Pain Management Demystified
This post will be discussing a subject that is a favorite of mine: mindfulness. First, I’m going to explain a little bit about what mindfulness means, and then I’ll talk about uses for pain conditions. I’ll wrap up by providing some resources if you’re interested…
Radiofrequency ablation is an exciting technique used in interventional pain management. In this post, I am going to explain how it works, what it is used for, and what you might expect from a radiofrequency ablation or RFA. Nerve blocks are common procedures for pain…
Let’s talk about sciatica- one of the most common complaints I get in my clinic. The medical term for sciatica is radiculopathy, so I’ll be using that term from here on in this post.
Most of my readers probably can spot the symptoms of radiculopathy. This type of pain is often described as burning, sharp, shooting and is associated with numbness and tingling in the same area as the pain. Sometimes people who have radiculopathy can also experience weakness, meaning that when they try to move a certain muscle or group of muscles, the area feels less strong. This is different from having trouble moving a part of the body due to pain, and it can be tricky to tease this out without a good physical examination.
Radiculopathy can occur in the legs, known as lumbar radiculopathy, and in the arms, known as cervical radiculopathy. Lumbar radiculopathy can be associated with low back pain too, and cervical radiculopathy can also show up with neck pain.
The causes of lumbar radiculopathy are most commonly related to either a disc that has herniated in the spine, or stenosis, which is a narrowing in the spine. Foraminal stenosis is narrowing of the hole that the spinal nerve goes through on its path down to the arm or leg, and central stenosis is narrowing of the area in the center of the spinal canal where the spinal cord and nerves run. A disc herniation is a way of describing an issue where the disc, the squishy Jello-like material between the spinal bones, has moved out of its normal position. No matter which cause, the end result is compression of a spinal nerve, which gives the symptoms I mentioned earlier.
To better determine what the exact issue is, the next step in diagnosis is generally an MRI of the neck or the low back. Unfortunately, sometimes insurance companies will not approve this test unless the patient has tried and failed some type of therapy, which I discuss next.
The treatment options for radiculopathy are widely varied. Generally the most effective type of medications are nerve pain medications, which target the true cause of the problem- irritation of the nerve. These are generally anti-seizure medications or antidepressant medications that we know also work on nerves. Sometimes I will use anti-inflammatory medications or muscle relaxants if the patient has a lot of muscle spasm too, but these are less effective for the burning/tingling nerve pain.
I almost always recommend a course of physical therapy to patients with radiculopathy. Physical therapy is very helpful in not only relieving some of the pain, but also being proactive about preventing radiculopathy from turning into a chronic issue. For lumbar radiculopathy, patients will be taught exercises to strengthen their core muscles (abs and muscles of the low back), and will work on posture and walking mechanics, among other therapies.
Injections are another common therapy for radiculopathy. Epidural steroid injections can be very helpful in reducing inflammation that may be present near the nerve as a result of the compression. These are done with an X-ray machine in order to precisely target the area of the problem. If the pain is persistent and severe, sometimes I will consider a different type of therapy called a spinal cord stimulator, which is an implantable device that hides the pain of radiculopathy from the brain.
Complementary therapies are useful too- I have many patients who do well with acupuncture and mindfulness-based therapies for this type of pain. It is very common to have patients who need more than 1 type of therapy in order to feel their best.
If the pain persists despite these therapies, or if the patient has weakness when I examine them, I will send the patient to a spine surgeon for evaluation. Sometimes patients may need surgery to relieve the compression of the nerve.
If you’re wondering if you have radiculopathy, the best way to find out is to see a pain management doctor in person! Don’t forget to subscribe to my blog here so that you never miss an update.
Now that it’s finally getting warm out, that means that more of my office visits become sport related! In this post I am going to discuss tennis elbow, also known as lateral epicondylitis. Tennis elbow does occur often in people that play a lot of…
To celebrate my mother finishing her last round of chemotherapy today, I wanted to talk about cancer pain. When I was a fellow, I rotated through one of the major cancer centers in New York City, and was exposed to many patients being treated for…
In this post I’m going to be discussing low dose naltrexone, which is a treatment I primarily use for fibromyalgia. I’ve also tried it for some other widespread pain conditions with success, but I’m going to focus on fibromyalgia because that is the best studied. Low dose naltrexone, also abbreviated as LDN, is a relatively new therapy and is not officially approved for the use of chronic pain. I wouldn’t be surprised if in the future it does get approval for this, though.
Naltrexone is a medication that has been around for a long time and was originally created as an opioid receptor blocker. Opioids are medications like oxycodone and morphine. In order for these medications to cause pain relief, they bind to specific receptors called opioid receptors. Naltrexone is similar to Naloxone (Narcan), which you’ve probably read about because it is a rescue medication for people who are experiencing an opioid overdose.
You may be sitting here wondering why, if I am trying to use a medication for pain relief, I would be using a medication that BLOCKS opioid receptors. That doesn’t make sense right? But, with low dose naltrexone, the dose that is used is much much lower than the doses that are used to fully block those receptors. And when we use low doses like this, the drug starts to have different effects and actually gives pain relief instead of blocking it.
Two popular theories exist as to how low dose naltrexone works, and it may be some of both. The first is that LDN acts as a glial cell modulator. To understand what this means, we have to take a step back and talk a little bit about the nervous system. The nervous system has many cells that are involved in communication called neurons. But, there are also many other “helper cells” that are involved in helping the nervous system to function properly and stay self-regulated. These are the glial cells. It is possible that LDN may help these cells to function in a more healthy manner, which in turn, can lead to less pain.
The second theory involves the idea that when LDN blocks the body’s opioid receptors, the body may compensate by making its own opioids. Everyone makes some of their own opioids at baseline, and these are called endogenous opioids. Endogenous just means “coming from the self”. You can imagine, that if the body senses that its opioid receptors are blocked, it might try to overcome this by creating a little extra of its own opioids to balance it out. These self-made opioids could potentially provide patients with pain relief.
The important thing is that there are a few small, but well designed studies, which showed that LDN had benefit for patients with fibromyalgia in terms of reducing pain scores and also improving mood. Some of the studies also showed that it may help with fatigue. The really nice thing about LDN is that the side effects are very rare and manageable- mainly vivid dreams if they do happen. A lot of the other medications available for fibromyalgia can have difficult side effects that lead to patients discontinuing the therapy.
LDN is only available through a specialized pharmacy called a compounding pharmacy, because the only commercially made version of naltrexone is way too high- 50mg. So this means that unless patients have compounding pharmacy benefits, the cost of the pills is completely out of pocket. The price varies a lot depending on the materials the pharmacy uses, and can be as low as 30-35 dollars a month and as high as $90-100.
If you’re wondering if LDN might be helpful for you, the best thing to do is find a pain management specialist who is used to prescribing it and can make an assessment for you. Don’t forget to subscribe to my blog by clicking on this link so you never miss a new post! Subscription link
Today I’m going to be focusing on a common office-based procedure for pain management physicians: trigger point injections. These injections are commonly abbreviated as TPIs. Trigger point injections are a treatment targeted to address pain coming from muscles, specifically, muscle spasms. If you’ve ever had…
One class of medication that I’ve mentioned a few time in other posts is topical medication. Topical means that the medication is applied to the skin, directly over the painful areas, as opposed to being taken in a pill or other formulation. There are some…
In this post I’m going to be discussing low back pain, but a slightly different type of low back pain than the previous post addressed. I want to talk about the sacroiliac joint, which often times gets overlooked as a cause for low back and buttock pain.
The sacroiliac joint, also called the SI joint, occurs where the hip bones (ilium) connect to the tailbone (sacrum). The joint has much less mobility than a joint like the knee or the shoulder, but it does move slightly as the back turns and flexes. The joint is supported by soft tissue and muscles surrounding it.
Pain can occur when the sacroiliac joint has too much motion, too little motion, and when it gets inflamed. Sometimes the sacroiliac joint pain is a secondary issue, meaning, it is painful as a result of strain put on it from something else, like arthritis in the back. A lot of times I will treat someone for a low back issue from arthritis or a herniated disc, and then discover that there is some residual pain in the sacroiliac joint too.
Pregnancy is a time when the sacroiliac joint is especially vulnerable to becoming irritated. Hormones secreted during the pregnancy, like relaxin, help to loosen the ligaments in the pelvis, which makes sense because extra space is needed for the baby to come out. But sometimes this extra mobility can cause pain and irritation in the SI joint. Also, depending on how the baby’s head is positioned, this can put even more pressure on the joint.
The pain from the sacroiliac joint is usually low down in the back, just around the buttocks, and is often right around where a person wears a belt. There are certain additional tests that I can perform during the physical examination that puts extra stress on the joint, and allows me to test whether it is a cause of the patient’s pain.
How do we treat the pain from irritation or inflammation of the sacroiliac joint? I use a combination of medications, other modalities, and injections. (I find breaking the plan down like this is helpful to keep all the treatment options organized). Medications that are beneficial include anti-inflammatory medications like ibuprofen and numbing medications that are applied as an ointment or a patch, like lidocaine.
Other modalities include physical therapy to help with muscle imbalances that might be contributing to the pain and using an SI joint support belt, which is a skinny belt that wraps around the waist and helps to offload some pressure from the joint. I also often send people for osteopathic manipulation of the joint, which is performed by an osteopathic physician with special training in hands-on therapy.
Interventions can be very helpful in alleviating this pain. I usually start with a sacroiliac joint injection of steroid, which is performed using X-ray guidance to ensure the needle is in the joint. If patients get good relief from this but it does not last for a long enough time, then I consider doing radiofrequency ablation, which is a treatment that turns off the tiny nerves that feel the sacroiliac joint.
If you think you might have pain coming from your sacroiliac joint, the best way to figure that out is to see a pain management doctor in person! As you can see, once the joint is identified as a cause of pain, there are many different ways to treat it.
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Now that I’ve relocated my practice to Manhattan, I’ve noticed that many of my patients are interested in alternative options to conventional medical treatments. I love talking with people about these kinds of options because my priority is to develop a treatment plan that is…