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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 | 3 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

Hopeless Case Of Lower Leg CRPS Helped by Pulsed Radiofrequency of Sciatic Nerve at Knee

Pulsed radiofrequency to dumb down treated nerve is becoming a useful adjunct to treating untenable pain CRPS states. Post hip fracture leg painv pain state left patient with VAS 6-7/10 with breakthru of 9/10.  Following dropped to 3/10 – after 8 months went back to 6/10 and was repeated and then down to 2-3/10.

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Posted in complex regional pain, foot, Leg Pains, neuropathic | Tagged | Leave a comment

Good Cane Use

In Dr. Travell and D. Simon’s book they talk about proper cane position:
– on opposite side to leg pain (it become good leg when you lift good leg)-shoulder horizontal with cane held out 15 degrees from body

Now additionally, 15% of your weight should be applied when using it.
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Vertebroplasty Does Work For Vertebral Back Compression Fractures

Clin Cases Miner Bone Metab. 2016 Sep-Dec;13(3):234-236.
doi:10.11138/ccmbm/2016.13.3.234
Safety and efficacy of vertebroplasty in the treatment of osteoporotic vertebral compression fractures: a prospective multicenter international randomized
controlled study.
Leali PT, Solla F, Maestretti G, Balsano M, Doria C
https://www.ncbi.nlm.nih.gov/pubmed/28228788

  • 200 patients in each group (good study size)
  • VAS pain scores dropped from 4.8 to 2.3/10 within 24 hours (p <0.023)
  • 65%) treated with Vertebroplasty were able to stop any analgesia after 48 hours (p ≤ 0.0001)
  • Control group – pain medication, osteoporosis medication, physiotherapy or bracing – very little change
  • “Pain relief and improve mobility, functionality physics after VP
    are quick and significantly better in the near compared to non-surgical treatment.”

MORON NEJM STUDY

don’t ask me why but NEJM has put through three MORON pain studies that have slowed progress in pain medicine – one on vertebroplasty, one on facet injection without any local added, and one involving arthroscopy knees.

NEJM Vertebroplasty study:

Kallmes, David F., et al. “A randomized trial of vertebroplasty for osteoporotic spinal fractures.” New England Journal of Medicine 361.6 (2009): 569-579.
http://www.nejm.org/doi/full/10.1056/NEJMoa0900563#t=article

  • they took fracture cases up to 1 year old and relied on bone scan for evidence of active process present where arthritis in areas (and facet loading does occur) can give false positive results. It has been shown since that older fractures don’t do well. Reminds me of the Women’s Health Initiative where they made it clear early on they were out to show estrogens were bad for women. They took women up to 80 and got the results they wanted. When later re-analyzed it was clear estrogens were beneficial under age of 60- and actually showed regression of coronary calcifications. Most compression fracture activity is in first 4-8 weeks; not a year later. Pumping cement into a back where facet arthritis is the active issue is going to make things worse.
  • They only injected 3 mls cement which is considered small in one arguing article:
    An Objection to the New England Journal of Medicine Vertebroplasty Articles
    Smith, Steven J, MD; Vlahos, Athanasios, MD; Sewall, Luke E, MD. Canadian Association of Radiologists Journal; Montreal61.2 (Apr 2010): 121-2.
    http://search.proquest.com/openview/f99bb8433c971c069b63959c66427c63/1?pq-origsite=gscholar&cbl=34862
    they state that experienced operators reposition, wait and reinject – but no point of doing that if you are out to prove it did not work.
    This reminds me of one steroid injection article where they injected trivial doses of steroid and as a result, concluded steroid injections don’t work
  • the sham procedure was an injection of bupivacaine into the periosteum next to the facet joints. Well, facets may be where the pain is, in late compression fractures, and injecting can make a difference:
    Pain Med. 2010 Nov;11(11):1674-7. doi: 10.1111/j.1526-4637.2010.00953.x.
    Facet pain in thoracic compression fractures.
    Mitra R(1), Do H, Alamin T, Cheng I.
    https://www.ncbi.nlm.nih.gov/pubmed/21029349
  • People with low pain to start with do not improve with any treatment – I’ve seen that frequently enough – they don’t give stats on pain so low pain subjects could have easily nullified results
  • The authors of the NEJM article were caught out by the fact 4 times as many patients crossed over to get verteboplasty in their study
  • The Canadian rebuttal makes it clear “These patients do extremely well as a group, leave their hospital beds, stop disorienting narcotics, and get their live back.” Shame on you NEJM.
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Kidney Stone – Renal Colic – Ketoralac and Nifedipine Superior to Ketoralac and Tamsulosin

Spanish journal which I do not get but results seem clear enough – ketoralac 60 mg ?IM and Nifedipine XL 30 mg by mouth give best results.

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Bacterial Overgrowth and Irritable Bowel Syndrome (IBS) – What is the Hypothyroid/Levothyroxine Connection?

Hypothyroid victims on Levothyroxime have a 3 times relative risk to having bacterial overgrowth and the IBS connection that goes with it.

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New Effective Treatment for Intractable Sore Mouth Mucositis

0.05% Methylene Blue oral rinse therapy was cheap and effective treatment for mucositis from chemotherapy or radiotherapy. Amazing result could be big help.

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Posted in Abdominal pain, Drugs, ENT, Injection, neuropathic, skin | Leave a comment

Reasons Why Vit D Helps Chronic Pain Coming Clearer – Vit D Genes

A Fokl DNA gene polymorphism in the Vitamin D receptor would reduce its sensitivity to vitamin D. Vitamin D supports many metabolic processes beyond calcium and gene variations are even associated with certain cancers.  In athletes, the FF Fokl genotype is found in 58.3% of those with pain and only 27.8% without with an enormous relative risk OR= 5.78.

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Posted in Back Pain, Drugs, Fibromyalgia, pain mechanisms, Uncategorized | Leave a comment

Can Pharyngeal GERD Be Cured?


Reflux into throat has a something in throat “globus “feel, throat clearing and annoying  cough. When ulcer “PPI”pills fail one author suggests injecting T5-6, 1 cm from spine, to influence sympathetic nerve trunks and gradually reset the nervous system – for relief.

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Vulvodynia or Pudental Neuralgia -Simple Repeated Injection Breakthrough Treatment

A simple perivulvar way to do pudental like blocks, if repeated, can lead to astounding improvement in pain in perineal areas – either vulvodynia or pudental neuralgia. I have achieved control in one case of either but don’t know yet the long term story.

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Posted in gynecologic, neuropathic, pelvic | Leave a comment

Sweet Epidural Caudal Sugar-Water Injections Cut Back Pain Longterm

Re back  pain and scioatica – Astoundingly, you can get 50% back pain reduction short term and 30% relief long term with repeated simple injection of D5W sugar water given caudally. Caudal injection has been dumbed down to a simple vertical injection into hiatus.

I considered this article so important that although you can see in in referred site I have reproduced it in total because referred sites often disappear:

Smigel, L. R., Reeves, K. D., Lyftogt, J., & Rabago, D. P. (2016). Poster 385 Caudal Epidural Dextrose Injections (D5W) for Chronic Back Pain with Accompanying Buttock or Leg Pain: A Consecutive Patient Study with Long-Term Follow-up. PM&R, 8(9), S286-S287.

http://www.pmrjournal.org/article/S1934-1482(16)30595-0/fulltext?rss=yes

Assess short and long-term effects on pain and function following caudal epidural injection of 5% dextrose (D5W) for low back pain (LBP) and either buttock or leg pain. A prior randomized study documented short-term pain reduction compared to saline control.
Design:
Consecutive participant open-label trial.
Setting:
Outpatient pain medicine practice.
Participants:
Adults with chronic, moderate-to-severe, non-surgical LBP and either gluteal or leg pain.
Interventions:
Four biweekly epidurography-confirmed caudal epidural injections of 10 ml of D5W and then as needed for 1 year.
Main Outcome Measures: Numerical Rating Scale (NRS) (0-10) for pain before and 15 minutes, 2, 4 and 48 hours following each injection, and at 6, 12 and 41 months; Oswestry Disability Index (ODI) at 0, 6, 12, and 41 months; the fraction of participants with 50% reduction in NRS for pain.
Results:
Thirty-three participants (55 +/- 10.3 years old; 10 female) with moderate-to-severe LBP (6.7 +/- 1.3 points) for 11.16  +/-10.6 years were enrolled. Diagnoses included lumbar spinal stenosis (n ¼ 11), nonspecific low back pain (n = 11), lumbar radiculopathy (n= 7) and “other  diagnoses of low back pain” (n = 4). They received 3.6 +/-1.6 injections of D5W during the first 3 months, and 2.4 +/- 2.3 injections from months 3-12.

A post-injection analgesic response was consistently demonstrated. Pain (NRS) and disability measures (ODI) improved by 3.8 +/- 2.3 points (56%) and 18.5  +/- 15.9 % respectively at 12 months.

Long-term data showed pain (NRS) and disability measures (ODI) improved by 2.5 +/- 3.5 points (38%) and 13.3 +/- 22.7% respectively. The fraction of participants with 50% reduction in pain on the NRS was 70% at 1 year and 45% at 41 months.
Conclusions:
D5W demonstrated consistent analgesic responses and resulted in a long-term improvement in pain and disability when injected in the caudal space of consecutive participants with moderate-to-severe chronic non-surgical low back pain and radiation to either buttock or leg areas

Comment -Initially they published how short term it had benefit – just in press now:

Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial
Liza Maniquis-Smigel 1 ; Kenneth Dean Reeves 2, * ; Howard Jeffrey Rosen 3 ; John Lyftogt 4 ; Cassie Graham-Coleman 5 ; An-Lin Cheng 6 ; and David Rabago 7
Anesthesiology and Pain Medicine. In press(In press): e42550 , DOI: 10.5812/aapm.42550
http://anesthpain.com/?page=article&article_id=42550v

found 50% short term pain reduction effect with one shot

I use this technique in Low Back Pain and it helps but author is now using 20 mls D5W  and I add 2ooo ug preservative free B12.
An old article found B12 spinally improved nerve pain from diabetic neuropathy:

Clin Ther. 1987;9(2):183-92.
Clinical usefulness of intrathecal injection of methylcobalamin in patients with diabetic neuropathy.  Z
Ide H, Fujiya S et al
https://www.ncbi.nlm.nih.gov/pubmed/3568063

 

If there is serious back pain issues without sciatica, I would add 2 mg midazolam to 20 mls of caudal solution (but given epidural when caudal).

Serrao, Juliet M., et al.
Intrathecal midazolam for the treatment of chronic mechanical low back pain: a controlled comparison with epidural steroid in a pilot study.
Pain 48.1 (1992): 5-12.
http://www.sciencedirect.com/science/article/pii/030439599290125U

I have discussed this before:
Midazolam Augmentation of Lumbar Steroid Injections – Use, in Just Mechanical Back Pain
http://painmuse.org/?p=370

Worked better than epidural methyl prednisolone (80 mg) and lasted at least 2 months.

I have wrote about midazolam injection benefits in herpes zoster and failed post laminectomy patients

Confirmed – Intrathecal (Spinal) Midazolam Gives 1-3 Months Relief in Chronic and Failed Back Pain
http://painmuse.org/?p=478

Midazolam Augmentation of Lumbar Steroid Injections – Use, in Just Mechanical Back Pain
http://painmuse.org/?p=370

Miracle Treatment – Low Back Post Herpetic (Post Shingles)Neuralgia Treated With Epidural Steroid and Spinal Midazolam Without Local Can Give Significant Relief For Over 3 Months
http://painmuse.org/?p=351

Older people find caudal blocks painful but not if they are given though a vertical placement of needle through caudal canal insertion point:

Anesth Pain Med. 2016 May 10;6(3):e35340. eCollection 2016.
Vertical Small-Needle Caudal Epidural Injection Technique.
Maniquis Smigel L1, Dean Reeves K2, Jeffrey Rosen H3, Patrick Rabago D4.
https://www.ncbi.nlm.nih.gov/pubmed/27826539

  • use a 25 gauge 3.7 cm hypodermic needle
  • if placement is not right it will be hard inject but a simple adjustment on the hole will make it work better and then patient will feel the pressure in back higher up as it goes in
  • use 20 mls solution

This is very exciting news as even elderly can tolerate a vertically placed injection of D5W. Had one elderly recently express gratitude over shot  – (mine you, I work on her impacted ribs, Quadratus lumborum spasms,  piriformis, thoracolumbar syndrome, cluneal nerve tract pains, SI joint, gluteal triggers and so on as well)

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Dry Eyes More Common In Certain Chronic Pains and Made Worse by Low Vitamin D – Replacement Helps

Prior I wrote about a Dry Eye- Mouth Syndrome (DEMS) that has some joint involvement. DEMS is associated with thyoid antibodies suggesting an autoimmune process (1).

Now It was found more commonly in irritable bowel, chronic pelvic pain and irritable bowel. But most interestingly, low Vitamin D worsens the symptoms and supplementation helps

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Complex Regional Pain (CRPS) Dorsal Foot and Ankle- Dramatic Treatment and Could This Work in Forearm?- And New RX for Tennis Elbow

It was recently found that CRPS of leg might be obviated with attention to Superficial Peroneal nerve in shin by pulse radiofrequency. This is exciting news. I have a CRPS arm helped temporarily by nerve block to superfical antebrachial nerve in forearm. Question is, whether similar measures to Cutaneous Antebrachial Nerve (Thumb palmar side of forearm) would help arm.

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Low Vitamin C Linked to Chronic Pain

Nationwide survey found low vitamin C highly prevalent in population and increases risks of chronic pain.

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Simulating Ketamine Infusions with Repeated Detoid Muscle Injections

Protocol from Anodyne Headache and Pain Care in Texas gave 0.3 mg – 0.4 mg/kg ketamine divided into 3 deltoid IM shots separated by 15 minutes for headache and neuropathic pain.  A remarkably successful ketamine IV treatment for depression gave 0.5 mg/kg iv over 1oo minutes. Could they be different flavours of the same thing?

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Shooting Trigeminal Neuralgia – Facial Epicrania Fugax – and a New Treatment

6-8 years ago a brief neuralgic pain in the scalp that radiated to front or back of head was described. I wrote about it here:
http://painmuse.org/?p=1516

Now a facially originated version has been defined and sounds very much like trigeminal neuralgia except it shots up or down the face. The same superior cerebral artery compression was found on MRI as you see in Trigeminal neuralgia.

Facial epicrania fugax

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Posted in Drugs, neuropathic, Trigeminal Neuralgia, Uncategorized | Leave a comment

Hand Sanitizer Proves Cheap Ultrasound Gel

Regular ultrasound gel bottle may not be sterile and individual packets are costly so hand sanitizer was tried with success.

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I Stand Corrected- CT Do Help Problems – Alzheimer’s and Asthma Treatment

Some specialists will leave patients in abject pain with the implication that the imaging they have ordered will in some way help their pain. It does not.  However, an Alzheimer victim was subjected to 4 head CT and has made some recovery. It was suspected the excessive radiation had anti-inflammatory properties. A 5th CT temporarily set her back and was assumed to be beyond the acceptable radiation dose. There is good evidence radiation can control asthma and perhaps improve lifespan. Continue reading

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TMJ – Upper Joint Injection Technique

I had always thought injecting the TMJ laterally in upward direction would be best. A posterior approach was found more effective in the swine equivalent.

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Post Lobectomy Persistent Chest Pains Prevented by Kinesiology Taping(KT)

Presently there is a battle in attempt to find measures to prevent persistent post-operative pain.  Persistent pains after chest surgery can approach up to 50%.  Post-operative, Kinesiology Taping (KT) was done over  three areas: at the chest access site pain trigger point; over the ipsilateral deltoid/trapezius; and lower anterior chest. In control group 30 day persistent pain was 30% versus only 7% in the KT group.

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New Acute Headache – ? Cause

Eliminating chronic headaches and “cephalic illnesses” (stroke, seizures, cranial lesions, sinusitis, or central nervous system infections” left a group with new moderate- severe headaches that attended emergency. These people could have comorbid serious health issues such as heart failure, worsening asthma or  emphysema, hypertension and pneumonia or something as trivial and an acute viral illness.

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Foot Morton’s Neuroma – New Treatment – Capsaicin Injection

Mortons’s Neuroma can cause severe foot pains often between the bases of the 3rd-4th toes. Cortisone injection may lead to atrophy of tissues and more rubbing of area as result so options are needed. Injection 0.5 mls of 0.1% Capsaicin lead to pain reduction from 5.9 to 2.4/10
mortonsneuromainject Continue reading

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Gabapentin Fails to Help Back Pain With or Without Sciatica

Not all that long ago, Canadian Indian Affairs mandated that native pain sufferers had to try  gabapentin/cymbalta like drugs first before certain opioids. I wrote about how poorly cymbalta worked:
http://painmuse.org/?p=2179

Now even gabapentin failed to help back pain with or without sciatica. One wonders about the ethics of such sweeping proclamations.

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Posted in Back Pain, Drugs | Tagged | 1 Comment

Chronic Severe Abdominal Pain is a Skin Nerve Pain

Lidocaine freezing, administered rectally, can eliminate bowel pains temporarily. Having done that in a case of severe chronic abdominal pains, I found very tender nerve tracts from back to lower abdomen and pelvis on right side, explaining most of the pain.

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Does Etanercept Nerve Irritation Limit Use?

Many years ago I was injecting enbrel paraspinously near the nerve exit of sciatica nerve location. I was using a full 25 mg and found it had minimal effects. I wrote E. Tobinick at times and wondered if it was irritating the nerve. He wrote back “Who are you?” and that was the end of it. Now they have found that any more than 0.5 mg injected near nerve transforaminally gave reduced benefits for treatment of sciatica. This irritative effect of higher doses could explain reduced effects in some studies.

transforaminal

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Pregnancy Gone Badly – needs Quick Diagnosis and Treatment

Came across this while searching pain. It is so deadly, I had to write it up.

Catastrophic antiphospholipid syndrome (CAPS) is a rarely occurring condition leading to death in up to to 1/3 of cases. It can be confused with several other conditions like hemolysis   elevated   liver enzymes low platelets syndrome (HELLP), thrombotic thrombocytopenic purpura(TTP), and hemolytic uremic syndrome (HUS); so easily missed. It can present with generalized malaise,  abdominal  pain,  chest  pain,  shortness of breath and  hypertension,  altered mental status and seizures. Immediate  triple treatment with heparin, IV methylprednisone, and  IV immunoglobulins or plasmaphoresis can save lives.

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