Featured - Padda Institute Center for Interventional Pain Management

Diabetes and Neuropathy

Diabetic Peripheral Neuropathy (DPN) is the most common complication of diabetes, and often presents as a distal, symmetric, sensorimotor neuropathy. In the United States, 26.8 million people are affected by diabetes; by the year 2030, that number is predicted to increase to approximately 35.9 million people.

In the U.S. alone, the annual total direct medical and treatment costs of diabetes were an estimated $44 billion in 1997, representing 5.8 percent of total personal healthcare expenditures during that year. When it comes to diabetic peripheral neuropathy and its complications, management is resource intensive and long-term, accounting for a large proportion of this total expenditure. In 2001, the total annual cost of diabetic peripheral neuropathy and its complications in the U.S. was estimated to be between $4.6 and $13.7 billion. Up to 27 percent of the direct medical cost of diabetes may be attributed to diabetic peripheral neuropathy.

More than half of patients who have type 1 or 2 diabetes develop DPN. Diabetes is associated with both macrovascular and microvascular complications, in which the major microvascular complication is diabetic neuropathy (DN) with a prevalence of 50–60%. The neuropathy progresses with decreasing nerve functionality and nerve blood perfusion which may result in malnourished nerve and leads to permanent nerve damage. The clinical manifestations of diabetic neuropathy include numbness, burning and tingling sensation, and intractable pain.

 

Many patients with neuropathy simply don’t now they have it

You may have nerve damage well before you experience its symptoms. The first time you may notice diabetic nerve pain symptoms is when the nerve damage has already progressed. Neuropathy is known to develop well before the patient has any symptoms, and the literature states unequivocally that the sooner treatment can be initiated, the greater the chances of reversal of the symptoms. Microvascular circulatory deficiencies, caused by errors in glucose metabolism, for example, have direct effects on the circulation to the nerves, and there are direct effects on the nerves themselves. Pain signals, in turn, trigger secondary peripheral and central hyperalgesia which enhance the body’s response to the microvascular insult. On a local level, microinflammation and edema around the nerves also contribute to the neuropathy. While this nerve damage can cause pain, it can also result in a loss of feeling in the feet and hands. Numbness can cause cuts and foot ulcers to go unnoticed. These cuts can lead to an infection. In severe cases, an untreated infection can even result in amputation.

 

DPN affects the nerves in the hands and feet, causing numbness, tingling, and pain. Clinical symptoms associated with DPN involve poor gait and balance associated with large sensory fibers and abnormal cold and/or heat sensation associated with small sensory fibers. Chronic pain associated with diabetes is represented by hyperalgesia, allodynia, paresthesias, and spontaneous pain. Symptoms are described as tingling, “pins and needles,” burning, itching, and an abnormal sensation to pain and temperature. Over time, these symptoms may advance from the toes to the foot and up the leg, and these symptoms may occur in the fingers and hands.

Tingling and Numbness

Scientists aren’t sure exactly how diabetes damages nerves. Some theorize that the excess blood sugar affects the protective coating on nerves. Others believe decreased blood flow to the nerves can cause damage.

Either way, as the disease progresses, patients may feel a tingling or numbness in the fingers, toes, hands, and feet. Patients may also report a “pins and needles” feeling, or even a burning sensation.

 

Shooting Pain

A nerve that’s pinched or suffering from damage may send out signals that cause shooting pains. People also described this sensation as an electric shock, or a sharp, stabbing pain. The sensations usually come and go, but they may also remain more constant at times.

These types of pains are most common at night, and can disturb sleep. They may also be the result of damaged nerves that are sending out mistaken signals to the brain (misfiring).

 

Inability to Feel Hot and Cold

Our nerves help us to sense the world around us. They are how we notice when we’re feeling hot or cold. They also tell us when we’ve stubbed a toe or suffered a paper cut.

When nerves are severely damaged, they can actually die off. Suddenly, you may no longer be able to tell when you’ve stepped on a tack or suffered a blister. That means small injuries can go unnoticed and untreated. This can cause more problems down the road.

 

Foot Problems

Once a person loses function in some of the nerves in the feet, they may not notice a blister, infection, or wound until it becomes infected, swollen, and inflamed. Nerve damage can also lead to changes in the shape of the toes. This can require shoe-fitting adjustments. Doctors always recommend that people with diabetes check their feet and hands daily for injuries, especially those who’ve suffered nerve damage and lack feeling in the fingers or toes.

 

Difficulty Walking and Performing Other Daily Tasks

It’s because of our nerves we can button up a shirt, create a hairstyle for ourselves, or even open a doorknob. Nerve damage in the hands and feet can make these everyday tasks more difficult or even impossible. But there are tools available that can help. Specialized orthotic inserts, diabetic shoes, and gripping tools are just a few examples.

 

Autonomic Symptoms

Did you know that nerves control the digestive system? They are also involved in perspiration, sexual function, heart rate, urinary function, and more. If diabetes affects any of these nerves, patients may experience the following symptoms:

  • stomach upset (constipation, diarrhea, nausea, vomiting)
  • urinary problems (incontinence or urinary tract infections)
  • erectile dysfunction or vaginal dryness
  • inability to stay warm or cool
  • difficulty focusing your eyes
  • dry, cracked skin

 

Nerve Pain and Sleep

Some nerve pain is worse at night and as a result, the individual can have difficulty sleeping. This loss of sleep can cause additional problems so people with this type of nerve pain need to discuss the problem with their doctor to receive early treatment.

 

Coping with Nerve Damage

To avoid or limit any of these symptoms, concentrate on controlling your blood sugar levels. The more you can keep your levels in the normal range, the slower any nerve damage will progress. Exercise regularly, manage your weight, and take steps to reduce stress.

Talk to your doctor about lifestyle changes and tools that can help you cope once nerve damage has occurred. Medications and specific treatment methods are also available to help reduce symptoms. Your doctor is your partner in controlling nerve pain. By answering all questions asked (pain type, duration, and how it has changed your lifestyle), you help your doctor to determine the cause of the pain and how to treat it.

 

Treating diabetic nerve pain requires a specific treatment:

Diabetic nerve pain, or painful diabetic peripheral neuropathy, is a separate condition from diabetes that is caused by high blood sugar related to diabetes. This nerve damage may cause foot pain and hand pain. If you suffer from diabetic nerve pain, you can’t undo the damage that has already occurred but it’s very important that you don’t ignore your pain either. The pain, which may get worse over time, can be treated.

Control of your blood sugar

If you have diabetes, it is important to control your blood sugar. Your doctor has probably tested your A1C level before. This measures your average blood sugar level over the past 3 months. The American Diabetes Association recommends a goal of 7% or lower.

Do something about your diabetic nerve pain

Controlling your blood sugar can prevent further nerve damage. However, that won’t reverse the damage or relieve your diabetic nerve pain. And since nerve pain isn’t like other kinds of pain, you may need to receive a specific diabetic nerve pain treatment.

 

What treatment options are available for diabetic nerve pain?

The most common approach is oral medications that only mask the symptoms.

  • 50 percent of patients with diabetic peripheral neuropathy receive treatment with opioids
  • 40 percent take anti-inflammatory drugs
  • 20 percent use serotonin selective reuptake inhibitors (SSRI)
  • 11 percent take tricyclic inhibitors
  • 11 percent take anticonvulsants (Neurontin and Lyrica).

 

Although there is a range of pharmacological agents available for treating the pain associated with diabetic neuropathy, only duloxetine and pregabalin are approved by US Food and Drug Administration (US FDA) for the treatment of diabetic neuropathic pain. The “gold standard” in treating peripheral neuropathy, pregabalin (Lyrica, Pfizer), helps 39 percent of patients achieve a 50 percent reduction in their discomfort and pain, but causes at least 38 percent to have complications. These medications have drawbacks and major adverse effects.

 

Over-the-counter pain relief pills are not approved by the FDA to treat this specific pain. Diabetic nerve pain is a form of nerve pain, a unique type of pain that is different than other types of pain, like pain from a headache, muscle ache, arthritis or sprained ankle. Over-the-counter pain relief pills are not approved by the FDA for the treatment of diabetic nerve pain.

 

What is Combined Therapy?

Combined therapy incorporates two well established procedures that have been combined into a protocol that is showing great promise as an effective treatment solution for diabetic and idiopathic neuropathies. Combined therapy consists of two procedures, an ankle block performed with local anesthetic, and Electronic Signal Treatment (EST), as delivered by a unique sophisticated electroanesthetic wave generator.

 

Ankle Block

The ankle block targets five nerves responsible for sensory supply distal to the ankle. The nerves consist of four branches of the sciatic nerve (the superficial peroneal, the deep peroneal, the sural, and the posterior tibial nerve) and one cutaneous branch of the femoral nerve (the saphenous nerve). The sciatic nerve gives off two terminal branches, the common peroneal and the tibial nerve.

 

Electronic signal treatment

EST is an electrical signal wave treatment that regenerates nerves and increases blood flow by using electrical waves to simulate nerve function in the damaged areas. Electronic signal treatment utilizes computer-controlled, exogenously delivered specific parameter electronic cell signals using both varied amplitudes (AM) and frequencies (FM) of electronic signals. This

digitally produced electronic sinusoidal alternating current with associated harmonics produces scientifically documented and/or theoretical physiological effects when one applies them to the human body. The electronic signal treatment medical device uses sophisticated communications technology to produce and deliver higher frequency signal energy in a continually varying sequential and random pattern via specialty electrodes. This alternation of sequential and random electronic signal delivery eliminates neuron accommodation.

With the help of 0.25% Marcaine, which is a vasodilator (opens the blood vessels for a short time to increase blood flow) and a local anesthetic. The more blood flow that your nerves get while stimulated the faster your regeneration takes place.

 

Combined therapy is believed to:

  • Increases cellular growth
  • Increases Metabolic Activity
  • Reduces swelling around the nerve
  • Stimulates nerve function
  • Increases oxygen and blood directly to the nerve
  • Promotes wound healing
  • Anti-inflammatory action
  • Reduces scar tissue development

The patient has the ability to attain increased movement once again with an effective and favorable pain management treatment plan.

Severe Head and Neck Pain

Caution:

If you’re having your worst migraine ever or symptoms that are unusual for you or frightening, see a doctor as soon as possible. You need to be sure this IS a Migraine and not something more serious such as a stroke. 

Caution:

Pregnant women should immediately alert their physician as many of the medications used to treat migraines can cause birth defects.

 

 

The goal of the Padda Institute Headache Section is to provide diagnosis and treatment that will help people who experience severe pain regain a better quality of life.  (The treatment needs of patients who have occasional mild headaches are significantly different from those patients whose attacks are frequent and completely disabling.)  If your quality of life is impacted from migraine, chronic head pain, or nerve pain in the face you need a plan of action from a team of highly experienced specialists. We provide a collaborative approach combined with the latest technology resulting in individualized care. Our goal is to provide effective, compassionate care to improve your quality of life.

Headaches are serious

Headache remains one of the most common health issues which challenge physicians and other health professionals, migraine is the 12th most disabling disorder in the United States..  The symptoms of head pain are a frequent cause of human suffering and disability.  According to a World Health Organization analysis, severe Migraine attacks are as disabling as quadriplegia (paralysis of both arms and legs).  Suicide attempts are three times more likely among people who have Migraine with aura than among people who do not have Migraine.  More than 1,400 American women with Migraine with aura die each year from cardiovascular diseases compared to women who do not have Migraine.

Migraines permanently affect your brain

Some 37 million Americans suffer from migraines, those incredibly painful and often debilitating headaches. While they’ve been known to knock a person out, migraines weren’t thought to permanently affect the brain – until now.  A study published in the journal Neurology suggests migraines permanently alter brain structure in multiple ways.  The risk of white matter brain lesions increased 68% for those suffering migraines with aura, compared to non-migraine sufferers. Those who suffered from migraines without aura saw that increased risk cut in half (34%), but they too could get lesions in the part of the brain that is comprised of nerve fibers.  Migraine affects about 10 to 15% of the general population and can cause a substantial personal, occupational and social burden.  According to the American Migraine Foundation, migraines cost the United States more than $20 billion a year in both direct medical expenses like doctor visits and medication and indirectly when employees miss work resulting in lost productivity.

For many patients with headache, an organized, multidisciplinary headache center environment is necessary to provide the entire spectrum of headache management.

 

  • Patients in whom comprehensive services are essential to address the multifunctional components of their headaches.
  • Patients who have not responded to medication and have a history of recurring acute care needs or progressive persistent headache.
  • Patients who have undergone multiple diagnosis and therapeutic interventions yet the diagnosis remains uncertain or questionable.
  • Patients who have had frequent emergency room visits, who have used hospital inpatient services excessively, and who have overused different oral analgesics, including opiates, or who have been treated repeatedly with intramuscular or intravenous medications.

 

 

The History of Headaches

The clinical entity of headache dates back to ancient times.  As early as the dawn of civilization, primitive headache remedies included procedures aimed at ridding the body of the “demons and evil spirits” that were believed to cause headaches.  As early as the Neolithic period dating back to 7000 BC, skulls have been found bearing man made holes (called trephination) presumably done for medical reasons which may have included the treatment of headache.  Skulls demonstrating trepanation have also been found in Peru dating back to the thirteenth century.  The writings of the early Greeks referred to headache as a serious medical condition.

Hippocrates (400 BC) may have been the first to describe the clinical symptoms of migraine.  In the historical Hippocratic books Hippocrates discussed what appears to have been the visual aura that can precede migraine.  The term “migraine’ itself is derived from the Greek word hemicrania. Throughout history, there have been famous individuals such as Plato, Thomas Willis, Erasmus Darwin (Charles Darwin’s grandfather), and others who have contributed to our understanding of headache. More recent scholars, such as Dr Harold Wolff, played an important role in our classification of different types of headache and their treatment. Following his classic 1948 publication of the first edition of Wolff’s Headache, it was Dr Wolff who introduced important scientific concepts which have served to modernize the study of headache.  Since that publication there has been an explosion in headache research which has resulted in our better understanding of this clinical condition.

There are now scientific mechanisms which more clearly define the pathophysiology of some headaches such as migraine.  This has also led to the development of new migraine specific medications, specialized pain management techniques, and ultimately more effective treatment opportunities.

Migraines have affected people for centuries and played an influential role throughout world history. Many famous and accomplished people have experienced severe headaches.  Julius Caesar, Napoleon, Ulysses S. Grant and Robert E. Lee; great painters Vincent Van Gogh, Georges Seurat and Claude Monet,; and famous authors Virginia Woolfe, Cervantes and Lewis Carroll all experienced migraines. Thomas Jefferson wrote the Declaration of Independence during an intense period of productivity after being bedridden for six weeks with a migraine.  The famous authors Virginia Woolf, Cervantes (best known for Don Quixote) and Lewis Carroll (Alice’ Adventures in Wonderland) had migraine. There is even evidence to suggest that at least some of Alice’s Adventures were based on Carroll’s personal migraine visual aura perceptions. As Cheshire Cat observed, “One pill makes you smaller; one pill makes you larger, the pills mother gives you do nothing at all”.  There has been literature which indicates that Thomas Jefferson’s headaches were so severe and debilitating that they often interfered with his ability to function.  As he wrote to Martha Jefferson in February 18, 1784, “Having to my habitual ill health….lately added an attack of my periodical headache; I am obliged to avoid reading, writing, and almost thinking”.  In March 1807, while still President, Jefferson wrote “…Indeed, I have but little moment in the morning in which I can either read, write, or think, being obliged to be shut up in a dark room from early in the forenoon till night, with a periodical headache”.

Headache sufferers constitute one of the largest groups of patients within a neurological practice.  More patients who visit doctors complain of headache than any other single ailment. Headache and migraine in particular, may be considered as a universal human condition which continues to be under diagnosed, misdiagnosed and/or mistreated.  Whereas in some individuals, headache may be an occasional episodic, sometimes nuisance, for others the symptoms of headache may be a manifestation of a disabling chronic disease.  In the latter group, headache disrupts daily routines and impairs quality of life.  The frequency, severity, and even life consequences of headache sufferers vary widely.  The causes of headache are different in different individuals.

 

Range of Disorders:

Each year, millions of Americans suffer from chronic headaches.  There are four main headache types: tension, cervicogenic, migraine and cluster.

  • Tension headaches are the most common and may be described as a mild to moderate constant band-like pain, tightness, or pressure around the forehead or back of the head and neck.

 

  • While cervicogenic headaches are slightly less common and are caused by any number of conditions in the neck, causing referred pain, most often the cervical facets or the cervical discs.  Some studies suggest that the trigeminal sympathetics and parasympathetics mediate pain from the region of the Occipital Nerve, such to the degree that the Occipital Nerve may be considered the “V4” of the trigeminal.  Cervicogenic pain can trigger Migraine headaches and Cluster headaches.

 

  • Migraine headaches are severe headaches that are described as a chronic, throbbing head pain that can cause significant pain for hours or even days.  Symptoms can be so severe that light or sound can cause exacerbation and most patients must find a dark quiet room to lie down.  The typical Aura of Migraines is only present in 25-30% of all cases.

Status Migrainosus: A rare, sustained and severe type of migraine headache, lasting more than 72 hours that is characterized by intense pain and nausea, often leading to hospitalization.

Chronic daily headaches occur frequently, usually more than 15 days per month. Chronic daily headaches are classified as either long duration (lasting more than four hours) and short duration (lasting less than four hours). The majority of people who experience chronic daily headaches have long-duration headaches.

Medication overuse headaches, sometimes called rebound headaches, occur when people who experience migraine or tension headaches take too much analgesic or anti-migraine medication. When the effect of one dose wears off, the next headache occurs and another round of medication is taken. A vicious cycle is created of ever-increasing headaches and more frequent medication use.  Taking Migraine abortive medications, pain relievers, or alternating them more than two or three days a week can cause medication overuse headache.

Menstrual migraine is a headache that occurs during the menstrual cycle. It can occur two days before and up to three days after the beginning of a woman’s period. Although the cause is not explicitly known, menstrual migraine may be triggered by changes in hormone levels. The most likely cause is the fall in estrogen levels that takes place just before the beginning of menses.  When women experience menopause naturally, 1/3 experience worse Migraines. When women experience menopause following a hysterectomy, 2/3 experience worse Migraines.

Studies have shown that 90% of what people think are sinus headaches are really Migraines. A sinus headache is very rare without an infection.

  • Cluster headaches, also known as suicide headaches, are excruciating unilateral headaches of extreme intensity. The duration of the common attack ranges from as short as 15 minutes to three hours or more. The onset of an attack is rapid, and most often without the preliminary signs that are characteristic of a migraine. They are marked by repeated, short-lasting attacks of excruciating, unilateral head pain of short duration.  A cluster headache may be accompanied by redness or tearing of the eye and nasal congestion or runny nose. Often mistaken for sinus or migraine headaches, cluster headaches are characterized by sharp, stabbing pain in or around the eye, temple, forehead or cheeks.
  • Atypical facial pain of all types including trigeminal neuralgia

To assure an accurate diagnosis, we collect an extensive medical history and conduct a comprehensive neurological exam. At times we request a specialized MRI of the brain and neck or blood tests that search for causes of headache including hormone levels, vitamin levels, or markers of an overactive immune system. After the evaluation, treatment options are discussed including medications, lifestyle modification, pain relieving procedures and alternative therapies.  Nearly 30% of patients with dental pain after dental procedures are actually a form of trigeminal neuralgia.

 

Outpatient Treatment

For many people, medication is required to control their headaches. Avoiding the triggers which initiate headache onset is the most important step. There are two categories of headache medication: abortive and prophylactic.

 

  • Trigger Management

Trigger management is key to preventing a migraine attack, migraines don’t just happen; they have triggers.  Trigger factors are those circumstances or influences that can cause a migraine. Trigger factors vary from person to person; if recognized and avoided, a person may prevent a migraine from developing.

Examples of triggers include changes in weather or air-pressure, bright sunlight or glare, fluorescent lights, chemical fumes, menstrual cycles, and certain foods and food products, such as processed meats, red wine, beer, dried fish, fermented cheeses, aspartame and MSG.

  • Preventive or Prophylactic Medication Therapy

Prophylactic drugs are taken daily to prevent headaches. They may be prescribed for people who experience frequent severe headaches, usually two or more per month. These drugs may be taken until a person’s headaches are under control. Generally, the lowest effective dose is used for the shortest period possible. Examples of prophylactic drugs are anti-depressants, beta blocker and calcium-channel blockers.

Many people who take preventive or prophylactic medications will also need to take attack-aborting medications to relieve pain and other symptoms.

  • Abortive Medication Therapy

Attack-aborting medications can relieve the severity and/or the duration of migraine headaches and their related symptoms. In general, most attack-aborting medication should be taken as early as possible in an attack.

Many people who experience migraines or other severe headaches can recognize their early symptoms, allowing them to intervene early with the attack-aborting medication. This may allow them to avoid a more severe, prolonged episode. Attack-aborting medications include cerebral vascoconstrictor abortive agents and non-vasoconstrictive abortive agents.

Specialized Treatment Options for Headache, Migraine and Facial Pain

Our team cares for many patients each year which empowers countless people to achieve substantial improvement. Some of our specialized treatments offered include peripheral nerve injections, which numb the nerves of the scalp to shut off chronic migraine. On average, the injections can give patients weeks to months of benefit. In rare cases, our team provides occipital nerve stimulation by a surgically implanted device that delivers an electric charge to nerves in the back of the scalp to treat migraine, cluster headache, and other types of facial pain that doesn’t respond well to other treatments. This is a treatment few other centers offer.

We also offer a number of alternative therapies with special focus on nutraceuticals – nutritional supplements – and vitamin therapies that have anti-pain or anti-migraine suppressing properties. Also available is pain psychology which uses relaxation strategies and biofeedback to reduce migraine. Our clinic embraces a specialized hormone therapy, called bioidentical hormone replacement therapy. This is where a patient’s hormonal status is monitored and individualized hormonal therapy is provided to normalize the body’s natural cycle and reduce migraine or head pain associated with hormonal dysfunction. We also offer acupuncture.

 

Advanced therapies

  • Spenopalatine Block

The Sphenopalatine Gangion Nerve Block (SPG Nerve Block) is both a  preventative and abortive technique, and may infact prevent trigger activation altogether.

The Sphenopalatine ganglion (SPG) nerve block and the Trigeminal Nerve Block is a fast, highly effective, non-invasive treatment option for migraines and headaches without the use of pills or injections. This treatment uses a unique transnasal catheter to eliminate the pain in a safe and painless way. Aside from migraine and headache, It has been providing successful relief to a variety of painful conditions including trigeminal neuralgia.

Technical:

The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel’s ganglion) is located in the pterygopalatine fossa, posterior to the middle nasal turbinate. It is covered by a 1- to 1.5-mm layer of connective tissue and mucous membrane. This 5-mm triangular structure sends major branches to the gasserian ganglion, trigeminal nerves, carotid plexus, facial nerve, and the superior cervical ganglion. The sphenopalatine ganglion can be blocked by topical application of local anesthetic or by injection.

  • Trigeminal Blockade

Trigeminal neuralgia is an extremely painful condition that affects the trigeminal nerve in the face, which is also called the fifth cranial nerve.  The Trigeminal Nerve is often called the Dentist’s Nerve because it goes to the teeth, jaw muscles, jaw joints (TMJ),and periodontal ligament. Trigeminal innervation of the sinuses, eustacian tubes, tensor of the ear drum (tensor tympani), soft palate, tongue and meninges of the brain explain why there are so many disorders associated with jaw function, TMJ and TMD. The trigeminal nerve plays a very important role in the face, being responsible for sensing touch, pressure, pain and temperature in the jaw, gums, forehead and around the sensitive eye area. Since it controls sensation in almost the entire face, pain in the trigeminal nerve can affect many different parts of the face.  Many people speculate that most atypical facial pain, most dental pain, most sinus induced headache, and most headache originating from the base of the skull results from trigeminal activation.

 

Nine reasons why weight loss is so important for chronic pain patients.

Nine reasons why weight loss is so important for chronic pain patients.

1. Pain reduces activity

Pain often leads to reduced activity and exercise, which can cause patient’s to gain weight, due to loss of metabolically active muscle.

2. Pain prevents restful sleep

Pain disrupts sleep, reducing growth hormone production, which causes patients to gain weight.  Pain also causes elevated cortisol levels and epinephrine levels, which reduce sleep and independantly cause obesity.

3. Pain effects hormones

Excessive fat accumulation leads to a buildup of visceral fat which produces xenoestrogens, which inhibit the production of testosterone, which causes further fat weight gain and loss of muscle mass.

4. Obesity predisposes patient’s to diabetes

Excessive fat accumulation decreases insulin sensitivity and produces insulin resistance, a form of pre-diabetes.

5. Pain effects your pocketbook

Pain often leads to significant functional disability, reducing the patient’s standard of living, which encourages the consumption of subsidized foods, often rich in carbohydrates (food stamps buy significantly more calories of carbohydrates than protein).

6. Obesity effects joint load bearing

Excessive weight dramatically increases the amount of load joints must support. For every extra one-pound of fat you have, you increase the force on your lower back by nearly 20-24 pounds. If you are 10 pounds overweight, your back is carrying an extra 240 pounds of force, and if you lose 10 pounds of weight you will reduce load bearing by 240 pounds.

7. High blood sugar reduces the effects of pain medications

Patient’s with elevated blood glucose experience significantly more pain and find that their pain medications are less effective as the glucose level rises and more effective as the glucose levels fall. There is a direct effect on the opiate receptor by excessive glucose, which prevents activation of the receptor.

8. High blood sugar makes proteins sticky (Glycation)

Glucose or sugar is a sticky carbohydrate. Imagine if you poured sticky goo into the engine of your car, it would bind up the machinery. Extra glucose binds onto nearly all of the proteins in your body, making them work less efficiently, and predisposing patient’s to heart attacks and early aging.

9. Carbohydrates are themselves addictive

Although eating sugar may give you an immediate lift or rush, it quickly disappears when insulin drives the blood sugar into the cells, which then leaves you craving for more sugar because your blood sugar level drops precipitously. Elevated blood sugar temporarily seems to partially activate the endogenous opiate receptors and some people do actually become “addicted” to carbohydrates, requiring ever increasing dosages, which leads to fat accumulation.

 

Meditation

The steps of ho’oponopono meditation ritual.

 

  1. Get comfortable and relaxed, in a sitting position, upright. Take 5 minutes or more to get deeply relaxed.

 

There are two breathing techniques recommended for initiating meditative relaxation:

 

The Ha Technique from Hawaii

Take a full breath in through the nose, and out through the mouth with the sound, “Ha,” repeating five times. The goal is to relax the abdominal muscles during inhalation and completely empty the lungs during exhalation.

 

The exhalation technique from East Asia

A technique initiated in Sikhism East Asia utilizes the terminology “Sat Naam,”  breathing as deeply as possible through the nose, relaxing the abdominal muscles and then exhaling slowly through the mouth while saying the single word Sat Naam.  The goal is to initiate exhalation with the word Sat, then exhale as long as possible  till the lungs are completely empty while saying Naam.  This is repeated a total of five times.  This technique seems to more effectively empty the lungs

Once the initiation breaths are complete, a process of meditative flow or disconnection or quantum spreading begins (many individuals will continue the ritualistic breathing throughout the meditation ritual, but omitting the actual verbalization).  The western mind has tremendous difficulty creating a meditative internal silence, I have found the following beneficial

 

  • Pick a spot on the wall to look at, above eye level, so that your field of vision seems to bump up against your eyebrows, but the eyes are not so high so as to cut off the field of vision.
  • As you stare at this spot, just let your mind go loose, and focus all of your attention on the spot.
  • Notice that within a matter of moments, your vision begins to spread out, and you see more in the peripheral than you do in the central part of your vision.
  • Now, pay attention to the peripheral. In fact, pay more attention to the peripheral than to the central part of your vision.

 

This should take approximately five minutes, but remember, perception of time expands and contracts based upon our individual consciousness and the clutter of the mind.

 

 

2. Know that there is an infinite source of love and healing energy in the Universe, and it can be channeled down into you through the top of your head crown chakra. When you do this it reminds you of that state of complete love as you feel your heart open and accept it. Love is always there for us, if we let ourselves accept and feel it. Do this. Fill your head, your body, and your heart with the pink or peachy-gold energy of love and feel it heal you. (If you can’t feel it, perhaps you need to do something about your black bags that are clogging the works!) Sense the energy filling and overflowing out from your heart into your entire body. Let yourself drift and revel in it . . .

 

3. Now imagine a place in front of and below you that you will bring the persons to. (You may feel it, hear it, see it, know it, or sense it in another way – I will be asking you to see something; you just translate that into whatever sense works for you.)

 

4. Bring in the person you want to make things right with, starting with those you need to forgive, then those that need to forgive you.  Imagine that there is a quantum linkage or umbilical cord, which connects you to them individually.  This linkage represents the sum of all of your interactions with them, for some individuals this umbilical cord will be very strong and for others very flimsy.  This linkage is your quantum connection to the emotional memory of this person.

 

5. Ask the person if they will accept healing and forgiveness from you. (If they do not want healing, just skip the next part where you fill them up with healing.)

 

6. Fill your head with the healing pink or peachy-gold energy of love from the Universe and let it flow into your heart and overflow radiating out from your heart and into the person in front of you. Fill them up until they are overflowing with healing love energy.

 

7. When the person is filled with the healing energy, have a discussion with them, forgiving them for anything they’ve done intentionally or unintentionally that hurt you. Tell them you recognize that they are a magnificent being, and you support them connecting to their Higher Self.

 

8. Ask them if they’ll forgive you for anything you’ve done intentionally or unintentionally that hurt them. Ask them if they recognize that your are a magnificent being, and if they support your connection to your Higher Self.

 

9. Cut the cord or cords that bound you so you can let go. See your energy returning to you. See their energy returning to them.

 

10. See them float away to return, whole and healthy, to their lives. Make sure the people disappear.

 

11. Repeat numbers 3 – 9 with every person on your lists.

 

12. When done, check to make sure you have no negative feelings left when you think about any of these people.

 

13. Repeat your five breaths and close this stage.

 

– If you still have negative feelings about someone, do ho’oponopono again after making reparations.

 

 

Treating Anxiety, PTSD and chronic pain. (Using rituals for neuromodulation in pervasive anxiety.)

Many of our patient’s have suffered significant trauma, either psychological or physical, which maintains a chronic high level of anxiety, and they perseverate on these past events as if they are the active present.  This recurrent neurologic loop prevents them from healing and moving forward.  Symptoms of anxiety are not the memory itself, but the physical manifestation of the underlying emotional charge, which may develop a life of it self.  Historically we have advocated the use of medications to treat anxiety in order to disrupt this cycle of dysfunction, but have found that these medications can themselves lead to a significant dependence, and for some patients a failure to adequately address the root cause, create a self reinforcing loop of addiction and anxiety.

These reinforced recurrent loops of consciousness can become overwhelming, and are best addressed in a more direct method, rather than using medications to numb the global consciousness.  Temporarily altering perception in order to gain critical insight using a combination of psychological techniques and medications is effective, but using the medications alone is the equivalent of throwing gasoline on a smoldering fire. We do advocate the judicious use of medications to reduce systemic anxiety, on a temporary basis; and advocate the use of medications to assist in the process of meditation and enhanced introspection. This becomes especially relevant for patient’s experiencing chronic pain, which by definition is a perceptive dysfunction with an underlying physical cause.

The ritual created by recurrent pervasive thoughts is best quenched by a counter ritual, helping the patient regain a center locus of control.  Rituals have served man kind for eons, and we are hardwired to accept the construct of ritual transfer from the imagination to the reality of daily living, i.e. our consciousness is our reality, and altering our consciousness alters our reality perception.  Rituals are useful in creating a construct of internal accountability, which may have become lost for patients with overwhelming anxiety disorders.  Using a beneficial ritual to disrupt a pathologic pattern of thought can provide the framework of consistency needed to move on or extinguish the emotional charge from a memory.

These anxiety loops with their attached emotional charges are best viewed as negative baggage we trudge along behind us, they are the large elephant in the room in nearly every interaction we have with ourselves and the outside world.  Research studies demonstrate that people who exhibit rigid and unforgiving behavior have more stress, get sick more often, sleep less and face an elevated risk of heart-related illness; all of which are manifested physical signs of anxiety.

We hold grudges, we carry guilt, we blame, we hurt, and we’re dissatisfied because of some perception of lack in ourselves or in others; a lack of love, a lack of action, a lack of something.  This sense of lack and dissatisfaction is often connected to prior hurts, personal decisions and/or behavior or, a lack of action on previous commitments.

We need to forgive in order to move forward.  Forgiving others is key; asking for forgiveness is as well.  But we must first and foremost forgive our selves.  Extinguishing our negative loops and removing their emotional charges requires being at peace in our activities, requires forgiveness.

Confrontation with those we need to forgive (forget), or even their acknowledgement of their errors is not necessarily a benefit in psychological traumatic healing, and dwelling on the confrontational exchange serves only to further imprint our own psychological loops.

 

There are a variety of ancient healing techniques that are useful in framing a ritual of forgiveness, the one that we have found most useful is from Hawaii, called .  The words ho’o (“to make”) and pono (“right”), is an indigenous Hawaiian forgiveness process that involves letting go of all resentment and clearing out preconceptions about others.  It is designed to make right, twice, once for oneself and once for the other party.  In its traditional form, the ho’oponopono ritual, akin to the healing circles of North American aboriginals, tended to take place in a large group facilitated by a mediator.  It can also be done individually, using self guided imagery.

[learn_more caption=”For those that need a scientific explanation”]

The accepted psychological terminology for this ritual is called emotional disclosure.  One of the keys to ho’oponopono success is that the party that has aggrieved us or we have aggrieved, does not need to be present or even acknowledge that we have forgiven them and ourselves.  Most importantly, the visual manifestation of our torment and the disconnection of the emotional charge is the underpinning of the rituals success and depends on the following:

  • Reducing the irritability of the sympathetic nervous system and producing a more receptive state for suggestibility can be accomplished by meditative deep breathing exercises.
  • Accepting that all life forms are connected at a quantum level, some being more strongly connected, through a concept called entanglement.
  • Creating a model of behavioral interaction with others, utilizing quantum concepts of entanglement, and then severing those entanglements is the visualization and demobilization of the emotional charge.

[/learn_more]

The steps of ho’oponopono meditation ritual.

(You can record this for yourself. Remember to give yourself a few minutes between each direction.  Create a list of those that you need to seek forgiveness from, and those that you need to forgive—keep in mind that you may not know there actual names and you may not know what they actually look like, but it is the emotional representation that is important).

  1. Get comfortable and relaxed, in a sitting position, upright. Take 5 minutes or more to get deeply relaxed.

There are two breathing techniques recommended for initiating meditative relaxation:

The Ha Technique from Hawaii

Take a full breath in through the nose, and out through the mouth with the sound, “Ha,” repeating five times. The goal is to relax the abdominal muscles during inhalation and completely empty the lungs during exhalation.

The exhalation technique from East Asia

A technique initiated in Sikhism East Asia utilizes the terminology “Sat Naam,”  breathing as deeply as possible through the nose, relaxing the abdominal muscles and then exhaling slowly through the mouth while saying the single word Sat Naam.  The goal is to initiate exhalation with the word Sat, then exhale as long as possible  till the lungs are completely empty while saying Naam.  This is repeated a total of five times.  This technique seems to more effectively empty the lungs.

Once the initiation breaths are complete, a process of meditative flow or disconnection or quantum spreading begins (many individuals will continue the ritualistic breathing throughout the meditation ritual, but omitting the actual verbalization).  The western mind has tremendous difficulty creating a meditative internal silence, I have found the following beneficial

    •  Pick a spot on the wall to look at, above eye level, so that your field of vision seems to bump up against your eyebrows, but the eyes are not so high so as to cut off the field of vision.
    • As you stare at this spot, just let your mind go loose, and focus all of your attention on the spot.
    • Notice that within a matter of moments, your vision begins to spread out, and you see more in the peripheral than you do in the central part of your vision.
    • Now, pay attention to the peripheral. In fact, pay more attention to the peripheral than to the central part of your vision.

 This should take approximately five minutes, but remember, perception of time expands and contracts based upon our individual consciousness and the clutter of the mind.

2. Know that there is an infinite source of love and healing energy in the Universe, and it can be channeled down into you through the top of your head crown chakra. When you do this it reminds you of that state of complete love as you feel your heart open and accept it. Love is always there for us, if we let ourselves accept and feel it. Do this. Fill your head, your body, and your heart with the pink or peachy-gold energy of love and feel it heal you. (If you can’t feel it, perhaps you need to do something about your black bags that are clogging the works!) Sense the energy filling and overflowing out from your heart into your entire body. Let yourself drift and revel in it . . .

3. Now imagine a place in front of and below you that you will bring the persons to. (You may feel it, hear it, see it, know it, or sense it in another way – I will be asking you to see something; you just translate that into whatever sense works for you.)

4. Bring in the person you want to make things right with, starting with those you need to forgive, then those that need to forgive you.  Imagine that there is a quantum linkage or umbilical cord, which connects you to them individually.  This linkage represents the sum of all of your interactions with them, for some individuals this umbilical cord will be very strong and for others very flimsy.  This linkage is your quantum connection to the emotional memory of this person.

5. Ask the person if they will accept healing and forgiveness from you. (If they do not want healing, just skip the next part where you fill them up with healing.)

6. Fill your head with the healing pink or peachy-gold energy of love from the Universe and let it flow into your heart and overflow radiating out from your heart and into the person in front of you. Fill them up until they are overflowing with healing love energy.

7. When the person is filled with the healing energy, have a discussion with them, forgiving them for anything they’ve done intentionally or unintentionally that hurt you. Tell them you recognize that they are a magnificent being, and you support them connecting to their Higher Self.

8. Ask them if they’ll forgive you for anything you’ve done intentionally or unintentionally that hurt them. Ask them if they recognize that your are a magnificent being, and if they support your connection to your Higher Self.

9. Cut the cord or cords that bound you so you can let go. See your energy returning to you. See their energy returning to them.

10. See them float away to return, whole and healthy, to their lives. Make sure the people disappear.

11. Repeat numbers 3 – 9 with every person on your lists.

12. When done, check to make sure you have no negative feelings left when you think about any of these people.

13. Repeat your five breaths and close this stage.

– If you still have negative feelings about someone, do ho’oponopono again after making reparations.

 

 

 

 

 

 

 

 

 

 

Addiction and pain management


Get your life back! We specialize in Suboxone therapy for opiate addiction patient’s who also have chronic pain. The Padda Institute is an outpatient facility where we ease patients through the recovery process from addiction. We specialize in the confidential treatment of patients in both the physical and psychological aspects of addiction. Our experienced staff will develop a results based individualized treatment plan for you based on your addiction history and your specific needs.

Opiate Addiction and chronic pain are not uncommon

[learn_more caption=”Opiate Addiction and chronic pain are not uncommon”] Opiate addiction as well as chronic pain can impact so many aspects of a persons quality of life and sense of well being. We offer thorough evaluation and customized treatment plans to help patients achieve and maintain their best functional recovery from addiction, chronic pain or both. • Nearly 36% of people experience disabling pain in any given year. • In addition, 57% of people ages 65 and older experience pain that has lasted more than 12 months. • Reportedly 32% of chronic pain patients have addictive disorder, and nearly 60% of people addicted to opiates have chronic pain. These statistics, and my personal medical practice observation suggest that there is a tremendous overlap in patient’s who have chronic pain and also have addiction to medication. [/learn_more]

 

Specialized treatment is needed for patient’s with both addiction and chronic pain

Chronic pain and addiction are not static conditions. Both fluctuate in intensity over time and under different circumstances and

require ongoing management. Treatment for one condition can support or conflict with treatment for the other; a medication that may be appropriately prescribed for a particular chronic pain condition may be inappropriate given the patient’s substance use history. Other commonalities include the following:

  • Both are neurobiological conditions with evidence of disordered central brain function.
  • Both are mediated by genetics and environment.
  • Both may have significant behavioral components.
  • Both may have serious harmful consequences if untreated.
  • Both often require multifaceted treatment

Pain and addiction are related

[learn_more caption=”Pain and Addiction are related”] Pain Both pain and responses to pain are shaped by culture, temperament, psychological state, memory, cognition, beliefs and expectations, co-occurring health conditions, gender, age, and other biopsychosocial factors. Because pain is both a sensory and an emotional experience, it is by nature subjective. Addiction A person may use substances initially for several reasons, such as to experience the euphoric effects, to relieve stress, to overcome anxiety or depression (or both), or to blunt the pain. With repeated exposure, however, substance use in some people can become uncontrollable. Changes to the brain occur in a process that is mediated by both genetic and environmental factors, which result in an overvaluation of the substance, a devaluation of other things, andimpaired control of substance-related behavior. Evidence indicates that addiction is a chronic disease. The primary rewarding effects of addictive substances occur in the cortico-mesolimbic dopamine systems, where several structures link to control the basic emotions and connect them to memories, which drive behavior. These systems produce sensations of pleasure in response to actions that support survival (e.g., eating, sex) and sensations of fear in response to potential dangers. In a cascading effect, these sensations trigger the endocrine and autonomic nervous systems, stimulating bodily responses. The prefrontal cortex also plays a role in the formation of addictions, modifying pleasure and pain signals based on other considerations. Thus, the brain’s reward and stress systems reinforce life-sustaining behaviors. Development of addiction in pain patients: In some people, a cycle develops in which pain or distress elicits severe preoccupation with the substance that previously provided relief. This cycle—seeking pain relief, experiencing relief, and then having pain recur—can be very difficult to break, even in the person without an addiction, and the development of addiction markedly exacerbates the difficulty. The propensity to develop this cycle is influenced by genetic and environmental factors; some people will experience greater degrees of analgesia than others, and some will have more severe or prolonged abstinence symptoms. Genetic variability in susceptibility to these experiences may explain some cases of iatrogenic addiction. [/learn_more]

 

About our program for addiction and chronic pain

Suboxone therapy is a type of maintainance treatment for opiate addiction. Maintenance treatment is a method of minimizing opiate withdrawals and relapse episodes by using medications.  Suboxone was approved in 2000 for the maintenance treatment of opiate addiction. Suboxone effects the same area of the brain as other opiates. Suboxone also blocks the effects of any opiates that might be used. This eliminates cravings and diminishes the chance that the Suboxone will be abused. For opiate addicts, Suboxone has become an affordable, convenient, and safer alternative to Methadone. While regular monthly visits to the clinic are still required, the patient no longer has to visit the clinic every day.

 

Stated simply, Suboxone is designed to do two things:

1. minimize cravings

2. lessen the high felt when using an abused substance

 

We also advocate participation in AA (Alcoholics Anonymous) and NA (Narcotics Anonymous) which we believe can provide a strong support network for people in recovery.

 

 

We understand the process of recovery from addiction can be a long and painful one. By developing an individualized plan of care for each patient, we help aid the patient into sobriety. As clinicians’ we make the process as easy as possible by providing both medical support to minimize withdrawals and its symptoms  and psychological support that can increase the likelihood of treatment success.  We have three distinct phases of treatment:

 

Phase 1: Outpatient Detox and Titration

This involves an 8-12 hour stay at our facility for the first day. You will be given your first dose of Suboxone and monitored to determine the medication’s effectiveness. One or two follow-up visits will be scheduled over the next week to monitor your progress. (During this visit, a urine drug screen will be obtained.)

 

Phase 2: Maintenance Phase:

Following detox, you will progress to a monthly maintenance phase. This continues for the duration of the Suboxone treatment.

 

Phase 3: Weaning

A slow weaning phase is attempted after an appropriate period of time and if significant support is available as well as patient motivation.  After several months, patients will be gradually tapered off of Suboxone by lowering daily dose until patients no longer require Suboxone. At this time counseling is still strongly recommended to watch for any signs of relapse.

 

Detox can be the beginning of a new life for you… a life free from the chemicals that are causing such destruction and devastation in your life.

“Do It Yourself” detox from substances like Alcohol, Valium, Xanax, Klonopin, etc., can lead to life-threatening complications such as seizures, brain injuries, and death. The severity varies depending upon the person, the substance abused, the amount abused, and the frequency of abuse.  Detox should be medically supervised.

 

 

 

 

 

Whiplash Injury (Nagging neck pain after an accident)

Following a car accident, your nagging neck pain may not be just “soft tissue.”  Neck pain is one of the most common chronic pain conditions in modern medicine and can lead to depression, sleep disturbance, and inability to work.  Even though there may be minimal damage to your car, you can still sustain significant whiplash.  In fact, even at low speeds, occupants can experience severe whiplash, the video above demonstrates whiplash injury with a 5 mph collision.

 

 

 

 

 

The rapid motion of the neck during a crash can result in a number of injuries, with the majority of these injuries involving “soft tissue”:

  • Muscles
  • Tendons
  • Ligaments
  • Nerves
  • Discs
  • Micro fractures
  • Facet subluxation
  • Hemorrhage or edema of the pariarticular tissues (facet joints)
Soft tissue ligaments involved in whiplash

The term “soft tissue” is frequently tossed around as if it is an insignificant injury; this could not be farther from reality, as even the brain, liver, and heart are soft tissue, and it doubtful you could survive long with any of these structures damaged.

Nerves involved in whiplash injury

Soft tissue injuries are difficult to see on x-rays or MRI, and frequently require a diagnostic interventional workup to define.  Soft tissue injuries can lead to significant permanent impairments, and should be treated in a timely and medically appropriate manner in order to mitigate long-term consequences.

 

Injuries to bony structures are less common, but are usually apparent on x-rays

  • Rim Lesions
  • Endplate avulsions
  • Tears of the anterior longitudinal ligament
  • Uncinate process
  • Articular subchondral fractures
  • Articular pillar
  • Articular processes

 

 

 

Whiplash affects the cervical vertebrae of the neck as well as the first few upper thoracic vertebrae, and is most commonly caused by car accidents when the force of a blow from the rear causes the head to whip backward and forward.  The most common facets to be injured are at C2/C3 and C5/C6, which frequently results in referred pain at the locations indicated. As a result of facet joint injury, whiplash patients frequently encounter, headaches, back and shoulder pain in addition to neck pain.

Referred pain from facet injury

This action can cause tears in the muscles, tendons or ligaments of the neck. It can also cause a nerve to become pinched between two vertebrae, resulting in pain or numbness that may radiate down to the shoulder, arm and hand.

 

The neck is a particularly vulnerable part of the spine because:

  • The head is a free floating weight attached to the fixed thorax like a pendulum
  • The neck has relatively little muscular support
  • During an accident the head is moved with tremendous force back and forth, concentrating the biomechanical forces to just a few cervicothoracic vertebral bodies and their limited support

 

 

When the neck is moved quickly and forcefully, it places tremendous strain on the facet joints of the spine — which are located at the rear of the spine. The facet joints normally allow the spine to move in a very flexible manner through flexion, extension and rotation.

 

Xray of facet joints, range of motion
Normal motion of cervical facets
Damage to facet with whiplash

 

Injured people with cervical facet syndrome usually present with severe posterior neck pain and muscle spasms. Outpatient to the neck produces pain over the cervical facets. The pain typically increases with extension of the neck with symptoms of pain overlying the cervical facet joints or regionally to the head, neck or shoulder region.

 

Unfortunately radiographic diagnoses of these injuries are very difficult. Cervical spine x-rays may reveal focal or diffuse cervical spondylosis or loss of normal lordosis, but will not reveal the facet injury itself. The medial branch of the dorsal ramus transmits the pain from inflamed facet joints. Stimulation of the facet nerves often results in referred pain.

 

 

Cervical facet blocks at the appropriate level are frequently necessary in the accurate diagnosis of cervical facet pain. The cervical facet block at the appropriate level usually brings immediate relief to the injured person, with pain relief lasting four to six hours after injection being diagnostic.  If successful diagnosis with facet blockade is made, then a more permanent solution may be radiofrequency neurolysis.

 

Low back pain with lumbar facet involvement can also be diagnosed similarly. However, lumbar facet joint injuries are far less likely to occur following an auto accident; because the lower back (lumbar spine) is generally supported and not subject to fast and extreme range of motion following a rear end car accident. This is different than the neck (cervical spine), which can only rely on a headrest for protection from these quick acceleration injuries (whiplash).