PAIN EXPLAINED : PHYSIATRY & New Developments in PAIN & Regenerative Medicine

1. PAIN EXPLAINED:PHYSIATRY & New Developments in PAIN & Regenerative Medicine Suzanne Duncan MD Pain Diagnosis & Injury Rehabilitation New Patients and Follow-ups: Nantucket Cottage Hosp Pain Clinic Tel: (508) 825-8216 (Nurse Shelly) EMG Studies/Follow-ups: Dr Duncan at the Westmoor Tel: (508) 680-4864

2. Physiatry • Physiatry, Greek for ‘the art of healing,’ is a medical specialty originally developed at the Mayo Clinic in 1936 by Dr Frank Krusen, MD to train doctors in the diagnosis and management of severe injuries due to war, genetic abnormalities and diseases such as polio. • Physiatrists undergo lengthy comprehensive training in both medicine and anatomy, and treat the whole person, body, mind and soul.

3. Four Year Residency Training • INPATIENT: 6 Month rotations • Spinal Cord Injury, Trauma, Burn Unit • Pediatric Rehabilitation • Traumatic Brain Injury/Stroke • OUTPATIENT: • NeuromuscularskeletalDiseases • Amputation/Prosthetic/Orthotics Lab • EMG/Nerve Conduction Studies • Pain Management • Procedures • Epidural Spine injections • Joint/Muscle/Tendon injections

4. WWI & WWII • WWI during and after, Physicians began practicing "physiotherapy" in "reconstruction hospitals" to rehabilitate injured and disabled soldiers • WWII - Howard Rusk, MD: Set up a controlled experiment in one barracks in which: Active Rehabilitation was carried out vs Control Barracks that continued the passive program of convalescence RESULTS:THREE-FOLD RETURN TO FRONT The dramatically rapid recovery of strength and endurance and to active duty were so remarkable that the Army Air Corps extended the program throughout the military services, to this day. This return of manpower is credited with signifcant influence in winning the war., and physiatry programs

5. Physical Medicine & Rehabilitation • Physical Medicine is the study of physical agents and their use in the diagnosis and treatment of a disease or disability, (i.e. strengthening, stretching, modalities...). • Modalities’ are physical treatments that produce a therapeutic response in tissue. • Examples of Modalitie are: Heat, cold, water, sound. More recently electricity and electromagnetic waves (infrared, visible and ultraviolet light, shortwaves, microwaves) • Rehabilitation is an approach to the restoration of function utilizing : medical, psychological, vocational, social resources that are used in an interdisciplinary program to help a disabled individual reintegrate into society and return to a productive and enjoyable life.

6. WWII endedPolio epidemic • Created an increased demand for physicians trained in a comprehensive approach to rehabilitation, including the physical, mental, emotional, vocational and social aspects. • More cohesive union between the fields of Rehabilitation Medicine, and Electromyography. (EMG). Clinical and educational and research opportunities multiplied • Association of Academic Physiatrists (AAP) was formed in 1967,Ernest W. Johnson, MD, considered the "founding father” of academic rehabilitation medicine

7. Areas covered in rehabilitation programs include: • PATIENT NEEDS: • Self-care skills, including activities of daily living (ADLs): Feeding, grooming, bathing, dressing, toileting, and sexual function • Physical care: Co-moribitiy, Nutritional needs, medication, and skin care • Mobility skills: Walking, transfers, and self-propelling a wheelchair • Respiratory care: Ventilator care, if needed; breathing treatments and exercises to promote lung function • Communication skills: Speech, writing, and alternative methods of communication • Education: Patient and family education and training about the condition, medical care, and adaptive techniques

8. Rehabilitation Areas continued: • Cognitive skills: Memory, concentration, judgment, problem solving, and organizational skills • Socialization skills: Interacting with others at home and within the community • Vocational training: Work-related skills • Pain management: Medication, interventional procedures, and alternative methods of managing pain • Psychological counseling: Identifying problems and solutions with thinking, behavioral, and emotional issues • Family support • Assistance with adapting to lifestyle changes, financial concerns, and discharge planning

9. History of Physiatry – 2012+ • Despite the changes, the need for a physician to provide holistic medical care to patients with disabilities should continue and increase. • New Developments in Pain and Regenerative Medicine offer promise to challenging cases • Advances in technology such as limb replacement, traumatic brain injury (TBI) and wound care have created further demand for physiatrist’s services. • Continuing research will lead to advances that will ultimately benefit our patients and help physiatrists provide state of the art care.

10. Pain Management • 4th vital sign • Demand increasing • Many specialties participating • New requirements from fellowships mandate multidisciplinary training • Interventional option • Subspecialty boards

11. Spinal NervesParasympathetic/Sympathetic Nervous System

12. Somato Sensory Pathways (vertical)Propriocepsis Muscle tension, tendon stretch Fine Discriminative TouchLight touch, pressure, vibrationPain and Temperaturetickle and itch(Mechano-thermo-chemical nociceptive system) THIRD ORDER NEURONS FIRST ORDER NEURONS (C&Aδ fibers Capsaicin sensitive/TRPV1 nerves) SECOND ORDER NEURONS with sub branch to Hypothalamus

13. SUBCUTANEOUS NERVES

14. Peripheral Nerve Trunk and its Organization

15. John Marshall, MD ‘Nervi Nervorum’Bradshaw Lecture (1883)

16. Marshall and Sir Victor Horsley postulate in 1883 that ‘Nervi Nervorum’were responsible for the inflammation of the nerve trunk sheath causing “neuralgia”.

17. How do these Injuries Occur? • POSTURE • Trauma • Repetitive Shear • Toxic Overload • Nutrient Deficiency • Disease http://www.antiaginghacks.com

18. Epidemic of the 21st Century

19. 60 million years of Biologyvs 2 million ‘Bright Idea’

20. The Human Spine

21. Why Do We Still Have Back Pain? • Theories continue to be improved upon • In the past a ‘straight spine’ was promoted both in the Armed Forces and Dance • Many practices in the past were based on hypermobile ‘Dancer bodies,’ for example Joseph Pilates, a German movement specialist whom initially worked exclusively with the dance corps • More comprehensive cadaver studies have revealed the need for cervical and lumbar curvature in order to bear the body’s weight

22. Stooping is an Option

23. Stooping Arises from the Evolutionary Cost of Hanging from Trees:Unless Chest is Elevated, then the Rhomboid Muscle Contracts andOpens and Relaxes the Pectoral muscles

24. Common Myths • Suck it In A Healthy Stomach supports the spine • Chin Tuck Elevate Chin to Stack Cervical Spine • Flatten Back Keep back curved to support weight • Bend Stretch Arch down and back up • Tilt Pelvis Keep low back arch, only tilt if hyperlordic

25. Consequences

26. Standard Treatment Options • REDUCTION OF INFLAMMATION: • ICE • Steroid Injections to base of skull, Trigger Points, Joint, Tendons and Ligaments • Lidocaine Patches • Oral medication: Ibuprofen/Advil, Alleve, Tylenol • PAIN MEDICATION

27. DANGERS OF OPIODE USE • For more than 100 years, the use of opioid analgesic agents has been linked with modulation of the immune system in man. More recently, it has become apparent that both exogenous and endogenous opioids exert some effect upon the immune system…. Of the strong opioid analgesics in current use, the majority are seen to cause immunosuppression in man. • Biomed Pharmacother. 2006 Aug;60(7):310-7. Epub 2006 Jun 30., Pain management: is opioid immunosuppression a clinical problem?, Budd K.Source:Pain Management, Newlands, Chevin Avenue, Menston LS29 6PE, UK. keithbudd@tiscali.co.uk

28. Anaesthesist. 2003 May;52(5):442-52.Welters Opioids and immunosuppression. Clinical relevance? • Abstract: First observations that opioids may have disadvantageous effects on the immune response have been made more than 100 years ago. Today the immunosuppressive effect of morphine is well established.Drug-induced immunomodulation is of growing importance in modern anesthetic concepts. The reduced stress response observed after morphine application contributes to this effect as well as direct impairment of immune effector cells such as bactericidal activity, intracellular killing,proliferative response or cytokine synthesis. Opioid-induced immunomodulation is mediated by opioid receptors found on immunocytes and in the central nervous system.

29. Developments in PAIN and Regenerative Medicine • Low Dose Naltrexone (LDN) • Suboxone: Naltrexone 50mg/Bupenorphine 8mg • FDA approved at 50mg for opiate addiction, at low doses such as 4.5mg taken at night have been proved to boost and normalize the immune system • www.lowdosenaltrexone.org • Increased AIDs survival and remission, Cancer remission, MS progression significantly slowed, Crohn’s resolved, Thyroid normalized, Autoimmune diseases alleviated

30. LDN Clinical Studies • Two studies in Mali, Africa demonstrating LDN’s successful use in HIV/AIDS—published October 2011. • A study of LDN in the treatment of MS at the University of California, San Francisco, published February 2010. • A multi-institutional clinical trial of LDN for PPMS in Italy, which includes endorphin measurements, completed in fall 2007, published September 2008. • A Phase II placebo-controlled clinical trial of LDN for Crohn’s disease at Penn State.

31. LDN Clinical Studies continued • A Phase II placebo-controlled clinical trial on the efficacy of LDN for children and adolescents with Crohn’s disease at Penn State. • A clinical trial of LDN in the treatment of fibromyalgia at Stanford Medical Center, published May-June 2009. • A study by the MindBrain Consortium in Akron, Ohio of, especially, the affective changes in MS treated with LDN, begun late 2007. • Animal research on neurodegeneration at NIEHS, suggesting a protective role for naltrexone.

32. Developments in PAIN and Regenerative Medicine • PROLOTHERAPY is a medical term which means 'proliferation therapy,' here in reference to nerve, soft tissue and cartilage, damaged after injury from trauma or disease. By selective restoration and strengthening of these areas with prolotherapy, the integrity of the system is preserved and the area becomes pain free. This technique has also proven effective in softening and decreasing the hypersensitivity of scars.

33. Prolotherapy • Prolotherapy traditionally is the injections of solutions that cause a controlled healing response of the area through mild inflammation and nutrition. The solution injected is an irritant, often dextrose (sugar) and water. This triggers the natural inflammation response of the body, which then rebuilds the target area with the surrounding addition of nutrient, glucose. This strengthens pathologically weaked ligaments and tendons.

34. Controlled Inflammation Heals and Strengthens • Inflammation is the process by which the body heals., and as this happens, the tissues deposit new collagen, the substance that ligaments and tendons are made of. The new collagen soon shrinks, strengthening the treated ligament and reducing or eliminating pain. The small amount of bleeding that is generated in this technique also delivers platelets to the area, which are rich in growth factors and promote further healing.

35. Prolotherapy Regenerates Tissue • Prolotherapy specifically refers to injections at the ligament and tendon bon-interface to strengthen and balance the unit, but is also an over-arching term for other regenerative procedures such as Platelet Rich Plasma autologous blood injections and Auto Stem cell injections.

36. Prolotherapy continued • Prolotherapy Joint injections that promote cartilage production and intra-articular (within the joint), strengthening of tendons. Solutions such as glucose and lidocaine within the joint result in cartilage regrowth and strengthen intra-capsular ligaments and tendons. Example of Injection Sites for the Inferior Posterior Glenohumeral Ligaments and Teres Minor Origin. Access to all points marked is by entry at Green dot

37. PRP & Auto Stem Cells • Platelet Rich Plasma (PRP) is the application of concentrated platelets rich in growth factors from the patient’s own blood. It is commonly used in professional athletes to repair torn tendons and ligaments. • Auto Stem Cells takes multipotent stem cells from the patient’s own fat cells or from hip bone to regrow cartilage, tendon, ligament and bone.

38. Developments in PAIN and Regeneration • TENSEGRITY is an important term in these procedures, coined by Buckminster Fuller for the concept of ‘tensional integrity.’ • Tensegrity concerns inteself with the stabilization of a three-dimensional structure, here the body's components of hard and soft tissues, which support and cushion the body against gravity and force. Imbalances in these structures, such as weakened ligaments surrounding a joint from trauma or disuse, can lead to uneven wear, breakdown and pain.

39. Prolotherapy Benefits • Arthritis relief • Back pain, especially involving the lower area or sciatic pain • Neuropathic pain • Joint laxity or weakness • Swelling or tenderness at a joint • Pain as a result of complications from surgery • Scar release and repair- headaches resulting from neck problems • Acute trauma, such as sports injuries & other musculoskeletal injuries or conditions • Treatments usually involve three to six sessions with a doctor. Sessions are usually two to six weeks apart. Expense is out-of pocket, although Workman’s Comp and the VA presently cover it.

40. Developments in PAIN and Regenerative Medicine • Perineural Subcutaneous Injections )also known as Neural Prolotherapy or Neural Facial Release Technique (NFRT) for nerve repair and regeneration is highly effective in resolving pain. Sugar is injected (glucose, mannitol or glycerol) with sterile water in quantities of 1-2cc's (approximately half a tablespoon),under the skin and above the muscle every 2-3 inches where there is pain. Sugar is the body's major fuel and building block. The sugar hydrates and nourishes the micro-nerve network that informs the structures above and below, restoring health to the area.

41. Developments in PAIN and Regenerative Medicine • Prolo Sonophoresis utilizes therapeutic Ultrasound to deliver sugar to the painful areas without the need for injections. The sugar passes through the skin by micro sound waves, hydrating and nourishing the structures that have become starved and scarred from injury and lack of nutrients. These solutions are generally personally compounded by the treating physican with knowledge in this area. Dr John Lyftogt and Dr Howie Rosen have developed commercial products to treat the subcutaneous nerve environment.

42. “An ounce of prevention is worth a pound of cure.” • In conclusion, the best medical advice may be that of our Benjamin Franklin quoted above. • POSTURE POSTURE POSTURE POSTURE is the ill of most painful conditions; better posture – better body • Children texting or game playing with bent necks are a disaster waiting to happen, their vulnerable necks cannot sustain the weight of their head for extended periods of time. In a bouncing car the force is further compounded and serious spinal cord injury is possible. • CHEST UP, CHIN UP, STRONG STOMACHS! • ‘Be Kind to Yourself and Others’

43. Thank you www.suzanneduncanmd.com