New Pain Treatment: Platelet Rich Plasma

Blood spinning PRPRecently, platelet rich plasma (PRP) has been making news as a treatment for hip bursitis after a presentation at the American Academy of Orthopedic Surgery annual meeting. PRP is blood that has been spun and has concentrated factors that stimulate tissue repair and growth. This concentrated solution can be injected back into the body in affected areas to improve healing in damaged tissue. New areas for use are being found regularly.

Initially, PRP was first used in trials for repair after a heart attack, but it has expanded into areas of tendon repair, nerve injury and bursitis. Most commonly it has been used in sports injuries, and for many of these patients it has been quite successful. Instead of just calming down inflammation like many medical treatments, PRP helps more intensely stimulate the body to repair the injury. The downside to this treatment is that it is still considered experimental and insurance rarely covers the cost which can be in the several thousand dollar range.

PRP for Tendonitis and Bursitis

The most common uses in pain management for platelet rich plasma is for shoulder, elbow, hip and knee pain especially related to tendinopathy, tenosynovitis and bursitis. Blood is taken from the patient and then spun in a centrifuge. The residual plasma is rich in a number of proteins and substances that promote healing in the body. The plasma then is injected with either ultrasound or X-ray guidance into the appropriate area, whether the shoulder, hip or by certain tendons to stimulate healing. A series of several injections may be necessary to fully promote healing.  Since it is an all natural product of the patient themselves, it is very safe, and may be very effective for the right conditions.

Tendonitis, bursitis, joint and ligament pain is always treated conservatively first. Rest, heat and ice, and physical therapy are the first lines of treatment. If the problems are not improving, medications like oral or topical anti-inflammatory drugs combined with exercises and therapy may also be effective. If those treatments do not help, corticosteroid injections may also be indicated and evaluation by a physical medicine pain specialist to guide treatment would be beneficial.

The medical literature at this time is showing that the use of platelet rich plasma may have many benefits in the treatment of some of these joint related conditions of pain and inflammation. PRP is not the first line of treatment; it is used when other courses have failed. Furthermore, insurance has not endorsed its use and the cost will most likely be the responsibility of the patient. As of now, the injections are mainly for athletes or people who can afford the treatment when other avenues have failed.

Does Glucosamine Work for Knee Pain?

7525071_sA recent study in Arthritis and Rheumatology has cast new doubt on the use of glucosamine for knee pain. Glucosamine is a natural supplement that has been promoted for years to improve joint health. It is supposed to reduce pain and promote healthy cartilage in all joints. Knee joint pain has been one of the main claims for success over the past years.

The recent study reported that glucosamine had very little if any impact on any aspect of knee health. This study covered treatment over a 6-month time period.  It used medical exams and MRI scans at the beginning and end points as well as periodic X-ray films to objectively measure knee changes. Overall, pain and functional ability were not impacted by the use of glucosamine.

Knees and Age

Degenerative changes of the knees are common as we all get older. As we all age, the joints start showing signs of change including deterioration of the joint space and cartilage. Many of the activities we have done over time may worsen the problem. Sports, bending, twisting, kneeling, as well as being overweight may excessively stress the knee and lead to deterioration.

Treatment of the knees always starts conservatively. Most important is to ensure a patient doesn’t put unnecessary stress on their knees. One of the biggest culprits of knee issues is obesity, so weight control is essential. Keeping active helps facilitate blood flow to joints and maintains tissue health. Strengthening the muscles above the knee is also helpful.

Medication’s Role

The next level of intervention is medication. As noted above, natural supplements have not been found to be especially helpful when studied in a rigorous manner. Over the counter nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen as well as acetaminophen may be helpful. If the above treatments are not helping, seeing a pain specialist for knee joint injections with steroids or viscosupplements may be worthwhile. Lastly, when all else fails, sometimes Orthopedic surgery may arthroscopically clean up the knee joint or at times, the knee is so deteriorated, joint replacement may be a good option.

Knee arthritis is very common, but any treatments are available. So far, natural supplements have not shown significant positive results. If the simple stuff is not working, your doctor can guide you through the other available options.

Woods Undergoes Surgery For Lumbar Microdiscectomy  

1280px-Tiger_Woods_at_Earl_D._Woods_Memorial_Pro-Am_2009-07-01Augusta National Golf Club will have a different feel to it when golf’s first major gets underway tomorrow as its most polarizing figure, Tiger Woods, won’t be in attendance. Instead, he’ll be recovering from a recent back surgery.

Tiger Woods has been having back problems for over a year. The initial reports said he was only dealing with a bulging disc that would not need surgery, but this week it was announced that Tiger underwent an operation called a Microdiscectomy since conservative care failed. Since we can only make educated guesses as to what is wrong, we can give only a basic primer on Tiger and lumbar pain management.

Woods’ Woes

Hopefully Tiger is only dealing a single lumbar disc problem. This type of injury and corresponding surgery is best only for pain into the leg caused by an isolated herniated lumbar disc. He has tried the basics; rest, physical therapy, working with another golf pro on body mechanics, and medications to control pain and back spasms. It sounds like he has also tried injections, and despite all these efforts, he is still having issues. The latest MRI scan of his back showed a disc herniation bumping a nerve root that is most likely the cause of his pain. After not being able to play up to his usual standards, Tiger decided it was time to consider surgery.

A Microdiscectomy is a minimally invasive surgery, often using only a small incision of about an inch in length. Using special tools, the surgeon removes a small portion of bone, possibly a joint, and the offending piece of disc. The surgery is usually done as a hospital inpatient operation with an overnight stay to monitor for complications. The patient should be up and active within a day, and often has significantly improved leg pain. This stands to reason, as Tiger didn’t announce that he had undergone surgery until a few days after the operation, and the media was none the wiser. If one does not perform heavy work, returning to employment can occur within a week.

Complications and Rehab

As with any surgery, especially back surgery, there are risks of complications. In properly selected patients, success is at about 90 percent. Spinal fluid leaks, infection, recurrent disc problems, scar tissue, and ongoing pain may be seen despite surgery. The surgery will only be successful for very select group of patients who have failed all conservative care. It will not cure back problems that are related to multi-level disc problems.

The rehabilitation from a Microdiscectomy surgery is fairly rapid. Activity including stretching and walking is encouraged within a week. Guided strengthening and back exercises are often reasonable to start within a month. By three months post surgery, most activity should be possible if treatment has been successful.

Hopefully Tiger will be able to return to golf within three months. Looking at the timetable, that puts his return right around the U.S. Open, which is historically played on the third weekend in June. A more reasonable projection would be that he could return for The Open Championship, which takes place in late July.

Time will only tell what more may happen with his back.  Since professional golf at the highest level is very demanding, hopefully this surgery will work and there will not be any complications.  If Tiger retires, we will know, it was not the perfect cure.

Naloxone for Narcotic Overdoses 

25095355_s (1)Opioid and narcotic abuse is rampant, and overdoses killed over 16,500 people in 2010 and the numbers are rising. The death toll is about one person every 30 minutes. The awareness of the problem has been rising with the deaths of prominent celebrities, but the problem strikes at all levels of society and all ages.

The FDA recently approved a new treatment for narcotic/opioid overdose called the Evzio auto-injector. The new medication is Evzio, a form of naloxone, which has been available for medical use since 1971. The drug reverses the opioids’s effectiveness and prevents the drug from binding to its normal receptors on a short-term basis. Opioids at too high of a dose cause people to have impaired ability to breathe, and this difficulty breathing is the major cause of death from an overdose. Naloxone can only be given by injection into a vein for best results, therefore it has been difficult for anyone but trained medical personnel to administer. Programs have been established in some areas to authorize some first responders to give the medications. This has saved over 200 lives in Philadelphia in one year.

Evzio’s Effectiveness

Evzio won FDA approval in record time, most likely due to its need and safety. The medication is in an auto-injector; all one has to do is press the unit against the leg and trigger the mechanism. The set dose will help most overdose victims. The initial unit comes with a training sample injector that has voice prompts to walk a person through the correct use. The dose of naloxone delivered by Evzio will likely reverse breathing problems for 1-3 hours, enough time to obtain full medical support and treatment.

There are many people at risk for accidental overdose. Many people using opioids for chronic pain also have anxiety and may be receiving benzodiazepines that potentiate drug effects and poor breathing. Combining sleep medications, alcohol and other drugs can have a similar effect with opioids. The ability to have the new Evzio auto-injector available to reduce the chance of an accidental overdose is wonderful.

The biggest challenge ahead is to have laws that allow easy access for family, friends and first responders to obtain and use this new medication. Currently the status is a bit unclear. Every state regulates these medications differently, and there is an urgent need to save lives versus argue about the morality of the issues. Hopefully, the availability and use will become common in the near future and lives will be saved.

The Devastating Consequences of Addiction

11850338_sAddiction is one of the leading concerns for physicians in the field of pain medicine. Pain management is a broad and complex field with a range of treatments crossing many different disciplines of medicine. When pain is chronic, there is often not a magical single solution or pill. Pain is managed – it may not be cured – and the patient will have to do a significant amount of individual work and treatment to keep the pain under control.

What is Addiction?

Addiction is a disease of the brain. It is often described in terms of the “4 C’s” of behaviors that are seen.  The four C’s are:

  • Loss of Control
  • Continued Use Despite Harmful Consequences
  • Compulsion
  • Craving

The first C is for loss of control over use. One pill is not enough, and the person will take more and more until they pass out. The behavior does not stop at one episode; it continues multiple times. The second C is continuing use despite harmful consequences. An addict may be hospitalized for repeated overdoses of medication. Some people steal medications of others, or sell their medications in order to be able to afford more drugs in the future. The third C is a compulsion to use a drug.  One may not have any pain, but continues to use the drugs because they want the “high”.  The fourth C is a physical craving for the substance. If they stop the drug, they will go into a withdrawal.  They will physically shake, become nauseated and have other symptoms.

Addiction is a bio-psycho-social issue. There are multiple circumstances that surround addiction, but a big influence is a person’s environment, which may stimulate addiction. If the people you associate with and the activities they participate in promote addiction, for instance hanging out at the bar drinking every evening, addiction can occur.

If a person has family members that have an addiction issue, genetically they are also prone to the same problem. Certain chemicals to the brain also stimulate addiction. Compounds that increase dopamine levels in the brain can cause a prone person to have problems. Opioids and some antidepressants affect dopamine and taking these medications can promote problems in an at-risk individual.

Addiction Prevention

Pain medicine physicians have many solutions to pain. Pain physicians are trained to recognize which medications may lead a person towards addiction, and to spot addiction symptoms at early stages. A physician will shy away from certain medications if they see that a patient has had a problem with medication abuse in the past. Prescribing drugs that are less likely to lead to addiction is one way to prevent addiction, but there are a lot of related prevention techniques that should be discussed and implemented by your physician.

If you have ever had a problem with addiction, a wise pain physician will help you find a solution to your problem and try to avoid a new issue. Pain is difficult to treat and it will take significant effort on the part of the patient and treatment team to develop a reasonable solution over time. New discoveries will also improve management. There is hope on the horizon.

New Pain Medication Issues: The Zohydro Case

ZohydroA new pain medication has debuted and has set off major controversy. The new medication is called Zohydro, and it is a long-acting form of hydrocodone.  This is the same medication as Vicodin or Norco, without the acetaminophen. Vicodin and Norco are the most abused short acting opioid/narcotic medication. Despite knowing this, the FDA recently reversed its stance and approved the high potency long-acting drug. Zohyrdro will certainly help some people who deal with chronic pain, but it will also undoubtedly be abused by others. This begs the question, will Zohydro cause more harm than good?

The answer to question is up in the air, but it certainly looks like it will cause significant harm. It will cause problems, especially since some physicians will ignore the risks and prescribe the drug because it will do a great job relieving pain. This new drug can be easily abused, and has no abuse-deterrent properties. Many potent opioids have abuse-deterrent properties like smaller doses and pills that are designed so the user can’t alter the contents to snort or inject the substance, but Zohydro has no such properties. It will be abused.

Physician Care

Pain physicians, at their annual meeting last week, came to the understanding that opioids are important, but the most potent medications need to be abuse-deterrent. Opioids have a tendency to be abused, and therefore pain physicians have an obligation to help reduce abuse. This new medication adds very little to our treatment regimen, but it opens up more opportunities for abuse.

There are many abuse-deterrent formulations that can be used to treat pain. As far as pain physicians are concerned, there are just to many medications available that are being abused. In reality, it is unlikely we really need this medication.

Pain physicians would like to see more pain medications designed with abuse-deterrent properties. These are medications that have properties which do not stimulate a “high”. These tend to be slower acting, or have specific properties that do not stimulate the brain areas that give a rush. The future in pain care is developing more medications that treat pain but do not lead to abuse. Opioid/narcotic abuse is rampant in the United States, and physicians can play a key role in reducing this problem. Aggressively prescribing Zohydro is not one of those ways.

Whiplash Treatment and Symptoms

WhiplashWhat is Whiplash?

Whiplash – a soft tissue injury to the neck – is also called neck sprain or neck strain. It is characterized by a collection of symptoms that occur following damage to the neck, usually because of sudden extension and flexion. The disorder commonly occurs as the result of an automobile accident and may include injury to intervertebral joints, discs, ligaments, cervical muscles and nerve roots.

The classical definition of whiplash comes from the sudden “whipping motion” of the head and neck during the rapid deceleration that occurs in a motor vehicle accident. The damaging motion most often occurs in a rear-ended type collision but can occur with other trauma. According to some studies, the amount of damage to the car involved in the accident is inversely proportional to the incidence of whiplash injury.

The name or denomination “whiplash” derives from the etiopathogenic description of the sudden sharp whipping movement of the head and neck, produced at the moment of a traffic accident, particularly subsequent to collisions from the rear, head-on or side collisions.

Clinical Syndromes of Whiplash

  • Spinal Cord Injury
  • Occipital Neuralgia
  • Tempomandibular Joint Dysfunction
  • Cervical Vertigo
  • Cervical Radiculopathy
  • Cervical Facet Syndromes
  • Thoracic Outlet Syndromes
  • Shoulder and Arm Pain

Whiplash Grades

Grade 1 – Complaints of neck pain, stiffness or tenderness, but no physical signs are noted on exam.
Grade 2 – Neck complaints, and the examining physician notices decreased range of motion and point tenderness in the neck.
Grade 3 – Decreased range of motion, plus neurological signs such as decreased deep tendon reflexes, weakness, insomnia, and sensory deficits.
Grade 4 – Neck complaints and fracture or dislocation, or spinal cord injury.

Symptoms of Whiplash

  • Neck pain occurs in 62-100% of those injured and is the hallmark symptom.
  • Headaches occur in 82% of those injured and are often in the suboccipital region.

Imaging Tests & Diagnostics

  • Plain radiographs should be obtained early in the evaluation of whiplash injury to exclude fractures or subluxations; findings usually are normal.
  • Dynamic X-ray films (flexion and extension views) should be included to exclude abnormalities that suggest instability of the neck.
  • MRI abnormalities have included increased signal changes in cervical ligaments (eg, intraspinous) suggestive of tears, disk herniations, tears of the cervical musculature, and annular tears of the disk.

Treatments

  • Physical therapy
  • Modalities – Heat, ice, ultrasound, traction, TEN’s
  • Active strengthening
  • Neutral spine stabilization
  • Stretching
  • Education of mechanics
  • Developing independent home programs
  • Steroid Injections

Whiplash Management

During the management stage of whiplash, it’s important to remember that 90 percent of individuals with whiplash heal with symptomatic (acute) management. Acute management of whiplash includes:

  • Evaluating for significant bony or neurologic injury.
  • Judiciously use medications for acute pain.
  • Keeping the patient moving to strengthen muscles.

10 percent of individuals will not recover within 12 weeks after undergoing acute management. They need subacute management. They should seek out the help of a Interventional Pain Specialist and their multidisciplinary team.

Medications to use

  • Nonsteroidal Anti-inflamatory Drugs (NSAIDS)
  • Steroids – Prednisone, Medrol Dose Pak
  • Muscle Relaxants
  • Antispasmotics – Baclofen, Zanaflex
  • Antidepressants – TCA’s, SSRI, Cymbalta
  • Anticonvulsants – Neurontin, Topomax, Lyrica
  • Narcotics – Short Acting vs. Long Acting

Medications To Avoid

  • Benzodiazepine
  • Soma
  • Sleep inducers – Restoril, Ambien

Whiplash Statistics

  • There are an estimated 13-18 million motor vehicle accidents yearly in the U.S.
  • One million people suffer whiplash type injuries.
  • The management of these injuries cost about $30 billion dollars annually in terms of diagnosis, treatment, litigation and insurance costs.
  • Many studies indicate that 15% of the patients remain significantly symptomatic and require ongoing treatment.
  • 26% of patients have intermittent neck pain one year after injury.
  • 4% of patients had continuous discomfort.
  • 30% of patients lost some work.
  • 59% of patients had disruptions of daily routines for many months.