Pain Quarterly - Winter Spring 2013

PAIN care in PAIN

Treating

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Volume 1 - Winter/Spring 2013

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Volume 1 • Winter/Spring

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FEATURE

From The Editor: Dr Ty Thomas

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Dr. Thomas talks about why he wanted to produce this magazine and touches up on what he thinks about pain management.

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Chronic Back Pain

When one of the most common physical pain issues arise, what you can do.

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Pain Management: 101

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An introduction to pain management

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Is a Block a Block?

What makes various types of blocks different and how they are performed on the spine.

Find the Right Doctor For You

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Pain comes in many forms, but being comfortable with the right doctor is the most effective treatment.

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The Many Faces of Arthritis

An introduction to the many forms of arthritis and how it can affect one’s life.

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Table Of Contents Prisoner to Cancer Pain

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Rejoining Life

After years of pain a young woman is able to rejoin a life she had given up.

Learn what treatment finally released her suffering

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Therapeutic Exercise

One of many tools to fight pain. Exercise is often the best way to improve pain and quality of life.

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Platelet Rich Plasma for Knee Pain

Learn about PRP, a regenerative treatment for knee pain.

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Prepare Properly for Spring Activity

Expand your taste buds. Two recipes that can enrich your diet and help manage your pain.

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Genetic Testing and Pain

How effective is your medication? Genetic testing can help give you the answer.

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Not only is consistent exercise good for you but sufficient preparation is key to avoiding injury.

Featured Recipes

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Eat Your Medicine: Food for Pain Relief

Introduce new foods that could actually help relieve pain.

My Freedom Sometimes the best pain relief is to relax and soak in the comfort of enjoying what makes you happy.

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From the

Editor

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Dr. Ty Thomas Talks about the publication

Pain Quarterly is a guide for you to learn about different types of pain and the multiple treatments available.

Unfortunately, many people suffering from chronic pain go undiagnosed and untreated. Most people-even most health care providers-- are not fully aware of the existing and emerging options. It is my goal to inform you about chronic pain and what can be done to manage it. Whether you are the one in pain or know someone who is, too many people suffer unnecessarily. This free publication is a take home resource for you.

This magazine is organized to introduce you to pain management, highlight specific pain syndromes, share some comforting stories, and offer games to play perhaps while waiting. I also want ideas in here to help you feel good. Sometimes even doing little things can go a long way to help relieve pain.

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Feel free to pick up this magazine and take it home.

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Chief Editor Ty Thomas Contributor Avery J. McCall Art & Design Christopher Feldmann This magazine is published by Big Hat Management

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For advertising information, contact Big Hat Management at (205) 868-3167 4 | Winter/Spring 2013

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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 few hours.

A lot of forms asking all types of questions, some quite personal, will need to be filled out. In the age of electronic medical records, this data will then be entered digitally where the team of health care providers will go through the information and start the process of determining where the pain originates.

The health care team will then ask additional questions to fill in any gaps and then proceed with a detailed physical exam. Based on this information, lab tests, x-rays,

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nerve tests, vascular studies, MRIs and diagnostic injections may also be ordered.

Next, a detailed treatment plan will be made. Treatment may include medication, physical therapy, supportive bracing, injections, counseling, and other advanced interventions including radiofrequency and neuromodulation.

One of the most difficult parts of the treatment process is finding the pain physician who best suits your needs. For more information on this process, turn to the next article.

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Find the right pain doctor for you

One of the most important and personal decisions you make is choosing a doctor, but if you are hurting, choosing a pain specialist can be even more difficult. Many different types of pain doctors exist, but not all are the same. Some can even be unsafe.

One type of pain doctor is known as a “block jock.”

These doctors often do injections as their only mode of treatment. At the other end of the spectrum are “pill mills.”

They often only prescribe narcotic pain medications as their only mode of treatment without investigating the possible causes. It is important to find a doctor who explores a variety of treatment options. The provider should first try to make an accurate diagnosis by talking with and listening to you, performing a physical exam and ordering labs, X-rays and MRIs. For example, Barbara, a 45-year-old woman with chronic neck and shoulder pain is seen in a pain clinic, she should get a thorough physical exam. It is crucial to document and diagnose the location of the problem. X-rays and/or MRIs can help hone in on the cause of the pain. An EMG or nerve conduction study can determine if some of the pain is caused by the nerves. These tests can also help determine if the problem is old, new or healing. Once

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this data is collected, the doctor may choose a diagnostic or therapeutic injection. This type of diagnostic procedure is important to pinpoint the problem and to develop a long-term treatment plan. Following a solid diagnosis, a multi-modal treatment plan is the patient’s best chance at a long term solution.

After going through the diagnostic process, Barbara was found to have a common form of arthritis in her neck that caused her pain. X-rays showed degeneration in the discs with resulting facet arthritis. The EMG and nerve conduction study were normal, meaning that the nerves in her neck were probably not contributing to her shoulder pain. The doctor prescribed pain medication and a diagnostic nerve block. This procedure resulted in 100% relief from her pain for eight hours. Another block was performed to confirm the results of the first and yielded the same result. For longer lasting results, a radio-frequency ablation was performed and physical therapy was ordered.

Treatment plans range from simple to complex depending on the problem. It is important to use as many approaches to treat your pain in

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FindThe the Right right pain doctor for • • Find Pain Doctor For you You • •

order to achieve the best possible outcome. For example, oral pain medication may give 20-30% relief, topical pain medication may give another 20-30% and physical therapy may help 20-30%.

The relief adds up making a big difference in your pain level and daily function.

Not all pain doctors have the skills and experience that are required to perform procedures or injections.

Your pain doctor may perform the procedure or have a colleague take over. When choosing your doctor, it is important to choose one who will provide a comprehensive approach.

Though a “block jock” may be great at executing procedures, your first priority should be choosing the pain doctor who keeps your total health in mind. This doctor may not always be available, so your primary care doctor may be directing your care.

A primary care doctor might order a slightly different procedure than a pain doctor would, but that slight difference can change the outcome.

Pain medicine is very complicated and usually requires special training.

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Many doctors order a set of three epidurals with little regard for their exact location. If this treatment plan does not work, some doctors would consider your treatment a failure.

As well, insurance may not pay for any additional epidurals beyond this point because the first three were not beneficial. A pain specialist will be able to find the location of the pain to achieve a better result.

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Consider the following when choosing a doctor:

Doctor’s Credentials

Board certification is one of the most important factors to consider. This designation tells you that the doctor has the training, skills and experience in their specific field.

Pain specialists who are board certified in physical medicine and rehabilitation (PMR) or anesthesiology are usually the best. PMR doctors are trained longer in diagnosing, while anesthesiologists have more training with procedures.

Neurologists and psychiatrists sometimes specialize in pain management.

Fellowship training is another important consideration. This additional training may be specifically in pain management or interventional spinal procedures.

You should also confirm that the doctor has no history of malpractice claims or disciplinary actions.

Doctor’s Experience

The higher the level of a doctor’s experience with a condition or procedure, the better your results are likely to be. Age does not equal experience, as many young doctors may have gained more experience in their training.

Gender

It is important for you to feel comfortable with your doctor’s gender because you will need to openly discuss personal information. Since good pain doctors are hard to find, other considerations may take priority over this one.

Communication Style

Choose a doctor whose communication style makes you feel comfortable.

What Your Insurance Covers

Your insurance coverage is a practical matter. To receive the most benefits for the least expense, you may need to choose a doctor who participates in your plan.

Bottom line: Not all pain doctors are the same. Choose one who is board certified, takes a comprehensive approach and spends time trying to make a diagnosis.

Choose one who wants to develop a multi-modal treatment plan to reduce your pain and improve your function.

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Arthritis comes in many forms and can wreak havoc on our lives by interfering with our daily routines. Learn about ways to beat arthritis pain and improve your quality of life.

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ccording to the Arthritis Foundation, arthritis is a complex family of musculoskeletal disorders that is not fully understood. This family consists of more than 100 distinct diseases and conditions with varied causes.

No cure for arthritis has yet been found. The different types of the disease can hinder or halt physical activity as joints, bones, muscles, cartilage and other tissues are destroyed.

Almost one in five adults and approximately 300,000 children are affected. Arthritis is the leading cause of disability in America, and is the second most frequently reported chronic condition. It also causes more limitations on activity than heart disease, cancer or diabetes.

Osteoarthritis (OA) is the most common form of arthritis. This progressive degenerative disease

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causes the breakdown of joint cartilage. You may be at risk for developing OA if you have a history of joint injury, are overweight or obese, or are aging.

Some of the most common pain complaints in the back, neck, knees, hips and hands can be attributed to OA. The goal in treating arthritis is to decrease pain and improve function. Common strategies include weight loss, physical activity, joint protection, heat and cold applications, medications, injections and/or surgery.

Weight loss is the most important way to prevent and slow the progress of OA in weight bearing joints such as the knees, hips and lower back. One study found that every pound of weight lost reduces the pressure on the knee by four pounds. Another study determined that losing 10-15 pounds may PAIN |

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decrease the risk of developing OA by 50% in some.

Physical activity helps to reduce weight, strengthen muscles around the joints, and preserve the joint’s flexibility and functionality. One common form of arthritis can develop in the knee if the quadriceps muscle is weak. If allowed to progress, this disease can move the kneecap out of the groove where it moves. The under surface of the kneecap may break down early, resulting in degenerative arthritis.

Protecting the joint can prevent stress and strain on its surface. A hinged knee brace can take just enough weight off the joint to prevent further damage. Alternately, a cane can help protect an injured hip by shifting weight to the other leg. Back braces reposition weight and keep it off the facet joints, and shoe inserts can properly align or shift pressure off a bad ankle, knee, hip or back.

Medications can help, but should only be used as one of many tools to improve quality of life. Acetaminophen

“Losing 10-15

pounds may decrease the risk of developing OA by 50%.

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• Beat Arthritis Pain •

and NSAIDs (Non-Steroidal AntiInflammatories) can reduce pain and swelling. Opiate medications can be used to treat severe pain. Dietary supplements such as glucosamine and chondroitin may improve pain and function in some people.

Joint injections may also provide lasting benefits. Corticosteroids reduce pain by blocking inflammation and ease swelling in the area.

Another injectable gel-like substance, hyaluronic acid, can coat the joint to provide cushion.

If the gel or steroid does not provide significant relief, alternative treatments may be available. Platelet

Rich Plasma (PRP) can then be injected into the joint. Some early studies have shown that this therapy can regenerate cartilage and improve pain and joint function.

If conservative treatment options have failed and the pain is severe, the nerve transmitting the pain can be altered to stop transmitting the pain signal.

Zapping the nerves in a procedure called radio-frequency can provide relief for 9-12 months.

Many treatments and management techniques exist that can help beat arthritis pain. For more information, schedule an appointment with a qualified pain management doctor.

7 Ways to Beat Arthritis Pain

Weight Loss Physical Activity Joint Protection

Medications Joint injections Radio-frequency Ablation Neuromodulation 14 | Winter/Spring 2013

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CHRONIC 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 16 | Winter/Spring 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. Regardless, this is a

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successful management tool 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.

Medial Branch Block

Facet Join

Interlaminar Epidural Steroid Injection Transforaminal Sacral Epidural Steroid Injection

Caudal Steroid Injection

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The Many Faces of Arthritis According to the Arthritis Foundation, arthritis is a complex family of musculoskeletal disorders consisting of more than 100 different diseases or conditions that destroy joints, bones, muscles, cartilage and other connective tissues, hampering or halting physical movement. When treating arthritis it is important to have an accurate diagnosis which sometimes can be challenging and time consuming. Listed here are brief descriptions from the Arthritis Foundation of some more common diseases.

Ankylosing Spondylitis (AS) Ankylosing spondylitis (AS) is a chronic inflammatory disease that primarily affects the sacroiliac joints (where the spine attaches to the pelvis), spine, and hip joints.

Ankylosing is a term meaning stiff or rigid and spondylitis means inflammation of the spine.

Enthesitis (inflammation of the place where ligaments and muscles attach to bones) accounts for much of the pain and stiffness of AS. This inflammation eventually can lead to bony fusion of the joints (where the fibrous ligaments transform to bone, and the joint permanently grows together).

lining of the joint), with lower limb joints more commonly involved than upper-limb joints.

AS is one of a family of arthritisrelated diseases called the seronegative spondylarthropathies.

Seronegative means people with the disease test negative for the antibody rheumatoid factor and spondylarthropathy means joint disease of the spine.

Ankylosing spondylitis most often develops in young adult men and it lasts a lifetime.

Other joints can also develop synovitis (inflammation of the

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Fibromyalgia (FMS) Fibromyalgia is a syndrome characterized by long-lasting widespread pain and tenderness at specific points on the body.

The term “fibromyalgia” means pain in the muscles, ligaments and tendons. Although not defining characteristics, sleep disturbances and fatigue are also integral symptoms of fibromyalgia.

This condition is referred to as a syndrome because it’s a set of signs and symptoms that occur together with no known cause or identifiable reason. Although considered an arthritis-related condition, Fibromyalgia is not truly a form of arthritis because it does not cause inflammation or damage to the joints, muscles or other tissues. It is, however, considered a rheumatic condition because it impairs the joints and/or soft tissues and causes chronic pain.

Fibromyalgia is an especially confusing and often misunderstood condition. Because its symptoms are quite common and laboratory tests results generally are normal, people with Fibromyalgia were once told that their condition was “all in their head.” However, medical studies have proven that Fibromyalgia does indeed exist, and it is estimated to affect about two percent of the U.S. population today.

Although Fibromyalgia has no cure, it isn’t a progressive disease, meaning that it will not get worse over time and it’s never fatal. With a treatment plan that integrates several modalities that include exercise, rest, stress relief, coping skills and medications, people with Fibromyalgia can live happy, productive lives.

Gout Gout is a form of inflammatory arthritis that causes sudden, severe pain, swelling and tenderness – most often in the large joint of the big toe. However, gout isn’t limited to the big toe; it can affect other joints including the feet, ankles, knees, hands, wrists, elbows and sometimes soft tissue and tendons.

It usually affects only one joint at a

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time, but it can become chronic and, over time, affect several joints.

A gout attack can last anywhere from a few days to two weeks, if untreated. An estimated 6.1 million Americans have experienced at least one gout attack. The disease most commonly affects men and can manifest anywhere from age 30 onward.

Women get gout too, although they are at a slightly lower risk, and it usually appears after menopause.

Lyme Disease Lyme disease is an infectious disease that can cause arthritis as one of its symptoms. The infection occurs when a deer tick that is infected with the spirochete bacteria Borrelia burgdorferi bites a human and transmits the bacteria to the human. The bacteria usually produce a rash and mild flu-like symptoms at first. These symptoms are often not noticed or are ignored by the person. After weeks and months of untreated infection, more symptoms may develop, including heart and nervous system problems and arthritis.

Lyme disease can be cured with antibiotic treatment. If the disease is caught early, treatment does not 22 | Winter/Spring 2013

take too long and is very successful.

If the disease has gone on for a long time before antibiotics are begun, treatment may take a while and it can take months for the symptoms to clear up.

Anyone who is bitten by an infected tick can develop Lyme disease.

Ticks in different sections of the United States and Europe are most likely to be carrying the bacteria.

Endemic areas of the United States include the northeastern, middle Atlantic and north central states, as well as some areas of the north Pacific coast. Children tend to get Lyme disease more often than adults because they tend to play in the tall grass and woods where deer ticks live.

Myositis Myositis is defined as the inflammation of muscles (“myo” means muscle and “itis” means inflammation). The inflammatory myopathies are a group of disorders characterized by inflammation and weakness mainly of the muscles closest to the trunk of the body (proximal muscles). These disorders include polymyositis, dermatomyositis and inclusion body myositis. Myositis may be associated with inflammation in other organs, including the joints, heart, lungs, intestines and skin. In dermatomyositis, a rash PAIN |

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• The Many Faces of Arthritis • develops in addition to the muscle inflammation.

Osteoarthritis Osteoarthritis (OA) is one of the oldest and most common forms of arthritis and is a chronic condition characterized by the breakdown of the joint’s cartilage. Cartilage is the part of the joint that cushions the ends of the bones and allows easy movement of joints.

The breakdown of cartilage causes the bones to rub against each other, causing stiffness, pain and loss of movement in the joint.

Today, an estimated 27 million Americans live with OA, but, despite the frequency of the disease, its cause is still not completely known and there is no cure. In fact, many different factors may play a role in whether or not you get OA, including age, obesity, injury or overuse and genetics. Your OA could be caused by any one or by a combination of any of these factors.

Psoriatic Arthritis Psoriatic arthritis (PsA) is a type of chronic inflammatory arthritis associated with the chronic skin condition psoriasis, which is believed to be an inherited condition. Psoriasis, which affects about 2 percent of the U.S. PAIN |

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population, most often causes patches of thick, reddened, irritated skin with flaky, silver-white patches called scales.

Psoriatic arthritis typically appears about 10 years after the onset of psoriasis, which can manifest at any age, though most people are diagnosed between the ages of 15 and 35.

Reflex Sympathetic Dystrophy Syndrome (RSDS) / Complex Regional Pain Syndrome (CRPS) Reflex sympathetic dystrophy syndrome, or RSDS for short, involves a disturbance in the sympathetic nervous system which is the network of nerves located alongside the spinal cord and controls certain bodily functions, such as opening and closing blood vessels or sweat glands. It primarily affects the hands and feet but can involve many areas

Rheumatoid Arthritis Rheumatoid arthritis (RA) is a form of inflammatory arthritis and an autoimmune disease.

In RA, for reasons no one fully understands, the immune system – which is designed to protect our health by attacking foreign cells such as viruses and Winter/Spring 2013 | 23

bacteria – instead attacks the body’s own tissues, specifically the synovium, a thin membrane that lines the joints. As a result of the attack, fluid builds up in the joints, causing pain in the joints and inflammation that’s systemic – meaning it can occur throughout the body.

An estimated 1.3 million people in the United States have RA—that’s almost 1 percent of the nation’s adult population. There are nearly three times as many women as men with the disease. In women, RA most commonly begins between the ages of 30 and 60. It often occurs later in life for men.

Systemic Lupus Erythematosus (Lupus) (SLE) Lupus is one of many disorders of the immune system known as autoimmune diseases. In autoimmune diseases, the immune system turns against the body it’s designed to protect for unknown 24 | Winter/Spring 2013

reasons. Most often when people speak of lupus, they are speaking of systemic lupus erythematosus (SLE) and it is what this article primarily is about. SLE is an inflammatory, autoimmune disease that affects nearly every organ system in the body, including the skin, joints, kidneys, heart, lungs, and central nervous system. SLE is only one type of lupus.

Tendinitis A tendon is a cord of tough tissue that connects muscle to bone. The tendon is surrounded by a sheath that protects and lubricates the tendon. This sheath is lined by a layer of cells called the synovium.

Occasionally, the tendon will become inflamed (called tendinitis) or the tendon sheath will become inflamed (called tenosynovitis).

These conditions together are known as tendinitis and result in pain, stiffness and sometimes swelling.

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• The Many Faces of Arthritis •

Tendinitis usually is caused by a specific injury or by repetitive overuse, especially when using poor body position. Tendinitis can occur in young athletic people in response to sports injuries and overuse. However, tendons become less flexible with aging and tendinitis is common in middle aged and older adults.

In general, tendinitis can occur suddenly, may last for days, weeks or longer, and then go away. It can, however, occur again in the same place. When properly treated, it general doesn’t result in permanent damage or disability.

Prisoner to Cancer Pain One woman’s struggle with cancer pain and finding pain relief Written by Avery J. McCall

The elevator doors slid open to reveal the nurses at their posts. I did not need to ask which room my friend occupied. I could hear her cries from around the corner and down the hall. It was 2:54 am. It had taken me 45 minutes to wake up and make the 21 mile drive. I knew what to expect as I steadied myself at the door before entering. I had made this same trip many times.

“Hon? Can you tell me what level your pain is?” The nurse held her clipboard, prepared to scribble down Donna’s response. My eyes met those of Donna’s bewildered husband Nick. He sat worn and speechless.

Witnessing his beloved 42-year-old wife’s pain had become a daily routine, yet it was one he would never grow accustomed to.

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I took off my wool coat as I stepped in.

“I think it’s safe to assume it’s a 10.” I hoped my words were not too harsh, but it was a stupid question. Unable to speak through the pain and involuntary rhythmic moans, Donna attempted a slight nod of confirmation.

We had been through this routine with the doctors and nurses countless times over the past four months. Donna suffered from colorectal cancer. The pain she endured was more than a human body could withstand. Daily cocktails of pain medications left her almost comatose and unable to recognize or respond to her three children.

“The pain she endured was more than a human body could withstand.“ Donna was diagnosed on March 18, 2010 with stage 3 colorectal cancer, and spent the first months afterwards at home trying to maintain a level of normalcy for 18-year-old Kirk, 14-yearold Jayson and 8-year-old Mattie.

Homeschooling them kept her mind focused and off her constant pain. The fear of the unknown and the persistent pain were a constant reminder of the fragility of life.

Radiation and chemotherapy successfully shrank the tumor for removal, but scar tissue and a fistula 28 | Winter/Spring 2013

from the radiation forced an unwelcome colostomy. The pain and discomfort mounted. Further testing to confirm remission left us all on edge as we waited, hope and fear intermingled in our thoughts.

Many prayers and meals from family and friends helped sustain the family’s semblance of life. A debilitating phone call came from the doctor after seven months of their new regular routine. “By the way Donna, the cancer is back.”

In 13 days, Donna underwent 26 proton therapy treatments in conjunction with chemotherapy to fight the recurring tumor. The growth of a new mass explained the unremitting pain.

The family structure Donna’s family was accustomed to no longer existed, but a new form of normal began to take shape. Dinners delivered by extended church family and visits from friends took the place of homework. Donna could no longer lie flat in her bed. The luxury of sleeping next to her husband was replaced with restless nights trying to find a moment’s relief in the family room recliner.

The pain intensified. Large doses of oral pain medications caused agonizing constipation which added to the anguish.

The number of weekly visits to the emergency room increased, sometimes to three in a seven-day period. When the combination of nearly lethal doses of PAIN |

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medications would not ease the pain, the emergency room was the only option.

The oncologist and pain management team at the hospital did not have any other suggestions for controlling her pain. I do not believe they did not care. I believe they did not know.

who home-schooled her three children and made a home for her family.

Eighteen months into her battle, I would enter her hospital room to find books and spiral-bound notebooks spread across her bed while Mattie practicing her fractions. Sitting in the corner, Jayson would be “The luxury of sleeping quietly watching over his mother next to her husband was while his father had to work. Kirk replaced with restless would join after his nights trying to find a classes at the local university. moments relief in the

Unbearable pain was simply a part of her cancer.

Everyone was sympathetic, but as I witnessed the episodes my friend underwent, I grew angrier and This family was no family room recliner.” more frustrated. stranger to cancer My questions after Jayson won his went unanswered. I was surprised battle with leukemia as a 3-year-old. at the doctors’ and nurses’ apparent This family knew how to be tough. They lack of knowledge about this level of knew how to be strong. They did not pain and how to treat it. While she know how to give up. There had to be a was hospitalized, she was offered way to alleviate the pain. a combination of her at-home The pain increased and the doctors grew medications and IV administered drugs cavalier in their “comatose is better than to help ease her suffering. Overdose pain” attitude. I began to think outside was a constant threat at the heels of oncology. Good pain management was complete lethargy from so many drugs. what Donna needed. How could she The side effects took their toll as Donna fight the cancer if her body was trying to tried to shuffle to the restroom from her survive the pain? hospital bed. When she lost her balance I contacted my brother – a pain and landed on her face, the result was a management specialist in Birmingham, broken nose.

Alabama – for help. He too was Donna had been a stay-at-home mom PAIN |

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frustrated and disappointed that health care professionals are still unaware of the many interventions available for this type of severe pain. He recommended a pain pump as an option. A pain pump administers controlled doses of medicine directly into the spinal cord, reducing the side effects of heavy oral medication.

When I mentioned this to Donna’s doctors and nurses, they were completely unaware of this treatment or did not consider her a candidate. After weeks of being dismissed by local specialists, my brother made the necessary contacts in our area to get a pain pump placed.

Twenty-one months after her battle began and a few weeks before Christmas 2011, Dr. Douglas Beall implanted the pain pump.

“Good pain management was what Donna needed.”

30 | Winter/Spring 2013

The pump became our new best friend and was a miracle to our search for relief. Donna enjoyed going to the movies with her kids for the first time since the battle began. She was able to help them with their homework and have conversations without falling asleep.

Mattie’s rushing to the front doors to escape her mother’s cries of pain came to an end.

“Mama was able to go to Wal-Mart with me for the first time since she got sick.” Mattie did not realize it had been nearly two years.

Here was a newfound freedom from pain, a new life.

Christmas found Donna’s family back in the hospital to tweak the dosage of the pump as her body grew accustomed to it. The nurses at Dr. Beall’s facility a Christmas tree to decorate the room. Dr. Beall took time from his own family to check on Donna and her family’s progress and comfort

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• Prisoner to Cancer Pain • during his own Christmas celebrations.

This treatment was a welcome change from earlier experiences. After a few days of adjustments, she and her family returned home.

The most joyous moment after receiving the pump came when Donna was able to leave the family room recliner. Her eyes grew misty with gratitude as she described the feel of her husband’s arms wrapped around her as she lay beside him for the first time since the pain from the tumor invaded their lives.

This was a hope she had given up.

“Who knew my greatest anniversary gift would be the ability to lie next to my wife?” Nick reflected on the moment he

Cancer pain is a terrible thing to endure and to witness.

It should not have been so difficult to find some relief.

was able to hold his wife again without causing her great pain.

Donna celebrated her 42nd birthday alert and coherent and in minimal pain. Friends and family gathered with food and gifts to mark the occasion, and Donna was able to sit up and enjoy the party.

The frequency of visits to the emergency room was lessened as was the nightly monitoring and administering of oral medications.

Unfortunately, the cancer had begun to spread. Donna had eight months of relatively controlled pain as a more interactive part of her family. Out of 29 months of battling for her life, 21 were spent in excruciating pain.

Time Donna should have had to spend with her children was wasted in the hospital begging for relief or being heavily medicated in her recliner, a prisoner to pain.

Her long and frustrating battle was not only against the cancer but with the team of physicians and nurses as well. Her quality of life for the remaining weeks and months made a difference in a 9-yearold’s last memories with her mother.

Cancer pain is a terrible thing to endure and to witness. It should not have been so difficult to find some relief. “We just didn’t get it in time.” Nick whispered.

His regret was mixed with thoughts of “what if.” What if she had gotten the pump twelve months earlier? What if she would have been stronger to fight the cancer? What if she had been able to

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• Prisoner to Cancer Pain • make the long ride in the car to treatment facilities?

Donna did not survive her battle with colorectal cancer and passed on Aug. 8, 2012. However, her last days were not spent suffering in pain. For that, her family and friends are forever grateful.

Editorial Comment:

Above: Donna able to interact and help her daughter, Mattie, with homework.

Below: Donna with her Husband and children before the Cancer.

I was personally involved with this story.

Unfortunately, cases like this one occur too often. Many of us know someone with cancer and have seen how painful cancer can be. This pain often destroys any remaining quality of life. While everything about pain or how to cure it is not known, we have come a long way in its management. It saddens and angers me when someone suffering from terminal cancer pain is denied relief because many in the medical community do not know what treatment options are available. Stories like Donna’s need to be heard so others do not have to suffer unnecessarily.

Managing pain is about adding quality to life, and I wish we could have provided Donna this valuable time earlier.

-Ty Thomas, MD.

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SynchroMed® II Stands the Test of Time More than 1 billion patient-hours of drug delivery provided by SynchroMed® devices each year.*

professional.medtronic.com

© 2012 Medtronic, Inc. Printed in USA.

*Approximately 122,000 implanted devices x 8760 patient-hours per year.

SynchroMed® II Drug Infusion System Brief Summary: Product technical manuals and the appropriate drug labeling must be reviewed prior to use for detailed disclosure. Indications: US: Chronic intraspinal (epidural and intrathecal) infusion of preservative-free morphine sulfate sterile solution in the treatment of chronic intractable pain, chronic intrathecal infusion of preservative-free ziconotide sterile solution for the management of severe chronic pain, and chronic intrathecal infusion of Lioresal® Intrathecal (baclofen injection) for the management of severe spasticity; chronic intravascular infusion of floxuridine (FUDR) or methotrexate for the treatment of primary or metastatic cancer. Outside of US: Chronic infusion of drugs or fluids tested as compatible and listed in the product labeling.

Contraindications: Infection; implant depth greater than 2.5 cm below skin; insufficient body size; spinal anomalies; drugs with preservatives, drug contraindications, drug formulations with pH ≤3, use of catheter access port (CAP) kit for refills or of refill kit for catheter access, blood sampling through CAP in vascular applications, use of Personal Therapy Manager to administer opioid to opioid-naïve patients or to administer ziconotide. Warnings: Non-indicated formulations may contain neurotoxic preservatives, antimicrobials, or antioxidants, or may be incompatible with and damage the system. Failure to comply with all product instructions, including use of drugs or fluids not indicated for use with system, or of questionable sterility or quality, or use of non-Medtronic components or inappropriate kits, can result in improper use, technical errors, increased risks to patient, tissue damage, damage to the system requiring revision or replacement, and/or change in therapy, and may result in additional surgical procedures, a return of underlying symptoms, and/or a clinically significant or fatal drug under- or overdose. Refer to appropriate drug labeling for indications, contraindications, warnings, precautions, dosage and administration information, screening procedures and underdose and overdose symptoms and methods of management.

Physicians must be familiar with the drug stability information in the product technical manuals and must understand the dose relationship to drug concentration and pump flow rate before prescribing pump infusion. Implantation and ongoing system management must be performed by individuals trained in the operation and handling of the infusion system. An inflammatory mass that can result in serious neurological impairment, including paralysis, may occur at the tip of the implanted catheter. Clinicians should monitor patients on intraspinal therapy carefully for any new neurological signs or symptoms, change in underlying symptoms, or need for rapid dose escalation. Inform patients of the signs and symptoms of drug under- or overdose, appropriate drug warnings and precautions regarding drug interactions, potential side effects, and signs and symptoms that require medical attention, including prodromal signs and symptoms of inflammatory mass. Failure to recognize signs and symptoms and seek appropriate medical intervention can result in serious injury or death. Instruct patients to notify their healthcare professionals of the implanted pump before medical tests/procedures, to return for refills at prescribed times, to carry their Medtronic device identification card, to avoid manipulating the pump through the skin, to consult with their clinician if the pump alarms and before traveling or engaging in activities that can stress the infusion system or involve pressure or temperature changes. Strong sources of electromagnetic interference (EMI), such as short wave (RF) diathermy and MRI, can negatively interact with the pump and cause heating of the implanted pump, system damage, or changes in pump operation or flow rate, that can result in patient injury from tissue heating, additional surgical procedures, a return of underlying symptoms, and/or a clinically significant or fatal drug underdose or overdose. Avoid using shortwave (RF) diathermy within 30 cm of the pump or catheter. Effects of other types of diathermy (microwave, ultrasonic, etc.) on the pump are unknown. Drug infusion is suspended during MRI; for patients who can not safely tolerate suspension, use alternative drug delivery method during MRI. Patients receiving intrathecal baclofen therapy are at higher risk for adverse events, as baclofen withdrawal can lead to a life threatening condition if not treated promptly and effectively.

Confirm pump status before and after MRI. Reference product labeling for information on sources of EMI, effects on patient and system, and steps to reduce risks from EMI. Precautions: Monitor patients after device or catheter replacement for signs of underdose/overdose. Infuse preservative-free (intraspinal) saline or, for vascular applications, infuse heparinized solutions therapy at minimum flow rate if therapy is discontinued for an extended period of time to avoid system damage. EMI may interfere with programmer telemetry during pump programming sessions. EMI from the SynchroMed programmer may interfere with other active implanted devices (e.g., pacemaker, defibrillator, neurostimulator). Adverse Events: Include, but are not limited to, spinal/vascular procedure risks; infection; bleeding; tissue damage, damage to the system or loss of, or change in, therapy that may result in additional surgical procedures, a return of underlying symptoms, and/or a clinically significant or fatal drug underdose or overdose, due to end of device service life, failure of the catheter, pump or other system component, pump inversion, technical/programming errors, or improper use, including use of non-indicated formulations and/or not using drugs or system in accordance with labeling; pocket seroma, hematoma, erosion, infection; post-lumbar puncture (spinal headache); CSF leak and rare central nervous system pressure-related problems; hygroma; radiculitis; arachnoiditis; spinal cord bleeding/damage; meningitis; neurological impairment (including paralysis) due to inflammatory mass; potential serious adverse effects from catheter fragments in intrathecal space, including potential to compromise antibiotic effectiveness for CSF infection; anesthesia complications; body rejection phenomena; local and systemic drug toxicity and related side effects; potential serious adverse effects from catheter placement in intravascular applications. Lioresal® is a registered trademark of Medtronic, Inc. USA Rx Only Rev 0911

Rejoining Life

Written by Avery J. McCall

How Peripheral Nerve Stimulation Changed a Life.

“Here, Summit!” Jenny called to her over-zealous yellow lab as he retrieved the stick she had just thrown.

“I cannot believe I am doing this!”

Jenny’s enthusiasm matched her dog’s as she tucked an auburn strand back into her ball cap. It had been over three years since they had played fetch. Pain had taken over and kept Jenny a prisoner in her bed. For that time, she had been unable to socialize and miserable each morning until she escaped into a medicated sleep.

Twenty-four-yearold Jenny and her mother made countless appointments with various doctors: her

Another trip to yet another doctor led Jenny down a path no woman wants to go. gynecologist, pain specialists and surgeons. Tests were repeated with the same inconclusive results. No doctor could determine the source of her pain, which radiated from her abdomen. She had undergone multiple local blocks and epidurals for temporary relief. No one doctor agreed with another. Jenny and her mother just wanted someone to manage Jenny’s countless tests and reports and to find a direction.

Another trip to yet another doctor led Jenny down a path no woman wants to go.

“Jenny, I am sorry to have to tell you this, but you need to have a complete hysterectomy. This is where we believe your pain originates.” The doctor was kind and expressed his heartfelt sympathy, but it did nothing to ease the devastating blow. This was not something she was prepared to embrace; the realization that she would never bear her own children.

Convinced her life would be confined to a medicated stupor to avoid her pain, Jenny agreed that surgery was her only option.

Jenny and her mother were hopeful the drastic measure would end the

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suffering. As the recovery process progressed, they waited for the pain to subside, confident the current discomfort was due to the actual procedure. Six weeks into the postsurgical healing, Jenny’s hopes were dashed.

“Mom, it didn’t help.” Her tears in mourning her future overshadowed those from her physical pain.

The pain continued. Months of physical therapy only left her with more tenderness. Work was no longer an option when Jenny could not get out of bed for many days in a row. Friends began to fade away, but she did not blame them. They did not know what to do or say, and she only slurred her words and fell asleep when they visited. Her mother made her meals and brought them to her room. Sometimes they would sit together and watch TV. It became difficult to read when the narcotics caused her eyes to blur and

They refused to start hoping only to have their hopes broken.

help control her pain. She contacted him right away and scheduled yet one more appointment. They refused to start hoping only to have their hopes dashed.

The doctor explained the need to know where the pain was coming from. After a few diagnostic blocks, the doctor decided that Jenny was a good candidate for something called a peripheral nerve stimulation trial. He told her this trial was one of the very few things in medicine that patients get to try before the device is surgically implanted. Jenny only wished this option had been available before her hysterectomy.

Anxiety seized Jenny’s mind as they arrived at the doctor’s office for the procedure. The doctors and nurses gave her medication to calm her nerves, but she remained awake for the process.

The area was injected with a numbing medication so she did not feel much pain during the 30 minute procedure.

For the next hour, she began trial programming to block her pain. She was sent home with several

grow heavy. Summit would sit with his chin perched on her bed until he would give up and curl up on the floor.

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• Rejoining Life •

possible programs to try over the next few days.

With Christmas and New Years right around the corner, the trial was determined a success and the doctor scheduled the implant procedure immediately. Jenny was pleased to learn she would not be awake for the permanent implant. The nurses were very reassuring as they prepared her for the sedation.

waking up, you can come on back.” The nurse’s voice brought her back to the present.

Jenny held a cup of Sprite as her mother rounded the corner to recovery.

They prepared to go home with Jenny experiencing only mild soreness due to the tiny incisions. She dressed and climbed into the chair. She was apprehensive to acknowledge the absence of the intense pain that had been her constant enemy.

“Is it in my head or could it possibly be working already?” tried to contain her head or Jenny optimism.

“Is it in my could it possibly be working already?”

Jenny’s mother waited as her daughter received the device. Why had no one told them of this before?

She determined right then to ask questions and discover why it had taken so long to get help.

“Mrs. Davis, Jenny is

36 | Winter/Spring 2013

“It can most definitely be working.” The doctor informed them. “That is how the stimulator is designed to work.”

Tears of relief threatened to spill over but Jenny was still afraid to believe it possible. They would go home and return the following day. Over the next two days the doctor was very patient as he tweaked the stimulator to Jenny’s specific needs.

“Good morning, Mom.” Jenny greeted her mother in the kitchen one week after having the implant.

“I would not have believed it if I hadn’t witnessed it with my own eyes.”

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Jenny’s mother squeezed her daughter until they both were laughing through their tears. “Mom, I think I would like to go shopping. I am ready to start my life again.�

Editorial Comment: A patient of mine came to me after seeing me on the news talking about spinal cord stimulation and peripheral nerve stimulation treatments for chronic pain. Jenny, whose name has been changed, suffered from severe abdominal pain.

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She had seen many other doctors and had some serious surgical procedures for pain relief. I see this all too often.

I am a supporter of surgical intervention, but only as the last option. Jenny had a hysterectomy and cannot have children now as a result of a surgery which, sadly, did not help her pain. Her story illustrates the importance of keeping aware of emerging medical procedures before choosing to proceed with significant surgery. The peripheral nerve stimulator is not a well-known treatment option for chronic abdominal pain. I hope to change that.

-Ty Thomas, MD.

Winter/Spring 2013 | 37

PRP A promising treatment may reduce knee pain

First, blood is drawn from a vein.

Platelet Rich Plasma Regenerative Pain Medicine Regenerative medicine is a relatively new and rapidly evolving field of pain management. This treatment uses processes that regenerate or repair damaged tissue. The initial results from studies are promising for its application to common knee pain.

Arthritis is the most common cause for knee pain. By definition, arthritis in this area causes the destruction of the knee joint. Platelet Rich Plasma (PRP) is plasma that contains a lot of platelets. When the body is injured, platelets are the first responders that direct and control healing. With chronic knee pain and joint injuries from arthritis, injecting a concentration

of platelets to the damaged area should, in theory, heal the tissue. In the knee specifically, cartilage degenerates from arthritis. In some studies, platelets have been shown to regenerate cartilage. More significantly, PRP injections have been shown to decrease arthritis related pain.

The first step in PRP therapy is to draw a small blood sample, which is sent through a centrifuge. This process separates the platelets from the other parts of the blood by spinning the sample at a high speed. The resultant concentrated platelet rich plasma (PRP) is injected into and around the point of injury to jump start and

Blood is centrifuged and platelets are concentrated and separated

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strengthen the body’s natural healing. This procedure carries no risk of a transmissible infection and a very low risk of allergic reaction because your own blood is used. The procedure is performed in a medical office and takes approximately one hour, so no hospital stay is required. Most people return to their jobs or usual activities immediately following the procedure.

Research studies and clinical practice have shown PRP therapy to effectively relieve pain and allow patients to return to their normal lives.

Both ultrasound and MRI images have shown definitive tissue repair after PRP therapy, confirming the healing process.

Treating injured tissues before the condition is irreversible can greatly reduce future need for surgery.

The goal of PRP therapy is to resolve pain through natural healing, so it may have lasting results. Initial improvement can be seen within a few weeks, and further improvement may be noted as the healing progresses.

Concentrated platelets suspended in plasma are injected.

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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 individuals’ response while reducing the chance of serious side effects and drug interactions.

Winter/Spring 2013 | 41

Therapeutic Exercise Exercise is often the best way to improve pain and quality of life. It can not only reduce pain, it can also improve functions that are often compromised by severe pain.

If you are suffering from back or joint pain, the last thing you may want to do is exercise. In the old days, doctors used to prescribe rest for pain. Since then, studies have found that inactivity actually makes pain worse. Exercise can increase your pain threshold, which means it will take more painful stimulus for you to feel pain. Chronic pain reduces your pain threshold, making even little aches potentially painful.

Therapeutic exercise is a term describing bodily movement prescribed by a health care provider to correct an impairment, improve musculoskeletal function, or maintain a state of well-being. Therapeutic exercise seeks to accomplish the following goals: • Improve ability to get around and walk

• Improve ability to breathe freely

• Help relax painful contracted muscles, tendons, and fascia

• Reduce overall body stiffness

• Get stiff and painful joints mobile • Improve blood flow

• Improve balance and coordination • Improve muscle strength • Improve exercise performance and endurance

Therapeutic exercises aimed at achieving and maintaining physical fitness fall into the following major categories: • Endurance training

42 | Winter/Spring 2013

• Resistance training

• Flexibility training

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One of many tools to fight pain Exercises that use large muscle groups that can be maintained continuously and are aerobic in nature are recommended. These exercises include the following: • Walking

• Stair climbing

• Skating

• Running

• Cycling

• Jogging

• Swimming

• Aerobic dance/exercise classes

• Dancing

• Rowing

• Jumping rope

The exercise session should consist of the following: • A warm-up period of approximately • Endurance training (20-60min).

10 minutes - This should combine • A cool-down period of 5-10 minutes. stretching exercises and progressive aerobic activity that should increase the heart rate close to the prescribed heart rate for the session.

Progression must be a part of an exercise program to ensure continued results.

With endurance training, progression can occur by increasing the duration or the intensity. Several factors contribute to the optimal rate of progression; current activity levels, exercise goals, age, and physiologic limitations should be considered. Most importantly, a rate of progression should be used that results in long-term participation.

For detailed instruction about starting a therapeutic exercise program, I recommend seeing a doctor to make sure you are safe to begin and to help set goals. Your doctor may then refer you to a physical therapist, athletic trainer, or personal trainer to guide you to your overall health goals.

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Prepare Properly...

Regardless of weather and temperature, proper preparation for activity helps to prevent injury while making the activity more enjoyable. Most injuries occur when we go from a relatively dormant inactive state during colder winter months to increased activity when the weather changes.

Surprisingly most of us do not have a routine to prepare.

to the point where you begin to perspire. Then begin your stretches slowly without bouncing. Stretch to where you feel a slight, easy stretch. Hold the stretch for 10 to 30 seconds.

As you hold

Prior to engaging in activity this season, try stretching and warming up first. The following pages show stretches for different body parts you can perform based on the activity you plan to do.

These stretches should be performed prior to activity. To really improve your overall flexibility for your activity, perform these stretches daily. Plus, stretching makes you feel good.

First, let's review how to warm up and stretch. Do a light warm-up of walking, light jogging, jumping jacks, or side shuffling prior to stretching 44 | Winter/Spring 2013

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for Spring Activity! this stretch, the feeling of tension should diminish. If it doesn't, just ease off slightly into a more comfortable stretch. Once the feeling of tension diminishes, then move a fraction of an

inch farther into the stretch until you feel mild tension again. Hold here for an additional 10 to 30 seconds. This feeling of stretch tension should also slightly diminish or stay the same. If the tension increases or becomes painful, you are over-stretching. Ease off a bit to a comfortable stretch.

Hold only stretch tensions that feel good to you. The key to stretching is to be relaxed while you concentrate on the area being stretched. Your breathing should be slow, deep and rhythmical. Don't worry about how far you can stretch.

Most injuries occur to areas deconditioned around a joint. The joints which take the most loads are the knee, shoulder and lower back.

To help prevent injury, strengthen the muscles around these joints which help the joint function properly.

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Prepare Properly for Spring Activity Golf is one popular spring activity for which most people neglect to properly prepare. Many golfers arrive at the golf course, may hit a few range balls, then step onto the first tee. The following preparation routine can help loosen and prepare the muscles for a great round of golf while significantly reducing chance of injury.

Brief Warm Up Period This can begin to warm up your body and bring your heart rate up to activity level while also beginning to stretch the torso, low back, arms, and legs. Perform for 2-5 minutes.

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This routine should be preceded by a brief (2-5 minutes of light jogging/walking/jumping) warm up period to bring the heart rate up to activity levels, the point where you begin to perspire.

This routine can also be used for a variety of spring time activities, such as tennis, gardening, swimming, baseball, and cycling.

Shoulder Warm Ups Start by slowly rotating the shoulders with arms moving in a small circular motion. Perform for 20 rotations forwards and backwards. Repeat again but with a larger circular motion.

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Prepare Properly for Spring Activity

Shoulder Shrugs Shrug your shoulders loosely. Try adding forward and backward rotation to the movement. Perform 20 times in each direction.

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Shoulder Capsule Stretch Hold a golf club in one hand while using the opposite hand to pull the club across your body. Perform on both sides.

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Prepare Properly for Spring Activity

Shoulder Stretch Starting in rest position, pull up on one arm as indicated while stretching the other. Perform right hand up and left hand up positions.

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Lower Extremity Stretch A golf cart is a good prop to use for these stretches.

Anchor your foot in a comfortable position on the cart. Slightly bend the knee and gently lean in to stretch the lower back and buttock.

From the previous position, stand up straight and bend the knee 90Ëš. With your hands on your hips, gently push your hips forward to stretch your hamstring while also stretching the opposite thigh and calf.

From the previous position, straighten your knee and gently lean forward to stretch the hamstrings.

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Prepare Properly for Spring Activity

Lower Extremity Stretch

Lower Extremity Stretch

Cross your legs. Place your hands on your hips. Gently lean to one side to stretch the outside of your hip.

Stand with your feet shoulder width apart or wider. Gently bend forward to reach your toes.

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Lower Extremity Stretch From the previous position, widen your stance. With the opposite arm, gently bend forward to touch your toes. Upon completion, bend your knee and slowly lean to your side to stretch the groin area.

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Prepare Properly for Spring Activity

Upper Torso Stretch Elevate both arms as shown.

Bend your arm over your head. With the opposite arm, gently pull and lean to stretch the upper back and side.

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Forearm & Wrist Stretch Bring your hands together.

Gently push your hands down and lift your elbows up to stretch the forearm.

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Low Back Warm-Up Forearm & Wrist Stretch Hold your arm straight as shown. With the opposite hand, gently grasp the hand and bend down to stretch the extensor forearm.

While holding a golf club parallel to your body, slowly rotate the low back and hip region comfortably in both directions. Perform 20-30 times until you feel loose.

Now you are ready to hit the course.

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Eat Your Medicine:

Food for pain relief

A healthy diet can help maintain health, prevent disease and even fight chronic conditions. The body requires a balance of vitamins, minerals, proteins, carbohydrates and fats to keep every part functioning at its best. Though some benefit can be gained by taking multivitamins, eating nutrient-rich foods can naturally fill this need.

Ginger Foods and herbs have been used since ancient times to fight pain. Ginger has been and still is used in India, Asia and The Middle East to combat many symptoms and diseases including the common cold, nausea and even arthritis. This yellowgreen root is rich in compounds that fight inflammation. According to two recent studies, patients taking ginger experienced decreased levels of pain compared to patients taking a placebo.

Turmeric Another cooking spice believed to fight pain is turmeric. In Sept.

2012, 71 registered clinical studies of the health effects of turmeric and its main ingredient curcumin were underway. This member of the ginger family has been used medicinally in India for thousands of years.

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Capsaicin Capsaicin is the chemical that gives chili peppers their spice. It is also the main ingredient in many over-the-counter pain relief creams like Arthricare, Capsagel and Zostrix. By interfering with the chemical that sends pain signals to the brain, capsaicin can reduce and relieve pain.

As with any major lifestyle changes, consult with your primary care physician before making significant modifications to your diet.

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Cinnamon Like capsaicin, cinnamon has been shown to reduce pain and inflammation. Cinnamon has many other healing attributes.

It’s flavor is mild enough for drinks, on fruits, and stews and soups. Cinnamon’s phytochemical compounds help control blood sugar, cholesterol, and triglycerides. Cinnamon is very safe and only the most sensitive will react to this spice when used topically.

Anthocyanins These include cherries, blackberries, blueberries, raspberries, red grapes, strawberries, and plums.

These work mostly by reducing inflammation.

Oleocanthal This is olive oil. This compound may help prevent arthritis related inflammation. The stronger the taste, the higher the amount of oleocanthal the oil will likely contain.

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Eat Your Medicine: Food for pain relief

Vietnamese “Pho” Rice Noodle Soup with Beef

Pho (pronounced "fu") is a Vietnamese dish consisting of broth, noodles made from rice, a few herbs, and meat. The word "pho" may be derived from French pot-au-feu (beef stew). There are two main varieties-- chicken pho and beef pho. There is also Saigon-style pho (sweetened) and Hanoi-style pho (no sugar). Pho originated in the early 20th century in northern Vietnam. The variations in meat, broth and additional garnishes, such as lime, bean sprouts, cilantro, Thai basil, bean sauce, and hoisin sauce appear to be innovations introduced in south Vietnam. Cinnamon, ginger, and peppers are a few of many spices that make up the broth. This dish is great for breakfast, lunch, and dinner.

Pho is served in a bowl with white rice noodles (pho noodles) in clear beef broth, with slim cuts of beef (steak, fatty flank, lean flank, brisket). Variations 58 | Winter/Spring 2013

feature tendon, tripe, or meatballs.

Typically, the broth is boiling hot and is poured over a bowl containing noodles and cooked and or raw beef cuts. The hot broth cooks the slim cut raw meat.

No specific recipe can possibly be recommended. If you have never been exposed to this dish, I recommend you looking up different recipes and start experimenting. You will know when you get it right. There are versions out there to make the broth quickly with limited ingredients which are quite good, but I recommend the slow simmer using bone with marrow.

For a good version, refer to chef Mai Pham's recipe featured in her book Pleasures of the Vietnamese Table also located on www.epicurious.com website, search for “Pho Noodle”.

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Eat Your Medicine: Food for pain relief

Indian style spinach dip This simple and low-cost dish brings together several ingredients believed to fight pain and inflammation. To stretch it into a meal, top with shredded chicken or pan-seared tofu and serve with rice.

STEP 1 Add the olive oil and two cloves of garlic and onion (minced) to a large skillet. Peel and grate the ginger straight into the t List skillet. Cook over medium heat for about 5 Ingredien minutes or until softened. oil

STEP 2

Add the bag of frozen spinach to the skillet.

Stir occasionally until the spinach is entirely thawed and heated through.

STEP 3 Add the cumin, garam masala, and cayenne. Stir and cook for about three minutes more. Dice the tomato and add it to the skillet. Stir and cook for about five minutes more or until the tomato has broken down.

STEP 4 Stir the evaporated milk into the skillet. Add the turmeric and salt. Stir and heat through. Transfer to a food processor or blender (water and all) and pulse a few times to blend the ingredients, but do not puree the mixture. Stir, taste, and add more salt if desired. Serve hot with flatbread for dipping.

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2 Tbsp olive llow onion 1 large ye esh ginger 2 inches fr rlic 2 cloves ga en spinach le leaf froz 1 bag who 2 tsp cumin

m masala

1 tsp gara

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yenne pep

1/4 tsp ca

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1 large tom

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1/2 tsp tu

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1/2 tsp sa

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1 cup who

Winter/Spring 2013 | 59

My Freedom

Written by Avery J. McCall

Remember to take comfort in some of the small things in life. mare picks up her pace. A tap from my right foot guides her to the left to avoid a low-hanging branch. We move as one.

This power is not the power of control, it is the power of connection.

Freedom courses through my body, mind and spirit as I relax in the Western saddle.

Wind and sunshine brush my face as I inhale the warm scent of the pines and earth. The rustle of leaves under my horse’s hooves is only interrupted by the screech of a hawk or a snort from my companion’s horse.

For a few hours, I am swept away from all of life’s worries to share an afternoon trail ride with a friend. Here, I can clear my head of outside interference and just live in the moment. With a slight squeeze of my legs, my 16-year-old

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The pure joy of communicating with a horse through trust, respect and movement isn’t limited to trail rides.

The thrill of walking in to a show arena and working a cow are also a part of it.

Sixteen-year-old Curly is a palomino mare bred for speed and chasing down cows. Sitting astride our horses, my friend and I watch the others as they sort the 10 numbered calves. Curly’s ears flick as she listens and watches. The adrenaline builds as we take our place at the gate. The announcer calls out a number. I angle my body towards that calf and Curly takes over. She knows where I am looking from the slightest move of my body and legs. We guide the calf through the gate as my partner goes for the next. We rotate gathering the calves until each is penned. We exit the gate and find our place in line to do it again.

The hours on the trail, in the arena and in the pen are my escape from stress.

Inner stillness does not mean outer stillness; for me it means clearing my mind of clutter.

Winston Churchill stated, “There is

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something about the outside of a horse that is good for the inside of a man.� It is difficult to deny a horse’s majestic presence regardless of whether you like horses or not.

My horses bring a little peace and tranquility to my life. I enjoy quietly gliding a brush over their coats and combing through their manes and tails, braiding them as I choose.

An afternoon visit to a friend’s horse ranch has turned into a passion that has given me a strength and confidence I never knew I had. Where uncertainty had gripped me is now a sense of awareness. An inner strength fills me with joy, and transports me to a place where nothing else matters.

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Editorial Comment: Activity is critical when managing chronic pain. Finding an activity that can bring a sense of freedom can go a long way when taking the edge off. This story is a good example how a hobby, an enjoyed vocation (rare these days), or a sport can provide a sense of inner peace which is needed when controlling chronic pain.

-Ty Thomas, MD.

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N W C J U O P S U W A M G C F X U A V X

S O F R T D M M U E Z T N M I R O O E Y

Q V I J N T C H Z B I V E G W S P K R K

I J I T S L I F V L Q K W H S H I P T S

E W H C C I W O I F P J C Q I B A X E E

D B M I O E T S W A U C I X T X T G B S

Word

ARTHRITIS OSTEOARTHRITIS INSURANCE PHARMACOGENETIC COMPREHENSIVE OPIATE 62 | Winter/Spring 2013

E M L T M S J I I V B S N F I G E T R I

U U Z E P U T N R C S M O G R B N S A C

A H I N R F W N I H M E R G H X V I M R

I Y B E E I U S O D T D H B T H N L F E

Y U F G H S N R S I E R C W R N S A A X

C R S O E O A S P S T N A H A D H I C E

PLATELET FACET CHRONIC REGENERATION INJECTION PAIN

Find Cross

G Z K C N K D P U P P A E O A T M C E T

P Y O A S R R R J R L J R E E V O E T H

P N X M I P M F T Q A D G E Y T I P H Y

F F C R V I A K C I T N I E N R S S T R

T F E A E V M H I F E X C F Y E U O Z C

F U L H O K W B P G L J D E B M G J X R

J H L P J E T M L E E Z A G Q O G E N W

R V I X Y D X P P T T S C A V U H J R I

SPECIALIST VERTEBRA EXERCISE INJURY

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Across: 3) Must be part of an exercise program to ensure continued results.

9) A type of block used as a treatment to relieve pain.

11) The goal of PRP therapy is to resolve pain through ____ healing.

12) Arthritis is a complex family of ____ disorders that is not fully understood.

14) Treatment plans range from simple to ____ depending on the problem.

15) An EMG and nerve conduction study can help determine if the pain is from the ____.

16) Response to treatment may be in the ____.

18) A good pain management clinic will take an ____ approach to diagnose and treat pain.

19) Prior to engaging in activity this season, try____.

21) Means inflammation 22) The most important way to prevent and slow the progression of arthritis.

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Down: 1) Muscle.

2) A syndrome characterized by long-lasting widespread pain and tenderness.

4) The most common form of arthritis.

5) Reduce pain by blocking inflammation.

6) Rheumatoid arthritis is an ____disease.

7) Testing designed to detect genetic variations in enzymes involved in medication metabolism.

8) Inflamed tendon sheath.

10) Vietnamese noodle soup.

13) Platelet Rich Plasma (PRP) can ____cartilage.

17) Yellow-green root rich in compounds that fight inflammation.

20) Popular spring activity for which most people neglect to properly prepare.

For crossword solution visit... www.bamapain.com/images/crossword.png Winter/Spring 2013 | 63