Chronic neck/low back
Chronic headaches and migraines. Temporo-mandibular joint arthritis.
Natural herbs, acupuncture, Imitrex, Botox, Dysport, Stem Cell Therapy, trans-cranial electric stimulation, homeopathy, hypnosis. Prolotherapy, Platelet rich plasma PRP, Botox, Dysport, Stem Cell Therapy.
Patients with chronic neck and back pain are the most challenging in any physician’s practice. Medical management of those patients might cause both the physician and the patient frustration. Every time I open a new chart I remember my old professor saying: “Chronic pain management requires a combination of science and art. Usually more art…”
Chronic neck and back pain is the most common cause of disability in the United States in persons younger than 45 years, and it is the third most common cause of disability in those older than 45. There are over 15 million office visits every year for mechanical neck and low back pain in the United States. Lack of physical activity, increased body weight, limited ambulation, trauma, accidents, and repetitive injuries to the spine all result in back pain. Ninety percent of acute back pain resolves itself in 6 weeks without any intervention. However, the remaining 10% become chronic, causing disability and a negative impact on the patient’s quality of life. Famous professor Gordon Waddell called back pain the twentieth century a “medical disaster”. Despite continuous research, we still don’t have a consensus on how to treat chronic pain.
Chronic neck and back pain is the most common cause of disability in the United States in persons younger than 45 years, and it is the third most common cause of disability in those older than 45. There are over 15 million office visits every year for mechanical neck and low back pain in the United States. Lack of physical activity, increased body weight, limited ambulation, trauma, accidents, and repetitive injuries to the spine all result in back pain. Ninety percent of acute back pain resolves itself in 6 weeks without any intervention. However, the remaining 10% become chronic, causing disability and a negative impact on the patient’s quality of life. Famous professor Gordon Waddell called back pain the twentieth century a “medical disaster”. Despite continuous research, we still don’t have a consensus on how to treat chronic pain.
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Our Center offers a new program for the treatment of chronic neck and back pain:
Detailed physical examination
We carefully analyze your past medical history, current symptoms, family history, and all medications you have been taking in the past, their effectiveness and side effects. X-ray and other imaging studies of your neck and low back spine are usually recommended for an accurate diagnosis and determination of the stage and extent of the pathological changes in your vertebral bodies, tendons, intervertebral disks and corresponding nerve roots.
Electrodiagnostic Study
A nerve conduction study (NCS) is a medical diagnostic test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body. Nerve conduction studies, along with electromyography, measure nerve and muscle function and may be needed when there is pain in the limbs, weakness from spinal nerve compression, or concern about some other neurologic injury or disorder.
Nerve conduction studies are used mainly for evaluation of paresthesias (numbness, tingling, burning) and/or weakness of the arms and legs. Some of the common disorders that can be diagnosed by nerve conduction studies are: Carpal Tunnel Syndrome, Cubital Tunnel Syndrome, Peripheral Neuropathy, Spinal Disc Herniation, and Ulnar Neuropathy. When done by an experienced physician or electro diagnostician, nerve conduction studies and electromyography are relatively quick (last for 45-60 minutes) and are well tolerated.
Medications
Anti-Inflammatory medications are an important part of the program.
These medications are necessary to control pain and inflammation in the major joints.
Even though these medications are unable to reverse arthritic changes in the cartilages, bony tissue, and surrounding soft tissue, scientific research demonstrates the great importance of non-steroid anti-inflammatory medications in pain and inflammation control. There are several pharmacological groups of medications that we recommend for osteoarthritic patients: Tylenol and Aspirin, non-steroid anti-inflammatory drugs (NSAIDs such as Ibuprofen, Motrin, Naproxen, Aleve), and others. These medications block special inflammatory enzymes called cyclooxygenase (COX-I). This is why they are called COX-I inhibitors. These medications can stop an inflammatory cascade and help with pain, edema, tenderness, and redness. They are effective and potent medications; however, they can upset your stomach causing abdominal pain and even bleeding.
Taking into consideration that our patients are suffering from multiple chronic disorders, we have decided to choose newer medications for our program that are known for high efficacy and have fewer side effects. We will be using COX-II inhibitors, which are similar anti-inflammatory medications with a favorable side effects profile: Celebrex and Mobic (Meloxicam). Recent clinical research studies have demonstrated that Meloxicam is highly effective in patients with different stages of osteo and rheumatoid arthritis.
Steroid medications
For more severe arthritic symptoms, we may prescribe steroidal anti-inflammatory medications, but those drugs should be taken for a short period of time because of their substantial side effects. We may use oral steroids (Medrol Pack) or inject steroid solutions directly into inflamed arthritic joints. Those medications are highly effective in fast control of acute inflammation, pain and edema. Major problems of steroid medications that they do nothing with natural restoration of arthritic joints, and their frequent use might actually destroy joints tissues and surrounding tendons. One old professor compared the use of steroids medications with switching off a fire alarm in a house that is on fire – no alarm, but the fire continues. In the joint– no pain, but the inflammation goes on.
Pain Medications
Opioids are very potent pain killers and they are also known as narcotic analgesics. Recent research and literature demonstrate opioids are helpful in chronic low back pain in arthritis patients. There are potential side effects with long-term opioid use, such as dependency and side effects. We usually choose longer acting opioid medications in combination with the short acting medications since they stay longer in your system and are more effective for chronic pain problems. Our program has very strict guidelines that require regular urine testing. We ask patients to sign an opioid agreement before we prescribe these medications.
Herbal and natural medications
Our patients often ask about natural alternatives to non-steroid and steroidal anti-inflammatory medications. There are a huge variety of natural alternatives and herbal dietary supplements on the market, but we include only safe and effective natural medications: Chondroitin, Glucosamine, MSM, Microlatin, so-called Joint Formula.
These natural medications are highly effective, provide good pain control and have favorable side effect profiles. We also recommend generalized conditioners like Gingko Biloba, Guarana, Saw Palmetto and other immune stimulators for joint health.
Topical medications and ointments
Part of the program includes topical ointments which are recommended for application on the skin of impaired joints. These transdermal formulas, called compounding medication, include special ointments prepared by the pharmacy according to a physician’s prescription. They usually contain a combination of non-steroidal anti-inflammatory medications, topical anesthetics, and muscle relaxants. Additionally, we use Capsaicin cream, made from red chili pepper, Lidoderm patches and other topical formulas.
Invasive procedures (injections)
Epidural Steroid Injections, also known as cortisone shots, are Steroid mixed with a local anesthetic (numbing medication) which is injected directly into the epidural space. The epidural space is the space in the spine between the spinal cord and the posterior bony part of the spine. By using this technique, physicians avoid the potential side effects of steroids when given orally, and increase the efficacy of the medication by delivering it to the exact place where the inflammation occurs. Epidural steroid injections are useful to control symptoms and facilitate recovery.
Botulinum Neurotoxins (BoNT) Injections (chemodenervation)
One of the newer treatments for muscular pain and spasms is BoNT intramuscular injections. BoNT are natural bioactive substances, a product of Clostridium botulinum microorganism. There are 2 types of neurotoxins, type A, Botox and Type B, Myobloc. In big doses BoNT might be poisonous, but in small doses prescribed by a physician BoNT is an excellent and safe tool to control muscle spasm and pain.
Recent research has proven that nerve inflammation or arthritic facet joints in the spine could cause pain, and local muscle spasm, cervical dystonia might be effectively treated with BoNT injections. The usual chemodenervation procedure takes 15-30 minutes, depending on the amount of painful muscles, followed by ice application for half an hour. The injections are not painful and are well tolerated. The effect of pain relief and muscle relaxation lasts for 2-3 months, with injections repeated as needed.
Prolotherapy
Prolotherapy is a rejuvenating injection therapy that helps to accelerate the collagen synthesis inside impaired ligaments and restores their tendon’s elasticity. The idea of this therapy is that an injection of a proliferant solution inside the impaired structures (in order to rejuvenate the ligamentous tissue), stimulates stem cells and naturally stabilizes the joint.
Prolotherapy is an ancient method that was actually proposed by Hippocrates and developed in this country by Dr. George Hackettt and Dr. Gustav Hemwel. Both physicians have actively been promoting prolotherapy for 60 years in their Chicago- based clinic.
This method might be used in patients with severe allergies and patients who don’t tolerate traditional medications well because of side effects or gastro-intestinal discomfort. Prolotherapy might be a good adjunctive therapy to intra-articular steroid shots, non-steroidal anti-inflammatory medications, and viscosupplementation.
Platelet Rich plasma, Stem Cell Therapy and blood injections
Platelet Rich Plasma, Stem Cell Therapy and whole blood injections are different types of so-called “regenerative therapy”. They use the body’s most basic “raw materials” (blood, blood fractions, and stem cells) to grow or regenerate new cells that the body needs. Stem cells are “undifferentiated” or “unspecialized” cells, meaning that they are “blanks” that can be developed into another type of cell that is required to repair or replace damaged tissue. In the musculoskeletal field, stem cell therapy can stimulate the formation of new bone, cartilage, tendon, ligaments, fat, and fibrous connective tissue and is an important part of our program. A lot of patients are reluctant to take chemically-based medications and favor homeopathic alternatives. Blood and blood fraction injections are very popular in Europe and have been used for ages there. Today those procedures are becoming increasingly popular in the USA.
Physical and occupational therapy, chiropractic manipulations, massage
Proper exercise performed on a daily basis is an essential part of arthritis management.
Exercise, done carefully and regularly, helps build and preserve muscle strength, keeps joints flexible, and protects them from further damage. Isometric exercises (non-movement exercises) can help strengthen muscles around joints and reduce wear and tear. Chiropractic doctors use gentle chiropractic manipulations in order to restore and maintain range of motion in major joints. We also recommend stretching programs that benefit muscles in order to maintain flexibility and range of motion. Massage improves the blood flow and decreases pain. Joints need to move to remain healthy and well lubricated.
Braces, canes and other assistive devices
In our clinic you can find a wide variety of braces, canes and other assistive devices that help with better pain control and provide mechanical support of the joints. Orthotics, braces and new propylene sleeves can help support joints and decrease wear on cartilage. Temporary use of crutches, canes, walkers, or a wheelchair may be helpful for some patients.
Acupuncture
Acupuncture is a useful part of the program. It helps to relieve pain, stress, stiffness and poor joint movement. Acupuncture helps to find right balance for each person, and our medical providers will be happy to assist you in establishing pain free health.
Physical modalities
Depending on your preference, heat or ice will be used for your arthritic pain.
Ice or heat is typically applied 3-4 times a day for 10-15 minutes. Heat may be applied in our clinic in many forms including warm packs, paraffin baths, electric TENS units, or ultrasound. Cold therapy will utilize ice packs, frozen bags of peas and corn or a wet towel that has been placed in a freezer. We are well equipped with different ultrasound devices, microwave machines, and diathermy. Also, ultrasound and phonophoresis with different medications might be used.
Weight management
It is very important to maintain a healthy weight while treating arthritic joints. Research all over the world has demonstrated that a reduction of weight can significantly decrease the impact on impaired joints. This is an important part of our program and includes a combination of a healthy diet, appetite suppressants, and aerobic exercises for weight reduction and maintenance. We may use special medications recommended by the FDA for weight control like Xenical and Meridia, or herbal formulas and Botox injections for cravings control. We offer fat melting injections and body wraps.
Orthopedic surgery
We do our best to help with joint pain and inflammation; however, unfortunately sometimes patients come to us with severely impaired and actually destroyed joints, and they are at the end stages of degenerative osteoarthritis. When conservative management fails, we may recommend a consultation with the best orthopedic surgeons in the area. And we are available for you for post-surgical rehabilitation.
Detailed physical examination
We carefully analyze your past medical history, current symptoms, family history, and all medications you have been taking in the past, their effectiveness and side effects. X-ray and other imaging studies of your neck and low back spine are usually recommended for an accurate diagnosis and determination of the stage and extent of the pathological changes in your vertebral bodies, tendons, intervertebral disks and corresponding nerve roots.
Electrodiagnostic Study
A nerve conduction study (NCS) is a medical diagnostic test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body. Nerve conduction studies, along with electromyography, measure nerve and muscle function and may be needed when there is pain in the limbs, weakness from spinal nerve compression, or concern about some other neurologic injury or disorder.
Nerve conduction studies are used mainly for evaluation of paresthesias (numbness, tingling, burning) and/or weakness of the arms and legs. Some of the common disorders that can be diagnosed by nerve conduction studies are: Carpal Tunnel Syndrome, Cubital Tunnel Syndrome, Peripheral Neuropathy, Spinal Disc Herniation, and Ulnar Neuropathy. When done by an experienced physician or electro diagnostician, nerve conduction studies and electromyography are relatively quick (last for 45-60 minutes) and are well tolerated.
Medications
Anti-Inflammatory medications are an important part of the program.
These medications are necessary to control pain and inflammation in the major joints.
Even though these medications are unable to reverse arthritic changes in the cartilages, bony tissue, and surrounding soft tissue, scientific research demonstrates the great importance of non-steroid anti-inflammatory medications in pain and inflammation control. There are several pharmacological groups of medications that we recommend for osteoarthritic patients: Tylenol and Aspirin, non-steroid anti-inflammatory drugs (NSAIDs such as Ibuprofen, Motrin, Naproxen, Aleve), and others. These medications block special inflammatory enzymes called cyclooxygenase (COX-I). This is why they are called COX-I inhibitors. These medications can stop an inflammatory cascade and help with pain, edema, tenderness, and redness. They are effective and potent medications; however, they can upset your stomach causing abdominal pain and even bleeding.
Taking into consideration that our patients are suffering from multiple chronic disorders, we have decided to choose newer medications for our program that are known for high efficacy and have fewer side effects. We will be using COX-II inhibitors, which are similar anti-inflammatory medications with a favorable side effects profile: Celebrex and Mobic (Meloxicam). Recent clinical research studies have demonstrated that Meloxicam is highly effective in patients with different stages of osteo and rheumatoid arthritis.
Steroid medications
For more severe arthritic symptoms, we may prescribe steroidal anti-inflammatory medications, but those drugs should be taken for a short period of time because of their substantial side effects. We may use oral steroids (Medrol Pack) or inject steroid solutions directly into inflamed arthritic joints. Those medications are highly effective in fast control of acute inflammation, pain and edema. Major problems of steroid medications that they do nothing with natural restoration of arthritic joints, and their frequent use might actually destroy joints tissues and surrounding tendons. One old professor compared the use of steroids medications with switching off a fire alarm in a house that is on fire – no alarm, but the fire continues. In the joint– no pain, but the inflammation goes on.
Pain Medications
Opioids are very potent pain killers and they are also known as narcotic analgesics. Recent research and literature demonstrate opioids are helpful in chronic low back pain in arthritis patients. There are potential side effects with long-term opioid use, such as dependency and side effects. We usually choose longer acting opioid medications in combination with the short acting medications since they stay longer in your system and are more effective for chronic pain problems. Our program has very strict guidelines that require regular urine testing. We ask patients to sign an opioid agreement before we prescribe these medications.
Herbal and natural medications
Our patients often ask about natural alternatives to non-steroid and steroidal anti-inflammatory medications. There are a huge variety of natural alternatives and herbal dietary supplements on the market, but we include only safe and effective natural medications: Chondroitin, Glucosamine, MSM, Microlatin, so-called Joint Formula.
These natural medications are highly effective, provide good pain control and have favorable side effect profiles. We also recommend generalized conditioners like Gingko Biloba, Guarana, Saw Palmetto and other immune stimulators for joint health.
Topical medications and ointments
Part of the program includes topical ointments which are recommended for application on the skin of impaired joints. These transdermal formulas, called compounding medication, include special ointments prepared by the pharmacy according to a physician’s prescription. They usually contain a combination of non-steroidal anti-inflammatory medications, topical anesthetics, and muscle relaxants. Additionally, we use Capsaicin cream, made from red chili pepper, Lidoderm patches and other topical formulas.
Invasive procedures (injections)
Epidural Steroid Injections, also known as cortisone shots, are Steroid mixed with a local anesthetic (numbing medication) which is injected directly into the epidural space. The epidural space is the space in the spine between the spinal cord and the posterior bony part of the spine. By using this technique, physicians avoid the potential side effects of steroids when given orally, and increase the efficacy of the medication by delivering it to the exact place where the inflammation occurs. Epidural steroid injections are useful to control symptoms and facilitate recovery.
Botulinum Neurotoxins (BoNT) Injections (chemodenervation)
One of the newer treatments for muscular pain and spasms is BoNT intramuscular injections. BoNT are natural bioactive substances, a product of Clostridium botulinum microorganism. There are 2 types of neurotoxins, type A, Botox and Type B, Myobloc. In big doses BoNT might be poisonous, but in small doses prescribed by a physician BoNT is an excellent and safe tool to control muscle spasm and pain.
Recent research has proven that nerve inflammation or arthritic facet joints in the spine could cause pain, and local muscle spasm, cervical dystonia might be effectively treated with BoNT injections. The usual chemodenervation procedure takes 15-30 minutes, depending on the amount of painful muscles, followed by ice application for half an hour. The injections are not painful and are well tolerated. The effect of pain relief and muscle relaxation lasts for 2-3 months, with injections repeated as needed.
Prolotherapy
Prolotherapy is a rejuvenating injection therapy that helps to accelerate the collagen synthesis inside impaired ligaments and restores their tendon’s elasticity. The idea of this therapy is that an injection of a proliferant solution inside the impaired structures (in order to rejuvenate the ligamentous tissue), stimulates stem cells and naturally stabilizes the joint.
Prolotherapy is an ancient method that was actually proposed by Hippocrates and developed in this country by Dr. George Hackettt and Dr. Gustav Hemwel. Both physicians have actively been promoting prolotherapy for 60 years in their Chicago- based clinic.
This method might be used in patients with severe allergies and patients who don’t tolerate traditional medications well because of side effects or gastro-intestinal discomfort. Prolotherapy might be a good adjunctive therapy to intra-articular steroid shots, non-steroidal anti-inflammatory medications, and viscosupplementation.
Platelet Rich plasma, Stem Cell Therapy and blood injections
Platelet Rich Plasma, Stem Cell Therapy and whole blood injections are different types of so-called “regenerative therapy”. They use the body’s most basic “raw materials” (blood, blood fractions, and stem cells) to grow or regenerate new cells that the body needs. Stem cells are “undifferentiated” or “unspecialized” cells, meaning that they are “blanks” that can be developed into another type of cell that is required to repair or replace damaged tissue. In the musculoskeletal field, stem cell therapy can stimulate the formation of new bone, cartilage, tendon, ligaments, fat, and fibrous connective tissue and is an important part of our program. A lot of patients are reluctant to take chemically-based medications and favor homeopathic alternatives. Blood and blood fraction injections are very popular in Europe and have been used for ages there. Today those procedures are becoming increasingly popular in the USA.
Physical and occupational therapy, chiropractic manipulations, massage
Proper exercise performed on a daily basis is an essential part of arthritis management.
Exercise, done carefully and regularly, helps build and preserve muscle strength, keeps joints flexible, and protects them from further damage. Isometric exercises (non-movement exercises) can help strengthen muscles around joints and reduce wear and tear. Chiropractic doctors use gentle chiropractic manipulations in order to restore and maintain range of motion in major joints. We also recommend stretching programs that benefit muscles in order to maintain flexibility and range of motion. Massage improves the blood flow and decreases pain. Joints need to move to remain healthy and well lubricated.
Braces, canes and other assistive devices
In our clinic you can find a wide variety of braces, canes and other assistive devices that help with better pain control and provide mechanical support of the joints. Orthotics, braces and new propylene sleeves can help support joints and decrease wear on cartilage. Temporary use of crutches, canes, walkers, or a wheelchair may be helpful for some patients.
Acupuncture
Acupuncture is a useful part of the program. It helps to relieve pain, stress, stiffness and poor joint movement. Acupuncture helps to find right balance for each person, and our medical providers will be happy to assist you in establishing pain free health.
Physical modalities
Depending on your preference, heat or ice will be used for your arthritic pain.
Ice or heat is typically applied 3-4 times a day for 10-15 minutes. Heat may be applied in our clinic in many forms including warm packs, paraffin baths, electric TENS units, or ultrasound. Cold therapy will utilize ice packs, frozen bags of peas and corn or a wet towel that has been placed in a freezer. We are well equipped with different ultrasound devices, microwave machines, and diathermy. Also, ultrasound and phonophoresis with different medications might be used.
Weight management
It is very important to maintain a healthy weight while treating arthritic joints. Research all over the world has demonstrated that a reduction of weight can significantly decrease the impact on impaired joints. This is an important part of our program and includes a combination of a healthy diet, appetite suppressants, and aerobic exercises for weight reduction and maintenance. We may use special medications recommended by the FDA for weight control like Xenical and Meridia, or herbal formulas and Botox injections for cravings control. We offer fat melting injections and body wraps.
Orthopedic surgery
We do our best to help with joint pain and inflammation; however, unfortunately sometimes patients come to us with severely impaired and actually destroyed joints, and they are at the end stages of degenerative osteoarthritis. When conservative management fails, we may recommend a consultation with the best orthopedic surgeons in the area. And we are available for you for post-surgical rehabilitation.
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