Pain - 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.

How are allergies and pain related?

What is the relationship between allergies and pain?

Allergies can create a generalized inflammatory state with systemic release of inflammatory cytokines, which may present as:

Muscle and joint pain, typically observed in food borne allergens such as gluten or gliaden.

Sinus congestion triggering migraine and cluster headaches, typically observed in aeroallergens such as pollens or molds

Aeroallergens such as dust, ragweed, pollen, and mold impact half of all Americans.   Symptomatic treatment with decongestants, histamine blockers, and steroids do not reduce the allergic potential of the allergen and do not change the course of disease. Many patients treated symptomatically become hyper sensitized and allergic to multiple additional antigens within three to five years, unless a desensitization immunotherapy protocol is initiated. Immunotherapy protocols use a low dose exposure to habituate the immune system to the allergen.

You might have allergies if you have any of the hollowing symptoms:

Sinus related issues (sinus pressure/pain, headaches, sinusitis) Restless sleep, challenges sleeping through the  night, snoring
Re-occurring Seasonal Colds Consistent or Re-occurring coughing
Chronic colds (lasting longer than 2 months) Feeling of fatigue, irritability, & restlessness
Migraine Headaches Asthma

Skin Conditions (dry and/or itchy skin, etc…)

 

Both allergies and pain are associated with overlapping inflammatory processes, with a resulting hypersensitivity of the central nervous system. Reciprocal signalling between immunocompetent cells in the central nervous system (CNS) is associated with pathological and chronic pain mechanisms. Glial cells, including parenchymal microglia, perivascular microglia, astrocytes and oligodendrocytes, constitute > 70% of the total cell population in the central nervous system. Glial cells have been identified as key neuromodulatory, neurotrophic and neuroimmune elements in the CNS. Neuronal excitability can be powerfully enhanced both by classical neurotransmitters derived from neurons, and by immune mediators released from CNS-resident microglia and astrocytes, and from infiltrating cells such as T cells. During autoimmune inflammation of the nervous system, microglia release and respond to several cytokines, including IL-1, IL-6, TNFα and IFNγ, which are instrumental in astrocytic activation, induction of cellular adhesion molecule expression and recruitment of T-leukocytes.

Left untreated, allergies can have a significant impact on an individual’s quality of life and wellbeing. Asthma is just one potential consequence of leaving allergies untreated.

Daily in the United States:

  • 30,000 People have an Asthma attack
  • 5,000 People visit the ER due to Asthma
  • 1,000 People are admitted to the Hospital, with an avg. hospital stay is 4.3 days
  • 11 people die from Asthma

36 states have laws prohibiting driving while under the influence of OTC and prescription antihistamines.

People are 50% more likely to have a work-related accident when using non-prescription sedating antihistamines.

A study in the American Journal of Managed Care reports that workers are 25% less productive for two weeks each year if they use sedating drugs to manage allergy symptoms.

 

 

What are aeroallergens?

Aeroallergens include pollen grains, biogenic waste, mold spores, and occupational allergens. Clinically significant aeroallergens are small proteins or glycoproteins, which are buoyant and able to travel long distances when propelled by wind such as pollen grains, biogenic waste, mold spores, and occupational allergens.

 

Pollen grains

Pollen grains are living male gametophytes (sperm) of plants and are microscopic in size. Ragweed is about 20µ in diameter; tree pollen is 20-60µ; and grass pollen is 30-40µ. High volumes of pollen are produced annually. A single ragweed plant can produce one million pollen grains in a single day. Some trees (conifers, for example) can release so much pollen that the microscopic grains form a cloud and can form a visible carpet on the ground. Ragweed pollen is so light that it can be transported hundreds of miles by the wind and has become one of the most significant sensitizing aeroallergens.

Biogenic waste

Dust mites are highly allergenic and cause significant symptoms of allergic rhinitis, sinus disease and bronchial asthma. Dust mites are tiny (.33 mm) barely visible, eight-legged insects. They eat human skin, animal dander, fungi and anything rich in protein. High humidity and warm temperatures allow dust mites to thrive and are found at their highest concentration in the temperate zones—particularly in people’s beds. They have an affinity for materials such as bedding, drapes, carpets and upholstery. In fact, dust mites are often most numerous right under your nose, as your head rests on your pillow.

German cockroaches are common in cities when apartments are heated. They produce potent allergens that are associated with asthma.

Dog and cat dander occur through desquamation of skin. Dander is skin flakes that contain highly allergenic, water-soluble proteins. Cat dander contains the potent Fel d 1 allergen, while dog dander contains the Can f 1 and Can f 2 allergens. Animal dander often remains in homes for many months, leading to persistent symptoms long after the pet’s removal. Further, dander can remain in air ducts or walls and hidden areas for years.

Mold Spores

Outdoor mold

Outdoor fungi are also called field fungi and thrive on plants decaying in the soil. Their spores are released in the highest numbers between the spring and fall, when humidity is high. Mold exposure is associated with a variety of allergy symptoms. One study indicated that children exposed to fungal spores had a 10% to 30% increase in asthma symptoms for every 1000 spores/m3 of air.

Indoor mold

Aspergillus and Penicillium are often referred to as “storage fungi” since they grow on dead and dying stored grains, rotting fruits and vegetables. These fungi on stored items in basements will appear as green mildew. Black-colored fungi is associated with Rhizopus and Stachybotrys.

Occupational allergens

Allergic reactions to aerosolized allergens in the workplace may result in occupational disability. Identification of occupational allergy early in its development may prevent permanent lung damage and long-term disability.

Although most allergy sufferers experience symptoms at home or outdoors, a smaller group of these individuals encounter potent allergens at work. Knowledge of potential workplace allergens can lead to early detection of occupational allergic disease. At first, symptoms might be mild, but they can progress to produce severe allergies—including permanent lung damage. These allergens are often unique to specific occupations and therefore, one must always consider the workplace as a source for aeroallergen exposure.

How do contact or food allergies effect pain?

For all intensive purposes, imagine the human body as a donut floating in space. The entire gastrointestinal system is a complex sensory monitoring system and a nutrient absorption system, it would be the center hole. The outer ring of the donut would be the skin. Food contact allergens presented to the surface of the donut interact with the surface of this donut, individuals with food allergies to substances such as gluten and gliaden develop a leaky gut by loosening the zonules (anchor point between cells) permitting other large molecules to transfer into the body and at the same time activate a large autoimmune neurological response, which often include pain mediators.

 

Allergy testing

Aero allergies are immediate hypersensitivity reactions caused by an IgE antibody, triggering the release of chemicals such as histamine. Because an IgE antibody causes such allergies, it is possible to perform allergy testing to determine the exact trigger and establish a specific diagnosis. One advantage is that skin-testing shares the same exact allergens used in immunotherapy, assuring that the treatment program incorporates all essential allergens.

 

Immunotherapy

Of all the therapies offered for respiratory allergy, injection therapy or immunotherapy is perhaps the most specific and effective treatment available in preventing recurrent symptoms in a hypersensitive patient. However, immunotherapy is only effective if the offending allergens are identified and incorporated into the allergy serum in adequate concentrations. Half-measures often prove inadequate in stubborn cases. A careful and comprehensive allergy history and skilled allergy testing are the basis for an effective treatment program.

 

Allergy injection treatment is carried out over a long period of time (3 – 6 years in most cases). At first, patients receive weak solutions of allergens. The dose is then gradually increased to induce tolerance without reactions. The goal is to achieve a high enough maintenance dose, which affords the best symptom relief. Improvement in symptoms usually lasts for years after completing a successful course of allergy injections.  85% of people treated with immunotherapy for hay fever may achieve symptom relief within the first year of starting immunotherapy.

Serious treatment options for serious foot pain

Nearly 60% of patient’s with chronic forefoot pain presenting to a podiatry practice have surgical intervention, yet only 50-60% of them get relief of foot pain long-term and 20% get significantly worse, requiring multiple surgeries. Accurate diagnosis is critical to appropriate treatment, common areas where foot pain is misdiagnosed include:

 

  • Plantar plate disruption

The metatarsophalangeal joint plantar plates are major stabilizers and form part of the plantar capsule. The plantar plates provide strength and support during ambulation. Disruption can lead to toe deformities.  The normal plantar plate is a slightly hyper echoic broad-curved band, which protects the metatarsal head and inserts onto the proximal phalanx. Plantar plate tears typically appear as hypo echoic defects.  The torn plantar plate is often swollen and hyper vascular in the acute phase of degeneration.

 

  • Adventitial Bursitis

Adventitial bursitis is acquired bursitis in the metatarsal fat pad as a result of trauma. Sonographically these areas may either be ill-defined or focal collections. These are generally compressible and hypo echoic, although complex collections may appear heterogeneous.

 

  • Synovitis

Joint effusions are compressible anechoic collections best seen on the dorsal aspect of metatarsophalangeal joints. Synovial proliferation appears on ultrasound as a thickening of the synovial layer. Hyper vascularity and bone erosions may also be present.

 

  • Morton’s Neuroma/ intermetatarsal bursitis

A Morton’s neuroma is caused by mechanical damage to the interdigital nerve, resulting in perineural fibrosis. On ultrasound it commonly appears as an ovoid hypo echoic mass, although the shape and echogenicity may vary. Intermetatarsal bursitis appears as a hypo echoic or anechoic zone in a normally echogenic webspace, generally dorsal to the interdigital nerve, although sometimes enveloping it. This soft tissue collection may become complex and heterogeneous with time. Dynamic assessment of a webspace will show poor compressibility of a neuroma and high compressibility of a bursitis (note: complex bursa may mimic a neuroma).  Treatment options include ultrasound guided cortisone or alcohol injection.

 

Morton’s neuroma or more appropriately entrapment syndrome

Common causes of forefoot pain include joint inflammation (arthritis, capsulitis & synovitis), plantar plate tears, tendinosis (“tendinitis”), bursitis and Morton’s neuroma.

A Morton’s neuroma occurs when scar tissue builds upon a nerve in between the toes known as the interdigital nerve (nerve between the digits, or toes). In Morton’s entrapment, the common plantar digital nerve, also referred to as the intermetatarsal nerve, gets compressed from forefoot plantar pressure in the late midstance and propulsive phases of gait against the distal margin of the transverse intermetatarsal ligament This is most frequently seen in women and is and is attributed to high heeled shoes. The pain is often severe and has an electric shock character to it.  Common symptom descriptions include some or all of the following: “It feels like my sock is wadded up under my foot,” “cramping,” “numbness,” “burning,” “radiating sensations into the adjacent toes,” “the inability to walk barefoot on a hard floor,” and “tingling.”   Others describe a feeling like having a pebble in their shoe or walking on razor blades.  Symptoms include: pain on weight bearing, frequently after only a short time. The nature of the pain varies widely among individuals. Some people experience shooting pain affecting the contiguous halves of two toes. Burning, numbness, and paresthesia may also be experienced.  Usually, patients with Morton’s entrapment demonstrate pain with plantar palpation of the interspace between the metatarsal heads.

As a true nerve entrapment no different in pathology from carpal tunnel syndrome, Morton’s entrapment treatment should be oriented toward decompression. Indeed, the treatment success rate of peripheral nerve decompression in Morton’s entrapment is higher than with surgical resection, has a much lower complication rate, and precludes serious complications associated with nerve excision.

Diagnostic lidocaine blocks are extremely beneficial in assisting in making an accurate diagnosis and can help the practitioner decide on a course of treatment, specifically when two adjacent interspaces are symptomatic.  It has generally been recommended that prior to surgical treatment for Morton’s entrapment, all methods of “conservative” care should be exhausted, including corticosteroid injections, application of offloading pads, sclerosing injections with alcohol or phenol, or radiofrequency ablation.

RADIOFREQUENCY

Radiofrequency nerve treatment is a technique, which has been used for over 10 years for the treatment of longstanding pain. Using local anesthesia, an electrode is placed into the tissue at the painful site and an electric current is delivered, generating heat that destroys the sensory nerve fiber.

The RF Procedure

A medical provider experienced in interventional procedures performs Radiofrequency ablation. The patient is placed in an appropriate position for the procedure; a diathermy pad is placed on the thigh and the injection site cleansed. Pain relief is achieved by injecting a local anesthetic around the nerve that is responsible for the patient’s pain. Once the nerve and area is anaesthetized (numbed), a fine needle is positioned in proximity to the nerve, with the position of which confirmed by imaging guidance (ultrasound or fluoroscopy).

A thin probe is then passed through the needle, which is connected to a generator that results in radiofrequency energy passing through the probe, resulting in heating of the probe tip. The result of this heat is to destroy the targeted nerve and therefore disrupting the ability of the nerve to transmit pain signals. Finally, long-term local anesthetic and cortisone are injected around the treated nerve in order to minimize discomfort, which may arise following the treatment. Treatment via RFA takes approximately 30 minutes. Further time spent at the clinic for post-procedure recovery may be suggested, depending on the exact nature of a patient’s condition. Ultrasound-guided RFA has successfully alleviated patients’ symptoms of Morton’s neuroma/ entrapment in >85% of cases. Less than 10% of patients progress to surgical intervention, such as endoscopic plantar fasciotomy.

ENDOSCOPIC PLANTAR FASCIOTOMY

EPF is an outpatient procedure. It takes about an hour to perform, and is be done at a hospital or a same-day surgical facility. Using special instrumentation we release the inside band of the plantar fascia responsible for causing your pain. After the procedure, you’ll be taken to a recovery area. As your foot heals, new tissue fills in the gap where the fascia was cut. This lengthens the fascia and reduces strain during foot movement. For best results, see your doctor as directed during the next few weeks or months. Physical therapy or stretching exercises are often prescribed to improve recovery. Wearing shoes with good support is essential for your long-term recovery.

 

 

 

 

Migraine Headache: Our position on five medical treatment options that patients with migraines should avoid

Headache is among the principal reasons for physician visits and a common cause of emergency department visits. The costs of tests and treatments for headache are not insubstantial, and when unwarranted, they needlessly expose patients to potential harm. In a recent study of the treatments and procedures that contribute most to the $13 billion dollar annual cost of outpatient neurology visits, migraine alone was the diagnostic category with the second highest costs. For example, using data from the National Ambulatory Medical Care Survey, CT scans ordered at neurology visits (many of which were probably done to evaluate headache) resulted in costs of roughly $358 million dollars.

Five tests and procedures associated with low-value care in headache medicine according to the American Headache Society (AHS).  Listed are five things that “physicians and patients should question” in order to make “wise decisions about the most appropriate care based on the individual situation.”

 

[box] (1) avoiding neuroimaging studies with stable headaches that meet the criteria for migraine

(2) except for emergency situations, computed tomography should not be performed for headache when magnetic resonance imaging is available

(3) outside of a clinical trial, surgical deactivation of migraine trigger points is not recommended

(4) opioids or butalbital-containing mediations should not be prescribed as first-line treatment for recurrent headache disorders

(5) prolonged or frequent use of over-the-counter pain medication is not recommended for headache [/box]

(1) avoiding neuroimaging studies with stable headaches that meet the criteria for migraine

In clinical practice, it is common to encounter patients with headache who have undergone multiple imaging procedures. These often involve exposure to ionizing radiation. The reasons for these repeated and unnecessary scans are not well understood, but probably include physician fear of missing a dangerous cause of headache and a desire to allay patient anxiety over possible missed abnormalities, especially when treatment is unsuccessful. In some cases, duplicate scans may be ordered because the physician is unaware of previous testing. The risk of unneeded testing may be especially high in the emergency department, where physicians are unfamiliar with the patient and fear missing serious causes of headache.

In ordering diagnostic tests, though, the possible adverse effects of testing must be balanced against the likely benefits to the patient. In particular, the potential adverse health effects of radiation exposure should be taken into consideration when ordering diagnostic testing for headache. In many situations, it is very unlikely that a repeat imaging study of the head will identify any abnormality that will alter management. The radiation risks of CT scanning are not negligible. Younger people are at higher risk of radiation adverse effects than older people.

Numerous evidence-based guidelines agree that the risk of intracranial disease is not elevated in migraine. However, not all severe headaches are migraine. To avoid missing patients with more serious headaches, a migraine diagnosis should be made after a clinical history and an examination that documents the absence of any neurologic findings, such as papilledema.

The key element is a change in headache symptomology or a new diagnosis of severe headache.

(2) except for emergency situations, computed tomography should not be performed for headache when magnetic resonance imaging is available

When neuroimaging is needed for the evaluation of headache, good quality evidence supports the view that MRI is more sensitive than CT scanning to detect most serious underlying causes of headache. The exception is settings in which acute intracranial bleeding is suspected. A Canadian government health technology assessment group recently reviewed the evidence and cost-effectiveness of the use of CT and MRI scanning for the evaluation of patients with headache. The researchers found that when performed for the indication of headache, the diagnostic yield of CT scans was 2%, while that of MRI scans was 5%. Because MRI was better at detecting abnormalities, the cost per abnormal finding of CT scans was $2409 compared with $957 for MRI.

When neuroimaging for headache is indicated, MRI is preferred over CT, except in emergency settings when hemorrhage, acute stroke, or head trauma are suspected. MRI is more sensitive than CT for the detection of neoplasm, vascular disease, posterior fossa and cervicomedullary lesions, and high and low intracranial pressure disorders. CT of the head is associated with substantial radiation exposure that may elevate the risk of later cancers, while there are no known biologic risks from MRI.

(3) outside of a clinical trial, surgical deactivation of migraine trigger points is not recommended

The idea of a surgical “solution” to migraine is inherently attractive to patients. Interest in surgical approaches to migraine has been motivated by serendipitous improvement in headaches noted in patients who have undergone various plastic surgery “forehead rejuvenation” procedures. These procedures are based on the premise that contraction of facial or other muscles impinges on peripheral branches of the trigeminal nerve.

The procedures involved are often referred to collectively as “migraine deactivation surgery,” although a variety of surgical sites and procedures are involved. These include resection of the corrugator supercilii muscle with the placement of fat grafts in the site, “temporal release” procedures involving dissection of the glabellar area, transection of the zygomatical temporal branch of the trigeminal nerve, and resection of the semispinalis capitus muscle with placement of fat grafts in the area with the aim of reducing pressure on the occipital nerve. Finally, some surgeons also perform nasal septoplasty or otherwise attempt to address possible intranasal trigger points.

The value of this form of “migraine surgery” is still a research question. Observational studies and a small controlled trial suggest possible benefit. However, large multicenter, randomized controlled trials with long-term follow-up are needed to provide accurate estimates of the effectiveness and harms of surgery. Long-term side effects are unknown but potentially a concern

(4) opioids or butalbital-containing mediations should not be prescribed as first-line treatment for recurrent headache disorders

Primary recurrent headache disorders (of which migraine, tension-type, and cluster headache are the most common) are conditions of long duration for which such treatment will be used repetitively over many years. Risks and harms that are unimportant in treating a single attack can become important when treatment is used for long periods of time. Once established, medication overuse can be difficult to treat and recidivism is common. Thus, treatments such as triptans or nonsteroidal anti-inflammatory drugs, which are not associated with dependence or sedation, are preferred first-line.  However, there are many clinical situations in which the use of opiates and butalbital is appropriate, including some situations where they are first-line treatments. These include patients for whom triptans or nonsteroidal anti-inflammatory drugs are contraindicated or ineffective.

These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk for the young, otherwise healthy people most likely to have recurrent headaches. They increase the risk that episodic headache disorders such as migraine will become chronic, and may produce heightened sensitivity to pain. Use may be appropriate when other treatments fail or are contraindicated. Such patients should be monitored for the development of chronic headache.  This is not meant to imply that opioid or butalbital medications are always inappropriate treatments for recurrent headache treatments. Rather, it is meant to address the appropriate order in which medication classes should typically be used.

(5) prolonged or frequent use of over-the-counter pain medication is not recommended for headache

Over-the-counter (OTC) medications are appropriate treatment for occasional headaches if they work reliably without intolerable side effects. Frequent use (especially of caffeine-containing medications) can lead to an increase in headaches, resulting in “medication overuse headache” (MOH). To avoid this, OTC medication should be limited to no more than 2 days per week. In addition to MOH, prolonged overuse of acetaminophen can cause liver damage, while overuse of nonsteroidal anti-inflammatory drugs can lead to gastrointestinal bleeding.

 

 

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.

 

Nutritional Supplements

Nutrition

Successful weight loss is best complimented by a customized nutrition plan based on your individual needs. Ensuring a daily dose of heart-healthy vitamins, getting your metabolism in balance and ensuring you have all the nutrients necessary will help build the energy you need to transform your body and mind during your weight loss journey.

Policosanol (or polycosanol) is a natural extract of plant waxes (a mixture of alcohols isolated from Cuban sugarcane wax) It is used as a supplement to lower LDL cholesterol (“bad” cholesterol) and increase HDL cholesterol (“good” or “healthy” cholesterol), and to help reduce atherosclerosis.  It also decreases the stickiness of particles in the blood known as platelets, which might help reduce blood clots, and may have a significant blood thinning effect when combined with garlic extract.

 

Alpha-lipoic Acid (ALA)

Alpha-lipoic acid regenerates other antioxidants.  Antioxidants neutralize “free radicals,” which are waste products that can damage cells in the body.  Most antioxidants work only in water (such as vitamin C) or fatty tissues (such as vitamin E), but alpha-lipoic acid is both fat- and water-soluble, working throughout the body, by regenerating other antioxidants and make them active again.

Alpha-lipoic acid has been used for years to treat diabetic peripheral neuropathy, and diabetes-related condition called autonomic neuropathy such as cardiac autonomic neuropathy.  There is also evidence to support improved insulin sensitivity.

 

Vitamin B12 (cobalamin)

Vitamin B12, also called cobalamin, is one of 8 B vitamins, which help the body convert food (carbohydrates) into fuel (glucose), and also help the body use fats and protein.  Fatigue is one of the symptoms of a vitamin B12 deficiency.

Vitamin B12 is an especially important vitamin for maintaining healthy nerve cells, and it helps in the production of DNA and RNA, the body’s genetic material. Vitamin B12 also works closely with vitamin B9, also called folate or folic acid, to help make red blood cells and to help iron work better in the body. Folate and B12 work together to produce S-adenosylmethionine (SAMe), a compound involved in immune function and mood.

Vitamins B12, B6, and B9 work together to control blood levels of the amino acid homocysteine. High levels of homocysteine are associated with heart disease.

 

Green Tea

Green tea extract is an herbal derivative from green tea leaves, which contain potent antioxidants called catechins, which are 20 times stronger than the antioxidants contained in Vitamin C and Vitamin E.  In addition there are caffeine like substances, which increase metabolic rate, amounts of carotenoids, vitamin C, and trace elements (including chromium, manganese, selenium and zinc).   Additionally, Epigallocatechin-3-gallate (or EGCG), which is an important compound found in green tea reduces lipid absorption.  It should be noted that caffeine, independent of its effect on metabolism, is also a cathartic agent and serves to reduce transit time and nutrient absorption in the colon.

 

Garlic Extract

Garlic is rich in antioxidants, which help destroy free radicals — particles that can damage cell membranes and DNA, and may contribute to the aging process.  Garlic may reduce heart disease, by slowing atherosclerosis (hardening of the arteries) and lowering blood pressure, between 7% and 8%. Garlic also seems to be an anticoagulant, meaning it acts as a blood-thinner, which may also help prevent heart attacks and strokes, and works in conjunction with polycosanol.

 

 

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.

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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.

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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.

 

 

 

 

 

 

 

 

 

 

Stellate Ganglion Block

 

 

 

 

Stellate Ganglion Block

Your body has special nerves known as sympathetic nerves in your neck which ,control blood supply and sweating to your arms and hands . These nerves can be anesthetized to change the blood flow to a limb and to decrease the pain which is mediated by these sympathetic nerves:

 

 

 

 

Reflex sympathetic dystrophy (RSD), also called Complex Regional Pain Syndrome (CRPS) typically involves a nerve injury involving the sympathetic nervous system.

 

 

  • Reflex sympathetic dystrophy  (RSD), also called Complex Regional Pain Syndrome (CRPS) typically involves a nerve injury involving the sympathetic nervous system.  Patients who suffer crushing or partial nerve injury develop excruciating burning pain accompanied by changes in blood supply to the area of the injury.   People with CRPS may exhibit abnormal sensation throughout all or part of the affected area. This often includes increased sensitivity to stimuli such as touch, pressure, or temperature.
  • Patients with severe ischemic limb pain have sharp, aching pain as a result of circulatory insufficiency.  Patients in end-stage PVD (peripheral vascular disease) will complain of rest pain with or without ulcers.
    1. Severe pain (claudication and rest pain)
    2. Decreased pulse in the limb
    3. Abnormal skin temperature
    4. Abnormal skin color
    5. Nonhealing ulcers
    6. Other trophic changes

Common types of PVD

  • Arteriosclerosis
  • Diabetic arteriosclerosis
  • Raynaud’s disease
  • Buerger’s disease

What is the purpose of Stellate Ganglion Block?

The Stellate Ganglion Block is an injection procedure used to block or decrease pain located in the head, neck, chest, or arm. It also helps increase circulation.

The Stellate Ganglion is a group of nerves located in the upper neck and is part of the sympathetic nervous system. After an injury or illness, the sympathetic nervous system may not function properly, causing pain. Some of the more common conditions are: complex regional pain syndrome (CRPS) also known as reflex sympathetic dystrophy (RSD), causalgia (nerve injury), and herpes zoster (shingles) of the head and face. The Stellate ganglion block is also used to treat intractable angina (severe pain caused by heart disease) or severe peripheral vascular disease (PVD).

 

If this treatment relieves your pain, the doctor will perform a series of blocks at another time in an attempt to break the pain cycle and provide long lasting pain relief. The number of blocks you will need depends on how long the pain relief lasted between injections. Usually you will get more and longer pain relief after each injection.

 

Some patient’s get short-term relief with Stellate blockade, but the series of blocks fails to provide long-term relief.  These individuals are usually considered candidates for Dorsal Column Stimulation (DCS).

 

What does the procedure involve?

The nerves going to the arm can be anesthetized in one of two place; the low neck which is known as a stellate block, or the upper chest area known as a T2 sympathetic block.

 

The Stellate Ganglion Block is an outpatient procedure, usually done in the Operating Room or a Procedure Room. For your safety and comfort, you will be connected to monitoring equipment (EKG monitor, blood pressure cuff, and a blood-oxygen monitoring device). The doctor or nurse may start an intravenous line and give some medicine to help you relax. You will also have skin temperature monitors placed on your hands.

 

The procedure is performed with you lying on your back. A rolled-up sheet or other support is placed between your shoulder blades, which may be a little uncomfortable.

 

After cleansing your neck with an antiseptic solution, the doctor will inject numbing medicine into the skin and tissue. This may cause a burning sensation for a few seconds. The doctor will also apply some pressure on your neck to determine exactly where to place the needle. It is very important that you do not talk, swallow, or cough. If you have to swallow or cough, raise your hand to let someone know.

 

After the numbing medicine takes effect the doctor will insert another needle, and with the assistance of a special X-ray machine called a fluoroscope, inject a radiopaque dye (contrast solution) to confirm correct needle position. When satisfied with the needle position, the doctor will inject a small mixture of numbing medicine (anesthetic) and anti-inflammatory medicine (cortisone/steroid).

 

Although it takes about 10 to 20 minutes for the medication to take effect, you will remain at the Clinic until the doctor feels you are ready to leave.

 

If the block works, then your hand will warm up and (depending upon the source of your pain) your pain may improve.  When utilized for CRPS (RSD), stellate blocks are used as a way of getting you to work with physical \ occupational therapy to desensitize your arm or hand.

 

Can I go to sleep for the procedure?

It is not necessary for you to go to sleep for this procedure; you must be awake and communicate with the physician during the procedure.

 

 

How long will the procedure take?

Normally, a Stellate ganglion block procedure takes no more than 30 minutes.

 

 

What should I do before the procedure?

• Since you will be receiving medication, it is recommended that you do not eat within four or five hours before the procedure. If you are a diabetic, be sure to discuss your eating and medication schedule with the doctor.

• You may need to stop taking certain medications several days before the procedure. Please remind the doctor of all prescription and over-the-counter medications you take, including herbal and vitamin supplements. The doctor will tell you if and when you need to discontinue the medications.

• It is very important to tell the doctor if you have asthma, had an allergic reaction (i.e. hives, itchiness, difficulty breathing, any treatment which required hospitalization) to the injected dye for a previous radiology exam (CT scan, angiogram, etc) or if you have had an allergic reaction to shellfish (shrimp, scallops, lobster, crab). The doctor may prescribe some medications for you to take before having the procedure.

• Tell the doctor if you develop a cold, fever, or flu symptoms before your scheduled appointment.

 

 

Is there anything special that I need do after the procedure?

You need to be aware of several potential side effects. These side effects, which usually disappear four to eight hours after the block may include: • A droopy eyelid on the side of the block; Redness and blurred vision in the eye on the side of the block; A feeling like a lump in your throat; Difficulty swallowing; Hoarseness of your voice; Warmth and weakness of the arm on the side of the block.

•          Drink plenty of clear liquids after the procedure to help remove the dye from the kidneys and do not eat solid food until you are comfortable swallowing.

•          Do not drive for the remainder of the day. Please have an adult drive you home or accompany you in a taxi or other public transportation.

•          Depending on how you feel, you may resume normal activities and return to work the following day.

•          If the doctor prescribes physical therapy, it is very important that you continue with the physical therapy program.

•          Although you may feel much better immediately after the injection (due to the numbing medicine), there is a possibility your pain may return within a few hours. It may take a few days for the steroid medication to start working.

•          You must participate in physical therapy, in order to get long-term control of symptoms.  Desensitization physical therapy can be an effective way to treat hypersensitivity, especially when used in combination with other medical and/or therapeutic interventions.

 

The stellate blockade is both diagnostic (helps diagnose the cause of your pain) and therapeutic (treats the cause of your pain).  You may need a series of injections in order to achieve long-term pain control.  Please keep track of your symptoms after the block.

 

What are the risks of a Stellate Ganglion Block?

The risks, although infrequent, include:

  • Collapsed lung
  • Numbness of an arm that may last for hours
  • Temporary weakness or numbness from the neck down
  • Allergic reaction to the medication
  • Nerve damage
  • Bruising at the injection site
  • Infection at the injection site
  • Injection of medication into a blood vessel with possibility of stroke or seizure
  • Post-injection flare (nerve root irritation with pain several hours after treatment, which may last days or weeks)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Destruction of a motor or sensory nerve in the path of the needle
  • Bleeding, nerve injury, organ injury and death are rare but possible

Note: If you experience new shortness of breath 24 – 48 hours after the injection or any signs of infection in the area of the injection you should go to your nearest emergency room immediately.

 

 

 

 

 

 

Lumbar Sympathetic Nerve Block (including Celiac Plexus Block and Ganglion Impar Block)

 

 

Lumbar Sympathetic Nerve Block (including Celiac Plexus Block and Ganglion Impar Block)

Your body has special nerves known as sympathetic nerves in your back which ,control blood supply and sweating to your legs and feet . These nerves can be anesthetized to change the blood flow to a limb and to decrease the pain which is mediated by these sympathetic nerves:

 

 

 

 

Your body has special nerves known as sympathetic nerves in your back which ,control blood supply and sweating to your legs and feet .

 

 

  • Reflex sympathetic dystrophy  (RSD), also called Complex Regional Pain Syndrome (CRPS) typically involves a nerve injury involving the sympathetic nervous system.  Patients who suffer crushing or partial nerve injury develop excruciating burning pain accompanied by changes in blood supply to the area of the injury.   People with CRPS may exhibit abnormal sensation throughout all or part of the affected area. This often includes increased sensitivity to stimuli such as touch, pressure, or temperature.
  • Patients with severe ischemic limb pain have sharp, aching pain as a result of circulatory insufficiency.  Patients in end-stage PVD (peripheral vascular disease) will complain of rest pain with or without ulcers.
      • Severe pain (claudication and rest pain)
      • Decreased pulse in the limb
      • Abnormal skin temperature
      • Abnormal skin color
      • Non healing ulcers
      • Other trophic changes

 

  • Common types of PVD
      • Arteriosclerosis
      • Diabetic arteriosclerosis
      • Raynaud’s disease
      • Buerger’s disease

What is the purpose of a Lumbar Sympathetic Nerve Block?

The Lumbar Sympathetic Nerve Block is a procedure used to block or decrease pain in the lower extremities caused by injury or disease of the sympathetic nervous system. The lumbar sympathetic nerves are located on either side of the lumbar spine (lower back).

After an injury or illness, the sympathetic nervous system may not function properly, causing pain. Some of the more common conditions include Complex Regional Pain Syndrome (CRPS) also known as Reflex Sympathetic Dystrophy, Sympathetic Maintained Pain and Herpes Zoster (shingles) involving the lower part of the body.

If the block relieves your pain, the doctor will then perform a series of blocks at a another time, in an attempt to break the pain cycle and provide long lasting pain relief. The number of blocks you will need depends on how long the pain relief lasted between injections. Usually you will get more and longer pain relief after each injection.  If the series of blocks do not relieve your pain, a radiofrequency lesion may be done, or consideration of stimulator implant may be necessary.

The Celiac Plexus Block is a type of Lumbar Sympathetic Block used to diagnose and treat pain from abdominal sympathetic mediated set of nerves such as chronic pancreatitis.

The Ganglion Impar Block is a type of Lumbar Sympathetic Block used to diagnose and treat pain from a pelvic sympathetic mediated set of nerves such as interstitial cystitis or coccyxodinia.

 

What does the procedure involve?

The Lumbar Sympathetic Block is an outpatient procedure, usually done in the Operating Room or a Special Procedure Room. For your safety and comfort, you will be connected to monitoring equipment (EKG monitor, blood pressure cuff, and a blood-oxygen monitoring device), and positioned on your stomach. The doctor or nurse may start an intravenous line and give some medicine to help you relax. Your back is cleansed with an antiseptic soap after which the doctor injects numbing medicine deep into your skin and tissue. This will cause a burning sensation for a few seconds. After the numbing medicine takes effect, the doctor will insert a another needle and, with the assistance of a special X-ray machine called a fluoroscope, inject a radiopaque dye (contrast solution) to ensure the needle is in proper position.  With the needle in position, a small mixture of numbing medicine (anesthetic) and anti-inflammatory medicine (steroid) is injected.

After the procedure, we ask that you remain at the Clinic until the doctor feels you are ready to leave.

 

Can I go to sleep for the procedure?

It is not necessary for you to go to sleep for this procedure; however, you will receive enough medication to keep you comfortable.

 

How long will the procedure take?

Normally, a lumbar sympathetic block  procedure takes no more than 10 or 15 minutes.

 

What should I do before the procedure?

  • Since you will be receiving medication, it is recommended that you do not eat within four or five hours before the procedure. If you are a diabetic, be sure to discuss your eating and medication schedule with your doctor.
  • You may need to stop taking certain medications several days before the procedure. Please remind the doctor of all prescription and over-the-counter medications you take, including herbal and vitamin supplements. The doctor will tell you if and when you need to discontinue the medications.
  • It is very important to tell the doctor if you have asthma, had an allergic reaction (i.e. hives, itchiness, difficulty breathing, any treatment which required hospitalization) to the injected dye for a previous radiology exam (CT scan, angiogram, etc) or if you have had an allergic reaction to shellfish (shrimp, scallops, lobster, crab). The doctor may prescribe some medications for you to take before having the procedure.
  • Tell the doctor if you develop a cold, fever, or flu symptoms before your scheduled appointment.

 

Is there anything special that I need do after the procedure?

  • You may experience some weakness and/or numbness in your legs a few hours after the procedure. If so, do not engage in any activities that require lifting, balance and coordination.
  • Drink plenty of clear liquids after the procedure to help remove the dye from the kidneys.
  • Do not drive for the remainder of the day. Please have an adult drive you home or accompany you in a taxi or other public transportation.
  • Depending on how you feel, you may resume normal activities and return to work the following day.
  • If the doctor prescribes physical therapy, it is very important that you continue with the physical therapy program.
  • Although you may feel much better immediately after the injection (due to the numbing medicine), there is a possibility your pain may return within a few hours. It may take a few days for the steroid medication to start working.
  • You must participate in physical therapy, in order to get long-term control of symptoms.

 

What are the risks of a Lumbar Sympathetic Nerve Block?

The risks, although infrequent, include:

  • Puncture of the abdominal organs or the lungs
  • Numbness of an legs that may last for hours
  • Temporary weakness or numbness from the neck down
  • Allergic reaction to the medication
  • Nerve damage
  • Bruising at the injection site
  • Infection at the injection site
  • Injection of medication into a blood vessel with possibility of stroke or seizure or sudden cardiac arrest
  • Post-injection flare (nerve root irritation with pain several hours after treatment, which may last days or weeks)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Destruction of a motor or sensory nerve in the path of the needle
  • Bleeding, nerve injury, organ injury and death are rare but possible