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15 Articles in Volume 16, Issue #6
Osteoarthritis and Central Pain
Uncovering the Sources of Osteoarthritis Pain
The Synergistic Effects of Mood and Sleep on Arthritis Pain
Nonsurgical Rx of OA: Analyzing the Guidelines
Osteoarthritis Disability Is Often Underestimated By Rheumatologists
10 Pain Medication Myths
The Use of Medical Marijuana for Pain in Canada
6 Common Concerns Regarding Medical Marijuana
What Pain Specialists Need to Know About Medicinal Cannabis
Applying Kinesiology as a Multipronged Approach to Pain Management: Part 2
Practical Guide to Adding Recreation Therapy Into Pain Management
A Novel Treatment for Acute Complex Regional Pain Syndrome
Genetic Testing in High-Dose Opioid Patients
No More “Fifth Vital Sign”
Letters to the Editor: Disc Herniation, SCS, Arachnoiditis, Tapering Opioids

Letters to the Editor: Disc Herniation, SCS, Arachnoiditis, Tapering Opioids

July/August 2016

Manipulation for Disc Herniation

When I was reading the article “Efficacy of Acupressure Plus Manipulation for Lumbar Disc Herniation: A Clinical Report” in the Jan/Feb issue of Practical Pain Management, I was hoping to learn a “newer” approach to herniated nucleus pulposus (HNP), but I think the authors are doing something similar to the McKenzie’s concept for contained HNP.1

Letting a patient lie in the prone position, which is the initial McKenzie position for HNP prior to repetitive lumbar extension, is usually tolerated provided you use radicular symptoms as a guide for treatment progression. Although the use of lumbar traction does not have strong double-blind studies to support it, I still use it for selective patients who show initial response to traction of their legs.

Depending on the severity of the pain, I use a generic soft lumbar brace during the initial stage of acute HNP to provide lumbar stability, but I eventually let the patient undergo progressive lumbar stabilization, extension biased, to improve active lumbar core stability so the brace can gradually be discontinued.

As a physical medicine and rehabilitation (PM&R) physician and physical therapist, my rationale for treatment is to make the patient be able to do the exercise regimen independently and be less reliant on a practitioner to provide passive care. I could see the “rolling,” as described by the authors, as enhancing the effect of lumbar extension. But you also can educate a patient to use progressive and repetitive extension of the lumbar spine to promote anterior disc displacement. In certain cases, you can provide manual assistance to promote the lumbar extension.

I prescribe medications to address the chemical irritation, nerve sensitization, and pain. Only when oral medications do not suffice to control the pain and that pain begins to interfere with a patient’s progression to an active program, then do I prescribe a lumbar epidural steroid injection.

Pedro Oliveros, MD, PT

Board Certified in PM&R

Subspecialty in Pain Medicine

Maitland, Florida

Dear Dr. Oliveros,

My treatments and those used in the MacKenzie exercise are significantly different, and I would hesitate to recommend the latter for the following reasons.

In disc herniation, the posterior intervertebral gap is bigger than normal. The spinal extension of MacKenzie’s exercise decreases this gap’s size, and the result is often that the herniated disc can become even more prominent than before the treatment.

A much more effective treatment of disc herniation is acupressure. Pressure is applied on certain points according to the herniated disc’s location.

I apply pressure for 10 to 20 minutes on the right side of the erector at the L4 level, for example. Pain is usually reduced, and in some cases, it may disappear. By reducing the inflammation around the sciatic root, lower back pain and sciatic pain are significantly relieved.

The application of acupressure to points on the hip on the same side as the disc herniation can also reduce sciatic inflammation and pain in the majority of cases.

Another technique of acupressure will help patients to improve local circulation and speed up the recovery process as well as to help with cold legs and feet. Pressure is applied to the femoral artery of the groin, also on the same side as the herniated disc, for a minute or less, then a gradual release of pressure; this method causes a dramatic improvement of local circulation.

An important method that I have used with success is “knocking and rolling” plus traction in alternating cycles, which may cause the herniated disc to partially return to its normal location. At my clinic, I’ve seen many cases, especially within a short period after the disc is herniated; the point beside the erector on the same level of the herniated disc cannot tolerate pressure due to severe pain. However, after repeated “knocking and rolling” plus traction in alternating cycles for several minutes, the pain becomes significantly less; then pressure can be applied. This means the disc is partially lodged back in its original state. This being said, the inflammation and swelling cannot be reduced in just a few minutes. Other manipulation such as flexion is only an assisting technique.  

The combination of all these treatments has resulted in a higher success rate.

Sincerely,

Zesheng Wang, OD, MD

Spinal Cord Stimulation for Arachnoiditis?

I live in Sweden, and 6 years ago, I developed cauda equina syndrome (CES). After 2 surgeries, I was diagnosed with adhesive arachnoiditis (AA). I had a spinal cord stimulator (SCS) implanted 2 years ago and recently have had increased pain in both legs. My question is: What is your recommendation for patients suffering from AA? SCS: yes or no?

Christer Johansson

Kinna, Sweden

Dear Christer,

Your question about the merits of a SCS in AA is most pertinent at this time. First, the increased pain in your legs may not be due to your stimulator, but it obviously did not prevent what I assume is progression of your AA disease.

In the past, I personally recommended SCS in AA patients because we didn’t have much else to offer. Today, the situation has changed. Current scientific information regarding centralization of pain, neurohormones, neuroinflammation, and microglial cell activation has allowed the development of new medical protocols to treat AA and other centralized pain conditions.2

The “missing links” have been control of neuroinflammation and promotion of neurogenesis.  Spinal cord stimulators should, in my opinion, only be used after a comprehensive medical regimen, which focuses on neuroinflammation, neurogenesis, spinal fluid flow obstruction, and pain relief, is in place. If the medical regimen is not satisfactorily controlling pain and improving physical function, a trial with a SCS is warranted. Click here for details of my medical protocol.

Best wishes always,

Forest Tennant, MD, DrPH

Adhesive Arachnoiditis Treatments

One of our patients provided us with your article on arachnoiditis. I found it interesting and very thorough. I was somewhat surprised that the use of neuromodualtion was not mentioned as an option, especially in the more difficult cases. The use of intrathecal medications and occasionally spinal cord stimulation has been beneficial in properly selected and treated patients.    

Dan Doleys, MD

Dear Dan,

You correctly mention in your note that many patients with AA have benefited from intrathecal medication and neuromodulation. As you are well aware, in the recent past, about all we could offer patients were opioids and neuromodulation. Today, we know enough to provide medical support to these patients with neuroinflammation control, spinal fluid flow maximation, and neurogenic measures. Once a sound medical regimen is in place, neuromodulation may not only be needed, it may complement and enhance the medical protocol.  

I especially believe that arachnoiditis patients need an effective neuroinflammation control regimen before a stimulator or intrathecal pump is placed, as these devices may irritate cauda equina nerve roots and cause inflammation. Neuroinflammation doesn’t respond well to the traditional anti-inflammatory agents, but it does to microglial modulators including ketorolac, corticoids, low dose naltrexone, minocycline, acetazolamide, and pentoxifylline. Also, some arachnoiditis patients have such severe pain that it cannot be controlled by standard oral, systemic therapy, so intrathecal administration will be needed.

In summary, I believe the new medical protocol, when combined with neuromodulation and possibly intrathecal administration, may bring a much higher degree of relief and recovery to a suffering group of patients who have been sorely neglected.

Best wishes always,

Forest Tennant, MD, DrPH

Tapering Opioids

Dr. Tennant, I’ve always appreciated your intelligence and compassion in the care of complex pain patients—I’ve learned a lot from you.

Below are 2 links that highlight a significant problem in clinical medicine: tapering pain patients off of opiates who meet criteria for an opiate use disorder (OUD) or more clinically relevant DSM-V criteria. One is a case report that reflects on a potential complication, and the other is an academic article and relates to the likely percentage of patient who met criteria for an OUD, which is published in Czech.  

I hope you agree that the above is further ammunition to argue against the tapering of opioids from legitimate chronic pain patients. I’ve concluded, however, that in certain controversies, the facts and critical thinking are not what matter.

J. Kimber Rotchford, MD MPH

Port Townsend, WA

Dear Dr. Rotchford,

You bring up one of the most difficult issues in pain management: the patient with an OUD who has legitimate pain. The articles you have written and to which you have referred here provide some sound guidance.

Some of the issues that I believe need to be clarified include, first of all, some specific guidance on how to make a diagnosis of OUD considering that most pain practitioners are neither psychiatrists nor familiar with DSM-V criteria. In addition, the issues of compliance and liability are paramount with these individuals. Anyone who attempts to treat chronic pain patients who also has a OUD case (ie, “addict”) soon observes noncompliance and the risk of overdosage, motor vehicle accidents, and diversion. Needless to say, all suggestions, ideas, and recommendations involving these needy patients is welcome.

Best wishes always,

Forest Tennant, MD, DrPH

Correction

During the editing process, the correct title for CRPS was inadvertently changed from Complex Regional Pain Syndrome to Chronic Regional Pain Syndrome in the June Editor’s Memo. We apologize for the confusion.

Last updated on: October 13, 2016
Continue Reading:
Letters to the Editor: Central Sensitization, Microglia Modulators, Supplements

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