7901 SW 34th Ave

Amarillo, TX 79121

Victor M. Taylor, MD, DABA

Board Certfied Pain Management

Ph: 806-352-7431

Fax: 806-352-2374

Physical Rehabilitation in Chronic Pain | Opioids and Chronic Pain | Approach to Treatment

Pain Management

 

Problems Treated:

 

Chronic and Acute pain need to be addressed in a multi-model approach.  Normally pain quickly subsides as tissue heals from injury.  When pain persist and becomes more chronic (lasting 3 months or longer) there is rarely a single approach that will be affective.  Using medications combined with appropriate physical therapy and exercise along with highly targeted interventional approaches can lead to great improvement for the majority of people.

 

Back Pain

 

Low back pain is a very common problem in the United States and is a leading cause of doctor visits.  Most Americans will deal with back pain at least once in their lifetimes.  Often physical therapy, NSAIDs and chiropractic treatment are effective.  However when these approaches fail or pain is too severe to tolerate an active approach we can get more aggressive and get back on the path to a healthy and functional life.  Treatment in cases of unremitting  back pain may include fluoroscopically guided epidural steroid injections (link here) combined with formal PT or home care.  When back pain is chronic adding specific medications to help reduce hyperactivity of the nervous system can be helpful.  Once the pain is better controlled  continuing with core strengthening and traction or inversion therapy can help prevent a return of the pain.  Protecting the back and using new approaches to daily activities is important to maintaining progress.

 

If epidural steroids fail a test of the small joints in the back can lead to a different approach.  Medial branch ablation or rhizotomy(link here) can block the pain signals from the joints and can provide relief so that home care and rehab is possible.  Even in people who cannot engage in spinal rehab, medial branch rhizotomy can provide relief lasting months or a year of more and can be repeated as needed.

 

Other approaches to treating back pain include trigger point injections (link here),  ligament injections (link here) and even experimental approaches such as pulsed RF or a disk or PRP injection into a disk.

 

When a person has had previous back surgery and in some other scenarios a Racz procedure also known as a lysis of adhesions may be effective is all other approaches have failed.

 

Back and Leg Pain (Sciatica)

 

Sciatica or pain down the leg is usually caused by irritation of the nerve roots rather than compression of the sciatic nerve itself.  The irritation may be due to a bulging disk or inflammation or adhesions within the epidural space.  A combined approach using x-ray guided transforaminal injections (link here) with a relatively high volume will be effective for the majority of people.  Combining the procedures with specific neural flossing exercises and certain medications along with other rehab often leads to long term improvement.

 

A less common cause of sciatic pain is entrapment of the sciatic nerve by the piriformis muscle in the buttocks area.  In cases where physical therapy or chiropractic treatment have not been able to treat this condition and injection of local anesthetic and sometimes steroid into the muscle, a piriformis injection (link here) can be very effective.  In cases where the injections work but do not last Botox injection can lead to longer term relief.

 

Lumbar Radiculitis- See back and leg pain (Sciatica)

Radiculitis- see back and leg pain/sciatica

leg pain- see back and leg pain/sciatica

Sciatica – see back and leg pain/sciatica

 

Neck Pain

 

Neck pain like back pain is a very common problem in the United States.  Often physical therapy, NSAIDs and chiropractic treatment are effective.  However when these approaches fail or pain is too severe to tolerate an active approach we can get more aggressive and get back on the path to a healthy and functional life.  Treatment in cases of unremitting  neck pain may include fluoroscopically guided epidural steroid injections (link here) combined with formal PT or home care.  When neck pain is chronic adding specific medications to help reduce hyperactivity of the nervous system can be helpful.  Once the pain is better controlled  continuing with stretches of the upper back, chest and neck can help reduce muscular strain on the neck. Strengthening and traction or inversion therapy can help prevent a return of the pain.  Protecting the neck by avoiding prolonged stressful postures and making sure the neck is well supported in sleep can help. Using new approaches to daily activities is important to maintaining progress.

 

If epidural steroids fail a test of the small joints in the back can lead to a different approach.  Medial branch ablation or rhizotomy(link here) can block the pain signals from the joints and can provide relief so that home care and rehab is possible.  Even in people who cannot engage in spinal rehab, medial branch rhizotomy can provide relief lasting months or a year of more and can be repeated as needed.

 

Other approaches to treating neck pain include trigger point injections (link here),  ligament injections (link here) and even experimental approaches such as pulsed RF or a disk or PRP injection into a disk. (link).

 

When a person has had previous neck surgery and in some other scenarios a Racz procedure also known as a lysis of adhesions may be effective is all other approaches have failed.

 

 

Neck and Arm Pain

 

Neck pain with pain radiating down the arm is usually caused by irritation of the nerve roots due to a bulging disk or inflammation or adhesions within the epidural space.  A combined approach using x-ray guided epidural injections (link here) with a relatively high volume will be effective for the majority of people.  Combining the procedures with specific neural flossing exercises and certain medications along with other rehab often leads to long term improvement.

 

Other causes of neck and arm pain include entrapment of the nerves by the scalene muscles or referred symptoms due to muscle issues such as trigger points in the upper back or even shoulder problems In cases where physical therapy or chiropractic treatment have not been able to treat this condition and injection of local anesthetic and sometimes steroid into the muscle using ultrasound guidance, called trigger point injections (link here) can be very effective.  In cases where the injections work but do not last Botox injection can lead to longer term relief.

 

Cervical radiculitis- See Neck and Arm Pain

Arm Pain- see neck and arm pain

 

Hip Pain

 

Pain in the hip joint is usually do to inflammation within the joint or arthritis and degeneration of the joint.  Pain around the joint may be due to bursitis or muscle or tendon inflammation.  Often what is called hip pain is actually due to nerve irritation in the lower back.  Physical examination and diagnostic imaging can help determine the source of the pain.

 

Injecting a steroid and local anesthetic directly into the joint using x-ray guidance can lead to significant relief of pain lasting months at a time.  These injections can be repeated from time to time as long as they give good relief.

 

If the pain is due to bursitis (inflammation of a bursa) again x-ray guided injection of the inflamed bursa can lead to resolution of symptoms.

 

If the hip pain is located more in the back part of the hip or gluteal region/buttocks, the cause is usually nerve irritation in the lower back- see back and leg pain above.

 

Knee Pain

 

Knee pain like hip pain is usually associated with inflammation or degeneration of the joint or inflammation of the bursae and tendons around the joint.   Injection of local anesthetic and steroid into the joint or other inflamed structures can give significant relief.

 

Even if the joint has been replaced injection of the inflamed bursa can be helpful.

 

When PT, injections and even surgery fail to relieve pain a pulsed radiofrequency procedure of the nerves that serve the joint may work- this is an experimental approach but has had success in many patients.

 

Shoulder Pain

 

The should is a complex joint and pain can be due to inflammation and deterioration of the joint itself, the joint between the collar bone and shoulder blade (clavicle and scapula called the acromio-clavicular joint), the sub-acromial bursae or trigger points in the muscles that support and move the shoulder.  Pain in the shoulder may also come from irritation of the nerves in the neck.

 

As with other joints a well-placed injection of local anesthetic and steroid using x-ray guidance can give relief of shoulder pain.  If the pain is due more to muscle issues such as trigger points then ultrasound is used to guide the injection.  As with all therapeutic injections precise placement using imaging for guidance is the key to a good result.

 

Muscle Pain/Trigger Points

 

Persistent localized muscle pain can be due to trigger points. Trigger points can cause symptoms that refer to other areas and may even cause symptoms that mimic sciatica or radiculitis down an arm.  This is a common problem associated with calf pain or pain in the forearm and elbow.

 

Trigger points are areas of severe spasm of just a few muscle fibers.  This leads to a vicious cycle of decrease blood flow to the area along with recruitment of surrounding muscles leading to chronic  pain and even fibrosis of the  tissue.  When techniques like massage or dry needling and PT are not sufficient to break up and release the trigger point then ultrasound guided injections can be very useful.  (link here).  Specific stretches, digital pressure, massage and manipulation all can help maximize recovery from chronic trigger points.  Being fully hydrated, avoiding smoking and excessive use of sugar can also help.

 

Chronic Abdominal Pain

 

Abdominal pain is a different type of problem than many musculo-skeletal problems.  It does not lend itself to rehab and exercise except if the pain is due to abdominal wall/muscle conditions.  The 1st step with abdominal pain is to be thoroughly evaluated by appropriate specialist such as a gastroenterologist or surgeon.  If there is no treatable cause then it is possible to treat this pain by blocking the splanchnic nerves (link here).  The splanchnic nerves carry sensation from the abdominal organs and blocking them can relieve pain.  Another option is a celiac plexus block.  Using the splanchnic nerve block avoids some of the side effects of the celiac block such as diarrhea and postural hypotension (dizziness when standing).

 

If blocking the splanchnic nerves relieves most of the pain then we can proceed with a pulsed radio frequency ablation of the nerves. This will usually provide relief for about 10 months in patients that it works for and it can be repeated as needed.

 

Other adjunctive treatments include medications and even dietary changes.

 

Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome

 

RSD/CRPS manifest as hypersensitivity stimulus, swelling, color changes and circulatory changes in the effected body part.  This occurs either do to major trauma to a large nerve or more commonly a minor trauma to a body part.  When this is in the arm or hand it is treated with a stellate ganglion block (link here).  These blocks are done in a series combined with desensitization exercises.  If the blocks work well but the pain returns a pulsed radiofrequency lesion of the stellate ganglion or the lumbar sympathetic chain can be performed.  Medications are important in treating RSD/CRPS as well.  If conservative treatment does not provide enough relief then a spinal cord stimulator can be very effective.

 

Trigeminal Neuralgia/Facial Pain

 

Persistent facial pain is often caused by irritation of branches of the trigeminal nerve leading to pain that ranges from a constant burning pain to severe sudden attacks of pain.   In some cases this pain is due to a blood vessel pressing on the nerve and this can be fixed surgically.  In other cases the cause of the pain is not understood.  Treatment of trigeminal neuralgia/facial pain includes medications, therapy and nerve blocks.  For many people blocking the sphenopalatine ganglion and or the stellate ganglion nerves can give relief.   A pulsed radio frequency lesion of the nerve is a semi-experimental therapy that can give a very high level of relief to many sufferers of facial pain.

 

Post Herpetic Neuralgia (PHN) is a burning pain along the course of a nerve that goes to the skin called a dermatome.  Post herpetic neuralgia occurs when a nerve becomes infected with the virus that causes chicken pox.  The best treatment for this very painful condition is prevention and everyone over 65 should be vaccinated against the shingles virus.  Some experts recommend vaccination at age 55.   In people who due develop shingles and PHN medications such as Lyrica or Neurontin can be very effective.  If medication treatment is not enough then nerve blocks including epidural steroid injections are often an effective addition to treatment.  In severe cases spinal cord stimulation or a pulsed radiofrequency lesion of the nerve may be needed.

 

Scar pain

 

Severe pain along a scar after an injury or even surgery can become a debilitating pain issue.  This type of pain may be caused by scar tissue or nerves forming little bundles called neuromas within the scar.  Scar pain is a result of the way the body heals and is not usually do to something “going wrong” with an operation.  Injection of a volume of fluid along with steroids into the scar helps break up the scarring and can crush the little neuromas leading to relief.  Topical medications including lidocaine  and capsacian can help along with desensitizing exercises.  Medications that help block nerve pain can be useful as well.

 

Occipital Neuralgia/Headache

 

Headache pain is an especially difficult symptom for many people.  There are over a hundred types of headaches and treatment is often only partially successful.  The underlying causes of headache are not completely understood.  However a significant percentage of headache pain is due to occipital nerve irritation at the base of the skull.  Irritation/entrapment of the occipital nerves can lead to severe headache pain that wraps around the base and side of the head and even behind the eyes.  Treatments include manipulation, medications, massage and stretching.  When these measure fail blocking the greater occipital nerve can lead to significant relief.  Cervical epidural steroid injections can also be very effective.

 

Pain after back or neck surgery

 

Spinal pain and the radicular symptoms that often accompany it are complex problems.  Sometimes even surgery is not successful.  The term for pain continuing after surgery is failed back surgery syndrome but this is not an accurate name.  The surgery may have been successful in that it was done perfectly but symptoms return quickly anyway.  The return of symptoms may be due to formation of scar tissue or adhesions along the nerves.  In this situation injecting a volume of fluid into the space around the nerves can often breakup the adhesions and help salvage the surgery.  When fluoroscopically guided injections fail a Lysis of Adhesions procedure also known as the Racz procedure may be necessary.

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