Jonathan Aarons M.D.

Tired of Chronic Pain?

Botulinum Toxin for Chronic Pain Management

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Most people are familiar with Botulinum Toxin, or BoTox, for cosmetic surgery but many are not aware of its application for the management of chronic pain.   It can be used for migraine as well as cervical dystonia among others.  We know that botulinum toxin prevents the release of acetylcholine from the presynaptic vesicles at the neuromuscular junction.  This accounts for its ability to decrease wrinkles.  Its mechanism for the treatment of chronic pain is not so well elucidated.

Cervical dystonia, or spasmodic torticollis, is a disorder of the muscles of the neck and shoulders. The injection of botox into these muscles will weaken the muscle and diminish abnormal muscle movements and contractions.

Chronic migraine is another painful condition that is often difficult to treat.  Studies have shown that botox type A can decrease headache, both in frequency and severity.

There are other painful conditions that can be treated with botox, but for which the evidence is not so strong.  These include myofascial pain,  temporomandibular dysfunction (TMJ), pyriformis syndrome, lateral epicondylitis ( tennis elbow), plantar fasciitis, chronic pelvic pain, interstitial cystitis, trigeminal neuralgia, post herpetic neuralgia and others.

The use of botulinum toxin for chronic pain management is not without risk.  These risks include infection, swelling, redness, allergic reaction and muscle weakness.  This muscle weakness can including trouble swallowing, blurred vision, drooping eyebrows, dry mouth among others.  The consideration of the use of botox should be made with the consultation of your pain management professional.

Spinal Cord Stimulation for Treatment of Chronic Pain

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Spinal Cord Stimulation for Treatment of Chronic Pain

Spinal Cord stimulation for the treatment of chronic pain is useful for those patients who have failed conservative management. It involves the implantation of a stimulation catheter near the spine. Patients with neuropathic pain, or pain caused by damaged nerves, are the ideal candidates for this procedure.

The mechanism by which spinal cord stimulation works is not well understood, but is best explained by the “Gate Theory” of pain. This theory proposes that stimulation of large nerves by electricity can close the gate for pain impulses to reach the spine.

During placement of this catheter, the electrodes are placed into the epidural space at a level in the spine close to where the pain impulses enter the spinal cord. Patients experience paresthesia, or tingling, in the area of pain. This can substantially reduce the perception of pain by the patients.

Usually, a patient is given a trial of stimulation to assess how well it works. It the trial is successful, then the spinal cord stimulator is implanted permanently. Usually a 50% or greater reduction in pain from the trial is needed in order to justify the permanent stimulator implant.

Complications can occur during the trial or permanent placement of the stimulator. Hardware malfunction, lead migration, and breakage are among some of the issues. Infection is always a concern when implanting any object.

Finally, spinal cord stimulation for the treatment of chronic pain is a useful modality of treatment. It is only used after all other conservative modalities of treatment have failed. It has the potential to alleviate pain where all other modalities have failed. It is not without risk and should be undertaken only by a trained pain management professional.

Stem Cells and Platelet Rich Plasma (PRP) in the Treatment of Chronic Pain

STEM CELL AND PRP FOR TREATMENT OF CHRONIC PAIN

Stem cells and Platelet Rich Plasma (PRP) are a new and innovative modality for the treatment of chronic pain. A short blog will not do the subject justice. However, I will try to communicate the basics.

Stem cells are the progenitor cell for almost every cell in the body. They are derived from bone marrow and can become almost any cell in the body. They are responsible for everyday tissue remodeling and turnover.

The majority of cells in the blood are red blood cells, white blood cells and platelets. Platelet rich plasma (PRP) is plasma with a high concentration of platelets. Although platelets are known for their effect on clotting, they also contain hundreds of proteins called growth factors which aid in healing.

Both stem cells and PRP are used to promote healing. Stem cells are usually taken from an area of high concentration, like your hip bone, and injected into an area where healing is occurring from an injury. PRP is derived from the blood, which is taken from a vein, put through a centrifuge to concentrate the platelets, and injected into the area of pain and injury.

Both stem cells and PRP promote healing. PRP contains many growth factors that can promote healing and decrease pain. Stem cells may have the ability to generate healthy cells to replace diseased cells.

Although this is a new and exciting area, many of these stem cell and PRP therapies are not covered by insurance. Many uses of stem cells are unproven and may be unsafe if used inappropriately. It is important to do your own research before undertaking this therapy.

What kinds of problems can be treated with stem cells and PRP? There are many including back pain, achilles tendon tear, shoulder rotator cuff tear, hip osteoarthritis, sacroiliac disease. It may take 3 weeks to 3 months after this therapy to see the full result. There is research ongoing as to the uses of stem cell and PRP. No guarantee can be given as to how effective this is. As with any procedure, the results are variable and depend on the patient and the severity of injury.

Pain After Breast Cancer Surgery

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Pain After Breast Cancer Surgery

A significant number of women report pain after breast cancer surgery. This pain can be in the area of the breast, chest wall or arm. Risk factors for post surgical pain include younger age, preoperative pain, anxiety, depression and the surgical approach.

The cause of persistent pain after breast cancer surgery can be multi-factorial. Nerve injury can occur during surgery. Phantom breast pain, which is the sensation of residual breast tissue with painful or non-painful symptoms, has been known to be a complication. Injury can occur to the intercostobrachial nerve causing pain along the medial and upper arm. Neuromas can lead to pain along the scar.

Reducing pain after breast cancer surgery can be accomplished. Preoperative nerve blocks can be used to decrease pain both during and before surgery. These nerve blocks may reduce the need for narcotics and thereby decrease post-operative nausea and speed recovery as well.

Furthermore, several other modalities have been used to decrease pain after breast cancer surgery. These include medications such as gabapentin, mexilitene, venlafaxine, EMLA and dexamethasone.

Non-pharmacologic approaches can also be used. These include exercise, physical therapy, TENS, and accupuncture.

In conclusion, pain after breast cancer surgery is an ongoing problem. Several strategies can be used to mitigate this pain. These strategies are particularly important in those patients with higher risk including those with pre-procedural pain. It is likely that a combination of nerve blocks, medications and non-pharmacologic therapies can be useful in decreasing this painful problem.

Fibromyalgia

Fibromyalgia Symptoms

Fibromyalgia is an abnormal condition causing widespread pain, fatigue, mood disorders and cognitive dysfunction. The pain can be described as stabbing, shooting, and throbbing with muscular aches. Patients with fibromyalgia often have fatigue, difficulty sleeping and sensitivity to touch, light and noise. These patients often have other associated problems such as headaches, irritable bowel, restless leg and temporomadibular joint dysfunction (TMJ).

No one knows what actually causes fibromyalgia but a combination of environmental and genetic factors have been proposed. An inflammatory model of disease has been studied. Changes in the central nervous system have been previously documented but their cause is unknown.

The American College of Rheumatology adopted criteria for the diagnosis of fibromyalgia which includes widespread pain for at least 3 months and the presence of pain at 11 of 19 predetermined tender points on the body. Fibromyalgia can also be diagnosed using the Widespread Pain Index (WPI) and Symptom Severity (SS) Scale. It can also be further divided into Type A and Type B using these indices. Treatment of fibromyalgia is multi-modal. Treatment includes psychological and social interventions. Medications for treatment include pregabalin(Lyrica), duloxetine (Cymbalta) and milnacipran(Savella). Each medication has its own mechanism of action and side effect profile.

Other treatments include cognitive behavioral therapy, acupuncture, and biofeedback. Physical deconditioning is a problem and physical therapy is an important component of treatment.

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