PAIN EXPLAINED TALK 12-4-12

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PAIN EXPLAINED:
PHYSIATRY &
New Developments in
PAIN & Regenerative Medicine
Suzanne Duncan MD
Pain Diagnosis & Injury Rehabilitation
New Patients and Follow-ups:
Nantucket Cottage Hosp Pain Clinic
(508) 825-8216 (Nurse Shelly)
EMG Studies/Follow-ups:
Dr Duncan at the Westmoor Tel: (508) 680-4864
Tel
Physiatry
 Physiatry, Greek for ‘the art of healing,’ is a medical
specialty originally developed at the Mayo Clinic in 1936
by Dr Frank Krusen, MD to train doctors in the diagnosis
and management of severe injuries due to war, genetic
abnormalities and diseases such as polio.
 Physiatrists undergo lengthy comprehensive training in
both medicine and anatomy, and treat the whole person,
body, mind and soul.
Four Year Residency Training
 INPATIENT: 6 Month rotations
 Spinal Cord Injury, Trauma, Burn Unit
 Pediatric Rehabilitation
 Traumatic Brain Injury/Stroke
 OUTPATIENT:
 Neuromuscularskeletal Diseases
 Amputation/Prosthetic/Orthotics Lab
 EMG/Nerve Conduction Studies
 Pain Management
 Procedures
 Epidural Spine injections
 Joint/Muscle/Tendon injections
WWI & WWII
 WWI during and after, Physicians began practicing
"physiotherapy" in "reconstruction hospitals" to rehabilitate
injured and disabled soldiers
 WWII - Howard Rusk, MD: Set up a controlled experiment in one
barracks in which: Active Rehabilitation was carried out vs
Control Barracks that continued the passive program of
convalescence
RESULTS:THREE-FOLD RETURN TO FRONT
The dramatically rapid recovery of strength and endurance and to active
duty were so remarkable that the Army Air Corps extended the program
throughout the military services, to this day. This return of manpower is
credited with signifcant influence in winning the war., and physiatry
programs
Physical Medicine & Rehabilitation
 Physical Medicine is the study of physical agents and their use
in the diagnosis and treatment of a disease or disability, (i.e.
strengthening, stretching, modalities...).
 Modalities’ are physical treatments that produce a therapeutic
response in tissue.
 Examples of Modalitie are: Heat, cold, water, sound. More recently
electricity and electromagnetic waves (infrared, visible and
ultraviolet light, shortwaves, microwaves)
 Rehabilitation is an approach to the restoration of function
utilizing : medical, psychological, vocational, social resources that
are used in an interdisciplinary program to help a disabled
individual reintegrate into society and return to a productive and
enjoyable life.
WWII ended
Polio epidemic
 Created an increased demand for physicians trained in a
comprehensive approach to rehabilitation, including the
physical, mental, emotional, vocational and social
aspects.
 More cohesive union between the fields of Rehabilitation
Medicine, and Electromyography. (EMG). Clinical and
educational and research opportunities multiplied
 Association of Academic Physiatrists (AAP) was formed
in 1967,Ernest W. Johnson, MD, considered the "founding
father” of academic rehabilitation medicine
Areas covered in rehabilitation programs include:
 PATIENT NEEDS:
 Self-care skills, including activities of daily living (ADLs):
Feeding, grooming, bathing, dressing, toileting, and sexual
function
 Physical care: Co-moribitiy, Nutritional needs, medication, and
skin care
 Mobility skills: Walking, transfers, and self-propelling a
wheelchair
 Respiratory care: Ventilator care, if needed; breathing treatments
and exercises to promote lung function
 Communication skills: Speech, writing, and alternative methods
of communication
 Education: Patient and family education and training about the
condition, medical care, and adaptive techniques
Rehabilitation Areas continued:
 Cognitive skills: Memory, concentration, judgment, problem
solving, and organizational skills
 Socialization skills: Interacting with others at home and within
the community
 Vocational training: Work-related skills
 Pain management: Medication, interventional procedures, and
alternative methods of managing pain
 Psychological counseling: Identifying problems and solutions
with thinking, behavioral, and emotional issues
 Family support
 Assistance with adapting to lifestyle changes, financial
concerns, and discharge planning
History of Physiatry – 2012+
 Despite the changes, the need for a physician to provide holistic
medical care to patients with disabilities should continue and
increase.
 New Developments in Pain and Regenerative Medicine offer
promise to challenging cases
 Advances in technology such as limb replacement, traumatic brain
injury (TBI) and wound care have created further demand for
physiatrist’s services.
 Continuing research will lead to advances that will ultimately
benefit our patients and help physiatrists provide state of the art
care.
Pain Management
 4th vital sign
 Demand increasing
 Many specialties participating
 New requirements from fellowships
mandate multidisciplinary training
 Interventional option
 Subspecialty boards
Spinal Nerves
Parasympathetic/Sympathetic Nervous System
THIRD ORDER NEURONS
Somato Sensory
Pathways
(vertical)
FIRST ORDER
NEURONS
(C&Aδ fibers
Capsaicin
sensitive/TRPV1
nerves)
Propriocepsis
Muscle tension, tendon stretch
Fine Discriminative Touch
Light touch, pressure, vibration
Pain and Temperature
tickle and itch
(Mechano-thermo-chemical
nociceptive system)
SECOND ORDER NEURONS with sub branch to Hypothalamus
SUBCUTANEOUS NERVES
Peripheral Nerve Trunk
and its Organization
John Marshall, MD ‘Nervi Nervorum’
Bradshaw Lecture (1883)
Marshall and Sir Victor Horsley postulate in 1883 that
‘Nervi Nervorum’
were responsible for the inflammation of the nerve trunk
sheath causing “neuralgia”.
How do these Injuries Occur?
 POSTURE
 Trauma
 Repetitive Shear
 Toxic Overload
 Nutrient Deficiency
 Disease
http://www.antiaginghacks.com
Epidemic of the 21st Century
60 million years of Biology
vs 2 million ‘Bright Idea’
The Human Spine
Why Do We Still
Have Back Pain?
 Theories continue to be improved upon
 In the past a ‘straight spine’ was promoted
both in the Armed Forces and Dance
 Many practices in the past were based on
hypermobile ‘Dancer bodies,’ for example
Joseph
Pilates, a German movement specialist whom initially
worked exclusively with the dance corps
 More comprehensive cadaver studies have
revealed the need for cervical and lumbar
curvature in order to bear the body’s weight
Stooping is an Option
Stooping Arises from the Evolutionary Cost of
Hanging from Trees:
Unless Chest is Elevated,
then the Rhomboid Muscle Contracts and
Opens and Relaxes the Pectoral muscles
Common Myths
 Suck it In
A Healthy Stomach supports the spine
 Chin Tuck
Elevate Chin to Stack Cervical Spine
 Flatten Back
Keep back curved to support weight
 Bend Stretch
Arch down and back up
 Tilt Pelvis Keep low back arch, only tilt if
hyperlordic
Consequences
Standard Treatment
Options
 REDUCTION OF INFLAMMATION:
 ICE
 Steroid Injections to base of skull, Trigger Points,
Joint, Tendons and Ligaments
 Lidocaine Patches
 Oral medication: Ibuprofen/Advil, Alleve, Tylenol
 PAIN MEDICATION
DANGERS OF OPIODE USE
 For more than 100 years, the use of opioid analgesic
agents has been linked with modulation of the immune
system in man. More recently, it has become apparent
that both exogenous and endogenous opioids exert
some effect upon the immune system…. Of the strong
opioid analgesics in current use, the majority are seen
to cause immunosuppression in man.

Biomed Pharmacother. 2006 Aug;60(7):310-7. Epub 2006 Jun 30., Pain management: is opioid immunosuppression
a clinical problem?, Budd K.Source:Pain Management, Newlands, Chevin Avenue, Menston LS29 6PE, UK.
[email protected]
Anaesthesist. 2003 May;52(5):442-52.Welters
Opioids and immunosuppression. Clinical relevance?
 Abstract: First observations that opioids may have
disadvantageous effects on the immune response have
been made more than 100 years ago. Today the
immunosuppressive effect of morphine is well
established.Drug-induced immunomodulation is of
growing importance in modern anesthetic concepts.
The reduced stress response observed after morphine
application contributes to this effect as well as direct
impairment of immune effector cells such as
bactericidal activity, intracellular killing,proliferative
response or cytokine synthesis. Opioid-induced
immunomodulation is mediated by opioid receptors
found on immunocytes and in the central nervous
system.
Developments in PAIN and
Regenerative Medicine
 Low Dose Naltrexone (LDN)
 Suboxone: Naltrexone 50mg/Bupenorphine 8mg
 FDA approved at 50mg for opiate addiction, at low
doses such as 4.5mg taken at night have been
proved to boost and normalize the immune system
 www.lowdosenaltrexone.org
 Increased AIDs survival and remission, Cancer
remission, MS progression significantly slowed,
Crohn’s resolved, Thyroid normalized, Autoimmune
diseases alleviated
LDN Clinical Studies
 Two studies in Mali, Africa demonstrating LDN’s
successful use in HIV/AIDS—published October
2011.
 A study of LDN in the treatment of MS at the
University of California, San Francisco, published
February 2010.
 A multi-institutional clinical trial of LDN for PPMS in
Italy, which includes endorphin measurements,
completed in fall 2007, published September 2008.
 A Phase II placebo-controlled clinical trial of LDN
for Crohn’s disease at Penn State.
LDN Clinical Studies continued
 A Phase II placebo-controlled clinical trial on the
efficacy of LDN for children and adolescents with
Crohn’s disease at Penn State.
 A clinical trial of LDN in the treatment of fibromyalgia
at Stanford Medical Center, published May-June 2009.
 A study by the MindBrain Consortium in Akron, Ohio
of, especially, the affective changes in MS treated with
LDN, begun late 2007.
 Animal research on neurodegeneration at NIEHS,
suggesting a protective role for naltrexone.
Developments in PAIN and
Regenerative Medicine
PROLOTHERAPY is a medical term which means 'proliferation
therapy,' here in reference to nerve, soft tissue and cartilage,
damaged after injury from trauma or disease. By selective
restoration and strengthening of these areas with prolotherapy,
the integrity of the system is preserved and the area becomes
pain free. This technique has also proven effective in softening
and decreasing the hypersensitivity of scars.
Prolotherapy
 Prolotherapy traditionally is the injections of solutions
that cause a controlled healing response of the area
through mild inflammation and nutrition. The solution
injected is an irritant, often dextrose (sugar) and water.
This triggers the natural inflammation response of the
body, which then rebuilds the target area with the
surrounding addition of nutrient, glucose. This
strengthens pathologically weaked ligaments and
tendons.
Controlled Inflammation
Heals and Strengthens
 Inflammation is the process by
which the body heals., and as
this happens, the tissues
deposit new collagen, the
substance that ligaments and
tendons are made of. The new
collagen soon shrinks,
strengthening the treated
ligament and reducing or
eliminating pain. The small
amount of bleeding that is
generated in this technique
also delivers platelets to the
area, which are rich in growth
factors and promote further
healing.
Prolotherapy Regenerates Tissue
 Prolotherapy specifically refers to injections at the
ligament and tendon bon-interface to strengthen
and balance the unit, but is also an over-arching
term for other regenerative procedures such as
Platelet Rich Plasma autologous blood injections
and Auto Stem cell injections.
Prolotherapy continued
 Prolotherapy Joint injections that promote cartilage
production and intra-articular (within the joint),
strengthening of tendons. Solutions such as
glucose and lidocaine within the joint result in
cartilage regrowth and strengthen intra-capsular
ligaments and tendons.
Example of Injection
Sites for the Inferior
Posterior
Glenohumeral
Ligaments and
Teres Minor Origin.
Access to all points
marked is by entry
at Green dot
PRP & Auto Stem Cells
 Platelet Rich Plasma (PRP) is
the application of concentrated
platelets rich in growth factors
from the patient’s own blood. It is
commonly used in professional
athletes to repair torn tendons
and ligaments.
 Auto Stem Cells takes
multipotent stem cells from the
patient’s own fat cells or from hip
bone to regrow cartilage, tendon,
ligament and bone.
Developments in PAIN and Regeneration
 TENSEGRITY is an important term in these procedures, coined
by Buckminster Fuller for the concept of ‘tensional integrity.’
 Tensegrity concerns inteself with the stabilization of a threedimensional structure, here the body's components of hard
and soft tissues, which support and cushion the body against
gravity and force. Imbalances in these structures, such as
weakened ligaments surrounding a joint from trauma or
disuse, can lead to uneven wear, breakdown and pain.
Prolotherapy Benefits
 Arthritis relief
 Back pain, especially involving the lower area or sciatic pain
 Neuropathic pain
 Joint laxity or weakness
 Swelling or tenderness at a joint
 Pain as a result of complications from surgery
 Scar release and repair- headaches resulting from neck problems
 Acute trauma, such as sports injuries & other musculoskeletal injuries or
conditions
 Treatments usually involve three to six sessions with a doctor. Sessions
are usually two to six weeks apart. Expense is out-of pocket, although
Workman’s Comp and the VA presently cover it.
Developments in PAIN and
Regenerative Medicine
 Perineural Subcutaneous Injections )also known as
Neural Prolotherapy or Neural Facial Release
Technique (NFRT) for nerve repair and regeneration is
highly effective in resolving pain. Sugar is injected
(glucose, mannitol or glycerol) with sterile water in
quantities of 1-2cc's (approximately half a
tablespoon),under the skin and above the muscle every
2-3 inches where there is pain. Sugar is the body's
major fuel and building block. The sugar hydrates and
nourishes the micro-nerve network that informs the
structures above and below, restoring health to the
area.
Developments in PAIN and
Regenerative Medicine
 Prolo Sonophoresis utilizes therapeutic Ultrasound to
deliver sugar to the painful areas without the need for
injections. The sugar passes through the skin by micro
sound waves, hydrating and nourishing the structures
that have become starved and scarred from injury and
lack of nutrients. These solutions are generally
personally compounded by the treating physican with
knowledge in this area. Dr John Lyftogt and Dr Howie
Rosen have developed commercial products to treat
the subcutaneous nerve environment.
“An ounce of prevention is
worth a pound of cure.”
 In conclusion, the best medical advice may be that of our
Benjamin Franklin quoted above.
 POSTURE POSTURE POSTURE POSTURE is the ill of most
painful conditions; better posture – better body
 Children texting or game playing with bent necks are a
disaster waiting to happen, their vulnerable necks cannot
sustain the weight of their head for extended periods of
time. In a bouncing car the force is further compounded and
serious spinal cord injury is possible.
 CHEST UP, CHIN UP, STRONG STOMACHS!

‘Be Kind to Yourself and Others’
Thank you
www.suzanneduncanmd.com
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