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WHAT
IS INTEGRATIVE TREATMENT OF
DEGENERATIVE DISEASE?
Why do traditional approaches to pain treatment
fail?
To
understand why integrative pain medicine succeeds when physical
exercises, surgery and pain medications often fail, consider these
concepts:
I.
Abandon linear thinking in which it is presumed that pain and
inflammation are coming from a specific and identifiable source.
Consider instead that pain may originate within a dysfunctional
central nervous system.
2.
Realize that the central nervous system may create or maintain
peripheral inflammation. This process can be triggered by injury
and inflammation in a site that is remote from where the patient
perceives the pain. This is why local treatment may be useless
for chronic pain.
Clinicians
in our networks are trained in manual medicine, prolotherapy,
nerve blockade, physical therapy and acupuncture, which they integrate
with neurology, orthopedic and sports medicine. This enables them
to understand and treat the complex mechanisms involved in chronic
pain.
Chronic
pain is often the result of injury or deterioration of the body's
connective tissue, coupled with an inappropriate response to painful
stimuli by the body's own nervous system. Thus, a muscle strain,
joint sprain or bone bruise might provoke abnormal discharges
in peripheral nerves, or in central nervous pathways, that perpetuate
or even augment the pain. Our treatment program alleviates chronic
pain by addressing these critical components of the pain control
system.
The
following information is provided to aid your understanding of
our treatment program.
THE
NATURE OF NEURO-ORTHOPEDIC PAIN
Degeneration
(weakness) of the spine and extremities results from normal wear
and tear on bones, joints and their supporting structures. Overuse
and injury cause additional deterioration, and in some persons,
there is a genetic predisposition to premature degeneration of
connective tissue. DIAGRAM #1
Ageing,
repeated micro and macro injuries lead to degeneration of the
connective tissue and result in pain and inflammation. For example,
in degenerative disease of the spine, it has been shown that pain
is generated by nerve receptors within degenerated discs, facet
joints, ligaments, compressed nerves, and other local tissues
that are affected by degeneration. Degeneration also changes bone
structure, disrupt blood circulation inside the bone, and leads
to increase of intrabone pressure. It has been shown that increase
of intrabone pressure can augment the pain perception and increase
the pain. The spinal cord carries these painful stimuli to the
brain which should, but doesn't always, respond by appropriate
release of inhibitory substances to decrease the pain. The interconnections
between the pain from damaged connective tissue and its mediation
through the peripheral and central nervous system, give the pain
specialist various levels at which the pain cycle can be interrupted.
DIAGNOSIS
AND MANAGEMENT OF NEURO-ORTHOPEDIC PAIN
Our
treatment of the patient with chronic pain addresses spasmed muscles,
weakened ligaments and joint capsules, increased intrabone pressure,
radiculopathy (nerve pinched or inflamed nerves), and central
nervous system processes that perpetuate and/or augment pain (DIAGRAM
2).
TISSUE
INFILTRATION
If
painful impulses are thought to arise from a particular site,
then an injection of local anesthetic into that site should be
of help in establishing the diagnosis. Injection of a small amount
of local anesthetic into the affected muscle, joint, tendon sheath,
scar, bursa, etc. helps to determine whether local anesthetic
injection relieves the pain at rest as well as the pain produced
by maneuvers that usually aggravate the pain.
MUSCLE
SHORTENING
Muscle
shortening usually felt by physician as a taut muscle band and
treated by needling and infiltration (N&I) with local anesthetic.
The anesthetic is injected into trigger points and attachments
to bone. N&I breaks up pockets of fibrous tissue where nerve endings
are entrapped with inflammatory, irritative substances. In addition
local anesthetics have potent and long-lasting anti-inflammatory
properties. N&I is preceeded by a nerve blockade, to decrease
the pain of needling. N&I is often followed by electrical stimulation
and ultrasound to improve blood circulation and stimulate tissue
regeneration.
PROLOTHERAPY
Prolotherapy
is an injection treatment designed to stimulate healing of chronic
ligament and tendon weakness. The painful weakened areas are injected
with a proliferant (Dextrose, or Sugar, with Lidocaine), which
is a solution that directly stimulates the growth of healthy,
strong tissues. The healing process can be expected to take about
four to six weeks after the initial treatment. As the tendons
and ligaments grow stronger and more capable of doing their tasks,
the pain is alleviated. Two double blind studies confirm beneficial
effects of prolotherapy.
RESTRICTED
RANGE OF JOINT MOTION
The
range of motion of the intervertebral joints can be diagnosed
by manual examination. This technique of diagnosing joint dysfunction
was determined to be as accurate as radiologically controlled
diagnostic nerve blocks in a double blinded study. The restriction
of the intervertebral joints may be a result of spasm or shortening
of local muscles or shrinking of the joint capsule. It is critical
to realize that the restriction of spinal joints in a particular
area of the spine may be the result of injury or dysfunction in
a remote part of the spine. It is therefore imperative that the
clinician evaluates the entire spine with particular attention
paid to the most susceptible to injury transitional zones, where
the spine curvature changes.
Treatment
of restricted movement of the spinal motion segments involves
manual manipulation/mobilization techniques. The therapist mobilizes
a joint by passively moving it through its physiologic range.
Smooth, repetitive passive joint oscillations at the limit of
the joint's available range of motion can mechanically enhance
the joint's mobility . The patient is also taught self-mobilization
and postisometric relaxation techniques that help maintain the
effect of mobilization techniques performed in the office. Our
Physical Therapist is trained in Manual Medicine and provides
one-on-one, personal care.
INCREASED INTRABONE PRESSURE
Bone
is a very dynamic body structure with a rich blood supply. Bone
pain can be caused by increased intrabone pressure secondary to
a variety of injuries and degenerative processes. At sites of
muscle attachments the bone is extremely tenuous, so that the
intramuscular and bone circulations are continuous (Fig. 1).
It
has also been shown that overstimulation of intrabone nerve receptors
enhanced pain perception and increased pain. Bone pain can be
effectively treated by several modalities: injection with 1% procaine
at the site of muscle attachments improves bone blood supply.
This procedure is followed by electrical stimulation of the muscles
whose contractions act as a pump to further increase blood circulation.
RADICULOPATHY
Radicular
pain ("pinched nerve") is usually the result of nerve compression
due to disc herniation, paraspinal muscle spasm, or both. The
presence and degree of sensory nerve compression and degeneration
can be diagnosed by "quantitative sensory testing," an office
procedure whereby the patient's responses to calibrated heat and
cold are measured. (Different pain nerve fibers respond to different
temperature). Treatment for radicular pain includes epidural injections
and/or nerve blockades. Studies show that if treated early, pain
from a nerve root injury caused by an extruding nucleus propulsus
or herniating disc, can be reduced by injection of lidocaine.
Nerve root compression can also be reduced by treating the spasm
of paraspinal muscles by the needling and infiltration and physical
therapy methods already mentioned.
CENTRAL
NERVOUS SYSTEM
Central
nervous system pain control mechanisms can also be impacted by
treatment of peripheral nerve pathways. Methods of treatment include
appropriate use of antidepressant pharmaceutical agents and acupuncture.
Expected Results of Treatment Although there are many variables
that will influence treatment outcome, including duration and
degree of pathology, the typical patient can expect four to six
treatment sessions to reduce pain approximately fifty percent
and to increase physical activity about thirty percent.
Summary
of Neuro-Orthopedic Pain Management
Each stage of development of the degenerative desease of spine and
joints has appropriate treatment
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