March, 2014 - Ask Dr. P

When NOT getting pain relief can be a good thing.

by Pain Doc | Mar 27, 2014 | Uncategorized

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

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

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

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

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

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

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

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

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

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

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

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

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

Chronic Back Pain – Here Are Your Options

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

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

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

Of secondary association, there are these traits:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Study Shows Benefit to Stratified Care for Low Back Pain

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

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

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

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

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

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

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

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

The Origins of Musculoskeletal Pain – Which Describes Yours?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

More to come, stay tuned!

Dr. Perez