the perimeter of protection. And it signals the body's pharmacy to produce its own potent natural painkillers called endorphins.
These chemicals, produced in cells throughout the body, act just like morphine and offer temporary relief from pain.
But sometimes the system goes haywire. In some cases, when nerves are injured, the wires for pain and everyday sensations cross. It can occur after an injury or spontaneously. It occurs in shingles, because the virus that causes the illness, varicella, nests in the nerves. Nerves for everyday sensations are co-opted into the pain system, transforming mild sensations, like the brush of a sleeve, into agony.
There is also a mental component to pain because the brain registers pain in the areas that govern emotion, Fishman says. Someone who suffers a serious injury also may feel anxiety, fear and depression, he says.
One of the most remarkable forms of chronic pain is phantom-limb syndrome. Because early humans who lost limbs couldn't survive, the nervous system has never adapted to amputations. It's as if the amputation didn't exist. The brain, it seems, can't accept such an overwhelming loss.
David Borsook of McLean Hospital in Boston is a pioneer in using magnetic resonance imaging to study phantom-limb pain. He says the brain's distortions of the pain experience are almost impossible to grasp. He tells of the time he touched a phantom-pain patient on the mouth, face, foot and stump where his arm used to be. "He was freaked out by it and said he could feel me touching the (back) of his missing hand," Borsook says.
Borsook gave him an injection to block his pain. Then he placed him in a magnetic imager that detects iron molecules in blood. By tracking blood-flow patterns, the device maps activation of regions of the brain. "If I brushed him on the affected side," Borsook says, "the one area that stood out in the imager is the area of the brain where the missing hand is represented."
Borsook and Alyssa Lebel of Children's Hospital in Boston are using the same imaging method in children to study how pain changes the physical architecture of the brain. They report witnessing entirely different brain patterns when they activate normal and abnormal nerves. The study offers a bonus for the injured children who take part. They can see that their pain is real, Lebel says. "I don't just tell them that it's in their head. I show them."
The treatment horizon
Unfortunately, efforts to treat pain have lagged behind the researchers' ability to understand it. To jump-start research, Congress five years ago declared this the Decade of Pain Control and Research. Researchers have made some strides, developing nerve stimulators like the one used by Vargas and implantable pumps that deliver morphine and other painkillers into the spine.
Researchers are making a major push to improve on opiates because they can promote addiction and because some patients must be given escalating doses or the drugs lose their effectiveness. Among the new drugs now on the market is a Lidocaine patch, made by Endo, that has proven effective against the pain from shingles.
A drug called Cymbalta not only combats depression but also eases the pain of nerve damage from poor circulation in diabetes cases. Perhaps the most interesting new painkiller, approved in December, is derived from the fish-killing toxin of the Conus magus snail.
Called Prialt, it is 1,000 times more potent than morphine and is delivered directly into the spine through an implantable pump. But Prialt has drawbacks. It causes severe dizziness and cognitive problems at high doses. Despite its potency, it works in just 50% of those who try it, says the drug's developer, George Miljanich of Elan Pharmaceuticals.
Randy Rubida, 48, of San Jose, Calif., injured his neck when his car was rear-ended by another vehicle. He says Prialt has eased the spasticity in his legs, making it easier for him to walk again. But it hasn't eased his pain much. "The pain is so intense at times I can't tell a difference," he says.
Prialt works by blocking a contact point between nerve cells called a calcium channel. Other drugs do this, too. A seizure medication called Neurontin is regarded as one of the best drugs available for nerve pain, but it isn't readily absorbed at the higher doses some patients might need for effective pain relief. A new anti-seizure drug, Pfizer's Lyrica, appears to be one of the most promising drugs yet for diabetic nerve pain and pain linked to spinal cord injury.
Fishman says medicine still has much soul-searching to do when it comes to treating pain.
"We've wandered away from the basic ethic of medicine that we cure what we can, but we alleviate suffering always. We've got to come back to our roots."
Contributing: Anthony DeBarros and Susan O'Brian

Wednesday, January 5, 2011

If YOU have Neck Pain, You have Options

Neck pain is a common problem, with two-thirds of the population having neck pain at some point in their lives.

What Causes Neck Pain?

Causes of neck pain include:
  • Abnormalities in the bone or joints
  • Trauma
  • Poor posture
  • Degenerative diseases
  • Tumors
  • Muscle strain

What Causes Shoulder Pain?

The shoulder is a ball and socket joint with a large range of movement. Such a mobile joint tends to be more susceptible to injury. Shoulder pain can stem from one or more of the following causes:
  • Strains from overexertion
  • Tendonitis from overuse
  • Shoulder joint instability
  • Dislocation
  • Collar or upper arm bone fractures
  • Frozen shoulder
  • Pinched nerves (also called radiculopathy)
    • Other medical conditions, such as fibromyalgia
    • Cervical arthritis or spondylosis
    • Ruptured disk
    • Small fractures to the spine from osteoporosis
    • Spinal stenosis (narrowing of the spinal canal)
    • Infection of the spine (osteomyelitis, diskitis, abscess)
    • Cancer that involves the spine

How Are Neck and Shoulder Pain Diagnosed?

  • X-rays: Plain X-rays can reveal narrowing of the space between two spinal bones, arthritis-like diseases, tumors, slipped discs, narrowing of the spinal canal, fractures and instability of the spinal column.
  • MRI:Magnetic resonance imaging is a noninvasive procedure that can reveal the detail of neural (nerve-related) elements.
  • Myelography/CT scanning: Sometimes used as an alternative to MRI
  • Electrodiagnostic studies:Electromyography (EMG) and nerve conduction velocity (NCV) are sometimes used to diagnosis neck and shoulder pain, arm pain, numbness and tingling.

How Are Neck and Shoulder Pain Treated?

The treatment of soft tissue neck and shoulder pain includes the use of anti-inflammatory medication (such as Aleve or Motrin) and/or acetaminophen (Tylenol). Depending on the source of pain, drugs like muscle relaxers and even antidepressants might be helpful. Pain also may be treated with a local application of moist heat or ice. Local corticosteroid injection is often helpful for arthritis of the shoulder. For both neck and shoulder pain movement exercises may help. Sometimes neck pain can signify something more serious. Seek immediate medical care from our Austin Pain Doctors if you experience:
  • Shooting pain into your shoulder or down your arm
  • Numbness or loss of strength in your arms or hands
  • Change in bladder or bowel habits
  • Inability to touch your chin to your chest
Chronic back or neck pain, on the other hand, often has to be managed. This is because what can cause chronic pain may be difficult to determine. The treatment plan may require multiple and/or combined therapies. The complexity of chronic pain may mean it takes a patient longer to find relief from their symptoms. Pain management specialists have many different therapies from which to create a chronic pain treatment plan. Such as:

Injection Therapies
There are many types of spinal injections available to diagnose and treat different disorders. A sampling includes:
Epidural Injections and Nerve Root Blocks consist of anesthetic and steroid medications that are injected into the epidural space of the spine. Such injections are used to help diagnose a condition and/or relieve pain. An epidural injection is often performed to ease pain that radiates into the arms or legs.
Facet Joint Injections and Medial Branch Blocks help to determine if the facet joints are the source of pain. Besides their value diagnostically, such injections may help reduce cervical (neck), thoracic (chest area), and lumbar (back) pain.
Sacroiliac Joint Injections target relief at the joints in the lower back where the pelvis and spine join. The injection offers a two-fold purpose. First, the medication (anesthetic and steroid) helps to reduce joint inflammation and pain. Second, it can help determine if the sacroiliac joint(s) are the pain source.
Other Invasive Options
Pulsed Radiofrequency Neurotomy (PRFN) is a minimally invasive procedure that disables spinal nerves and prevents them from sending pain signals to the brain.
Rhizotomy is a procedure that 'turns off' pain signals by using heated electrodes applied to specific nerves that carry pain signals to the brain.
Spinal Cord Stimulation (SCS) and Intrathecal Pumps are advanced invasive pain management options. These are usually performed on a trial basis first to determine if the patient will benefit from treatment.
Spinal Cord Stimulation (SCS) produces electrical impulses to block pain from being perceived in the brain.
An Intrathecal Pump is a surgically implanted device that delivers a measured amount of pain medication within the spinal canal.
Surgical Interventions
Surgery is always the last resort, unless the patient's condition warrants immediate surgical intervention (e.g. bowel, bladder or profound neurologic dysfunction). When non-surgical treatments are not effective, spine surgery may be considered. Percutaneous Discectomy/Nucleoplasty is a minimally invasive surgical procedure that removes disc tissue and relieves pressure from spinal nerves. There are other types of spine surgery; some are complicated and may require spinal instrumentation and fusion procedures.

To learn more call our office make your appointment.
New patients are roughly one hour [ yes, one hour ] and you can go over your pain, medical history and options with a neck pain specialist.

Sunday, January 2, 2011

Pain Management - Foods That Help Ease Pain

Pain - something that no one wants to experience even once let alone daily and yet chronic pain is not uncommon. The Chronic Pain Association estimates that 50 million Americans endure chronic pain on a daily basis. Whether you suffer from Fibromyalgia Arthritis, or a Sports Injury, pain from the inflammatory response finds us and can make life miserable. Taking anti-inflammatory medications is the first defense against chronic or acute pain. Research shows if you want to add even more relief to your pain symptoms you can make some small changes to your diet.

Foods that have the greatest effect on the inflammatory process are fats. The predominant omega-6 fatty acids present in the American diet tend to promote inflammation while omega-3 fatty acids help to inhibit the inflammatory process. The omega 6 to omega-3 ratio in the Western diet is a high 16:1.8 leading some researchers to say the typical Western diet is a pro-inflammatory diet. No wonder we are in such pain! Even though omega-6 fatty acids are good for us and needed in the diet, we are eating far too many of them and not eating enough of the health-promoting omega-3's. Omega-6 fatty acids are found in beef, pork, chicken, whole milk dairy products, egg yolks, vegetable and seed oils, and packaged convenience foods- all staples of the American diet. The pain reducing Omega-3 fatty acids are found in cold water fish (salmon, mackerel, halibut, and tuna), ground flax seeds, canola oil, and walnuts.

There is one more fatty acid to throw into the mix and that is omega-9. Not as much of an attention getting fatty acid but just as important to know about. These fatty acids are also involved in prohibiting the inflammation process bringing relief to its sufferers. Omega-9's are found in olive oil, avocados, pecans, almonds, peanuts, cashews, sesame oil, pistachio nuts and macadamia nuts. All those nuts you thought were off limits, not anymore. Just make sure you only eat 10 - 12 nuts for a serving size so you don't add to your waistline with these high calorie snacks.

Fruits and Vegetables- ah, here they are again. I wonder how long it will take us to realize they really are good for us. The antioxidants found in fruits and vegetables play a role in decreasing damage by free radicals which to you and I means it prevents the initiation of the inflammatory response nipping it in the bud. What's the recommendation? The same as it's always been, 5-8 servings of fruits and vegetables each day. It's not as tough as it seems. A serving size of fruit is the size of a tangerine or half of a banana while the serving size for vegetables is ½ cup cooked and 1 cup raw. Add some berries to your cereal, some vegetable soup with lunch or sneak veggies into your scrambled eggs, add them wherever you can.

Although this doesn't count as a legitimate study, my mother, a long time arthritis sufferer decided to put some of these ideas into practice. She decided to take 2 tbsp. of ground flax seeds per day which she added to her oatmeal in the morning. She also added almonds regularly. That was it. No other changes and she found her arthritis pain markedly decreased. It goes to show that small nutrition changes can make a big impact on your health.

Now that you know the information, let's get practical. Here are 8 small diet changes you can make starting this week to decrease inflammation.

1. Replace chicken, pork or ground beef with salmon, mackerel, or halibut 2 times each week.

2. Use canola or olive oil in place of other vegetable oils for salad dressings and cooking.

3. Add walnuts, almonds, or pecans to salads.

4. Snack on an ounce of cashews or macadamia nuts with a piece of fruit.

5. Use sliced avocado in your sandwich in place of the cheese.

6. Use omega-3 fortified eggs (can find at all local grocery stores: look for the sentence: fed with DHA and EHA).

7. Add 2 tbsp of ground flax seeds to your oatmeal or yogurt.

8. Add a side salad each night with dinner (filling up with veggies during your meals will also help with weight management).

Using medications alone to manage your pain is difficult because most drugs eventually lose their effectiveness and can cause side effects. Take some small steps to add these dietary practices so you can have a more complete support system to alleviate pain.
Owner of Real Living Nutrition Services, Meri Raffetto is a recognized professional in the area of nutrition and wellness. She specializes in weight management and cardiovascular nutrition and offers online programs to help people reach their weight loss and health goals. For more information visit

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