Our Philosophy

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 years (1). There are over 15 million office visits every year for mechanical neck and low back pain in the United States (2). Lack of physical activities, increased body weight, limited ambulation, trauma, accidents, and repetitive injuries to the spine result in back pain. 90% of acute back pain resolves in 6 weeks without any intervention. However, the remaining 10% will become chronic back pain and cause significant disability and have a negative impact on patient’s quality of life (2). Famous professor Gordon Waddell called back pain the 20th Century a Medical Disaster (3, 4). The situation with back pain has become so serious that the US Government declared 2000-2010 as bone and muscle decade. The correct diagnosis, treatment and rehabilitation of musculoskeletal disorders, osteoarthritis and back pain became the issues of national importance.

Despite continuous research we still don’t have a consensus how to treat chronic pain. Family physicians, primary care providers frequently ask questions about the best management for people suffering from neck, upper back, and low back pain; and this is why Alternative Medicine Clinic designed an innovative pain management protocol that combines traditional and not so traditional, ie. alternative methods of treatment. Our protocol includes not only the newer medications, but also therapeutic injections, herbs and acupuncture and other high tech modalities that become routine and well accepted by the practicing community of MN.

1. Detailed physical examination begins with careful analysis of the patient’s past medical history, current symptoms, family history, and all medications he or she had been taking in the past, their therapeutic effectiveness and side effects. X-ray studies of the neck and low back spine are usually recommended for an accurate diagnosis and determination of the stage and extent of the pathological changes in the vertebral bodies, tendons, intervertebral disks and corresponding nerve roots. If it is necessary, medical providers can proceed with a more sophisticated imaging study like CT or MRI, but those studies are usually reserved for confirmation of radiculopathy and more serious neurological and orthopedic conditions like spinal stenosis, advanced facet artropathy.

3. Medications. There are several pharmacological groups of medications that were proven to be useful in the management of neck and back pain. Well known traditional medications like Tylenol and Aspirin might be used in mild arthritic pain.
Non Steroidal Anti-Inflammatory (NSAIDs) are important in controlling more severe cases of arthritic inflammation in the small spine joints, (i.e., facet joints). Those medications, so called COX-I inhibitors, inhibit the special enzyme called cyclooxygenase (COX) type I. Working on this enzyme, those medications can stop the inflammation cascade and help with pain. Unfortunately the current research demonstrates that Ibuprofen (Motrin), Naproxen (Aleve), and Indocine have side effects causing gastric upset, discomfort, and even bleeding when chronically used (10, 11).

The newer class of non steroidal anti-inflammatory medications is COX-II inhibitors, medications that block cyclooxygenase (COX) type II. Some of the medications from this group, Bextra and Vioxx, were called off the US market because of cardio-vascular side effects, but, in general, COX-II inhibitors are effective and well tolerated. Celebrex is the only FDA approved COX-II inhibitor that is on the market. Mobic (Meloxicam) is atypical COX-II inhibitor that is also effective in patients with generalized osteoarthritis as well as small spine joints arthritis. This medication can be used for a long time in patients with different comorbidities and polypharmacy.

Steroid medications. Steroids are potent anti-inflammatory medications and can be useful in controlling back pain. Oral use of these medications is limited to acute back pain that is caused by disc herniation with nerve root compression. In acute cases Medrol dose pack is usually prescribed. The pack contains methylprednisolone that should be used over a one week period while daily tapering the dosage.

Antidepressants such as TCAs (tricyclic antidepressants) and SSRIs (selective serotonin reuptake inhibitors) are helpful in certain types of neuropathic pain. Neuropathic pain is defined as pain caused by spinal stenosis, disk herniation or other lesions of the peripheral or central nervous system. Spinal stenosis is narrowing of the spinal canal and is usually caused by disc degeneration or arthritis of facet joints in the back or neck. Radicular pain is the pain caused by irritation of the spinal nerves (nerves coming off the spinal cord). Usually inflammation occurs around the irritated nerve and causes back pain radiating to the legs when it is in the lumbar spine. Radicular pain is perceived as neck pain radiating to the arms (12).

TCAs such as amitriptyline (Elavil) and Nortriptyline (Pamelor) are both effective for neuropathic pain. However these medications can cause sedation, dry mouth, urinary retention, increased heart rate, hypotension, and constipation, especially in elderly patients.
SSRIs are well tolerated compared to TCAs. SSRIs inhibit the reuptake of norepinephrin and serotonin which is believed to play an important role in the mechanism of neuropathic pain. Venlafaxin (Effexor), Duloxetine (Cymbalta) and Preballin (Lyrica) are well proven to be effective for neuropathic pain and are the most commonly used SSRIs in our clinic.

Anticonvulsants also known as antiepileptic medications are medications initially invented for prevention and treatment of seizure disorders, but these medications have been also used for neuropathic pain (13). The most commonly used antiepileptic medication for pain is Gabapentin (Neurontin) that is usually well tolerated, but in some patients might cause excessive sleepiness. Lyrica is a new medication with a promising high effectiveness and favorable side effects profile.

4. Opioid Medications: Opioids are very potent pain killers and they are also known as narcotic analgesics. Research and scientific literature demonstrated that Opioids are helpful in chronic neck and low back pain in certain patients (5). However there are potential side effects with long-term opioid use. Many patients are concerned about the potential risk of addiction with these medications. When Opioids are used for pain control under the physician’s supervision, the risk of addiction is rare. Other side effects of Opioids are constipation, nausea, sedation, urinary retention and respiratory depression, but usually these side effects are manageable.
Medical providers should assess every patient very carefully in order to decide whether the patient is qualified for long-term opioid therapy. Every physician and clinic should have clear guidelines focused on initial patient evaluation, type and dosage of medications prescribed, frequency of ongoing follow up office visits.
Emphasis should be done on long acting opioid medications for chronic neck and back pain since these medications stay longer in your system and are more effective for chronic pain problems. Short acting Opioids should be used for the breakthrough pain only in addition to long acting Opioids and non opioid medications.

5. Herbal and natural medications. Our patients often ask about the natural alternatives to non-steroid and steroidal anti-inflammatory medications. There is a huge variety of natural alternatives and herbal dietary supplements on the market, but in comprehensive pain management program should include natural formulas with a proven clinical effectiveness and favorable side effect profile. Our first choice is a combination of Chondroitin, Glucosamine, and MSM in combination with Microlatin. Microlatin is a newer kid on the block and is produced from dairy products. We also recommend generalized conditioners like Gingko Biloba, Guarana, Saw Palmetto, Sea Buckthorn (popular Russian herb) and other Chinese folk medicine formulas.

6. Topical medications and ointments. Part of the comprehensive pain management program includes topical ointments recommended for skin application. Those transdermal formulas, so called, compounding medications, are special ointments prepared by the pharmacy according to physician’s prescription. They usually contain a combination of non-steroidal anti-inflammatory medications, topical anesthetics, and muscle relaxants. It is wise to have a special agreement with a pharmacy that will prepare those compounding medications for the particular patient. Additionally, we might recommend use Capsaicin cream, made from red chili pepper. Bioactive substances of red chili pepper block the substance “P” and by then reduce pain (14). 5 % Lidoderm patches made from a special gel and release the numbing medication Lidocaine within 12 hours.

7. Invasive procedures (injections): Epidural Steroid Injections, also known as cortisone shots. Steroid mixed with local anesthetic (numbing medication) injected directly into the epidural space under fluoroscopic guidance. Epidural space is the space in spine between the spinal cord and the posterior bony parts of the spine. By using this technique, physicians avoid the potential side effects of steroids when given orally, and we increase the efficacy of the medication by delivering it to the exact place where the inflammation occurs. Epidural steroid injections are useful to control the symptom and facilitate recovery. You can have 3 or 4 epidural steroid injections in a year.

There are different techniques of performing epidural injections, such as interlaminar way or transforaminal way. In both of these techniques the medication is given directly into the epidural space. The interlaminar or the translaminar way is when we give the injection at the midline into the epidural space on your back. If we give the medication slightly off from the midline, we call it transforaminal epidural steroid injection. The transforaminal technique also called selective nerve root injections, usually targets a certain nerve root coming off the spine.

If physician believes that pain is coming from the small joints called facet joints in spine, he might inject the steroid medication into these joints under fluoroscopic guidance. Like all the other joints in the body, facet joints degenerate with aging, become arthritic and cause pain. These facet joints in conjunction with discs in your spine carry most of your body weight. Sometimes after automobile accidents and whiplash injuries, there could be a misalignment between the small facet joints in the neck which could cause significant pain, headaches, decreased range of motion and disability. Steroid injections into these joints can facilitate the rehabilitation and faster recovery. (15)

Other injections and Invasive spine procedures include discograms, IDET (intradiscal electro thermal therapy), nucleoplasty, vertebroplasty, radiofrequency ablation (RFA) and implantable therapies such as neurostimulation, and intrathecal drug delivery therapies. All these procedures are done under fluoroscopic guidance. With fluoroscopic guidance, the risk of complications is minimized. These procedures are highly effective when used in appropriate patients.

8. Botulinum Neurotoxins (BoNT) Injections (chemodenervation). One of the newer treatments of 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 physician BoNT is an excellent and safe tool to control muscle spasm and pain. Recent research proved 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 (16). BoNT injections are safe, effective, well-tolerated, but expensive. Injections are usually done under the guidance of special electromyographic device that allows physician to identify the most spasmodic and inflamed muscles needed to be treated. 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 tolerated well. The effect of pain relief and muscles relaxation last for several months, then injections might be repeated as needed.

9. Prolotherapy (rejuvenative injection therapy). Another part of comprehensive pain management program is prolotherapy (sclerotherapy) or so called ‘Canadian injections’. Prolotherapy is an injection therapy that helps to accelerate the collagen synthesis inside impaired ligaments and restores their tendon’s elasticity. Research and clinical experience proves that inflamed injured tendons and ligaments are unable to stabilize the joint or spine and might be a source of constant, dull aching (17). The idea of this therapy is an injection of a proliferant solution inside the impaired structures in order to rejuvenate the ligamentous tissue and naturally stabilize the joint. Prolotherapy is an ancient method that was actually proposed by Hippocrates and developed in this country by Dr. George Hackett and Dr. Gustav Hemwel. Both physicians had 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 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 Opioids.

10. Exercise, physical therapy, and gentle chiropractic manipulations are the valuable part of comprehensive pain management program. In the past physicians recommended long term rest after an acute onset of back pain, recent literature does not support the advantages of prolonged rest (18). Today we recommend bed rest for no more than 2-3 days after acute pain onset that should followed by early mobilization and activity “as tolerated”. Prolonged rest may cause more muscle and joint stiffness and eventually will cause weak muscles, decreased mobility and increased pain. Proper exercise performed on a daily basis is essential for a healthy spine. Exercise, done carefully and regularly, helps build and preserve muscle strength, keeps joints and ligaments flexible and protects them from further damage. Certain exercises such as the McKenzie exercise program (extension exercises) are helpful for radicular pain. Gentle stretching, range of motion, back muscle strengthening, and posture training are typical exercise programs we use. These exercises strengthen the muscles supporting the spine and around the joints and reduce wear and tear. These exercises will be taught by our physical therapists and chiropractors. Initially, they should be supervised, but later on the patients will be able to continue their exercise program at home. The patient should be asked you to keep a log showing the regimen, intensity, and frequency of a home exercise program (18).

11. Accupuncture and other modalities. Depending on the patient’s preference, acupuncture, heat or ice can be used for different types of pain. Ice or heat is typically applied 3-4 times a day for 10-15 minutes. Why one person feels better with heat and another feels better with ice is not clear, but this treatment can bring pain relief and some reduction of inflammation. Heat can be applied in many forms including warm packs, showers, infrared lamps, and whirlpool. Cold therapy utilizes ice packs, frozen bags of peas and corn or a wet towel that has been placed in a freezer. Different ultrasound devices, microwave machines, diathermy and infrared lasers might be used. It is prudent to have different providers in the clinic with expertise in alternative medicine, acupuncture, herbal medicine, and biofeedback, and massage therapy, hypnotherapy and relaxation technique (19, 20).

12. Prosthetics/orthotics, assistive devices for ambulation. Orthotics and cervical and lumbo-sacral braces can help support the spine and decrease muscle spasms and disk pressure. Special vendors can assist in choosing the correct orthotics for mechanical support of the spine. Temporary use of crutches, canes, rollator walkers, cart walkers or a wheelchair may be helpful for some patients.

13. Weight management. It is crucial to maintain a healthy weight while taking care of patients with neck and low back pain and arthritic spine joints. International research demonstrated that weight reduction could significantly decrease the impact on an impaired spine (21). This is an important part of comprehensive pain management program and includes a combination of a healthy diet and aerobic exercises for weight reduction and healthy weight maintenance. Pain management specialists and primary care providers should collaborate with specialists in obesity management, with exercise physiologist proficient in metabolic testing. The goal of weight management program is to accelerate basic metabolic rate and to burn fat tissue.
There are several medications FDA approved for weight control like Xenical, Meridia, and they require evaluation and follow up of physicians specializing in weight management and metabolic disorders treatment. Patients might be interested in holistic approach: herbal food supplements, acupuncture, glyconutrients for appetite control and metabolism enhancement, body wrapping and mesotherapy for body contouring (22).

14. Multidisciplinary Chronic Pain Program: It is important to develop multidisciplinary chronic pain programs for individuals who failed all other types of treatment. Pain affects these patients physically, psychologically, and socially. The goal of multidisciplinary chronic pain program is to educate the patient about pain, physiology and anatomy; improve coping skills, aerobic conditioning, endurance, strength, treat depression and other underlying medical conditions, eliminate inappropriate medications, initiate appropriate medications and assist patient in establishing realistic goals and maintain treatment goals. Behavioral health is a crucial part of the chronic pain program. Clinical psychologists are experts closely involved in the chronic pain program to help the patient to improve coping and treatment of underlying depression, sleep disorders, anxiety, and post traumatic stress disorders. Research supports there is close relation between perception of pain, depression, sleep disorder, anxiety and post traumatic stress disorder. It is essential to treat these conditions in order to achieve better pain control (23).

15. Finally, about orthopedic surgery. Primary care physicians and pain specialists are doing all their best to design treatment and rehabilitation program for patients suffering from acute and chronic back pain. Unfortunately, in some patients conservative management fails, and in those cases surgical treatment is necessary.
There are conditions that need immediate attention and surgical intervention in order to prevent further neurological damage: progressive weakness, lose of bowel or bladder control, gait abnormalities, loss of sensation and severe pain.
In those cases the patient should be referred to an orthopedic surgeon for consultation and possible surgery, and pre- and post surgical rehabilitative program should be well planned in advance (22).

We believe that this brief overview of comprehensive pain management program will allow primary care providers; patients and non-pain specialists in general understanding of multifaceted pain management and different options available on the market.

References.

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