Office Ketamine For Chronic Pain Poster

here is poster in pdf format:


Poster CPS 2017 ketaminefinal (2)

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Please suggest help for this case of post back and post hip back-hip pain

A case in desperate need of help wrote and I have put it in a patient discussion forum:

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Welcome to Painmuse



I have a program that tracks where users are from – pain is worldwide:

Thanks admin


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Reaching “Critical Mass” to Achieving Pain Control – Procedure Pearls

I have recently achieved (previously unattainable) control in some of my chronic pain subjects using recent innovations – but to acheive this required use of multiple modalities at once.

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Posted in arm, Back Pain, Botox, complex regional pain, Drugs, Fibromyalgia, Headaches, Injection, IV therapy, Leg Pains, Manual Med, myofascial pain, Neck, neuropathic, Pain Dystrophy, piriformis, post herpetic neuralgia, radiculitis, shoulder, Uncategorized | 4 Comments

Finger pressure can relieve many migraine headaches

Over three minute pressure to occipital arteries can greatly relieve migraine pain in over 1/2 of cases; almost sounds too good to be true. Continue reading

Posted in Headaches | 11 Comments

Depression in Chronic Back Pain? – Twin Study Suggests More Genetic Than Related to Pain

Spine J. 2017 Jul;17(7):905-912. doi: 10.1016/j.spinee.2017.02.009.
Chronic low back pain and the risk of depression or anxiety symptoms: insights
from a longitudinal twin study.
Fernandez M

“The relationship between chronic LBP and the future development of depression or anxiety symptoms is not causal.”

Shared familial factors was considered more likely

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Peripheral Neuropathy Pain Unresponsive to Creams – Try 5% Doxepin

Child cancer case where chemotherapy induced peripheral neuropathy pain was not helped by usual topicals was helped by 5% doxepin cream

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Sad News of Hip Replacement – Less Pain and Better Function but No Increase in Physical Activity Seen

J Arthroplasty. 2017 Jul;32(7):2191-2198. doi: 10.1016/j.arth.2017.02.002.
Total Hip Arthroplasty Improves Pain and Function but Not Physical Activity.
Jeldi AJ et al

  • 30 cases ages 67 +/- 7 yrs
  • Physical Activity of Total Hip Arthoplasty  patients was quantified to 12 months postoperation
  • “Physical activity did not change from presurgery to 12 months postsurgery despite improvement”

Comment – my brother dislocated his artificial hip just bending down so there are certain restrictions. People need to be warned about their function after surgery not being associated with more activity

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Buttock-Posterior Thigh Neuropathic Pain – Posterior Femoral Cutaneous Nerve Injury and Treatment

Pain in butt and hamstring is not uncommon and usually involves hamstring. However, neuropathic level pain in areas can happen after surgery or injection suggesting nerve damage to Posterior Femoral Cutaneous Nerve. Present article used cryoablation successfully to treat.

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Pain News – Short Snaps June 2017

June 2017 Pain News: I put them up as short snaps because not going to blog note them – hope you like

  1. No evidence stem cells helps tendon  disorders;
    Pas, Haiko IMFL, et al.
    No evidence for the use of stem cell therapy for tendon disorders: a systematic review.” Br J Sports Med (2017): bjsports-2016.  – thank goodness for that because I cannot afford to offer that treatment
  2. Among Fibromylagia subjects: – spinal inflammation sometimes
    “Sacroiliitis was demonstrated among 8 patients (8.1%) and ASAS criteria for diagnosis of axial SpA were met in 10 patients (10.2%). Imaging changes suggestive of inflammatory involvement (e.g., erosions and subchondral sclerosis) were demonstrated in 15 patients (17%) and 22 patients (25%), respectively. The diagnosis of axial SpA was positively correlated with increased CRP level and with physical role limitation at recruitment. ”
    Ablin, Jacob N., et al.
    Prevalence of Axial Spondyloarthritis Among Patients With Fibromyalgia: A Magnetic Resonance Imaging Study With Application of the Assessment of SpondyloArthritis International Society Classification Criteria.
    Arthritis care & research 69.5 (2017): 724-729.

    Comment – I see morning stiffness etc and elevated CRP/ESR regularly in some FM cases – now I know it is inflammatory and prednisone/methotrexate might be useful
  3. Stem cells seemed to help hip – though no control group:
    J Hip Preserv Surg. 2017 Mar 19;4(2):159-163.
    doi: 10.1093/jhps/hnx011. eCollection 2017 Jul.
    Mesenchymal stem cell therapy in the treatment of hip osteoarthritis.
    Mardones R et al
    “The intra-articular injection of three consecutive weekly doses of ex vivo expanded autologous BM-MSC to patients with articular cartilage defects in the hip and proved to be a safe and clinically effective treatment in the restoration of hip function and range of motion.”
    Comment  – rats, I won’t be able to afford that
  4. Psychological intervention does not greatly help workplace absences:
    Pain. 2016 Apr;157(4):777-85. doi: 10.1097/j.pain.0000000000000434.
    Effectiveness of psychological interventions for chronic pain on health care use
    and work absence: systematic review and meta-analysis.
    Pike A et al
    “Analysis of work loss showed no significant effects of psychological interventions over comparisons, but the use of many different metrics necessitated fragmenting the planned analyses, making summary difficult.”
    Comment – only time I’ve ever had a patient want to go back to work was a subject on ketamine therapy which has anti-depressant effects which are hard to achieve in someone in pain
  5. Estrogen new pathway discoveries show it can effect “cognition, depression, homeostasis, pain processing, and other associated neuronal functions”
    Neurogastroenterol Motil. 2017 Jul;29(7). doi: 10.1111/nmo.13121.
    New roles for neuronal estrogen receptors.
    Lu CL et al –  still don’t know how to handle estrogens in chronic pain…
  6. Testosterone replacement can reduce opioid needs
    Am J Mens Health. 2017 Jul;11(4):1208-1213. doi: 10.1177/1557988316672396.
    The Role of Testosterone Supplemental Therapy in Opioid-Induced Hypogonadism: ARetrospective Pilot Analysis.
    Raheem OA et al equivalent use dropped by 25 mg in testosterone treated group but increased by 2.5 mg in placebo group
    Comment – I use testosterone except in heart disease males (females get so little it doesn’t matter). Women require very little (testosterone gel 0.2 ml/day) and get benefits from it.
  7. Much of peripheral sensitization is through TRPV1  pain receptors. Botulinum reduces their protein levels in dorsal ganglion.
    Toxicon. 2017 Jul;133:116-122. doi: 10.1016/j.toxicon.2017.05.001.
    Botulinum toxin type A reduces TRPV1 expression in the dorsal root ganglion in rats with adjuvant-arthritis pain.
    Fan C et al Comment – I inject peripheral sensitized tissue in occipital neuralgia etc. Looks like some of that needs to reach dorsal horn
  8. Chronic abdominal bloating and pain treatment approach – lactulose breath test for hydrogen and methane might indicate mild Small intestinal bacterial overgrowth (SIBO) so treatment involved a low-FODMAP diet, antimicrobial botanical therapy, and homeopathic medicine. (I presume homeopathic included probiotics)
    Altern Ther Health Med. 2017 Jul;23(4):56-61.
    Integrative Treatment of Chronic Abdominal Bloating and Pain Associated With Overgrowth of Small Intestinal Bacteria: A Case Report.
    Kwiatkowski L, Rice E, Langland J.
    Comments – both antibiotics cipro and flagyl have been used in Canada because more effective agents are not available here. I used to use neomycin but pharmacists are worried re renal toxicity
  9.  Women with sacroiliitis on MRI are more likely to show Pelvic congestion issues as well
    Acta Radiol. 2017 Jul;58(7):849-855. doi: 10.1177/0284185116675656.
    Evaluation of sacroiliac joint MRI for pelvic venous congestion signs in women
    clinically suspected of sacroiliitis.
    Cimsit C et al
  10. Fibromyalgia subjects experience more pain when included in games rather than when included (the people pleaser issue?)
    Clin J Pain. 2017 Jul;33(7):611-619. doi: 10.1097/AJP.0000000000000447.
    Impaired Pain Modulation in Fibromyalgia Patients in Response to Social Distress Manipulation.
    Canaipa R et al
    Clin J Pain. 2017 Jul;33(7):611-619. doi: 10.1097/AJP.0000000000000447.
    Impaired Pain Modulation in Fibromyalgia Patients in Response to Social Distress Manipulation.
    Canaipa R et al
    Comment – surprised exclusion did not have effect – but I guess the people pleasing stress of being included is the key…
  11. Fat tissues about knee may have direct effect – fat pads in medial joint line area may be inflamed and make knee arthritis worse and fat might have other detrimental effects.
    J Cell Physiol. 2017 Aug;232(8):1971-1978. doi: 10.1002/jcp.25716.
    Systemic and Local Adipose Tissue in Knee Osteoarthritis.
    Belluzzi E et al.
    Comments – should be no surprise when diabetes type 2 is now considered the toxic effects of fat around the pancreas…
  12. Injecting Interstial Cystitis Hunner’s ulcers with triamcinolone cortisone can cut pain at least in half but will need repeat in maybe 4 month
    Int Urogynecol J. 2017 Jul;28(7):1027-1031. doi: 10.1007/s00192-016-3213-3.
    Pain relief after triamcinolone infiltration in patients with bladder pain syndrome with Hunner’s ulcers.
    Mateu L et al
    “Pre- and postreatment VAS was 8 and 2.5 (p < 0.001), respectively. Pre -and postreatment VAS in those with muscular pain was 8 and 5 (p = 0.012), respectively and in those without muscular pain was 8 and 2 (p < 0.001), respectively. Three (15 %) patients required retreatment due to nonresponse and 5 (25 %) patients for pain recurrence after 4 months (3.5-8). Four of them (50 %) were performed with triamcinolone injection again. Seven of ten patients (70 %) followed for ≥8 months required at least one retreatment.”
    Comment – need an urologist interested in doing that…
  13. Transcranial DC stimulation tDCS in Fibromyalgia – better results were obtained stimulating DLPFC area rather than C2 motor cortex – former helped pain and fatigue while latter only pain
    J Neural Transm (Vienna). 2017 Jul;124(7):799-808. doi:10.1007/s00702-017-1714-y. Epub 2017 Mar 20.
    Differential effects of bifrontal and occipital nerve stimulation on pain and fatigue using transcranial direct current stimulation in fibromyalgia patients.
    To WT et al
  14. In another study tDCS found to help refractory migraines but stimulating motor cortex associated with more side effects – headache, heartburn, and sleepiness
    dorsolateral prefrontal cortex (DLPFC) area was better.
    J Neurol Sci. 2017 Jul 15;378:225-232. doi: 10.1016/j.jns.2017.05.007.
    Transcranial direct current stimulation over the primary motor vs prefrontal cortex in refractory chronic migraine: A pilot randomized controlled trial.
    Andrade SM et al
    Comment – tried motor cortex stimualtion on one subject who got bad dreams after so I stopped using it; guess I can try again with DLPFC area.
  15. tDCS over left DLPDC does seem to help attention in FM(fibromylagia) sufferers:
    Sci Rep. 2017 Dec;7(1):135. doi: 10.1038/s41598-017-00185-w.
    Anodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex modulates attention and pain in fibromyalgia: randomized clinical trial.
    Silva AF




Posted in Abdominal pain, celiac, chronic fatigue, Fibromyalgia, Headaches, Injection, Interstial Cystitis/Gynecologic, Knee, psychology, shoulder | Leave a comment

Dispelling Myth That Chronic Pain is Unresponsive to Treatment

This was the title of a recent article in British Journal of Sports Medicine. It is what my blog is all about – recognizing that there are new things coming out every week that make a difference –

However, there are so few pain clinicians out there that new treatments can take forever to become evident. For example, I believe twice weekly ketamine injections could make a major difference in “hopeless cases”
Office Ketamine For Chronic Pain Poster

I only saw three clinicians actually look at that poster so can’t imagine anyone will be seeing the benefits of it anytime soon.

I have tried to compile a list of potential treatments that anyone could try:
Reaching “Critical Mass” to Achieving Pain Control – Procedure Pearls

No one treatment is usually life changing but add up 4-5 measures and all of a sudden you get real benefits. So you can get feeling better. Here are some things that come with above article:


Every week there is something new. Just new for example is treating Complex Regional Pain by injection spots of sensitized skin nerve with D5W (%% dextrose) – not heard of at a recent course I was at because just came out:

Pain Med. 2017 Apr 26. doi: 10.1093/pm/pnx063. [Epub ahead of print]
Perineural Injection Therapy in the Management of Complex Regional Pain Syndrome:
A Sweet Solution to Pain.
Thor JA et al
no abstract

These new measure will probably not get used for several years (only took 30+ years for prolotherapy to be found useful)

But if you find something here, take it to you doctor and see.
You can get some better!



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Epidural Steroid Injection – Pain on Lumbar Extension Determines Extent of Benefit

In Chronic Low Back Pain and Radiculopathy (sciatica) epidurals are used with varying success.
“The mean length of relief duration is 38.37 weeks for individuals without painful lumbar extension and 14.68 weeks for individuals with painful lumbar extension.”

CONCLUSIONS:: The mean length of relief following a caudal injection is reduced by 62% in patients who exhibit pain with lumbar extension.

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Recurrent Abdominal Pain (RAP) in Children – More Than it Seems

European study found in RAP syndrome without any alarm features, 57% were found to have organic disease – and treatment of such lead to resolution of symptoms.

Things found included:

  • 19 (22.6%)  lactose intolerance.
  • 17 patients (20.2%)  celiac disease.
  • Two (2.4%) cow milk allergy.
  • 9 (10.7%) ureteral calculosis.
  • One (1.2%) was affected by teniasis = tapeworm

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Refractory Burning Mouth – Try Clonazepam and Venlafaxine

Venlafaxine (300 mg/d) and Clonazepam (5 mg/d) in Refractory Burning mouth – All responded with a reduction in pain from 8.6/10 to 3.2/10 after 3 months

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Subdeltoid Hyaluronic Acid Lubricant Injection in Supraspinatus Tendonopathy Helps

Subdeltoid hyaluronic acid injections 2 ml x 2 weekly associated with mild improvement in pain

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What Should Patients be Advised Post Shoulder Injection?

  • 116 patients
  • Forty-one (35.3%) patients experienced post-injection pain. The mean duration of symptoms was 3.9 days.
  • At 6 months, 81 (69.8%) patients were discharged successfully and, at a mean of 23.2 months, did not require re-referral;
  • 29 (25%) had surgery; and six (5.2%) were referred for a spinal opinion.

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Vulvodynia Treatments 2017

New approaches include topical neuromodulation which means “Podophyllotoxin (5 mg/mL) applied locally to tender points of vestibule after 5% acetic acid application. Treated area was covered with a mild estrogen cream and covered with gauze pads until the next day” . This may be repeated monthly up to 3 times.  I found little articles but came across a patent that found half of vulvodynias and post hysterectomy pain patients were better though article here did not find much.

Another approach, local injection of tender spots with 2 – 4 mL of cortisone (betamethasone) and long-acting anesthetic agent (bupivacaine), 1:1 , injected submucously to the painful site has been suggested. Other measures included topical 6% gabapentin, topical 5% lidocaine before sex, amitriptyline 40 mg,  pregabalin 150-300 mg /day, laser treatments (less often used), physiotherapy, sacral neuromodulation, and finally surgery.

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SSRI Antidepressants Work Better Than older TCA Antidepressants in Irritable Bowel

Traditionally, an old antidepressant, amitriptyline, has been used for irritable bowel at doses far lower than its antidepressant level, as an aid to stimulating endophin system etc. Now it appears that more up to date SSRI’s work better. This was determined in children with functional abdominal pain.

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Persistent Plantar Fasciitis – TENS Like Stimulation of Low Impedance Spots Helps Resolve

Point stimulation has been found helpful in nummular headaches:
Small Spot Body Pain Treatment – Pen like Electrical Skin Stimulation

This case, involved treatment of persistent plantar fasciitis. Using a point probe (like an acupuncture point locator), Spots of low impedance in the skin were found on the heel, and they were stimulated for 10 minutes each with probe (pointer-plus is what I have) then the used a multiple small pad tens pad to stimulate these spots for a further 10 minutes. This was done 3 times a week for total 10 times. Pain was cut in maybe half.

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Pain and Swollen Arm? – Upper Arm DVT Protocol

Upper arm pain and swollen and no other likely cause? – combinations of D-dimer testing and compression ultrasounds seem to be the approach.

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Do Pelvic Belts Help Back Pain? – Yes

Study on SI belts for pregnancy back pain found it reduced pain by 2/10.

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Osteoarthritis (OA) Knee Suffers Should Limit Walking to 30 min at a Time


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One Reason Osteoarthritis Bad in Canadian Prairies – Persistent Low Vitamin D Levels – and Supplements Prevent

I do vitamin D levels on all my patients coming in for physical – they are almost always low. – Recently demonstrated that persistently low levels of Vitamin D associated with accelerated osteoarthritis and helping that helps. …

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Failure Back Surgery Post Laminectomy Pain Treatment- New High Frequency or Burst Mode Spinal Stimulation

Spinal stimulation is primarily for the sciatica -only 1/2 of back pains respond.. This leave a subgroup, with predominately back pain, with a need for options. High 10 Kz frequency stimulation and Burst stimulation are two options.

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Confirmed – Resistant Ulcerative Colitis – Fecal Transplant Works 1/2 Time

70%  showed clinical response, and “13 of the 30 (43.3%) patients achieved clinical and endoscopic remission.”

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Stabbing Headaches

Rather new entity is the stabbing headache – primary stabbing headache (PSH) – often in occipital area, happening 2-100 times a day and more occipital (back of head) in location.  Treatment is not all what you’d think – its indomethacin, prednisone, gabapentin or tricyclic antidepressants.

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Does Job Rotation Reduce Illness?

Job Rotation reduces wrist and hand pains but doesn’t do much else according to a review. Continue reading

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Sacroiliac Joint – Leg symptoms

SI joints generate significant amount of lateral thigh and inguinal area pains.  About 1/3 will complain of lateral thigh numbness as well.

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Recurrent Aphthous Ulcers – Minocycline 0.5% Mouth Rinse Treatment

Canker sores respond to tetracycline/minocycline rinses – 0.5% minocycline works best

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