Pain Medical Musing

A call to Kenalog company office confirmed for me that it is the white precipitate that is the active ingredient.  Letting the powder precipitate, and taking off the supernatant was shown to reduce preservatives by 43%. Simply adding Normal saline solution and letting it settle out again and removing that supernatant could reduce it much more. Of course when adding result to your subsequent injection, you would have to go on visual appearance to get right concentration.

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Came across case in reddit/chronic pain that wanted to know what to do for undetermined chronic anal pain. Well there is lots but if constipation is also an issue, then anal biofeedback is treatment of choice.

In
Byrnes, Kevin Gerard, et al. “Optimal management of functional anorectal pain: a systematic review and network meta-analysis.” European Journal of Gastroenterology & Hepatology 34.3 (2022): 249-259.
https://journals.lww.com/eurojgh/abstract/2022/03000/optimal_management_of_functional_anorectal_pain__a.1.aspx

“As biofeedback is noninvasive and may address underlying pathophysiology, it is a reasonable first-line choice in patients with high resting pressures or defecation symptoms.”

Local injection with triamcinolone steroid or botulinum, and various injections to nerve center ganglion impar would be expedient in the right hands. More info below:

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6 months of 20 mg Methotrexate can improve significant early hand OA by 25%.

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Patients on gabapeninoids (gabapentin and pregabalin) for pain or epilepsy that have COPD are up to 1.5 times more likely to have a severe exacerbation. This scares me.

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Amoxicillin-clavulanic acid 100 day treatment was shown to have significant effect on chronic low back pain yet straight penicillin did not. Recent works on clavulanic drugs has demonstrated it can lower brain glutamate levels (pain transmitter) and help with withdrawal and addiction.

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Eradicating your bone marrow stem cells, and replacing with gene edited cells can cure the disease but leaves one sterile.  Preemptive egg and tissue freezing and sperm banking  saves the day but can cost up to $20,000 US dollars ( less for sperm) and In vitro fertilization (IVF) for women (not for sperm) comes with similar price tags. Concerns are, that one might carry the gene to baby, so outside donor IVF might be more sensible and carries similar price-tags. However, the cure is a miracle. Read more about it here:

New gene therapies confront many sickle cell patients with an impossible choice: a cure or fertility
https://www.statnews.com/2023/12/06/sickle-cell-infertility-crispr-vertex-casgevy-bluebird/?utm_source=pocket-newtab-en-us

Anxiety /GAD levels reduced to HALF with stellate ganglion blocks- better results with bilateral,

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In 41 case, right sided stellate block gave rapid relief of brain fog and  fatigue often within 15 minutes of injection. Magical.

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In my younger days, there was a group of pain experts that used opioids as their linchpin. Then studies came our showing only 1/2 can tolerate them and only 1/4 will stay on them. Opioid abuse reared its head. Pain reduction was not great except among a subgroup of responders.

Sadly, they fared better then many of the other agents (gapapentinoids, antidepressants fare poorly in back pains/scaiticas which account for over 1/2 pain patients).

Cannabinoids came under fire early in an issue of PAIN years ago (need to treat 25 to get one good case) and was ignored. Now a recent metanalysis found benefits were:
“Cannabinoids reduced chronic pain and improved quality of sleep, but the effect sizes are of questionable importance. Cannabinoids had no effects on acute pain or cancer pain and increased the risks of non-serious adverse events. The harmful effects of cannabinoids for pain seem to outweigh the potential benefits.

My experience with cannabinoids showed that titration took so long that patients really didn’t notice much benefit and were often unwilling to buy a second batch as a result. Now it looks like it really doesn’t do much significant difference.

I live by the philosophy of threes: – You need to do three things at once to obtain any meaningful results. – meds, exercise, massage/Tai chi and so forth. Maybe not abandon but couple with two other treatments to expect anything.

I’ve had to deal with some chronic pain and found botulinum injection, massage and regular gym use is making a difference.  Any one, by itself, would have done little.

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Saccharomyces boulardii supplement for four months reduced pain by 31% versus 12.5% by placebo. Fatigue reduced by 19% versus 8% by placebo.

Asghari, K.M., Dolatkhah, N., Ayromlou, H. et al.
The effect of probiotic supplementation on the clinical and para-clinical findings of multiple sclerosis: a randomized clinical trial.
Sci Rep 13, 18577 (2023).

https://www.nature.com/articles/s41598-023-46047-6

• repeated evidence that “gut microbiota can influence the inflammatory responses of individuals and animals with MS”
• BioDigest® is a commercial dietary supplement containing 250 mg of SB (1010 CFU), a lactose filler, and a magnesium acetate oil. – one/day ? 1010 colony forming units = 10 x10 to tenth power so maybe 10 biliion.
• That strength you can get off Amazon
  https://www.amazon.ca/Saccharomyces-Boulardii-Probiotic-Boulardii-Shelf-Stable/dp/B09GS9QZ4R
• multiple studies confirming improvement with inflammatory markers with probiotics

Comment – probiotics would be an easy option

Fasting promotes growth of Clostridium sporogenes which elevates levels of indole-3-propionic acid (IPA).  In mouse model, improves “promotes neutrophil infiltration into the dorsal root ganglia (DRG), which enhances the regeneration of sciatic nerve fibers”.

Nerve growth is contingent on a type of neurophils (and also a type of macrophages). Arthritis Pills/NSAIDs would interfere with that.

I sustained injury to the back skin nerves (cluneal) and I stayed off NSAID for  6 weeks to allow nerves to regrow. Tramadol would be a good option in meantime.

I tried some fasting but can’t say if helped.

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For years now, stellate ganglion blocks have been found to help anxiety and PTSD. Some are spectacular and some not. Most have been right sided stellate blocks only. Now a case with BILATERAL stellate blocks has been done with initial significant (>75%) results, and repeated 2 month later with bilateral (botulinum 50 u one side two weeks apart) of each other lead to immense improvement. Swallowing issues for 6 weeks is annoying. Radiofrequency to ganglions prolonged effect and Ketamine addition improved results.

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It has been widely shown that neuropathic pain to include significant changes in spinal support cells called Microglia. Now it’s been shown that “newly identified CD11c-positive microglia as a subset that increases during the remission phase of neuropathic pain”.

Jeff Mogil’s group in McGill has shown that although inflammation is involved in development of pain, there are inflammatory neutrophil leukocytes that  protect against development of chronic pain.

Blanket treatments against Microglia or White Blood Cell inflammation might be coounterproductive

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61% of Ehlers-Danlos (EH) syndromes cases have small fiber neuropathy

Fibromyalgia(FM) is now, in the worser forms, considered a small fiber neuropathy and in the milder forms with evidence of skin nerve immune attack. Hence EH could be said to have a version of FM with all the pain this entails. POTS like symptoms can occur in up to 3/4 cases.

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Diffuse idiopathic skeletal hyperostosis (DISH) disability should be ameliorated, by use of IV pamidronate, Vitamin D 3 4000 u/day and  methyl f0rm B12 3000 mg/day.  HCG shots are helpful. Mood could be relieved with Transcranial magnetic stimulation and hyperbaric oxygen treatments. Muscle knots might be helped with Intramuscular stiimulation (IMS devised by Dr. Chan Gunn from Vancouver and many physios now do).  Facet botulinum or stem cell injections might help. All expensive but she didn’t work all these years for nothing.
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Despite some thinking there is nothing that could be done for plantar fasciitis, combination of fascia exercises (prior post) and plantar stretches combined with high dose arthritis pills (often combined with an ulcer pill) can lead to satisfactory relief.  Regular plantar stretches by self can lead to over 50% improvement.

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Put foot on stairs (or a block of wood would do) and drop heel down – NOT really a stretch but strengthening and revising the plantar fascia has good effect on plantar fasciitis

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Good news is a recent meta- analysis concluded that steroid injections did not result in plantar fascia thinning. Bad news is that though it is effective, it wears off in 4-12 weeks. Rare plantar fascia ruptures can occur just like can happen with shoulder tendon injections. Continue reading →

Exciting discovery! Hydroxymethylglutaryl-CoA (HMG-CoA) Reductase is involved in cholesterol metabolism and cholesterol pills block that enzyme. People with a less functioning version of that enzyme ended up with statin induce myopathy according to one study. Another study found it implicated in some limb-girdle muscular dystrophy and treatable with a compound that helps this enzyme – called oral mevalonolactone.

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I’m a big advocate of B12 for nerve damage pain but have added B6 to my regimen as came across article using it for drug induced neuropathy. Been previously shown to help carpal tunnel symptoms. B6 is touchy as 400 mg can cause nerve damage so best stick to 100 mg/day.

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