What is Pain?

Pain is an evolutionary trait helping us protect damaged tissue by warning us with a feeling of distress, suffering, or agony. Pain induces the sufferer to remove or withdraw from the source of pain. The body recognizes tissue damage through chemical substances released by damaged tissues. These substances stimulate pain receptors and/or cause damage to the nerve endings. Nerves send signals to the brain for interpretation and subsequent action. Perception of pain is complex and individualized, and can be influenced by a variety of external and internal influences. In addition to neural signals and sensory input modulation, pain perception can be influenced by psychological and cultural responses to pain stimuli. There are theories related to physiologic control of pain. Pain impulses are mediated by internal systems such as neural pathway gates, the opioid system with endogenous analgesics enkephalins and endorphins, and the stimulation of large sensory fibers extending from the tactile receptors in the skin thus suppressing the transmission of pain signals from thinner nerve fibers. This last internal system eludes that nerve pathways to the brain can accommodate only one type of signal at a time, thus superficial tactile sensation trumps pain sensation. Endorphins and the inhibition of pain transmission by tactile signals has provided a reasonable scientific explanation for the success of relaxation, massage, application of liniments, and acupuncture in the control of pain and discomfort. Pain is generally a subjective phenomenon. The person reporting personal discomfort or pain is the most reliable source of information about its location, quality, intensity, onset, precipitating or aggravating factors, and measures that bring relief.

Objective signs of pain can assist in verification of a patients subjective reports of pain:
  • Physiologic signs of mild to moderate superficial pain are responses of the sympathetic nervous system, also know as Fight or Flight. These objectively measurable signs include changes in respiratory patterns, pallor, sweating, increased heart rate, increase blood pressure, dilated pupils, and muscle tension.
  • Physiologic signs of severe deep pain are responses from the parasympathetic nervous system. These objectively measurable signs include decreased blood pressure, decreased heart rate, pallor, nausea and/or vomiting, weakness, and syncope.

Psychosocial aspects include our personal tolerance and reactions to pain. Due to a varietal plethora of psychologic and cultural influences, psychosocial aspects of pain tend to be much more complex and less identifiable than physiologic responses, thus harder to modify. One’s degree of attention to and distraction from painful stimuli can also affect one’s perception of the intensity of pain.

Types of Pain

Acute Pain:Pain that is caused by traumatic injury, surgical procedures, or medical disorders; clinical symptoms include increased heart rate, blood pressure, and respiratory rate, shallow respiration, agitation or restlessness, facial grimaces, or splinting.

Chronic Pain: Pain that is persistent, lasting more than six months; clinical symptoms may be the same as for acute pain, or there may be no symptoms evident.

Bearing-Down Pain: Pain accompanying uterine contractions during the second stage of labor.

Cancer Pain: One of the three categories of pain established by the International Association for the Study of Pain, denoting pain associated with malignancies and perceived by the individual patient; there are various scales ranking it from 0 to 10 according to level of severity.

Pain Disorder: A somatoform disorder characterized by a chief complaint of severe chronic pain that causes substantial distress or impairment in functioning; the pain is neither feigned nor intentionally produced, and psychological factors appear to play a major role in its onset, severity, exacerbation, or maintenance. The pain is related to psychological conflicts and is made worse by environmental stress; it enables the patient to avoid an unpleasant activity or to obtain support and sympathy. Patients may visit many health care providers searching for relief and may consume excessive amounts of analgesics without any effect. They are difficult to treat because they strongly resist the idea that their symptoms have a psychological origin.

False Pains: Ineffective pains during pregnancy that resemble labor pains, not accompanied by cervical dilatation; braxton-hicks contractions. Also called false labor.

Growing Pains: Any of various types of recurrent limb pains resembling those of rheumatoid conditions, seen in early youth and formerly thought to be caused by the growing process.

Hunger Pain: Pain sensed within the GI tract and perceived as a need for food

Intermenstrual Pain: Pain accompanying ovulation, usually occurring 10 days after termination of menses.

Labor Pain: The rhythmic pains of increasing severity and frequency due to contraction of the uterus at childbirth.

Lancinating Pain sharp darting pain.

Phantom Pain: Pain felt in an absent or amputated limb or organ.

Psychogenic Pain: Symptoms of physical pain having a psychological origin.

Referred Pain: Pain felt in an area where it is not caused. Referred pain typically originates in a visceral organs and is felt on the skin or in another area deep inside the body. It’s hypothesized that referred pain occurs because pain signals from the viscera travel along the same neural pathways used by pain signals from the skin. The person perceives the pain but interprets it as having originated in the skin rather than in a deep-seated visceral organ.

Rest Pain: A continuous unrelenting pain due to ischemia of the lower leg, beginning with or being aggravated by elevation and being relieved by sitting with legs in a dependent position or by standing.

Root Pain: Pain caused by disease of the sensory nerve roots and occurring in the cutaneous areas supplied by the affected roots

How We Treat Pain

PROLOTHERAPY

Definition

Prolotherapy is the treatment of connective-tissue damage through the use of injections. The injections instigate delivery of collagen and growth factors to the damaged tissue thus stabilizing the joint and decreasing pain. The term prolotherapy is derived from the word prolo, short for proliferation, as the therapy is intended to proliferate tissue growth in the damaged area.

Origins

The idea behind this therapy dates back more than 2000 years to Hippocrates, who used it to treat soldiers with injured shoulders. Instead of injections Hippocrates used a hot poker, which he speared into the shoulder joint, causing inflammation and stimulating the body to repair itself. Prolotherapy was derived from a treatment developed by H.I. Biegeleisen called sclerotherapy, used to treat varicose veins. In the 1950s, George Hackett, often called a pioneer of prolotherapy, was experimenting with and touting the benefits of the procedure.

Benefits

Prolotherapy has been used to treat chronic neck and back pain, joint pain from arthritis, headaches,fibromyalgia, sports injuries, carpal tunnel syndrome, and partially torn tendons, ligaments, and cartilage. It’s a low cost, effective, non-surgical outpatient procedure, saving patients from undergoing anesthesia and surgery followed by a long recovery period. Patients can walk out of the office and go straight back to work.

Description

In prolotherapy, a doctor injects a mix of concentrated dextrose and lidocaine into the damaged ligament or tendon at the point where it attaches to the bone. The injection produces an inflammation, which increases blood flow, swelling, and pain. The body then launches a course of healing and stabilization known as the fibrosis of repair. The inflammation mimic’s an injury, the body responds by sending in cells called macrophages that ingest and destroy damged tissue, they clean up the area. The body then sends in fibroblasts, which are cells that help build fibrous tissue. The fibroblasts excrete collagen, a protein that makes the ligaments denser and stronger. The stronger ligaments provide more support for the joints, often alleviating the pain. The same process happens when we cut ourselves, notice a scar is tighter and less sensitive than the surrounding tissue. The length of treatment sessions varies and depends on the area being treated. For example, treatment of an injured elbow involves injections only in one site, whereas treatment of larger areas, like the neck and back, involves more injections. Treating an elbow may take only a few injections, whereas the back may involve up to 50 injections for one treatment. The treatment generally involves several sessions, usually three to six, occasionally more, Treatment sessions are separated by three to 6 week intervals depending on patient healing time and budget, both of which can vary from patient to patient. Another solution used in prolotherapy is Platelet Rich Plasma/PRP. Blood is drawn from the patient and centrifuged to derive a platelet concentrate that is then injected into the damaged area. This platelet concentrate is basically what we are trying to proliferate with standard dextrose prolotherapy. Both solution accomplish the same goal, PRP just does it quicker. The entire procedure is done in office and take around 90 minutes.

Preparations

Analgesics and sedatives may be given before treatment to reduce discomfort. Many patients, however, forgo sedation because they cannot drive home afterward. Many doctors use topical freeze sprays, ice packs, oranaesthetic cream to reduce skin sensation. It is recommended that patients drink plenty of water in the 24 hours before the procedure because it helps with cell hydration.

Precautions

As with all procedures, there are risks. Patients are asked to sign a consent and waiver. Since the treatment involves inserting a needle into the body, there is a chance of puncture to arteries, nerves, or even lung tissue, depending on the area to be treated. Although extremely rare, some patients may have allergic reactions to the substance injected.

Side Effects

The most common side effects include pain during the injections and soreness/stiffness afterward. Patients are reminded not to take any anti-inflammatory drugs, such as ibuprofen or aspirin, because these will impede the healing process prolotherapy aims to set in place.

Platelet Rich Plasma

Definition

Platelet rich plasma (PRP) is a volume of autogenous (meaning your own) plasma that has a platelet concentrate above the body’s normal level. Normal platelet concentrates in a person’s blood tend to be in the range of 150,000 and 350,000. Scientific proof has unequivocally demonstrated drastically improved bone and soft tissue healing using platelet rich plasma injection therapy with concentrations of 1,000,000.

The clinical applications of platelet-rich plasma are many and varied. It is used in denistry, orthopaedics and other areas.

Advantages of Platelet Rich Plasma

  • It’s safe. PRP is a by-product of our patient’s own blood; hence, disease transmission is not an issue.
  • It’s convenient. Platelet rich plasma is processed under strict sterile conditions.
  • It allows for faster healing. The super saturation of the wound with PRP produces an increase of tissue synthesis and thus faster tissue regeneration.
  • It’s cost effective. Platelet rich plasma harvesting is carried out with only a small amount of blood in the doctor’s office. The patient does not incur the expense of the harvesting procedure in the hospital or at the blood bank.

Trigger Point Injection

What is a Trigger Point?

Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. Acute Trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. Patients may have regional, persistent pain resulting in a decreased range of motion in the affected muscles. These include muscles used to maintain body posture, such as those in the neck, shoulders, and pelvic girdle.

How do I know if I have a Trigger Point?

Trigger points may manifest as tension headache, tinnitus, temporomandibular joint pain, decreased range of motion in the legs, low back pain, and pain referring into the shoulder, arm or hand. Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain toward a zone of reference and a local twitch response. Trigger point injection has been shown to be one of the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms. (Am Fam Physician 2002;65:653-60. Copyright 2002 American Academy of Family Physicians.)

What is used in a Trigger Point Injection?

The severity, duration, and location of the Trigger Point dictates the solution used. We use a customized solution of vitamins, minerals, anesthetics to include lidocaine, procaine or marcaine, and even NSAID’s.

How many treatments will I need?  

It depends on the condition. The most common ailment treated with Trigger Point Injections is Thoracic Outlet Syndrome (TOS). TOS is pain, numbness and/or tingling referring into the shoulder, arm and even the hand secondary to Trigger Points within the major upper thoracic and lower cervical muscle bellies. Tension headaches are often secondary to this condition. Successful treatment indicates 2-4 sessions, once weekly.

Will the Trigger Points come back?

Over time, if the situation that caused the Trigger Points is not identified and corrected, the pain will return, typically within 3-12 months. To help avoid this, Dr. Mcneil prescribes deep tissue massage, physical therapy and lifestyle modification.

Acupuncture

What is Acupuncture?

Acupuncture is a method in which very fine needles are used to stimulate the body’s natural healing. After careful assessment the acupuncturist can identify energy patterns that are disrupted and insert needles into specific anatomically defined locations to help restore the energy patterns to their optimal state. As such, the acupuncturist is using needles to assist the body’s own self healing response. Some conditions may call for additional electrical stimulation to enhance the effects of the needles. They may also use heat therapy by burning a specially processed herb next to the needle.

What does Acupuncture Treat?

Acupuncture has been used as an effective medical modality for over 2000 years. It has been recognized by the World Health Organization to treat over 300 conditions. In the US, people commonly seek treatment for the following conditions:

  • Digestive disorders: gastritis, colitis and hyperacidity, spastic colon, constipation, diarrhea, nausea, weight loss.
  • Respiratory disorders: allergies, asthma, sinusitis, sore throat, chest infections, colds & flu.
  • Neurological and muscular disorders: migraines, neck pain & tension, bursitis, low back pain, sciatica, osteoarthritis, acute trauma.
  • Urinary, menstrual, and reproductive problems: infertility, pre-menstrual syndrome, prostate, problems.
  • Emotional disorders: insomnia, addictions, stress, detox for chemical dependencies, PTSD.

What can I expect during my Acupuncture session?

Your treatment begins with an extensive conversation about your medical history, current health and lifestyle. Many first-time patients are amazed at how comfortable they feel during an acupuncture treatment. When the needle accesses the flow of Qi, a slight tingling, a heaviness, or a tugging sensation may be felt. Acupuncture needles have been scientifically proven to release endorphins giving patients a pleasant experience.

Course of Treatment

Initial treatments take approximately 2 hours in which a full history and overview of patient health is assessed. Follow-up appointments generally last between 45 minutes to 1 hour.  Patients need to eat at least 20 to 30 minutes prior to their treatment.  The length of the course of treatment depends upon several factors such as age, severity of condition and length of disease. Everyone reacts differently to acupuncture and will respond at different rates. Typically, acute cases resolve more rapidly than chronic cases which may take of course of approximately ten acupuncture treatments. Many people continue to use acupuncture to maintain good health by keeping the body’s immunity strong and emotions balanced.