Pain Management at The Marlowe Institute

The management of pain is a complex field that involves many different disciplines. For some patients, this requires only rest and therapy. Others require a team approach that may include psychotherapy, physical therapy, medications, and specialized injections.

All muscles, tendons, ligaments, and discs in the body are susceptible to wear and tear, and some tissues fail due to injury or overuse. Certain tissues have poor blood supply and therefore lack the full potential for repairing themselves. These include knee menisci, rotator cuff tendons, tennis elbow muscles, and discs. General treatment includes relative rest of the involved area (sometimes with splints/braces), ice or heat, anti-inflammatories, and physical therapy.

Certain injections may help. Although steroids can help get swelling down, they also may lead to tissue damage, and must be used cautiously or completely avoided when treating rotator cuff tears, Achilles tendinitis, patellar tendinitis, and plantar fasciitis.

CTS is a very common problem that is due to nerve injury at the wrist resulting in numbness, tingling, pins and needles, and pain in the hand. Pain can refer up the arm to the shoulder. CTS is not usually the cause of wrist pain. Work-up includes history, physical, and electrodiagnostic testing. Treatment is based on the duration of symptoms and severity of findings, and may include bracing, injections, ergonomic (workplace) correction, therapy, and ultimately surgery. Surgery is generally very safe, simple, and effective, and should not be deferred if advanced nerve damage is found.

Myofascial Pain Syndrome (MPS), or trigger points, is the most common diagnosis seen by Dr. Marlowe. Most people have some degree of muscle discomfort at times, but for many, this discomfort can become a chonic painful contraction of muscle that does not remit with time. Most often, these trigger or tender points are located throughout the trapezius muscles of the upper back, but can occur in any muscle, even between the ribs. The most common treatment of this is physical therapy with anti-inflammatories, and trigger point injections if needed. The goal of therapy is pain relief with passive modalities at first (ultrasound, electric stimulation, stretching), quickly progressing to strengthening to prevent relapse. Muscle relaxers have not generally been shown to be effective. Trigger point injections are commonly used to break up and relax remaining points of muscle contraction. The injections are generally only slightly painful, contain nothing that would damage tissue such as steroid, and usually have permanent effects. They can be effective after one treatment, or can be done multiple times if symptoms return. Dr. Marlowe uses Botox for resistant cases.

Dr. Marlowe has seen many patients with pain in the neck and back. Here is an outline of basic information regarding the work-up and treatment of these common problems:

1) Back pain occurs in a large majority of people at some point in their lives. It is almost inevitable to have an episode if you live long enough. This episode can cause severe pain even without a significant injury, and this does not necessarily mean serious damage to the spine has occurred.

2) The immediate treatment includes off-loading the area (resting) for a short time, starting an anti-inflammatory (ibuprofen, which is the same as Advil and Motrin; Aleve) on a regular basis, and putting ice on the area for 15 minutes every 2 hours. Aspirin has a higher association with bleeding problems and is generally not advised. Tylenol or pain medications can be added, but are not anti-inflammatories and won't shorten the duration of symptoms.

3) The immediate goals of treatment are to rest the injured area and to get the swelling down quickly. Swelling occurs at the level of the disc or other tissue, and is not necessarily visible. Bedrest, even for one day, has been found to slow the healing process and is never recommended unless the patient absolutely can't get upright.

4) The causes of back and neck pain are usually related to a disc or joint injury. Excessive muscle contraction can occur nearby, but Dr. Marlowe has found this to be a secondary problem, meaning there is usually an underlying problem that needs to be addressed as well.

5) Hip joint pain usually involves discomfort in the groin with pain on weight-bearing and pivoting on the hip, and loss of hip range of motion. Pain in the buttocks usually does not indicate the hip as a cause, as most people believe, but instead implies a problem in the low back. Likewise, many cases of shoulder pain are due to a neck problem.

6) X-rays may be obtained on the first visit. A lot of information besides bone anatomy can be gathered, including disc height, arthritis, problems of bone alignment (spondylolisthesis), and pelvic asymmetry. Fractures are also seen. In people at risk for osteoporosis, these fractures usually occur in the midback and not the neck or low back.

7) MRI is rarely needed unless symptoms related to a pinched nerve are suspected and the patient desires a more invasive treatment including epidurals or surgery. The results of the MRI are many times misleading and may not help in the management of pain. MRI results always must be interpreted in light of the clinical exam. Dr. Marlowe requires the patient to bring in any recent MRI and x-ray films for review, as the printed reports are sometimes inadequate.

8) A pinched nerve (sciatica) is suspected when pain, numbness, and weakness occur in the leg. Neck and back pain by themselves, even if severe, do not mean a nerve is being pinched. Pain shooting into the arm or leg can occur if there is an irritated muscle or joint, and do not always indicate a pinched nerve. EMG can be helpful in making this determination.

9) Treatment in the office starts with a thorough history and physical exam. Review of any prior work-up and treatment is carried out, and the patient is asked to bring all previous medical records related to the injured area in on the first visit. Generally, antiinflammatories are prescribed, and these may be over-the-counter or prescription. These can be taken with pain medications or Tylenol, but two different anti-inflammatories should not be taken at once. Muscle relaxers are generally poorly tolerated and don't particularly relax muscle so much as sedate, and are avoided for most people. If there is a difference in leg lengths, this may be corrected. Physical therapy, weight loss, chiropractic, or acupuncture may be suggested.

11) Surgery is needed in only a small percentage of patients, usually after all non-surgical options have been exhausted.

When back or neck pain persists, steroid injections may be employed. Placing the steroid into the inflamed area must be done accurately, or the steroid will not work. "Blind" injections (that is, done by feel) have been used for many years, but have fallen out of favor because they tend to be inaccurate compared to procedures performed with the assistance of fluoroscopy (a low-dose x-ray used to see the needle during placement into the spine).

The most common procedures for back and neck pain include epidurals and facet blocks. Epidurals have nothing in common with the spinals that women receive during childbirth. Because spinals are done without the assistance of x-ray guidance and the needle is inserted deeper, they can be more painful and have a greater risk of spinal headaches afterwards.

The goal of an epidural is to place steroid as close to the injured structures as possible, in order to reduce swelling. In the case of an epidural, these structures are usually disc and nerve root. Epidurals may allow permanent pain relief by getting the tissue swelling under control and enabling the body to repair itself; they may also stabilize the nerve membranes. Their goal is not to improve disc height or remove disc herniations, and they have no lasting effect on structural problems like spurs or stenosis (closing of the holes where nerves or the spinal cord pass). Epidurals are mostly used to help nerve symptoms into the arm, leg, chest, or abdomen.

Facet blocks are useful to determine if a patient is experiencing "facet-mediated" back or neck pain. The facets are joints that run on either side from the skull to the base of the low back, and can become arthritic like any other joint in the body. Epidurals are not used to help facet-mediated pain; facet blocks must be used for this. Local anaesthetic and a small amount of steroid are injected into the suspected joint, and the patient is asked to record their response for the first 4-6 hours, and for the next 2 weeks. A good response indicates that the facets are generating the pain. Treatment of facet-mediated pain is different from disc-mediated pain.

To get swelling under control, a person may use ice, oral anti-inflammatories, and/or receive a steroid injection. Corticosteroids are highly effective in reducing inflammation, particularly when nerves are involved. Dr. Marlowe presents some answers to common questions and myths regarding the use of steroids:

A) If repeatedly injected into one spot, or in high concentrations, steroids can lead to tissue damage. For this reason, steroids must not be used indiscriminately, and the dose should always be minimized to what will be safe and effective. When corticosteroids are used for other conditions (e.g. inhaled for asthma, topical for rashes), patients do not generally get overly concerned about their side effects. It's only when mention is made about injecting the medication into tissue that many patients become instantly alarmed about the risk; these fears are based on a combination of misinformation and a history of excessive use by some doctors.

Q) I don't want to look like a body builder. Do they have an effect on the body?

A) In low doses, injected corticosteroids generally don't cause any problems systemically (to the body). However, certain people need to be careful, especially diabetics, who can see changes in their blood sugars for days after a steroid injection. Oral corticosteroids can cause many systemic side effects. As for body builders, they may abuse an anabolic steroid, which is a completely different chemical than corticosteroids, and has totally different side effects.

A) Like oral anti-inflammatories, the goal of a steroid shot is to permanently reduce swelling at the tissue, which should afford pain relief. There are many reasons why some steroid shots are temporary. If the steroid is placed into an area that is not inflamed, it is unlikely any relief will occur. This may happen if the steroid gets washed away if injected into a blood vessel, or if the steroid is placed into the wrong area (if the facet is causing pain, an epidural won't give great pain relief - see above). If the cause of pain is structural and not inflammatory (e.g. spur pressing on nerve, or totally degenerated joint), the relief will likely be very short-lived. Likewise, if there is an issue of poor blood flow causing pain, as in plantar fasciitis, tennis elbow, and rotator cuff tendinitis, reducing inflammation is not as critical as improving blood flow. If too low a dose or poor technique are used, the injection may fail as well. Lastly, if the patient does not adequately rest the area after the injection (sometimes as much as a week), the relief will be temporary. Steroid injections generally work best when performed in the setting of a full program of therapy, rest from aggravating factors, and anti-inflammatories.

A) Not all injections are painful: it depends on the doctor's technique, the size of the needle, and the substance injected. Good technique involves preparing the patient for what is to happen, and minimizing surprises. It also involves directing the needle right into the inflamed tissue without a lot of poking around or bumping into bone. Sometimes this is unavoidable, but many times guesswork can be eliminated with the use of fluoroscopy (a low-dose x-ray that enables the physician to see the needle while advancing it). A needle that is thin can be inserted with minimal discomfort. Steroids are not painful; it's the local anaesthetic that gives the burn of the shot. When placed into a sore area, it may be inevitable that the injection will be painful. The use of intravenous sedation for certain procedures can reduce patient anxiety and discomfort, and patients should request this if they are concerned.

Spasticity is the involuntary contraction of muscles due to nerve injury in the central nervous system (CNS; i.e. the spinal cord and brain). People who have spasticity have sustained a stroke, spinal cord injury, traumatic brain injury, or multiple sclerosis as examples. Many times, spasticity can lead to pain, difficulty walking, and problems with activities of daily living.

To break the spasticity, two forms of injection are widely used. The standard treatment consists of injecting a low dose of alcohol or phenol at what are called "motor points." Motor points are areas of muscle that contain a high number of nerve endings. If the motor point is damaged by something like phenol, there will be weakening in the loop with the CNS, and the muscle will become less excitable and prone to contract. Motor point blocks are performed by Dr. Marlowe for certain patients with spasticity.

The second form of injection uses BOTOX, a diluted product of the bacteria that causes botulism. Although Botox injections are very safe, they also are very temporary, lasting 4 to 6 months. Botox acts by blocking the release neurotransmitters, the substance that nerve endings send to the muscle telling it to contract. Eventually, these nerves sprout new nerve endings, and form new communications with the muscle. As a result, the weakness caused by Botox will be temporary.

Those with knee osteoarthritis may be candidates for SYNVISC or EUFLEXXA injections. Not a steroid, Synvisc is a long-acting medication that is well-established in helping to reduce the pain of knee arthritis, often for 6 months or longer. A series of three injections is performed, one week apart, and can be done in conjunction with other treatments such as anti-inflammatories and physical therapy.