PAIN care in PAIN
Treating
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care PAIN
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8
4
FEATURE
Pain Management: 101
6
24
Migraines & Exercise
26
32
Trapped in the Dark
36
40
Is a Block a Block?
42
48
Counting Sheep?
50
56
Favorite Fall Food
60
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Oklahoma and Georgia Opening
Stretch for Success
8
Controlling Headaches
28
Food and Your Migraines
38
Chronic Low Back Pain
Spinal Cord Stimulation
46
We’ve Got Your Back
HCG for Chronic Pain
52
Custom Compounding
My New Normal
Recipes
62
Puzzles PAIN |
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Table Of Contents 56
Favorite Fall Food
From the
Editor Pain Quarterly is a guide for you to learn more about different types of pain and the various treatments available. Unfortunately, many people suffering from chronic pain go undiagnosed and untreated. Many, including some health care providers, are not fully aware of the existing and emerging treatment options. It is my goal to share with you some useful information about chronic pain and what can be done to manage it. Whether you are in pain or know someone who is, too many people suffer unnecessarily.
Dr. Ty Thomas Talks about Pain Quarterly
This edition is focused on headaches and the associated treatment challenges. We will explore options available in this issue and also include a few previous articles (‘Chronic Back Pain’ and ‘Is a Block a Block’) to serve as a reference, as these topics are of interest to many people. In this issue, I’ve included my favorite fall foods. The remainder of the magazine will highlight pain syndromes with real-life stories related to pain management. Feel free to pick up this magazine and take it home.
Chief Editor Ty Thomas Contributor Avery J. McCall Copy Editor Lisa Thomas Art & Design Christopher Feldmann This magazine is published by National Centers For Pain Management & Research For advertising information, contact Big Hat Management at (205) 868-3167
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Pain management is a specialty branch of medicine that aims to improve the quality of life and ease the suffering of patients living with chronic pain. A good pain clinic will take an interdisciplinary approach to diagnose and treat the underlying cause. Many different types of healthcare professionals can be involved in one patient’s care.
What to expect from a comprehensive pain management clinic. The initial visit is usually the longest and can take a couple of hours. There are some forms you will need to fill out. In this age of electronic medical records, your information will then be entered digitally to allow the team of health care providers to start the process of diagnosing your pain treatments. The provider team will ask additional questions to fill in any gaps in your medical history and then proceed with a detailed physical exam. Based on this information and a combination of tests, MRIs, and diagnostic injections may also be ordered.
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Next, a personalized and detailed treatment plan will be created for you. Treatment may include medication, physical therapy, supportive bracing, injections, counseling, and other advanced interventions including radiofrequency and neuromodulation. One of the most intimidating parts of seeking treatment is finding a pain physician who truly understands and who is 100% committed to delivering the relief you need. For more information on pain management, visit www.ncpmr.com.
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National Centers for Pain Management & Research would like to announce four new clinics, dedicated to providing high quality comprehensive pain management. Atlanta, Georgia
Edmond, Oklahoma
Bessemer, Alabama
Oklahoma City, Oklahoma
*New 10,000 square foot facility opening October 2013
National Centers for Pain Management & Research clinics have one goal: to improve the quality of life for our patients. We utilize cutting edge technology and advanced procedures to establish an accurate diagnosis and treatment plan to ultimately minimize pain and increase function.
No Referral Required Audra Eason, MD - Physical Medicine & Rehabilitation Wade Martin, MD - Anesthesiology
Brent Clower, DO - Physical Medicine & Rehabilitation
727 Memorial Drive Bessemer, AL 35200 office :: 205.332.3160 fax :: 866.702.0880 www.bamapain.com
6255 Barfield Road NE, Suite 155 Sandy Springs, GA 30328 office :: 404.334.7775 fax :: 877.795.8098 www.atlantapainphysician.com
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We strive to provide compassionate, comprehensive treatment for patients with painful conditions. Combined with the latest technology and one-on-one time with each patient, our Physicians are able to develop and implement a specialized care plan based on specific needs. As a medical team comprised of physicians and other medical staff, we offer respectful, creative, innovative and high quality care for our patients. Conditions Treated • • • • • • • • • • • • • • • • •
Pain Treatments Offered
Arthritis Pain Back Pain Leg and Hip Pain Joint Pain Neck Pain Herniated Disc/Bulging Disc Pinched Nerve Degenerative Disc Disease Headache Fibromyalgia Sciatica Nerve Pain Failed Back and Neck Surgery Pain Pelvic and Abdominal Pain Diabetic Pain Whiplash Pain Knee Pain Shoulder Pain
• Opiate and Non-Opiate Medical Management • Transforaminal and Interlaminar Epidurals • Joint Injections and Sensory Denervation • Selective Nerve Root Blocks • Epidural Steroid Injections • Provocative Discography • Radiofrequency Ablation • Spinal Cord Stimulation • Peripheral Nerve Stimulation • Peripheral Nerve Blocks • Sympathetic Blocks • SIJ Injections • Facet Injections and Medial Branch Blocks • Platelet Rich Plasma • Bracing
Most Insurance Accepted Ty Thomas, MD - Physical Medicine & Rehabilitation
J. Jason Jackson, MD - Physical Medicine & Rehabilitation
Oklahoma City: 3330 NW 56th Street, Suite 612 Oklahoma City, OK 73112 Edmond: 105 S Bryant Ave Suite 301 Edmond, OK 73034 office :: 405.601.8810 fax :: 877.795.8060 www.okiepain.com
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By Dr. Ty Thomas
Headaches are one of those pain syndromes that come in many forms and little progress has been made when it comes to identifying the cause and treating them efficiently. In the US, the prevalence of headache is 78% for women, and 68% for men. 40% of Americans will experience a severe debilitating headache at least once in their lifetime, while a vast majority suffer from recurrent headaches. Giving you the tools to control headaches is the goal for the following articles. Knowledge is power when it comes to managing headaches. The first few paragraphs serve as an introduction to how doctors approach a headache. Determining if the headache is primary or secondary is the first step.
Primary versus Secondary Headaches. What’s the difference? A primary headache has no clear structural or infectious cause, whereas a secondary headache is related to an identified abnormality. Secondary headaches can be a warning signal for underlying life threatening conditions such as head injury or stroke. Primary headaches are the most common headaches that interfere with quality of life and become a
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chronic pain syndrome. These include migraines, tension-type, cluster, chronic daily, cervicogenic, occipital neuralgia, hemicrania, exertional, cold-induced, hormonal, and coital. While there may be many other headache syndromes, not much is known about them, making it difficult to accurately identify and treat. The remainder of this article will discuss the more common primary headache syndromes.
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Head Split Over Migraines? Do you battle migraines? If you do, then you might be a migraineur. This means that you likely have a nervous system which is more sensitive and easily excited. Being a migraineur is part of who you are, part of your identity. So learning to understand migraines in actuality is learning about yourself. Migraineurs are light sleepers and often skip breakfast. They are affected by weather changes, odors, and bright lights. Generally, migraineurs are hardworking, prepared, success-oriented and resourceful. Attentive to their surroundings, they may sense the feelings and wishes of others. Migraine affects about 15% of the general population. It is one of the most common reasons people seek medical attention. During the last 1012 years, the prevalence of migraine has increased by almost 60%. Why the increase?
Today’s hectic lifestyle demands a lot from our nervous system. The nervous system is responsible for adjusting us to the lights, sounds, and activities of our fast-paced environment. It also helps us adjust to the weather, our emotions, hormones, and our thoughts. Also, environmental chemicals in the air, in our food, and in our drink can significantly impact how our nervous system communicates. In view of this, is it any wonder, that at times, the nervous system overloads? When the nervous system overloads, there is a change in neurotransmitters which can further excite or over stimulate the brain. Sooner or later, the brain loses the ability to slow down sensory information such as light, sound and odors. Muscles begin to tighten and become painful. Thinking slows. Communication from the brain telling it and the body to relax gets blocked. In the end, blood vessels do not regulate properly and become swollen and inflamed resulting in the headache associated with migraine. Now, let’s look at the migraine attack a little more closely.
The Five Phases of a Migraine Attack Migraine usually results when the nervous system becomes out-of-balance as described above. However, once it begins it does so in a predictable pattern. The migraine unfolds in five different phases: prodrome, aura, headache, resolution, and postdrome. 10 | Summer /Fall 2013
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Recognizing these phases will allow the migraineur to intervene early and perhaps avoid the migraine attack. Avoiding the migraine attack can be as simple as removing yourself from a hectic situation or by resting the nervous system with a nap. The first phase of a migraine is called the prodrome. This is an awareness that a migraine is imminent. Noticing the subtle changes of the prodrome is the first step in taking control over the impending headache. While most people experience the prodrome, not all do. Common prodromal changes may include mood variations, such as irritability, depression, or elation. Other common changes may involve alterations in mental processing. Light may appear too bright or halos may surround streetlights. Yawning and fluid retention are also common. Craving certain foods, such as chocolate, is frequently reported and may be confused as a migraine trigger.
The Five Phases of a Migraine Attack Prodrome Aura Headache Resolution Postdrome The most common auras are changes in vision. Frequently there are flashes of light or a blind spot in the field of vision, encircled by jagged, shimmering lights. Other auras may include numbness of the fingers, hands, and lips. Once in a while, auras can be spectacular involving changes in perception resulting in hallucinations. The most reassuring aspect of an aura is that it is brief. If auras continue beyond the headache, then it is important to discuss this with your physician.
“Is chocolate a migraine trigger or just a prodrome?�
The second phase of migraine is called an aura. Auras are disruptions of nervous system function that last several minutes up to one hour (it is rare for auras to last longer than this). They usually happen before the headache begins but can also occur during the headache. Auras are thought to be related to changing brain chemicals resulting in short circuits in the electrical connections of the brain. Only 15% of migraineurs have auras. PAIN |
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Doctors used to think that auras resulted from blood vessels constricting and limiting the flow of blood to areas of the brain. This was thought to result in the lack of oxygen causing the brain to misfire. Now, doctors view auras as electrical phenomenon in response to changes in brain chemistry. Unfortunately, there are no good medications to stop auras. Summer /Fall 2013 | 11
• Head Split Over Migraines? • The third phase of migraine is called resolve is still unknown. Most of the the headache phase. This is usually the time migraines resolve with sleep. It is worst part of the attack. The headache thought the neurotransmitter, serotonin, may begin in different ways even in the is restored in the brain and surrounding same person. For many, the headache tissue re-establishing balance. may be on one side of the head, Occasionally, and especially in children, pounding in nature, moderate to severe vomiting will stop a migraine. This may in intensity, and aggravated by routine be due to a release of serotonin that activities. In others, however, the entire is stored in the intestinal track. There head may hurt and not throb. Frequently are also reports of migraines stopping there is nausea but vomiting may also during an emergency allowing the occur. The nervous system becomes person to manage the situation. sensitive to light and sound. Thinking The final phase of an acute migraine may be difficult. Muscles in the head attack is the postdrome. This involves and neck often become painful and the lingering symptoms that resemble a tender. If untreated, the headache may last from 4 to 72 hours, rarely longer. Usually, the migraineur “I’m constantly afraid wants to be left that a migraine will alone in a dark quiet place. spoil my plans.” The headache phase usually produces the greatest disability. The attack interferes with productivity at home and work. On average, a migraineur misses 3.2 days of work per year due to migraines and may function at less than 50% of full capacity while on the job up to 6 days a month. The cost of migraine attacks to society is estimated to be in the 15-20 billion dollars per year range. Fortunately, treatment lessens lost productivity by almost 50%. The next phase of migraine is the resolution phase. How migraines
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hangover or the flu. Not every one has a postdrome. Postdromes usually follow migraines that last a long time. Common postdrome symptoms include fatigue, poor concentration, irritability, sick stomach, and tender muscles. Postdromes can usually be treated with rest or over-the-counter medications.
Serotonin and Migraine Serotonin levels in the brain drop during an attack and return to normal when resolved. Serotonin is involved in many
“The pounding pain and sick stomach interfere with my life.”
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communication systems within the brain and simply trying to alter these levels directly during a migraine can create bad side effects. So, pharmacists and chemists developed a serotonin like drug to help replace low levels in the brain during an attack. The first drug developed was sumatriptan or Imitrex. Other similar compounds, known as “triptans” have also been developed to treat migraine. Triptans have become the drug of choice for acute migraine headaches.
Migraine Types While there are five distinct phases of migraine, there are many different types of migraines. Some of the more common types are migraine occurring with aura, migraine without aura, early morning migraine, migraine related to menstruation, or a slow-developing migraine that may take hours or even days to develop. Treating these different types of migraines require specific strategies. For example, an early morning migraine with nausea may require medication given as a nasal spray or a shot; whereas, a pill may work well for a slowly developing migraine.
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The Different TYPES of Auras: Visual Auras • Bright lights and blobs
Sensory Auras
• Zigzag lines • Distortions in the size or shape of objects • Vibrating visual field • Shimmering, pulsating patches, often curved • Tunnel vision • Blind or dark spots in the field of vision
• Strange smells or tastes. Food and drinks taste different than usual • Heightened sensitivity to smell • Feelings of déjà vu or confusion • Feelings of numbness or tingling on one side of the face or body • Sudden perspiration
• Curtain-like effect over one eye
• Anxiety or fear
• Slowly spreading spots
• Being unable to read
• Kaleidoscope effects on visual field
• Temporary amnesia, such as forgetting how to do tasks you have been doing for years
• Total temporary blindness in one eye. Diagnostic of a retinal migraine. • Heightened sensitivity to light
• Lightheadedness • Feeling of floating above one’s body.
Auditory Auras • Hearing voices or sounds that are not there. • Modification of voices or sounds in the environment: buzzing • Heightened sensitivity to hearing. Someone speaking at a level and normal tone sounds like they are shouting loudly
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Genetic Testing & Your response to treatment may be in your genes
The medications that are often prescribed for pain management use different mechanisms to relieve various types of pain. In addition, medication metabolism, or how your body breaks down the medication and uses it, differs greatly from person to person. These differences may be partly caused by genetic variations in metabolizing enzymes, resulting in significant differences in patients’ responses to prescribed medications. A pharmacogenetic test is a salivabased test designed to detect genetic variations in the enzymes that break down commonly prescribed pain medications. The results can help doctors decide
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Pain
which medication or combination of medications will work best and which may be dangerous. Pharmacogenetic testing can help providers tailor treatment by identifying the dosages and drugs that will best treat the patient’s pain. Some of the treatments that may be tailored using genetic tests include narcotics, muscle relaxers, anxiety, and depression medicine. Genetics-based treatment is the new frontier of personalized medicine. It has the potential to improve an individual’s response while reducing the chance of serious side effects and drug interactions.
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Which Type Are You? Status Migrainosus This is the migraine that is severe, lasts longer than 72 hours and will not go away. There is a small risk for having a stroke with these types of migraines. For this reason, admission to the hospital for IV treatment may be required.
Menstrual Migraine Some women report having migraine headaches that are directly associated with their menstrual cycle. This may be the only type of headache reported, or it may be one of several types of headache for these individuals. Menstrual migraine appears to be associated with changes in hormone levels. When a definite pattern can be established, treatment may involve taking acute medication during the week before the onset of the menstrual cycle.
Tension-Type Headaches Tension-type headaches are episodes of headache lasting 30 minutes to 7 days. This is the most common type of headache in the general population and people rarely seek medical help because they can be easily treated with over-thecounter pain medication
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and stress management. The pain is typically on both sides of the head, pressing or tightening with mild to moderate intensity. Some describe the pain as a tight band around the head. The pain does not worsen with routine physical activity, and it may improve with activity. Sufferers frequently report the pain beginning in the neck. Tension headaches typically are not associated with nausea, but photophobia (sensitivity to light) or phonophobia (sensitivity to sound) may be present. Tension- type headache generally becomes a medical problem when it becomes chronic or occurs more than 15 days a month. Treatment for tension headaches include rest, physical therapy, over the counter medication, and rarely stronger prescription medications like baclofen and/or amitriptyline.
Cluster Headache The name cluster headache describes attacks of excruciating, one-sided pain that is usually located around one eye. Cluster headaches are less common than migraine, and the headaches are of shorter duration, lasting 15 minutes to 3 hours. Attacks usually occur in a
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series, or “clusters� of 1 – 8 headaches per day over a period of several weeks to months, separated by headachefree intervals that may last months or years. However, about 10-15% of patients have chronic symptoms without remissions. The attacks are associated with one or more of the following, all of which occur on the same side of the head: red and/or tearing of the eye, nasal congestion, runny nose, forehead and facial sweating, contraction of the pupil, drooping eyelid and eyelid swelling. Most patients are restless or agitated during an attack and are usually unable to lie down. It is common to see this person pace the floor during an attack. During a cluster period, attacks occur regularly and may be provoked by small amounts of alcohol, histamine, or nitroglycerin. Cluster headaches often occur at night. These headaches are 3 to 4 times more prevalent in men than in women. Treatment can be quite complex involving the use of 100% oxygen applied using a face mask, intranasal lidocaine, sphenopalatine block, triptans, IV steroids, and other powerful medications.
Sinus Headache
and a sinus infection, called sinusitis. Sinusitis is an acute infection of the sinuses which can produce a headache and is often accompanied by fever and discolored nasal drainage. This is rarely the cause of recurrent headaches. Most sinus headaches meet the criteria for migraine, and therefore, should be treated the same as migraine. Patients report that sinus medication brings relief within 72 hours, the same as the natural course of an untreated migraine. Treating the headache as a migraine can offer relief within 2 hours. Sinus headache is typically located in the sinus area of the face and forehead. Common symptoms may include nasal stuffiness and drainage, often at the beginning of the attack. As the headache develops, the symptoms begin to match those of a migraine, such as moderate to severe pain with nausea and sensitivity to light and sound. Many people with sinus pain also suffer other forms of headache, such as migraine and tensiontype. It is important to find a doctor experienced and well versed in treating headaches to help you get on the right path to relief and improved quality of life.
Sinus headaches require differentiation between migraines
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Migraine Transformation to Chronic Daily Headache By Dr. Ty Thomas
For many people with migraines, the attacks are infrequent and usually respond well to medication. However, for some people, their headache patterns change over time and transform to a chronic daily headache. Distinct migraine attacks become interspersed with different less severe but more frequent headaches. The feeling that a headache is always just around the corner develops. Ultimately, these different more frequent headaches take over and merge to a completely different headache with mixed patterns consisting of low grade headaches and few severe migraines. This transformation to the chronic daily headache is usually disabling and is a mystery.
Even though conversion may be part of the natural evolution of migraines, there may be catalysts contributing to the transformation. The term “Kindling� is used to describe this phenomenon. Think of the migraine as a fire not sufficiently put out--there are still some burning embers around acting as kindling making a repeat fire more likely. If migraines are not adequately controlled, kindling is still there making it much easier for a repeat headache to surface. So if the migraines are not treated, you can expect more to come and perhaps transform to chronic daily headaches. Trauma to the neck and or head can also act as a catalyst contributing to the transformation. Trauma, even minor, can cause microscopic injury to the nervous system. For example, an auto accident, even mild, can cause a whiplash type of injury which can contribute to this conversion. A head injury or concussion can create microscopic nerve damage in and around the brain also contributing to this conversion. So if you have noticed a worsening of your normal migraine after a head or neck injury, you need to discuss this with your doctor. Another catalyst, ironically, is medication prescribed to treat an acute migraine attack. The most common culprit is butalbital in Fiorcet or Fiorinal. This medication, while initially beneficial, if taken over an extended period of time, results in
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tolerance. You feel you need more and more to keep the severe headache at bay while a low grade persistent headache usually remains. If these medications are stopped, a severe “rebound headache� can occur. Rebound headaches occur because the medication alters the nervous system. Nerve cells communicate by sending chemical messengers from one cell to another. The communication chemical or neurotransmitter connects to the next nerve cell by fitting into a receptor, like a plug into a socket. When these sockets are exposed to certain chemicals found in some medications for periods of time, damage to the receptors may occur. If the receptors are damaged, normal communication is disrupted, making the person more vulnerable to headaches and rebound headaches. The only way to stop these headaches is to stop the medication. Once the medication is stopped, the receptors gradually return to normal or near normal but this takes time. In the meantime, an uncomfortable detoxification process takes place requiring other medications to help with the side effects. This is a difficult cycle to break. The bottom line: once a headache pattern is properly treated, daily headaches often return to intermittent migraines which are treatable with acute medication. PAIN |
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• Head Split Over Migraines? •
Risk Factors for Migraines Rick factors tend to overload the nervous system which can trigger a migraine.
Dietary
Hormonal
Sensory
MSG, Red Wine
Menstruation
Glaring Lights
Physical
Sleep
Injury or overexertion
Lack or abundance
Chemical
Emotional
Drugs or Air Pollution
Loss, Death, Argument, Fear
Trauma Emotional or Physical
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Protective Factors Protective factors help balance the nervous system which can help prevent migraines.
Take Care Of Yourself First
Prioritize Daily Obligations
Nutritious Meals
Regular Physical Exercise
Relax Daily
Adequate Sleep
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Managing Migraine 101 By Dr. Ty Thomas
To start managing Abortive treatment “You manage your own for mild to moderate your migraine you must understand headaches consists migraine” that “YOU” manage of NSAIDS (ibuprofen, it. It is imperative that you understand naproxen), acetaminophen (Tylenol), and the migraine process and treatment caffeine. For more severe headaches options. Over time you learn the not responsive to the above, triptan intricacies of your migraines. You learn medications can be prescribed. to accept what is known and what is still Medications with butalbital often a mystery. You accept the migraine as mixed with caffeine and either aspirin part of who you are as a person. You or Tylenol (Fiorcet, Fiornal) can be used learn to identify triggers and stressors but sparingly because these are habit which ultimately lead you to control forming and can worsen the headache your environment. Initially, controlling over time. Stronger opiate medication the acute migraine promotes confidence such as hydrocodone and oxycodone allowing you to refine your overall are sometimes prescribed, but these too management plan. are habit forming and can worsen the headache over time. It is also essential to understand that your doctor is an educator and helps The most common medications provide the tools necessary for your prescribed to treat associated symptoms success. Your doctor can help you are for nausea and include Phenergan create a management plan and assist and Reglan. in the early detection of migraine To prevent migraines, beta blockers transformation and migraine-associated (atenolol, propanolol) and clonidine medical conditions. Over time, migraine (typically prescribed for hypertension) treatment strategies become refined can be used. Tricyclic antidepressants and control is established. such as amitriptyline can also be tried. Migraine treatment is three pronged. For chronic migraines, which is defined The goals are to stop the migraine, as 15 or more headache days a month called abortive treatment, treat the with each headache lasting 4 hours or associated symptoms such as nausea, more, Botox injections are indicated if and prevent migraines from occurring. the above medications have failed.
“Your Doctor helps provide the tools necessary for your success” 22 | Summer /Fall 2013
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Medications for Migraines By Dr. Ty Thomas
Medication management for migraine treatment is usually a three pronged approach. The goals are to stop and prevent migraines while also treating associated symptoms such as nausea. Listed below are 10 medications to stop and prevent migraines.
Abortive Medications - Stop the headache once it starts. • Non Steroidal Anti-Inflammatory Drugs (NSAIDs) / Ibuprofen and Naproxen • Acetaminophen / Tylenol
• Caffeine • Triptans • Fiorinal / Fiorcet • Opiates (Lortab, Percocet)
Prophylaxis Medications - Prevent headaches from starting. • Beta Blockers (Atenolol / Propranolol) • Clonidine
• Tricyclic antidepressants (amitriptyline) • Botox
Treat Associated Symptoms (Nausea) • Phenergan
• Reglan
9 Interventions for Headache Relief • Physical Therapy
• Occipital Nerve Stimulation
• Transcutaneous Electrical Nerve Stimulation (TENS unit)
• Spinal Cord Stimulation
• Topical Compound Creams • Trigger Point Injections • Cervical Medial Branch Block / Facet Joint Injection • Cervical Epidural • Botox Injections
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Migraines & Exercise By Nancy Bullard
Exercise can play an interesting roll in the life of a migraine sufferer. On one hand, exercise can induce a migraine, but on the other, the proper kind of exercise can actually help prevent a migraine. We will look at both ends of the spectrum and I will give you concrete examples of exercises to avoid and to do along with some helpful stretching/relaxation tips that may also help prevent migraines from occurring. We will also look at the roles serotonin and tryptophan play in effective migraine prevention. I have studied multiple research sources and have compiled the following information that I think you will find helpful. Exercise can induce a migraine headache. It has been shown that sudden, strenuous exercise can induce a migraine. One example of this is starting a heavy weight lifting routine without preparing the body first for the load you are expecting it to do. This kind of lifting creates a sudden demand for oxygen, which has been found to trigger a migraine. 24 | Summer /Fall 2013
Straining too hard increases intracranial pressure, which can precipitate headaches as well. Likewise, doing any kind of strenuous exercise for too long a period of time can have the same effect. The right approach to this kind of exercise can help prevent migraine headaches. If you like to lift weights and strength train, it is important to have a proper warm up to prepare the body for the task. Working through your first set of reps slowly and with lighter weight properly warms up the muscles and allow you to lift without sudden strain. Proper breathing while lifting can help eliminate straining. Limiting lifting to 30-40 minutes can also help. Stretching the chest, shoulders, and neck can be very beneficial post strength training to lengthen the muscle fibers, relieve excessive tension, and help reduce stress. Women, in particular, tend to carry tension and stress in their neck and upper back so stretching is a vital part of a healthy exercise routine. PAIN |
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Aerobic exercise has been found to be the best exercise for keeping a migraine at bay. Exercises, such as brisk walking, jogging, swimming, cycling, and dancing are examples of aerobic exercises. Aerobic exercise stimulates the body to release endorphins, which are natural pain controllers in the body. The amino acid, Tryptophan, is also released during exercise. Tryptophan is used in the synthesis and release of serotonin, a chemical that has been shown to affect migraine headaches. When serotonin levels drop, the blood vessels in the brain swell and that is thought to cause the pain of a migraine. Yoga and pilates have also been found to help prevent migraines. The bottom line is that with proper exercise, stretching, hydration, and nutrition the migraine sufferer can reduce the occurrence of migraine headaches. Quality sleep and paying attention to trigger foods and stimuli are also helpful.
Nancy Bullard is a certified personal trainer with the National Academy of Sports Medicine (NASM) and is CPR/AED certified. She is trained in fitness and cardio-respiratory assessment, basic exercise science, cardiorespiratory, balance, flexibility, core, and resistance training, along with speed, agility, and reactive training. You can learn more at her website www.completelifestylechange.com
Sources • The National Institute of Mental Health The Migraine Trust • Dr. Weil – Natural Health Information Journal of Psychiatry and Neuroscience Livestrong.com Mymigrainesolutions.com
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Stretch Success By Nancy Bullard
Neck Rolls Sit or stand with shoulders relaxed, head in an upright, neutral position. Tilt the head to the left and roll around in a clockwise direction dropping the chin to the chest, head to the right, head to the back and continue to the starting position. Roll slowly 8-10 times making sure you allow the muscles along your neck to extend in each direction. Roll in the opposite directions for 8-10 rotations as well.
Neck Side to Side Sit or stand with shoulders relaxed, head in an upright, neutral position. Take your left hand over your head and place it above the right ear and gently pull the neck toward your left shoulder. Hold for 20-30 seconds, gently stretching along you neck into the top of the right shoulder. Relax and repeat 3-5 times. For a deeper stretch, extend the right arm slightly out to the side and back. Repeat this on the other side.
Neck Chin to Shoulder - Sit or stand with shoulders relaxed, head in an upright, neutral position. Take your right hand and place it comfortably between your right ear and chin. Gently push your chin to your left shoulder. Hold for 20-30 seconds, relax and repeat 3-5 times. Repeat on the opposite side.
Arm Circles Sit our stand with feet shoulder width apart, extend arms out to each side perpendicular to the body and make small circles forward for 15 count, then reverse circles for the same. You can also do large circles to really loosen up the shoulder complex.
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Shoulder Shrugs Sit or stand with feet shoulder width apart with head in an upright, neutral position. Pull shoulders up to your ears, squeeze at the top and relax shoulders back down. 10-12 reps.
Chest Stretch Find a corner of the room or a door frame that is not too wide. Put your arms out perpendicular to you body, elbows bent so your forearms are perpendicular to the floor with palms facing forward. Place your hands on each side of the door frame or each wall in a corner and step through, allowing the chest to open up and stretch. You can raise or lower your hands/elbows to stretch different muscles in the chest. Hold each stretch 20-30 seconds and relax. Repeat 3-5 times.
Spine/Hamstrings/Calves Stand with feet shoulder width apart, head in an upright, neutral position. Extend arms out to the sides, bringing them over head so your entire body is in a straight line from your finger tips to your feet. Slowly bend through your torso, bringing your fingers to your feet or the floor. Hang in that position for 10-20 seconds, allowing for a long, deep stretch from your calves, to your hamstrings, up your back. Very slowly, pull back up into a standing position as if you were lifting your torso one vertebrae at a time, rounding back up to a full standing position. Do this 5 or more times. PAIN |
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Food and Your Migraines By Claire Katzung, MS, RD/LD
The most common migraine-causing food triggers contain the amino acids tyramine and/or phenylethylamine. They are found in chocolate, aged or fermented cheeses, soy foods, all nuts and most seeds, citrus fruits, and vinegar. The cheeses include cheddar, Brie, blue, and all hard and ‘moldy’ cheeses. The vinegars include both red and balsamic vinegars. Alcohols such as beer, red wine, sherry, and vermouth also contain large amounts of tyramine, but an even greater cause-effect of migraines is the dehydration that these products can induce. Choosing carefully, sparingly, and maintaining good hydration is essential. As the content of tyramine increases with time, length of food storage should be noted. Improperly stored food is a risk factor, and airtight containers are imperative. Special attention should be given food left out over longer periods of time, such as at picnics, social events, etc. Nitrites are another common trigger for migraines and are
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found in hot dogs, deli meats, pepperoni, sausages of all kinds, meat jerky, corned beef, and other foods that have been smoked, cured, pickled, or canned. Barbecue and/or smoked entrées in restaurants are a huge red flag, and shopping for nitrite-free products may be required. Another concern regarding sodium nitrites is that after ingestion they react with powerful acids in the stomach to form nitrosamines, which are known to be one of the most potent cancer-causing agents there is to man. Tannins are plant compounds found in tea, red apples and pears, apple juice, cider, and red wine. These also can trigger migraines, and are noted for giving the astringent taste to the foods that contain them. Sulfites are used as a preservative in many processed foods, and reading food labels diligently is important. They are commonly found in most dried fruits, canned vegetables, wine – especially white wine, even foods that we commonly think of as ‘healthy’ foods. To assure sulfite-free products, look
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Simply staying hydrated can help you avoid headaches.
If you can’t pronounce it,
DON’T EAT IT!
for ‘preservative-free’ foods. Other food additives, such as monosodium glutamate (MSG), hydrolyzed vegetable and plant protein (HVP, HPP), kombu extract used in Japanese foods, and any products claiming to have ‘natural’ flavors may exacerbate a migraineprone condition. Some ‘flavorings’ that the general public may be unaware of are as follows: Benzyl acetate – an artificial strawberry flavoring that is also a nitrite solvent; Amyl acetate – an artificial banana flavoring which is also a paint solvent; Butyrlaldehyde – an artificial nut flavoring also used to make rubber cement; Ethyl acetate – an artificial pineapple flavoring used as a leather
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cleaner, whose vapors are known to cause chronic lung, liver, and heart damage; Perennial – used in place of vanilla flavoring and is also the chemical used to kill lice; Acetiel C17 – an aniline dye that is used in plastic, but also popular as a cherry flavoring for ice cream; Diethylene glycol – a chemical used as an emulsifier instead of eggs. As a general rule of thumb when reading labels, if you can’t pronounce it – don’t eat it! Look for additive-free products. Aspartame has long been used as a sugar substitute, and cannot only trigger migraines but can affect the nervous system. Unknown to most consumers, aspartame breaks down into its component chemicals in the body, or when exposed to heat. These components include methanol (wood alcohol), aspartic acid, phenylalanine, and diketopiperazine (DKP). Each of these components is, in itself, a
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known toxin. Aspartame sweetener is purchased under the name Nutra-Sweet and Equal.
partaking in alcoholic drinks, i.e. white wine would be a wiser pick than red wine.
Much safer sugar substitutes to use are stevia and xylitol. Most other sweeteners not mentioned in this article would need to be addressed individually in a separate report due to scientific data pros and cons.
A relationship between weight and migraines has not been proven, however migraine sufferers that were overweight had more frequent and more severe episodes, so maintaining a healthy weight is advisable. Stress can be a potent trigger for migraines, so alleviating stressors can be very important. Find time for rest and relaxation. Inflammation in the body can also trigger migraines, so any types of allergies or sensitivities, whether they be nutritionally driven or environmentally driven, should be avoided. This includes smoking. Two supplements excellent in aiding the liver in its function as filter for detoxifying your body and reducing inflammatory culprits are N-A-C (N-Acetylcysteine) and milk thistle. Incorporating either of these in your daily dietary regimen may be helpful in maintaining detoxification. Allergy testing may be required, however doing an elimination diet and reintroducing foods one at a time while keeping a food diary to monitor reactions to specific foods can also be extremely useful in determining your own personal triggers and the changes necessary to live migraine-free.
Caffeine is controversial as far as migraines go; it may trigger migraines in some individuals but be used to offset an oncoming migraine in someone else. Caffeine is found in coffee, black tea, green tea, and cola soft drinks. If using decaffeinated products such as coffee, the safest products are those using the Swiss water-method of decaffeination. It should be labeled as such on the container, and doesn’t use the harmful chemicals to draw out the caffeine that the other processes do. In summation, eating regularly is beneficial as migraine sufferers are sensitive to the effects of low blood sugar, which is often caused by ‘skipping’ meals. Maintain hydration, and use caution if
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Trapped in the Dark: Emily’s journey to migraine relief By Avery J McCall
The door clicked shut but to Emily it sounded as if her sister had slammed it closed. Hiding in her dark bedroom with all noise blocked out was the only way Emily could cope with the hammering going on inside her head. Her sister and friends headed to the movie theater but once again she was confined to darkness while the migraine controlled her life. “I started getting headaches during my freshman year of high school.” Emily had never experienced recurring headaches but she knew something was not right. “It was awful when I would get them during basketball practice,” the Oklahoma teen says. “Everything is ten times brighter and ten times louder with all the lights and whistles blowing.”
Emily’s headaches began to increase with frequency and intensity. “She seemed to get them at various times through out the weeks. I would give her acetaminophen and expect that to take care of it because it worked when I had a headache.” Emily’s mother Holly remembers. “I wasn’t asking anything about the headaches; I just had no idea they were any different from what I had experienced as a regular headache.” Emily struggled through her freshman year battling recurring headaches and nausea. Stress is a confirmed aspect of every teenage girls life and this seemed to add to the occurrences as well as the severity. Her parents were desperate to get some help for their daughter. Nothing they tried seemed to alleviate the pain so they made an appointment with her doctor. The pediatrician spent an hour asking questions to determine specific indicators as to the triggers for Emily’s headaches. What time of day do they seem most prevalent? Exactly where on your head do you feel the pain and is it in the same place each time? What have you had to eat or drink before you feel it coming on? Does it seem to be effected by the menstrual cycle? How long does your headache last? “I began to feel like such a bad parent because I didn’t realize how much Emily had been suffering; why didn’t I ask
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“I began to feel like such a bad mother, Emily had been suffering; why didn’t I ask these questions?” these questions?” Holly agonized over her regret. “We didn’t even think about the possibility of something more serious.” Emily began keeping a record of the headaches. For two months she journaled every time she felt herself slipping into the vice like grip. She kept track of everything; she made a chart detailing the foods and drinks, as well as what time she had them and how it made her feel. Emily and her parents begin to notice a pattern. The headache always felt the same at the onset. “It was always throbbing and felt like someone was stabbing me in the head.” Emily described the pain. Something else they noticed is the tension is always on the left side of her head. “I never get them on the right side, and I still have no idea why.” Armed with new detailed information about Emily’s daily routine, the doctor determined Emily suffers from more than just headaches. Her complaints of recurring severe pain in her head was diagnosed as migraine and she was sent to a specialist. An MRI was performed to rule out other underlying causes to her anguish. “I had been involved in a four wheeler accident when I was in the third grade and the doctor wanted to make sure there was no lingering effects.” The test confirmed the doctor’s belief of migraine as being the culprit. PAIN |
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“Does anyone in your family experience these types of headaches?” The doctor had more questions as they sought answers to help alleviate Emily’s misery. They were not considering a possible genetic link; Emily’s biological father suffers with cluster headaches so it was a plausible connection. The doctor also considered caffeine as a possible offender. “Some of my friends said I should drink caffeine when I get a headache but the doctor said for me I was probably drinking too much and it could be one source of the problem.” Emily’s friends were generous in their offers of treatment. “They just wanted me to get better so I wouldn’t keep missing all the fun.” Emily was willing to try anything at that point. She stopped drinking all caffeinated beverages and noticed a decrease in frequency and severity. This, coupled with an imbalance of hormones, lead the doctor to choose a preventive form of treatment. Emily’s family became more sensitive to what she was dealing with and had a new awareness of what she needed when a migraine would take hold. “It is hard to watch your child suffer through something that you don’t understand; I am much more sympathetic as she is lying on the bathroom floor crying from the pain.” Emily’s mother acknowledged. “I hung black-out curtains in her bedroom to eliminate Summer /Fall 2013 | 33
• Trapped in the Dark • the intense sensitivity to light and I keep everyone in the house quiet as she sleeps for as long as she needs.” After a year of medication and controlling her intake of caffeine and other migraine inducing foods, Emily and her family began to realize the headaches were much fewer and the level of intensity had decreased substantially. She was released from taking the prescription, but the headaches returned with a vengeance.
my head was throbbing and I was so nauseous.” Emily made it home and resumed the preventive headache medication as well as a prescription for the nausea that accompanies the attacks. Migraines are debilitating episodes but with the right doctor and treatment Emily has been able to keep them limited and less severe. She enjoys a full life involving school, sports and hanging out with friends.
Vacationing in the Bahamas has always Finding the right doctor for you or a been a favorite for Emily and her family. loved one is crucial in determining the The trip went according to plan until type and underlying causes associated the night before their scheduled flight with these headaches. They can be home. “I got so sick the night before we carefully managed and kept under left because control with of a migraine. right “Everything is ten times brighter the I could barely guidance so handle the and ten times louder with all the you can enjoy plane rides; your life.
lights and whistles blowing.”
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Winning the 2012 each of his kids to learn National Father Daughter the sport. At the age of Tennis Championship at nine years old Tim knew the Barnes Tennis Center he had found something in San Diego California was he loved. He played High an achievement that Oklahoma By Avery J McCall School tennis in Sapulpa tennis coach Tim Ritchie will Oklahoma and went on to play cherish forever. Watching him in perfect for Central State University, now known harmony with his nineteen year old as the University of Central Oklahoma daughter Whitney, as they execute in Edmond. He became All American in powerful overheads and backhands you 1992. would never guess he has a titanium His trouble began in 1996 with plate in his upper neck, or that severe tendinitis in his right he has had surgery on his elbow. Several trips to the elbow and back as well doctor and four cortisone as multiple steroid shots later, the tendon injections and lives with ruptured. Temporary persistent pain. relief had only been “This is my normal, I masking the problem. never have a day I feel His tendon was tied 100%,” the Oklahoma back together and he husband and father was off the courts for an of two says. “I won’t extended recovery. say I am at a level 10 Six long months of every day all day but it is rehabilitation and Tim constantly with me. I have was finally back to what just learned to accept it.” he loved; playing tennis and Tim comes from a tennis coaching others. Years of ten playing family. He and his seven hour days spent pounding on the brothers and two sisters were hard concrete surface day after day introduced to the sport as children. began to manifest in other areas Their father played and wanted of Tim’s body. “I had burning in my 36 | Summer /Fall 2013
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back, hips and down my legs.” In 1999 he knew something was wrong. “The pain never went below a level 2 and would sometimes reach 5 and 6 through out the day.” Prescription and over the counter pain medications would bring minimal relief for a few hours, but over time nothing seemed to work. “I couldn’t even walk my dog Miley anymore. The pain was so bad that I started driving the golf cart as she walked along.” Tim remembers. Sleep deprivation added to his discomfort as his condition went untreated. “I would sleep a few hours at a time until a wrong move would awaken me with a stab of pain. I tried a chiropractor and acupuncture and in 2001 I received two steroid injections before my doctor recommended a discectomy.”
ibuprofen and daily stretching help keep the pain at a level of tolerance. “This is my new normal.” Sports injuries are part of a coach’s life. It would be physically easier for Tim to put aside his passion for the sport he loves and stop coaching the countless other athletes to achieve their own successes; but he shouldn’t have to. There are other options to explore to allow the freedom to enjoy life and continue teaching others to do the same.
In the fall of 2002 Tim underwent surgery to remove one half of the disc at the L5 S1. “The pain decreased a small percentage but I was disappointed in the results. I was naive to think the surgery would fix the problem. I had to accept the fact that this would be my new normal.” Again, he was faced with months of recuperation before returning to the tennis court. Relief was short lived. In 2005 Tim began having neck pain; he turned to steroid injections as well as oral pain medications. Nothing worked. It was determined that a titanium plate was needed to relieve the pain and pressure. Today, Tim continues to coach and play tennis. Taking lower dosages of PAIN |
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CHRONIC
By Dr. Ty Thomas
Lower Back Pain
Chronic low back pain is one of the most common health complaints in the United States and accounts for countless visits to the doctor. The lower back includes structures such as the lumbar and sacral spine, discs, nerves, muscles, tendons, ligaments, and small joints. Injury to any of these can cause pain. However, when it comes to chronic low back pain, arthritis is often the culprit. Osteoarthritis is the most common cause for lower back in people between 45 and 65 years of age. In the lumbar spine, there are 5 vertebra which sit on each other forming the lower back. The 5th vertebra sits on top of the sacrum. These are separated by a disc and articulate with each other at the facet joint. Within the spine is the spinal cord. Nerves exit the cord through openings. Degeneration of the lumbar spine usually starts or is first noticed in the discs (called degenerative disc disease). When this happens, the disc narrows and the small facet joints become more bone-on-bone creating an arthritis state known as facet arthropathy. This can occur anywhere in the spine but is most common in the lower lumbar regions because this is where most of our weight gets transmitted causing wear. Over time, arthritic bone can grow 38 | Summer /Fall 2013
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creating spurs which can narrow the spinal cord (called spinal stenosis) and/or the opening of the exiting spinal nerve (foraminal stenosis). Chronic lower back pain is usually constant and felt in the middle low back across the belt line to the buttocks. It may have a deep ache feel with sharp pain aggravated by movement. Sometimes bending forward may alleviate symptoms. This pain can radiate down the leg usually to the thighs and knees and rarely below the knee. Sometimes this pain can get worse with weather changes. To diagnose back pain due to arthritis, a pain specialist will spend time going through your symptoms, perform a physical exam and order x-rays. The x-rays might show narrowing between vertebra and bone spurs. A nerve test may be ordered if there is radiating pain below the knees. A diagnostic nerve block called a medial branch block is the only definitive way to determine if the pain is coming from an arthritic facet joint. This test blocks the nerve transmitting pain from the painful arthritic facet joint. Sometimes a facet joint injection can be done instead but the joint space is often not open enough to accept medication due to the arthritis. Once the painful location has been identified, the nerve transmitting the pain can be destroyed by heating the nerve using radio-frequency in a procedure called radio-frequency ablation. Fortunately, this nerve is sensory only and destroying it does not cause any weakness. Unfortunately, this nerve does grow back and pain will usually return within 8-12 months. Even so, this is a successful management tool
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for moderate to severe chronic low back pain caused from arthritis. Treating chronic lower back pain secondary to arthritis requires a multimodal treatment plan. Medications such as non steroidal anti inflammatories (NSAIDs), muscle relaxers, and opiates can be used. Topical medications (patches, NSAIDs, custom compound creams) can also help. A lumbar brace can help position the spine to unload the facet joints and stabilize the spine. A TENS unit can aid with muscle and nerve pain. Physical therapy and therapeutic exercise are also important for long term pain relief and preventative pain. However,
it is important to first have a good diagnosis before starting therapy because not all therapy is helpful and can even be harmful. Fighting chronic lower back pain secondary to arthritis can be challenging. Understanding how arthritis contributes to back pain is important if you want the best possible outcome. Finding a specialist who can help you function to the best of your abilities despite arthritis is crucial to your care.
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Is A Block A Block? No! “Blocks” refer to many different types of injections and are often called a “block” by generalizing what it is. It usually refers to an injection performed on the spine and used in two ways. First, they can be performed to diagnose the source of back or neck pain (diagnostic).
Second, blocks are used as a treatment to relieve pain (therapeutic). Blocks are performed under X-ray guidance, called fluoroscopy or can be achieved under ultrasound. This helps confirm correct placement of the medication and improves safety.
Transforaminal Epidural Steroid Injection Intradiscal Injection Selective Nerve Root Block. DRG Ablation SIJ Injection
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No, No, NO! The following pictures represent the many different types of “blocks”. All aimed to stop different types of pain.
By Dr. Ty Thomas
Medial Branch Block
Facet Joint
Interlaminar Epidural Steroid Injection Transforaminal Sacral Epidural Steroid Injection
Caudal Steroid Injection
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Spinal Cord Stimulation By Dr. Chad Austin
Spinal Cord Stimulation was approved in 1989 by the FDA and is frequently used in patients with chronic pain syndromes who have not found pain relief from other treatments. Spinal cord stimulation can be used to treat patients with severe, chronic pain due to a variety of conditions, including failed back surgery/arachnoiditis, neuropathic pain/neuropathy and complex regional pain syndrome/reflex sympathetic dystrophy. Every patient experiences different relief from spinal cord stimulation, though most successful cases have at least a 50 percent decrease in pain allowing them to return to a more active lifestyle and reduced use of pain medications.
How does it work? In general, neurostimulation works by applying an electrical current to an area of the spinal cord to block unpleasant sensations from reaching your brain. This creates a pleasant stimulation that blocks the brain’s ability to sense the previously perceived pain. These electrical impulses applied to the spinal cord interrupt pain signals to the brain, replacing them with a tingling pleasant feel. This stimulus is generated by a small device which is implanted under the skin. The stimulation to the spinal cord is delivered from this tool through insulated wires called leads, which are placed next to the spinal cord. Using a hand-held generator that works like a remote control, the stimulator can be adjusted to specific areas and levels of pain, depending on activities and how the pain changes throughout the day.
to adjust the television. The area or intensity of electrical stimulation can be changed, and the system can be turned on and off or adjusted as necessary to provide optimal pain relief. Although programming is initially done at the physician’s office, patients can learn how to control the stimulation on their own and adjust it to their pain levels.
Who should have Spinal Cord Stimulation? The first step in the process is to get a comprehensive evaluation by a pain or spine physician. They will determine if you may be a good candidate for
This generator can be programmed in a way similar to using a remote control 42 | Summer /Fall 2013
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spinal cord stimulation treatment for chronic pain. While spinal cord stimulation can be used to treat chronic pain from multiple sources, it does not eliminate the source of pain or treat the underlying cause. Rather, it interferes with the transmission of pain signals to the brain, so the brain does
not recognize the pain. If your pain is caused by a correctable condition, then this must be addressed first. It is important to note that the degree of relief experienced from spinal cord stimulation varies from person to person. As pain changes or improves, stimulation can be adjusted as needed.
Spinal Cord stimulation is used to treat a variety of pain syndromes and symptoms, some of these include: • • • • • • • •
Chronic back pain with or without leg pain Chronic neck pain with or without arm pain Prior back surgery (or surgeries) but pain remains (or worsens) Peripheral neuropathy Peripheral vascular disease Reflex Sympathetic Dystrophy (RSD) Refractory angina Other treatments have not helped reduce the pain
How is it performed? Once you are deemed a candidate, the procedure is performed in stages: Stage 1 - Trial Stimulation Trial stimulation is very important to determine if the procedure will be successful. It will judge if stimulation is correct for the type, location, and severity of pain. It will also evaluate the effectiveness of various stimulation settings of the device. It is essentially a test drive before you decide if neurostimulation is right for you.
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• Spinal Cord Stimulation • Placement of the trial stimulator generally takes about 10 to 20 minutes; the patient can go home soon after the leads have been inserted. The procedure is an outpatient process often done in the office with mild sedation. The leads are placed through a needle inserted in the back (no incision is required) very similar to an epidural steroid injection. Once the leads are correctly positioned they are sutured in place and a sterile dressing is applied. The leads are attached to an external generator/power supply (worn on a belt) and stimulation settings are programmed. After the trial procedure, the patient will be sent home with instructions on how to use the trial stimulator and care for the site. Patients are encouraged to keep a written log of the stimulation settings during different activities and the level of pain relief. After 3-5 days, they will return to the doctor’s office to discuss the outcome of the trial period. If there is significant relief from pain during the trial, a permanent spinal cord stimulator can then be implanted. Stage 2 - Permanent Implantation For the permanent system, a surgical procedure is required to place the generator in the upper buttock or abdomen under the skin. The leads are again placed in the correct location as indicated by the trial and secured in place under the skin. Wires are then attached to the generator so that the entire system is under the skin. The procedure takes 1 to 1.5 hours to complete, and is done on an outpatient basis (meaning no overnight hospital stay is required). The generator and incisions are so small that patients can wear bathing suits, or participate in any other activities without inconvenience or interruption. Nothing is visible on the body, and there is nothing to carry. Batteries power the system. Depending on the amount of use the batteries will need to be replaced periodically (e.g. every two to five years) through a follow-up surgical procedure. The recent advance of rechargeable batteries in stimulator generators has reduced the need for frequent battery replacement. 44 | Summer /Fall 2013
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Advantages to Stimulation Treatment There are many advantages to spinal cord stimulation for the treatment of chronic back pain: • A trial can test patient response before the patient commits to a permanent implant. • It has few side effects and is easily reversible; if it doesn’t work or is no longer needed it can be removed. • Implantation of the system is minimally invasive, requiring a relatively minor surgical procedure on an outpatient basis. • Leads are inserted just under the skin, and patients can travel anywhere, and participate in recreational activities, including swimming. • Achieving pain relief with spinal cord stimulation can allow patients to reduce or eliminate their use of narcotic drugs. • Ongoing advances in neurostimulation technology give patients more control to adjust the stimulation if their pain changes in location or severity. • Continual improvements in the design of electrodes and longer lasting, rechargeable batteries mean that implantable systems can be placed in locations to give optimal and more efficient pain control than other modalities.
Disadvantages of Spinal Cord Stimulation As with any chronic pain treatment, there are also a number of potential disadvantages with spinal cord stimulation, including: • Spinal cord stimulation does not work for everyone. Most studies show that 50% to 60% of people find meaningful pain relief with spinal cord stimulation. • It does not eliminate the pain. A successful outcome of spinal cord stimulation is considered to be pain relief of 50% or more. • Spinal cord stimulation does not address the source of the pain. The system is designed to interrupt pain signals being sent to the brain, but it does not correct any underlying anatomical problem. For many people with chronic pain, this is the right approach to treatment. However, for those with a correctable anatomic lesion, treatments to address the source of the pain should be tried first. • The treatment involves an implant and surgery. As with any surgical procedure and implant, there are certain risks and potential complications associated with spinal cord stimulation.
As with all surgical procedures, there are potential risks to stimulation therapy, although most are relatively minor. Spinal cord stimulation is a therapy that can positively impact the quality of your life. Talk with your physician today to see if you are a candidate. PAIN |
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We’ve Got Your Back By Dr. Brian Thoma
A common reason for back pain is often not diagnosed quickly enough. A compression fracture is a break in the vertebral body of the spine. There are nearly 700,000 vertebral compression fractures in the United States each year. It often results in not only pain but a change in posture if it worsens. In addition, studies have shown that once a person has one compression fracture, he or she is more likely to suffer another. Patients at risk for compression fractures include those with osteoporosis, cancer, and trauma. Unfortunately many of these compression fractures are not detected soon after they occur. The main symptom is a sharp, severe pain in the
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middle of the back. The pain is often crippling, leading to an inability to function, and in some cases, walk or even stand up. A severe compression fracture can be detected by X-ray, but MRI is the most useful diagnostic tool. MRI allows doctors to determine how old the fracture is and whether it may be crowding the spinal cord or nerves. Historical management for compression fracture included bed rest; during which time, the hope is that the fracture will calcify and heal. Unfortunately the loss of height of the vertebral body cannot be restored with rest. In addition, patients will suffer further
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demineralization and weakening of their bones by lying in bed and not bearing weight. This inactivity also puts patients at risk for other problems such as blood clots and pneumonia.
Often, the kyphoplasty may restore the vertebral body to its natural height. The procedure typically results in excellent pain relief for the patient immediately after it is completed.
Fortunately, doctors have a new treatment option for this called kyphoplasty. If the compression fracture is detected early enough and evaluated by MRI, a patient may benefit from kyphoplasty. In this procedure, the doctor will insert a probe into the fractured vertebra and inflate a small balloon inside. This creates a cavity that cement is injected into so the fracture does not worsen.
If a compression fracture is detected, kyphoplasty may be an option, especially if the fracture is recent and the pain is debilitating. As with any procedure, the risks and benefits vary for each patient and should be discussed with your physician prior to undergoing the treatment.
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Counting Sheep? By Dr. Brian Thoma
An estimated 50-70 million Americans suffer with some form of poor sleep. This is a subjective experience that varies from one person to another. What seems to be consistent among experts is that adults should try to get at least 7 hours of sleep each night. While longer sleep duration does not appear harmful, short sleep duration of 5 hours or less is associated with undesirable physical changes. Interestingly, research has shown that forming strong memories is dependent on good sleep. Poor sleep can result from a variety of medical conditions, but there are some things we can do to improve the quality of our sleep. 1. Do not eat within 3-4 hours of going to sleep. 2. Avoid nighttime caffeine or tobacco (avoiding tobacco altogether would be best!) 3. Use your bedroom as a sleep sanctuary. Avoid spending much awake time there such as reading, eating, or watching TV. This will help condition your body to recognize the bed as a place for sleep first. 4. When you go to bed, give yourself 15-20 minutes to fall asleep. If you are unable in that time period, get up and leave the bedroom. Go to another room and read or watch TV until you feel sleepy. Then go back to bed and start over. 48 | Summer /Fall 2013
Millions of people suffer from obstructive sleep apnea, a condition where excessive tissue in the mouth and throat causes difficulty breathing during sleep. Listed below are signs that sleep apnea might be the cause of poor sleep and energy. 1. The patient is overweight 2. Daytime sleepiness, often falling asleep in the middle of the day without planning to do so. 3. The patient snores. 4. The patient has a short, thick neck. Sleep apnea can be diagnosed with a sleep study which your doctor can order for you. If sleep apnea goes untreated it can lead to more dangerous conditions such as heart failure.
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Chronic pain and sleep. Chronic pain interferes with good sleep and poor sleep worsens and contributes to chronic pain. Among those experiencing chronic pain, about 2/3 report poor or unrefreshing sleep. The problem of pain and sleep becomes even more complicated as commonly prescribed medications used to relieve pain, such as morphine and codeine can fragment sleep. When pain is first experienced, most people do not experience sleeplessness. However, when pain becomes chronic, it can be a vicious cycle. Someone experiencing lower back pain may experience several intense microarousals (a change in the sleep state to a lighter stage of sleep) per
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each hour of sleep, which lead to awakenings. However, microarousals are innocuous for a person not experiencing chronic pain. Pain is frequently associated with insomnia and these coexisting problems can be difficult to treat. One problem can exacerbate the other.
When is it time to see a doctor? It is time to seek professional help when pain causes sleep problems two to three times a night, and you are unable to fall asleep again. There are a variety of treatments available to ease the sleep problems of chronic pain sufferers, including medication and physical therapy. Doctors may also recommend seeing a psychiatrist or psychologist.
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HCG for Chronic Pain injured abnormal tissue. Animal studies support this finding.
O Ac
The use of HCG has potential value in chronic pain management. HCG (human chorionic gonadotropin) is the substance detected in home pregnancy tests because it is being produced by the placenta. However, HCG is also produced in the pituitary of men and non pregnant women of all ages. HCG binds to receptors throughout the body. This hints towards its larger and yet still unknown biologic role. While we do not understand how HCG works to reduce pain, initial small clinical studies suggest it works and is perhaps safe for both men and women as an adjunct medication for severe chronic pain management.
Forest Tennant, MD, a pain management physician in California, has studied the use of HCG clinically. In an interview with Medscape Medical News he stated he was contacted by a weight loss clinic and told that patients with chronic pain treated at the clinic with HCG, had reported significant reductions in several areas of pain. “Patients with painful fibromyalgia and arthritic conditions began to experience significant relief from their discomfort when prescribed HCG.� In-person interviews with the patients confirmed the positive effects of the treatment.
Chronic Pain can lead to multiple hormone deficiencies. HCG can help replace those deficiencies.
Why might HCG work for chronic pain? HCG is a hormone which stimulates the testes, ovaries, thyroid, and adrenal glands to produce testosterone, estradiol, progesterone, thyroid, and cortisol. Severe chronic pain patients who take opiates to relieve their suffering, develop multiple hormone deficiencies.
HCG Molecule
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c OA
HCG also has anabolic properties that stimulate tissue growth. This growth facilitates healing and regeneration of
Dr. Tennant published a study of eight patients. Each participant is described as suffering severe intractable chronic pain and taking significant amounts of medication. He followed them for a year while on HCG and reports that after twelve months of therapy, no side effects were detected. Each reported increased levels of energy and mental concentration, less depression, and PAIN |
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fewer episodes of severe pain. Seven of the 8 patients cut down on their use of opioids by 30% to 50%. All 8 patients expressed a desire to continue treatment with HCG.
conditions, fibromyalgia, neuropathy, arthropathy, and severe headaches and reports an 85-90% positive response rate.
CH
Dr. Tennant conceded that the study is small and that open-label studies such as this one are inherently biased and nonrandom. “Still,” he noted, “I’ve been specializing in treating pain for several decades, and the improvements I’ve seen in these patients have been impressive.” He currently offers HCG as an adjunct for his severe intractable chronic pain patients with spinal
“Patients with painful fibromyalgia and arthritic conditions began to experience significant relief from their discomfort when prescribed HCG.”
3
Editors Note:
O
I learned about HCG for chronic pain through my patients who were injected with HCG for weight loss. They told me the improvement in pain occurred within 24-48 hours of the first injection and at very low doses. I began asking my patients who were trying to lose weight and on the HCG diet if they too noticed improvement, and to my surprise, many did report significant relief. This piqued my interest; I have since learned there is very little published about this association. Dr. Tennant’s small clinical study is promising and definitely deserving of more investigation. Presently, this is an off label use of HCG and needs more data to support its safe and long term use. National Centers for Pain Management & Research is currently putting together a team to investigate and study the use of HCG for pain. ~ Ty Thomas, MD
• References • • Braunstein GD. Human chorionic gonadotropin. In: William’s Textbook of Endocrinology. 10th ed. Philadelphia, PA: Saunders; 2003:800-803. • Lei ZM, Rao CV. Neural actions of luteinizing hormone and human chorionic gonadotropin. Seminar Reprod Med. 2001;19:103-109. • Lei ZM, Rao CV, Kornyei JL, et al. Novel expression of human chorionic gonadotropin/luteinizing hormone receptor gene in brain. Endocrinology. 1993;132:2262-2270. • Patil AA, Nagaraj MP. The effect of human chorionic gonadotropin (HCG) on functional recovery of spinal cord sectioned rats. Acta Neurochir.1983;69:205-218.
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H3
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• Forest Tennant, MD, DPH. Human Chorionic Gonadotropin in Pain Treatment. Practical Pain Management. 2009, June 1. • US Food and Drug Administration. FDA, FTC act to remove “homeopathic” HCG weight loss products from the market. http://www.fda.gov/NewsEvents/Newsroom/ PressAnnouncements/ucm282334.htm. Accessed December 12, 2011. • Matura S, Okashi M, Chen HC, et al. Physiochemical and immunological characterization of an HCG-like substance from human pituitary glands. Nature. 1980;286:740-741. • Odell WD, Griffin J. Pulsatile secretion of human chorionic gonadotropin in normal adults. N Engl J Med. 1987;317:16881692.
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Custom Compounding By Katie Harbison
Compounding medications was part of the pharmacist’s daily routine before manufacturing companies began the mass production of prescriptions drugs. Pharmacists compounded, or specially blended, almost all prescriptions until the mid twentieth century when large pharmaceutical companies began dispensing medications. Today, pharmaceutical compounding is growing in popularity as physicians search for treatment alternatives for their patients who do not respond well to the typical “one size fits all� therapies. Treatment of acute and chronic pain is not easy. Patients often suffer from various ailments such as arthritis, tendinitis, diabetes, back injury and 52 | Summer /Fall 2013
headaches. Often the medicines prescribed to treat these conditions may be successful in reducing or alleviating the pain, but can leave the patient with intolerable side effects resulting in the inability or unwillingness to continue the treatment. For example, the dry mouth associated with certain drugs can be remedied in a compounded lollipop that increases salivation, therefore avoiding the annoying side effect. For others, the medicine may be working, but not well enough and additional treatment is needed. At National Center for Pain Management and Research Custom Pharmacy, the pharmacists specialize in compounding topical pain creams that allow the patient to apply medications directly to the site of pain. Topical and transdermal creams and gels can be formulated to provide high drug concentrations at the site of application (e.g., NSAIDs for joint PAIN |
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pain). By applying the medications locally instead of taking a pill, the gastrointestinal tract and the bloodstream are bypassed and harmful side effects can be avoided. Furthermore, topical pain creams can be used in conjunction with oral pain medication bringing greater comfort to patients who are currently experiencing limited relief from pain. For patients who suffer vaginal, rectal, or hemorrhoidal pain, suppositories or rectal rockets containing pain medications can be compounded to ease the pain. National Center for Pain Management and Research’s compounding pharmacists can customize treatments for each individual by creating different combinations and strengths of medications based on the physician’s orders. These customized medications usually contain more than one active ingredient and are truly “what the doctor ordered.” Our pharmacists can also tailor the base to which the active ingredients are added. Some patients prefer a thick, cream-like base while others prefer a thin, lotion-like consistency. Patients who have sensitive skin may need a formula prepared for their specific needs. Bases can also be changed to increase or decrease absorption. Compounding pharmacists will work with the patient and the physician to specialize each prescription to meet the unique needs of the patient, especially in the field of pain management. There has never been so many options for the topical treatment of pain as there are today. PAIN |
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Compounded pain creams can contain combinations of any of the following medications: • • • • •
NSAIDS Muscle relaxants Pain blockers Neuropathic agents Anesthetics
NSAIDS, such as, ibuprofen, are used to reduce pain and inflammation. They work by blocking enzymes that increase your pain. By using these drugs topically, we can avoid many of the serious side effects that can happen when NSAIDS are taken orally. Muscle relaxants, such as baclofen or cyclobenzaprine, relax the muscle and decrease muscle spasms by interfering with
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• What is this Stuff? •
neurotransmitters that cause muscle tightness. Pain blockers work by blocking pain receptors, and examples are ketamine and amantadine. Neuropathic agents, such as gabapentin and amitriptyline, interfere with nerves that transmit neuropathic pain. Topical application of these medications helps avoid systemic side effects and allow treatment directly at the site of pain. Additionally, anesthetics numb the area of application increasing pain relief. Examples of anesthetics are lidocaine, tetracaine, and bupivacaine. Prescribing physicians determine which combination of medications will work best for the patient. If the first formula does not work as well as expected, the pharmacist, physician, and patient can work together to create a new combination that better satisfies 54 | Summer /Fall 2013
the needs of the patient. Topical treatment of pain can work for almost everyone. It is a matter of finding the right combination and strength of drug that works best for the patient. Our pharmacy has seen great success in the treatment of pain with topical compounded medications. We believe they are a crucial part of the multimodal treatment of pain.
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Pain Syndromes that respond well to topical compounds: Fibromyalgia Muscle spasms Low back pain Neck pain Osteoarthritis Rheumatoid arthritis
Inflammation Diabetic neuropathy Peripheral neuropathy Hemorrhoids Herpes zoster / PHN Vascular pain (PAD/PVD)
Who Benefits? 90-93% of all pain patients report improvement with a custom topical compound.
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Approximately 50% of all pain patients report 50% or better improvement.
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Favorite Fall Foods
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By Dr. Ty Thomas
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As the summer winds down we start craving, at least I do, fall foods. What does this have to do with pain? Everything and absolutely nothing. This gets to my number one pain relief principle: If it feels or tastes good, it doesn't hurt. There are complicated and controversial neuro-biochemical and metabolic pathways to explain why and how certain good feelings actually relieve pain biologically, but trying to understand why would be painful and defeat the purpose. Instead, let's just talk about my favorite fall foods.
Pumpkin If it’s pumpkin it has to be in a pie. You either are or you aren't a pumpkin pie fan. If you are, then you understand why its number one. If you're not, then your pie is likely pecan. Pumpkin bread and pumpkin cookies are my favorites as well.
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• Favorite Fall Foods •
Apples Apple pie, apple cake (mixed with pumpkin), apple cider (preferably with Tuaca and a few cinnamon sticks perhaps topped with whipped cream.
Chili I don't care what kind of chili, I like it all. Green chili, red chili, deer chili, steak chili, chicken chili, black bean chili. I like it hot and spicy and covered in cheese. Any hot soup is a fall favorite to me. Potato soup, broccoli cheese, any seafood chowder or bisque, and stew are good but they all become great when served in a sourdough bread bowl. Not chili though, it must be served over cornbread. But I'm going to try to make a cornbread bowl now that I'm thinking about it.
Dressing When fall hits, I want this stuff. It has to be drenched in gravy and accompanied with turkey, mashed potatoes, and green bean casserole - The Thanksgiving Meal - another meal I have no interest in during the summer. But strangely, I start preparing it in early September. 58 | Summer /Fall 2013
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Chocolate Chocolate deserves its own page. Usually something so divine can be justifiably eaten any time of year, but I just don't want it when its scorching outside. But come fall weather, I need it. Hot cocoa is the first thing I think about especially at a cool night-time football game. A few of my favorites include: chocolate chip cookies, chocolate pie, a chocolate ganache on anything, chocolate truffles, dark chocolate bars (only because it's supposed to be better for me), and of course M&Ms. Throw some M&Ms in hot popcorn - delicious.
In Summary Certainly, my favorites are not all inclusive for everyone reading this, it isn’t even for me, but it gets my mind excited about it which brings me joy and a sense of well being (with perhaps a hint of guilt). This alone is natures analgesic.
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Eat Your Medicine: Food for pain Sage Stuffed Dressing
Ingredient List
Prepared cornbread the night before, crumble and set aside to dry over night. Set bread out to dry over night.
2 boxes of your fav orite cornbread mix
Preheat oven to 350 degrees F.
1 loaf white bread
Tear bread into pieces and mix with cornbread in large baking dish.
1 large onion, chop
ped
4-5 ribs celery, chop
ped
2 tablespoons fresh 4 cups chicken bro
th
1/2 stick butter salt and pepper
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sage
Heat butter in skillet, add onion and celery; saute until tender, about 5 minutes. Pour over cornbread and bread mixture. Slowly add chicken broth 1 cup at a time, stirring until consistency is mushy. Add sage and salt and pepper to taste. Cover with foil. Bake for 30 minutes then remove foil and bake for another 15 minutes.
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Baked Mac & Cheese
Preheat oven to 375 degrees. Prepare macaroni as directed on package, drain, set aside. Melt butter, stir in flour, mustard and salt. Add milk. Cook and stir on low-med heat until mixture thickens. (Mixture should coat spoon). Remove from heat. Add 1 1/2 cups of cheese. Stir until melted. Add cooked macaroni, mix. Pour into greased shallow baking dish, top with remaining cheese. Bake 20 minutes or until bubbly.
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t List
Ingredien
acaroni
ge elbow m
1 7oz packa
tter
2 tbsp. bu
1 tsp. salt
p cheddar
dded shar
2 cups shre cheese
1 tsp. dried
) mustard (prepared
ur
2 tbsp. flo
2 1/2 cups
milk
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Word Games O J D E U V Y W J Y Z M S V H
U Q O L I H W A W D T I N N H
T C P B Y F Y T Q E G G I E C
S E T A I P O E O S E R N X P
C I H T A P O R U E N A N O F
V E S C S Y E I N X A I A C Y
I H L A G U G P C B S N T P F
M Y C R T X L E A E H E C I J
X H B T Q S S F R N W C L K P
B F F N E I O O I N O V G T W
R X L I C R T E S T L V L K F
I V T R R O T A M Y E J B C K
X P E J N J I S M O V S O W U
V X D I N D A L S Y H Y P C O
E O N B T R I G G E R S Q J R
Word Bank EXERCISE HCG HOMEOSTASIS INTRACTABLE MIGRAINE NEUROPATHIC NSAID 62 | Summer /Fall 2013
OPIATE SEROTONIN STRETCH SULFITES TANNINS TRIGGERS WATER PAIN |
Q U A R T E R L Y
Down: 1) Low impact workout which improves overall fitness.
Across:
3) A risk factor for having a migraine.
2) The first serotonin like drug developed for acute migraine. 6) Spinal cord stimulation is FDA approved for _____. 8) Bone spurs that result in narrowing of the spinal cord is called spinal ______ . 11) A chemical messenger in the brain which drops during migraine. 12) Headache that is usually on one side and involves the eye. 13) A hormone that stimulates the testes, ovaries, thyroid, and adrenal glands. 14) Specially blended prescriptions applied topically. 16) An amino acid released during exercise. 20) Chronic pain can lead to multiple _____ deficiencies. 21) The most common migraine causing food trigger contains.
4) The first phase of a migraine.
For crossword solution visit www.NCPMR.com/puzzle.png
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5) An acute infection of the sinus. 6) ________ fracture is a break in the vertebral body of the spine. 7) Treatment option for a compression fracture. 9) Headache that can be a warning signal for something more serious. 10) Is a block a block? 14) Substance which can both trigger and abate a migraine. 15) Pain management aims to improve quality of ____. 17) Headache that is a result from stopping medication. 18) Type of headache with no clear structural or infectious cause. 19) A protective factor against migraine. Summer /Fall 2013 | 63