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Patient Testimonials

February 15th, 2015

PATIENT TESTIMONIALS

 

“. . . Thank you for using your finely tuned skills to take away my back pain, Wow! What a relief! I’m touting your praises to everyone I know, I’m so grateful for your help”   JA 11/5/2012

 

“ . . . Thank you again so much for all your patience. I don’t know any other doctors who would do what you did for me. “ LB 12/25/12

 

“. . . Denver Back Pain Specialists helped me get pain-free. Thank you so much for making the time and working me into your schedule on the same day you were to fly to San Francisco for a medical conference . . . Thanks again for going the extra mile to help me. “   CH

 

“. . . Your knowledge of anatomy – merely brilliant. Your manual dexterity – quasi-magical. With thanks for a 57th anniversary totally free of pain. . . “   NR 3/20/14

 

“ . . . You did a hip injection on me and it worked. You said you think we found the problem, and you did. . . . Thank you for the diagnosis. I really appreciate it”   SH 9/10/13

 

“ . . . Thank you so much for all your help this summer and fall to help figure out the source of my back pain and then the best course of action to treat it. Even though it needed surgery, it appreciate all you did and it meant so much” BT 11/2014

 

“ . . . Thank you so much for getting me in so quickly for the injection today. This was such a better experience than the injection I had 11 years ago. I really appreciate your help. “ NM 5/23/13

 

“ . . . I want to thank you for being so determined to find the source of my pain. I had surgery to my cervical spine three weeks ago and already feel better. My world was getting very dark, but I’m seeing the sunlight again . . . “ CM 10/14

 

“ . . . Thank you for the kind and wonderful care you have always taken of my ailing spine . . . I am forever thankful to you for helping me live well with my back problem” LK 12/13

 

“As a new patient, I just wanted to thank you and your staff for making me feel at east and comfortable in your office. You listened to my complaints, answered my questions and cared about my well being. I would highly recommend you to anyone. . . “ JC 11/12

 

“. . . The injections of Friday have been nothing short of miraculous in banishing pain and enabling me to stand upright (almost). Thanks seems a wholly inadequate response to what feels like a gift from the gods. . . ”   NR 5/13

 

“. . . The back pain is much mitigated. The leg pain, which came nearest to crippling me, is GONE! I’ve said this before but it bears repeating: I could not possibly be more grateful” NR 9/13

 

“I wanted to let you know how much better my back and neck are doing. I was able to do my big bike event, the Iron Horse Classic, which has been on my bucket list for about 10 years. The goal of the race is to beat the train that leaves Durango at the same time as the cyclists and I did it!!! I thank you for your help in getting me over the hump so I could accomplish my goal of doing the Iron Horse Classic”

AC 7/13

Sacroiliac Joint RF Ablation (L5DR, S1-3 LB)

December 23rd, 2012

SIJ RFN Review

J. Scott Bainbridge, MD

 

Back pain is a pervasive problem in the general population [1].  The origin of this pain is not always well understood, and as a result of this, there is mixed evidence for many treatments.  Living with chronic pain results in lost productivity, decrements in quality of life and substantial health care utilization, including the use of opiod medications, [2].  RF Neurotomy, when provided to appropriate patients by trained providers, has been shown to alleviate back pain associated with the sacroiliac joint complex, [3-8].

 

The prevalence of sacroiliac joint generated pain amongst those presenting with axial low back pain varies, according to age, history of lumbosacral fusion, or other population features, between 15-40%. [9-17]

 

The sacroiliac joint is a synovial articulation with contoured surfaces covered in hyaline cartilage which is thicker on the sacral side. There is a fibrous capsule and very strong supporting ligamentous structures consisting of the anterior sacroiliac, posterior SI, and interosseous SI ligaments, and the sacrotuberous and sacrospinous ligaments.  This construct allows for the absorption of great forces across the joint, and subtle movement with walking and other activities. [18]

 

The innervation of the SIJ is contentious [19, 20], with some postulating that it is innervated only dorsally [21, 22], while others [23, 24] believe the joint to be innervated both ventrally, via anterior rami, and dorsally, via the L5 dorsal rami and sacral lateral branches. The posterior capsule and dorsal ligamentous structures of the sacroiliac joint are innervated by pain sensitive nerve fibers [6, 21, 22, 24-26] arising from the L5 dorsal rami and sacral 1-3, but not the 4th lateral branches [27] Cadaveric studies have revealed the course of the sacral dorsal rami and lateral branches, [6, 27].

 

Dreyfuss, et al. [20] showed that multi-site, multi-depth lateral branch blocks, with green dye, were effective (91% accuracy) in staining the lateral branches, in a cadaveric study (2 cadavers; 4 joints).  Subsequently 20 volunteers were shown to be able to experience pain with experimental stimulation of the dorsal SIJ ligaments, and with distention of the SIJ capsule. It was found that performing active L5DR and S1-3 LB blocks on 10 rendered 70% of the subjects insensate to dorsal ligament stimulation, but only 20% insensate to capsular distention.  After saline (control) L5 DR and S1-3 lateral branch blocks the group (n=10) did not experience protection (anesthesia) from the experimental pain stimulus.  This study demonstrated the results of sacral lateral branch blocks cannot be attributed to non-specific effects and they are adequately physiologically effective to be used clinically. This was not the case with the use of single site lateral branch blocks, [19].

 

Given the findings of Dreyfuss, and the fact that only the L5DR and lateral sacral branches can be safely denervated, it follows that those patients who receive pain relief with screening multi-site, multi-depth lateral branch blocks will be most likely to benefit from SIJ RFN.  Based upon similar validated methodology when treating cervical and lumbar zygapophysial joint denervation, using two sets of confirmatory blocks should, in theory, be optimally predictive of a successful outcome following treatment with SIJ RFN.

 

Multiple researchers have studied clinical outcomes of the use of radiofrequency lesioning (RFL) techniques to treat sacroiliac joint complex pain. Patient selection methods for these studies have been variable, with many of the studies having been carried out before the publication of the multi-site, multi-depth lateral branch block technique noted above, [20]. Likewise, various RFL techniques and technologies have been employed.

 

Burnham, et al [28] prospectively selected 9 patients through intra-articular SIJ block and confirmatory single-depth, multi-site lateral branch blocks. He used a bipolar technique and 33% experienced >50% relief at 6-9 months. Yin, et al [6] followed 14 subjects, who were selected for SIJ RFN through response of >70% relief of pain with dual interosseous ligament block with 5cc of 0.5% bupivacaine, for 6 months. RFN was carried out using curved, blunt, 20 guage needles with 10 mm exposed tips and sensory stimulation guided lesioning. Succesful outcomes, as defined by >60% subjective and >50% pain score reduction at 6 months, was reported in 64%. Furthermore, 36% reported complete relief of pain.  Ferrante, et al’s outcomes following bipolar RF strip lesions along the joint line were poor, possibly related to patient selection and RFN methodology[6, 29, 30]. Kapural et al performed cooled RF on 27 subjects selected through two intra-articular SIJ blocks with >50% relief of pain. Two thirds experienced meaningful and statistically significant improvement in pain and function at 3-4 months post-procedure. [7] Karaman also selected patients who experienced at least 75% relief of pain with two SIJ blocks. Cooled RFN resulted in 80% of 15 patients reporting >50% pain reduction and 87% of those had > 10 point reductions of their ODI scores. [8]

 

Speldewinde[5] made use of a palisade technique modified from the method described by Cosman, [5, 31]. 20 patients were selected for SIJ RFN through dual SIJ blocks with 80% relief, and 15 were available for follow up. 12 of 15 had >50% relief and 46% experienced 100% relief of pain.

 

Cohen, et al. [4] published results from a randomized, placebo controlled trial (RCT) of L4-L5 dorsal rami and S1-3 lateral branch (LB) radiofrequency neurotomies (RFN), using cooled probe technology, for the treatment of sacroiliac joint pain.  Patients were selected based on > 75% relief of pain with each of two intra-articular SIJ blocks.  8/14 (57%) of those treated achieved >50% relief of pain and functional improvement at 6 months, whereas 0/14 of the placebo group (sham treatment) obtained that level of improvement.  A statistically significant difference between groups was present for pain (NRS), Oswestry Disability Index, Global Perceived Effect, medication reduction, and percent with a “positive outcome”.  There were no serious complications. Cohen’s outcomes were clinically significant and supportive of the procedure of SIJ RFN, despite his use of only intra-articular SIJ blocks for patient selection.

 

Patel and Gross [3] carried out a randomized (2:1), sham controlled, study of L5DR and S1-3 LB RFN on patients selected for inclusion through dual lateral branch blocks. The LBBs were done using a single site at the lateral margin of each sacral foramen, with injection of 0.5cc of local anesthetic. A successful outcome was defined as > or equal to 50% reduction in pain score, corroborated by significant functional improvement. 16/34 (47%) subjects who received the active treatment met the criteria for success at three months, while only 2/17 (12%) sham treated subjects did so.

 

Study results, as noted above, have been variable. This would be expected when the differences in selection criteria and RFL technique are taken into consideration.  However, the randomized, controlled trials (RCTs) that have made use of larger volume lesions show positive treatment results that cannot be attributed to a placebo effect. What is needed are additional studies using more rigorous selection criteria and larger volume lesions that incorporate the known target lesion zone.  Only then will we know the optimal treatment outcomes and rates of success from the use of RFL to treat pain related to the sacroiliac joint complex.

 

Applying the correct technique for the ablation of the L5 DR and sacral 1-3 lateral branches requires proper training and a precise approach.  A probe that delivers the radiofrequency lesions must be able to provide a higher volume lesion to accommodate the variable and more diffuse location of the target lateral branches. Ideally, this probe would also be available at a price that is affordable.  In recognition of, and as a solution for, these problems, a novel, direction-specific RF probe was designed (Nimbus Concepts, Inc.).  The probe allows for a facile and time efficient technique, which may enhance the probability of adequate coagulation of the targeted L5DR and S1-3 lateral branches.

 

Disclosure: Dr. Bainbridge is the Research Director for Nimbus Spine, LLC, and is leading research protocol development efforts and collaborating with outside researchers who will carry out what we hope will become the definitive clinical trial for the procedure of SIJ RFN.

 

 

1.            Frymoyer, J.W. and W.L. Cats-Baril, An overview of the incidences and costs of low back pain. Orthop Clin North Am, 1991. 22(2): p. 263-71.

2.            Luo, X., et al., Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine (Phila Pa 1976), 2004. 29(1): p. 79-86.

3.            Patel, N., et al., A randomized, placebo-controlled study to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain. Pain Med, 2012. 13(3): p. 383-98.

4.            Cohen, S.P., et al., Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology, 2008. 109(2): p. 279-88.

5.            Speldewinde, G.C., Outcomes of percutaneous zygapophysial and sacroiliac joint neurotomy in a community setting. Pain Med, 2011. 12(2): p. 209-18.

6.            Yin, W., et al., Sensory stimulation-guided sacroiliac joint radiofrequency neurotomy: technique based on neuroanatomy of the dorsal sacral plexus. Spine, 2003. 28(20): p. 2419-25.

7.            Kapural, L., et al., Cooled radiofrequency system for the treatment of chronic pain from sacroiliitis: the first case-series. Pain Pract, 2008. 8(5): p. 348-54.

8.            Karaman, H., et al., Cooled radiofrequency application for treatment of sacroiliac joint pain. Acta Neurochir (Wien), 2011. 153(7): p. 1461-8.

9.            Dreyfuss, P., et al., Sacroiliac joint pain. J Am Acad Orthop Surg, 2004. 12(4): p. 255-65.

10.            Schofferman, J., et al., Failed back surgery: etiology and diagnostic evaluation. Spine J, 2003. 3(5): p. 400-3.

11.            DePalma, M.J., J.M. Ketchum, and T. Saullo, What is the source of chronic low back pain and does age play a role? Pain Med, 2011. 12(2): p. 224-33.

12.            DePalma, M.J., J.M. Ketchum, and T.R. Saullo, Multivariable analyses of the relationships between age, gender, and body mass index and the source of chronic low back pain. Pain Med, 2012. 13(4): p. 498-506.

13.            DePalma, M.J., J.M. Ketchum, and T.R. Saullo, Etiology of chronic low back pain in patients having undergone lumbar fusion. Pain Med, 2011. 12(5): p. 732-9.

14.            DePalma, M.J., et al., Is the history of a surgical discectomy related to the source of chronic low back pain? Pain Physician, 2012. 15(1): p. E53-8.

15.            Depalma, M.J., et al., Does the location of low back pain predict its source? PM R, 2011. 3(1): p. 33-9.

16.            Laplante, B.L., et al., Multivariable analysis of the relationship between pain referral patterns and the source of chronic low back pain. Pain Physician, 2012. 15(2): p. 171-8.

17.            Liliang, P.C., et al., Sacroiliac joint pain after lumbar and lumbosacral fusion: findings using dual sacroiliac joint blocks. Pain Med, 2011. 12(4): p. 565-70.

18.            Standring, S. and H. Gray, Gray’s anatomy : the anatomical basis of clinical practice (Sacroiliac Joint). 40th ed2008, Edinburgh: Churchill Livingstone/Elsevier. xxiv, 1551 p.

19.            Dreyfuss, P., et al., The ability of single site, single depth sacral lateral branch blocks to anesthetize the sacroiliac joint complex. Pain Med, 2008. 9(7): p. 844-50.

20.            Dreyfuss, P., et al., The ability of multi-site, multi-depth sacral lateral branch blocks to anesthetize the sacroiliac joint complex. Pain Med, 2009. 10(4): p. 679-88.

21.            Fortin, J.D., et al., Sacroiliac joint innervation and pain. Am J Orthop, 1999. 28(12): p. 687-90.

22.            Grob, K.R., W.L. Neuhuber, and R.O. Kissling, [Innervation of the sacroiliac joint of the human]. Z Rheumatol, 1995. 54(2): p. 117-22.

23.            Ikeda, R., [Innervation of the sacroiliac joint. Macroscopical and histological studies]. Nihon Ika Daigaku Zasshi, 1991. 58(5): p. 587-96.

24.            Szadek, K.M., et al., Nociceptive nerve fibers in the sacroiliac joint in humans. Reg Anesth Pain Med, 2008. 33(1): p. 36-43.

25.            Vilensky, J.A., et al., Histologic analysis of neural elements in the human sacroiliac joint. Spine (Phila Pa 1976), 2002. 27(11): p. 1202-7.

26.            Szadek, K.M., et al., Possible nociceptive structures in the sacroiliac joint cartilage: An immunohistochemical study. Clin Anat, 2010. 23(2): p. 192-8.

27.            Willard, F., et al, The dorsal sacral plexus and its relationship to ligaments of the sacroiliac joint. Pain Medicine, 2009. 10(5): p. 953.

28.            Burnham, R.S. and Y. Yasui, An alternate method of radiofrequency neurotomy of the sacroiliac joint: a pilot study of the effect on pain, function, and satisfaction. Reg Anesth Pain Med, 2007. 32(1): p. 12-9.

29.            Ferrante, F.M., et al., Radiofrequency sacroiliac joint denervation for sacroiliac syndrome. Reg Anesth Pain Med, 2001. 26(2): p. 137-42.

30.            Hansen, H., et al., A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician, 2012. 15(3): p. E247-78.

31.            Cosman, E.R., Jr. and C.D. Gonzalez, Bipolar radiofrequency lesion geometry: implications for palisade treatment of sacroiliac joint pain. Pain Pract, 2011. 11(1): p. 3-22.

How to Rake Leaves Without Hurting Your Back

October 15th, 2012

How to Rake Leaves Without Hurting Your Back

Stretch before and after

To help alleviate the muscle pain that you feel after raking leaves you need to stretch both before and after your raking sessions. Raking can be an aerobic activity, just like when you do cardio at the gym. When stretching, try to remember that you use your whole body when you are raking. It would also be of benefit to warm up a little prior and do not start when your body is cold.

Use proper body position

Keep your legs slightly bent, keep your weight centered and your back straight.  Reach with your arms and not with your back. Avoid twisting by shuffling your steps and think about moving from your hips in order to reach the area around you. Do not over extend by keeping your strokes short.

Switch the lead arm and leg

Raking is a repetitive motion that can exhaust your muscles.  By switching your lead arm frequently you can help alleviate this problem.

Pace yourself

Do not decide that you are going to go out and handle a large accumulation of leaves in one shot.  The best-case scenario is to break it up over several days so that your muscles will not be overworked.  If this is not possible, try to take breaks and spread it out over the day.  Make sure that you stay hydrated.  Dehydrated muscles are more prone to strain.

Proper rake size

Use a rake that is properly sized for you. Rakes with thicker handles can decrease fatigue in your hands.  There are also several ergonomically shaped rakes that can assist with strain on the spine.

Lifting bags

Bend at the knees and lift with your knees and not from your back.  Keep the weight reasonable for your fitness level and strength.

Work smarter, not harder

Dry leaves are lighter than wet leaves.  While it may not seem like a big deal while raking it will become a lot bigger issue when you have to lift the bag.

Spine Intervention for Allied Healthcare Professionals: A Team Approach

July 11th, 2012




Stem Cell Study to Treat Low Back Pain

July 11th, 2012

Denver Spine Physicians Begin Enrollment in United States Stem Cell Therapy Study
in Subjects with Chronic Back Pain

DenverSpine today announced that it has enrolled its first patient in a nationwide FDA- cleared adult stem cell study testing novel treatment for chronic low back pain. The study will test the use of Mesenchymal Precursor Cells (MPCs) – adult stem cells derived from bone marrow that will be directly injected into the lumbar disc.  The minimally invasive procedure may offer an alternative to back surgery for eligible patients with chronic pain from degenerative discs.

An estimated 30 million people in the United States suffer from back pain. Degenerative disc disease is the most common cause of low-back pain, which develops with the gradual loss of a material called proteoglycan, which cushions the bones of the spine and enables normal motion.

Most patients with low-back pain respond to physical therapy and medications, but in advanced cases, artificial disc replacement or spinal fusion — removal of the degenerated discs and the fusion of the bones of the spine — is necessary. However, these surgeries often are not entirely effective.

J. Scott Bainbridge, M.D. is the lead researcher providing spinal injections for the study, and Gary Ghiselli, M.D. is the principal investigator. Both doctors agree on the critical need for a minimally invasive solution to a common, debilitating condition.

“The study is the first of its kind in the United States and we are very excited by the potential of these adult stem cells to provide a novel therapeutic approach,” said Dr. Bainbridge.

Researchers will enroll approximately 100 study participants. About 10 – 20 participants will be enrolled at the Denver site and the rest at 11 other medical centers throughout the United States.  The trial is scheduled to last for three years.

DenverSpine is enrolling study participants suffering from moderate low-back pain for a minimum of six months and whose condition has not responded to other, conventional treatments.

Once enrolled, patients are randomly assigned to one of four treatment groups:

  • One group will receive a high dose of MPCs, plus hyaluronic acid, a substance that facilitates the localization and retention of the stem cells;
  • A second group will receive a lower dose of MPCs, plus the hyaluronic acid;
  • A third group will receive the hyaluronic acid alone;
  • A fourth group will receive only the saline solution.

Patients will receive a single injection of their assigned test agent directly into the center of the target discs within their spine and will be monitored for safety.  Patients will also be monitored using imaging to identify any changes in their disease condition or disease progression. Use of pain medications, self-reports of pain, subsequent surgical interventions and assessments of disability, quality of life, productivity and activity will be evaluated. Repair of the disc and reduction of chronic back pain will be assessed in each patient.

Promising results have been observed in prior research using animal models when stem cells were investigated for the repair of damaged spine discs. The cells were well tolerated in these study animals.

This study is sponsored by Mesoblast Limited, a world leader in the development of biologic products for the broad field of regenerative medicine.  Mesoblast has the worldwide exclusive rights to a series of patents and technologies developed over more than 10 years relating to the identification, extraction, culture and uses of adult Mesenchymal Precursor Cells (MPCs).  The MPCs are derived from young adult donors’ bone marrow and are immune tolerant.

For more information, go to www.denverspine.com.

For additional information on the clinical trial, please see the listing on www.clinicaltrials.gov study identifier number NCT01290367

Behavioral and Psychological Interventions

April 22nd, 2012

Behavioral and Psychological Interventions

Spine or other pain is experienced by each individual through a complex interaction of neurological (peripheral and central), psychological, and social variables. Pain elicits various autonomic, neuro-protective, and affective responses. (Turk, Swanson et al. 2010) These physiologic and cognitive-behavioral responses can be altered with appropriate training and insight, leading to partial control of central processing of pain, or influence the activation of descending pain inhibition pathways. (Fishman, Ballantyne et al. 2010; Lorenz and Hauck 2010) Training in one or more behavioral interventions for [chronic] pain might impart effective pain management tools and strategies for cervical radiculopathy (CR) patients. (van Tulder, Ostelo et al. 2000; Argoff, Albrecht et al. 2009; Jain 2009; Jain, Culpepper et al. 2009; Henschke, Ostelo et al. 2010) Persson, et al (Persson and Lilja 2001) found that patients with CR often have concomitant behavioral or emotional dysfunction and suggested that treatment outcomes were enhanced by the inclusion of a cognitive-behavioral approach to the treatment program. It is clear that catastrophizing, fear of pain, and anxiety can have an impact on the pain experience. (Hirsh, George et al. 2008) There is evidence that catastrophizing has a biological influence on the endogenous opiod pain-control systems, systemic inflammatory processes, and may influence muscle tone, blood pressure, and heart contractility responses to pain. (Campbell and Edwards 2009; Quartana, Campbell et al. 2009) It is important to address depression, anxiety, and sleep disturbances as part of a comprehensive treatment program. (Smith, Quartana et al. 2009; Fishman, Ballantyne et al. 2010; McCracken 2010)

Reviews of biopsychosocial rehabilitation (Karjalainen, Malmivaara et al. 2001) and patient education (Haines, Gross et al. 2009) programs for the treatment of neck pain have not revealed high quality studies which would support these approaches. Nevertheless, it is recommended that conservative care practitioners include behavioral interventions in their conservative treatment plans, and develop a network of behavioral intervention providers so that treatment options can be paired with the unique needs and preferences of each subject.

Psychological Interventions:
SuggestedRequired:
1. Informal psychological inquiry screening may be carried out by the physiatrist, at the time of entry evaluation,done in all patients in order to screen for evidence of depression, anxiety, sleep disorder, high addiction potential, or other psychological disorders, which may influence subjects’ response to treatment. Patients will also be provided with educational written material, making them aware of some of the signs of depression, insomnia, or anxiety, as well as an introduction to some of the treatment strategies that may assist with pain management (Appendix IV). This will include an invitation to discuss these matters with their physician. Identified disorders should be treated with specific psychological, and possibly pharmacological, interventions.

2. One or moreAt least one of the following approaches maymust be offered to patients (Argoff, Albrecht et al. 2009): cognitive behavioral therapy (CBT), habit reversal, relaxation training, biofeedback, meditation, hypnosis and guided imagery, assertiveness skills training, and patient education. Written educational material can also be provided to each patient (download available).

Appendix:

Psychological Education Materials for Patients

It is well known and accepted that your state of mind can have a significant impact on how you perceive and manage your pain. There are many non-medication strategies that can be used to gain some control over how you are affected by pain. Treating associated problems such as depression, anxiety, or insomnia, which frequently accompany pain, can also help reduce pain levels.

Recognizing the signs of depression is not always easy. If you are experiencing feelings of sadness, emotional ups and downs, have lost interest in social or other (previously) fun activities, have trouble getting out of bed in the morning, have lost your appetite or energy, have a sense of hopelessness, you feel agitated or anxious, then please do not hesitate to discuss these symptoms with your doctor. These may be signs of depression or another medical condition.

Anxiety, the frequent feeling of nervousness, fear, or feeling uptight, can be present with or worsen in response to pain. It, in turn, can make your experience of pain tougher to cope with. Also, a lack of restful sleep can have a negative effect on your ability to manage pain. If you are experiencing significant difficulty sleeping, whether it is from pain, worry, or other reasons, you should bring this to the attention of your doctor.

There are many ways to deal with pain or associated problems with mood, anxiety, or sleep. Aerobic (cardio) exercise can be very helpful because it causes the release of chemicals in the brain that are helpful for all of these problems. This makes exercise an ideal form of pain and stress management. Your goal should be to gradually increase the amount of weekly exercise to 2 ½ total hours of moderate to vigorous exercise. Choose a form of exercise that you can tolerate and enjoy, and consider mixing types. Biking, walking, swimming or pool walking, endurance strength training, yoga, Tai Chi, or Pilates are good examples. Seek guidance on the safety or appropriateness of these exercises for you, specifically, from your doctor or physical therapist.

Relaxation training can be done with the help of instructional recordings, biofeedback specialists, or pain psychologists. This can be an excellent way to control pain or anxiety, and to promote sleep.

Good sleep “hygiene” includes the avoidance of television or computer work in bed before sleep, stopping caffeine at or before lunch, and having a notepad by your bedside to write down any recurring thoughts or ideas so that you can “let them go”.

These and other useful ideas for managing your pain can be learned through the help of a pain psychologist, or by working with other specialists. Your doctor can help counsel you, or direct you to the approach or specialist that is right for you. Medications may occasionally be used to treat pain, depression, anxiety, or sleep disorders, as well.

Cervical Epidural Steroid Injections (CESI) and Other Interventions for the Treatment of Neck and Upper Extremity Pain

April 22nd, 2012

Cervical Epidural Steroid Injections (CESI) and Other Interventions for the Treatment of Neck and Upper Extremity Pain

Cervical epidural steroid injections are the only form of conservative treatment for cervical radicular pain (CR) that has supportive data and some consensus opinion(Carragee, Hurwitz et al. 2008; Bono 2010) of their efficacy. There is evidence for the use of cervical transforaminal epidural steroid injections (CTFESIs) (Bush and Hillier 1996; Slipman, Lipetz et al. 2000; Vallee, Feydy et al. 2001; Cyteval, Thomas et al. 2004; Lin, Lieu et al. 2006; Anderberg, Annertz et al. 2007; Huston 2009; Lee, Park et al. 2009; Bono 2010), and also evidence supporting the use of cervical interlaminar epidural steroid injections (CILESIs) (Ferrante, Wilson et al. 1993; Stav, Ovadia et al. 1993; Kwon, Lee et al. 2007; Huston 2009). There are theoretical advantages, and known risks, to either approach, however (Huston 2009). CTFESIs offer the advantage of injection of local anesthetic and corticosteroid in a directed and concentrated manner to the involved nerve root(s). There have been cases of severe neurological injury or death with this approach, and there has been discussion in the literature regarding the risk vs. benefit of performing CTFESIs. (Brouwers, Kottink et al. 2001; Smuck, Rosenberg et al. 2009) The risks of CTFESI are minimized when a standardized technique, avoidance of excessive sedation, and soluble steroid are used. (Baker, Dreyfuss et al. 2003; De Cordoba and Bernal 2004; Rathmell, Aprill et al. 2004; Dreyfuss, Baker et al. 2006; Derby, Lee et al. 2008; Malhotra, Abbasi et al. 2009) Interlaminar ESIs offer the possible advantage of using particulate steroids, and targeting can be relatively well focused with a paramedian approach and the use of low volumes of injectate, although significant complications are still possible. (Siegfried 1997; Hodges, Castleberg et al. 1998; Field, Rathmell et al. 2000; Stojanovic, Vu et al. 2002; Abbasi, Malhotra et al. 2007; Huston 2009) Both approaches are reasonable options.

Additional CESIs can be offered towards the goals of the extinction of symptoms or the restoration of the initial response. It is postulated that the use of repeat injections, when there is a partial response to the prior, may lead to complete relief of pain, and, the best chance of establishing long term improvement of CR symptoms. Likewise, the use of additional injections to treat recurrent pain, following an initial cessation or substantial reduction of pain, may lead to improved long term outcomes.

It is important to ensure that providers of these injections are experienced, safe, and competent, and that they agree to use standardized procedural techniques (Stojanovic, Vu et al. 2002; Baker, Dreyfuss et al. 2003; Bogduk 2004; De Cordoba and Bernal 2004; Rathmell, Aprill et al. 2004; Schellhas, Pollei et al. 2007; Huston 2009). The recommended CILESI technique, as noted by Huston, should be modified to utilize a paramedian approach, due to the known incidence of absence of an interlaminar ligament/flavum in the midline, and a 50% chance of unilateral (but uncontrolled) flow of injectate from the midline. A paramedian approach somewhat controls for these variables. This necessitates the use of the “laminar” or ”rooftop” fluoroscopic view to check depth during the procedure.

The concomitant presence of both discogenic and facetogenic pain may be more prevalent in the cervical spine than in the lumbar spine. (Bogduk and Aprill 1993; Bogduk 2004) It is probable that there are not an insubstantial number of patients with CR who will also have pain and disability from concomitant cervical zygapophysial joint generation. Treatment of this cervical Z-joint (CZJ) related pain (or lumbar facet pain) might be indicated to optimize outcomes with CR. This would apply primarily to those cases where the presenting radicular pain has subsided, but there remains sufficient axial pain to effect patients’ reporting of pain, healthcare utilization, and disability. Use of standard techniques for CZJ related intra-articular, medial branch (MB) block, and MB radiofrequency neurotomies is required. (Fenton, Czervionke et al. 2003; Bogduk 2004) CZJ (or LZJ) procedures may be offered according to practice parameters based on parallel (lumbar) guidelines offered by Noridian in their coverage determination for Lumbar Z-Joint procedures (See Noridian Facet Coverage Determination), as well as the work of Lord, Barnsley, and others. (Lord, Barnsley et al. 1995; Lord, Barnsley et al. 1995; Lord, Barnsley et al. 1996; Lord, Barnsley et al. 1996) These guidelines (Noridian) were based on a multi-specialty, multi-society collaborative effort to reach consensus on the proper utilization of these (lumbar) procedures.

The judicious use of trigger point injections, dry needling, or similar myofascial approaches is acceptable, up to a maximum of 4-8 sessions(Goldman and Rosenberg 1991; Stav, Ovadia et al. 1993; Peloso, Gross et al. 2005; Dommerholt and Shah 2010).

Cervical Epidural Steroid (and other) Injections:

1. 1 – 2 (see exception below) and up to 56 total cervical ESIs [transforaminal (fluoroscopy, DSA if available, test dose, soluble steroid) and/or interlaminar (fluoroscopy, contrast, particulate steroid)] per first year of treatment, with up to 3 the subsequent year.
a. Second ESI 2 weeks after first, if less than 90% sustained relief of pain
b. If less than 50% sustained relief with first injection, second ESI should be through opposite route from first (TFESI vs. ILESI)
c. Third and subsequent injections may be done if > 50% sustained (> 2 weeks with second or > 6 weeks with third or subsequent injections) relief from earlier procedure(s). Goal of extinction of symptoms or re-instatement of initial response. 4th and subsequent ESIs should be spaced at least 3 months apart.
d. Avoid total corticosteroid exposure (from all sources – ESI, intra-articular, or p.o.) of > 5 mg/kg (triamcinolone or equivalent) per 6 month period.
e. See above for rationale and references

Optional:
2. CZJ/LZJ procedures may be included when indicated (may include intra-articular steroid injection and/or median branch block with subsequent radiofrequency ablation if successful) (Appendix II)
3. Trigger point injections or dry needling when indicated (maximum 6 sessions)

Physical Therapy for Cervical Radicular Pain

April 22nd, 2012

Physical Therapy for Cervical Radicular Pain

Physical therapy, when treating neck and/or arm pain, is more efficacious if performed in a multi-modal fashion – combining stretch, strength, and manipulation/mobilization components (Gross, Kay et al. 2002; Kay, Gross et al. 2005; Salo, Hakkinen et al. 2010) or when combined with other treatment options (Saal, Saal et al. 1996). Systematic reviews of the use of mechanical traction (Graham, Gross et al. 2006; Graham, Gross et al. 2008) or massage (Haraldsson, Gross et al. 2006; Ezzo, Haraldsson et al. 2007) have not revealed strong evidence for their use, although inclusion of these modalities as part of a comprehensive physical therapy program is believed to be warranted. The inclusion of “directional preference” and “centralization” principles has been commonly employed in therapy programs to treat neck pain. (Kjellman and Oberg 2002; Moffett and McLean 2006; Moffett, Jackson et al. 2006) Cervical stabilization, with or without concomitant mobilization or manipulation, has been beneficial in treating axial neck pain, cervical radiculopathy, or headaches. (Jull, Trott et al. 2002; O’Leary, Falla et al. 2003; Bronfort, Haas et al. 2004; Costello 2008; Dusunceli, Ozturk et al. 2009; D’Sylva, Miller et al. 2010; Gross, Miller et al. 2010) Strategies to overcome barriers to non-adherence to a long-term self-care program would include patient education, promotion of “self-efficacy”, and assistance in overcoming anxiety and fear-avoidance behaviors. (Moffett, Jackson et al. 2006; Jack, McLean et al. 2010)

There are various approaches or “schools” of physical therapy for the treatment of cervical spine disorders. These include those of McKenzie (www.mckenziemdt.org) (McKenzie and May 2006), Sahrmann (Sahrmann 2011), Comerford (www.kineticcontrol.com) (Comerford and Mottram 2001; Comerford and Mottram 2001; Mottram and Comerford 2006), and others (Grant 2002; Cooper and Chait 2010). While it is not practical or possible to have PT providers certified, or even well versed, in all of the possible schools of cervical physical therapy, it is important that they be experienced and educated in cervical spine care. They may draw from various PT approaches, based on their level of expertise in each area. It is expected that each therapist may have a primary approach that they employ for spine care, but they are expected to be able to draw from all “schools” in order to provide individualized care to each subject while conforming to the “guidelines” of treatment. Spine physicians should have working relationships with multiple PT facilities and groups so that reasonable PT geographic location options are available to patients. This will greatly enhance patient participation.

A stepped, multi-modal physical therapy approach was taken with the physical therapy protocol (see Appendix III). (Moffett and McLean 2006) It should be emphasized that the protocol represents a guide, and the education and experience of each physical therapist should be matched with the individual needs of each patient/subject. Each of the elements of this protocol should be included, however, for each patient, when possible and appropriate.

Physical Therapy (2-3 times per week for total of 6-12 sessions):
Recommended:
1. Postural and ergonomic education
2. Postural, directional preference, and stability exercise training
3. Trial of 1-3 manual and/or mechanical cervical traction sessions
a. Home traction with pneumatic (or OTD) device if positive trial
4. Manual therapy limited to grade 3 joint mobilization (muscle energy technique; no HVLA manipulation of cervical spine)
5. Strength, stretch, and conditioning (including aerobic) exercise
6. Development of home exercise and symptom management program
7. Evaluation of subjects’ knowledge of appropriate exercise, ergonomic, and symptom management program details before discharge.

Optional:
1. Home traction with pneumatic (or OTD) device if positive traction trial
2. Physical modalities– electrical stimulation, US, heat/ice, etc.
3. Soft tissue massage, myofascial release
4. HVLA manipulation of thoracic spine

Overview of Guide for Conservative Treatment of Cervical Radicular Pain

April 22nd, 2012

Cervical and Lumbar Spine Radicular And Axial Neck and Back Pain Conservative Treatment Guide

J. Scott Bainbridge MD

DenverBackPain.org

11.20.2011

Overview

This treatment guide was originally written for a research protocol, to guide the conservative treatment of cervical radicular (shoulder/arm) pain. This guide also serves, however, to help direct the care of neck and back pain, and, lumbosacral and thoracic radicular pain.

The conservative management of spine related pain and dysfunction requires a multi-disciplinary approach. Optimizing outcomes relies on the physiatrists’ use of physical, pharmacologic, and psychological options to provide individualized and comprehensive pain management and functional rehabilitation programs for each patient.

Physiatrists, or other conservative spine care providers, must also be able to provide counseling regarding the option of surgical consultation, in the context of a comprehensive care plan. Circumstances such as severe and disabling pain, progressive weakness, or loss of balance, coordination, or bowel or bladder function may require urgent surgical intervention.

Stem Cells for Low Back Pain

April 20th, 2012

Denver Spine Physicians Begin Enrollment in United States Stem Cell Therapy Study
in Subjects with Chronic Back Pain

DenverSpine today announced that it has enrolled its first patient in a nationwide FDA- cleared adult stem cell study testing novel treatment for chronic low back pain. The study will test the use of Mesenchymal Precursor Cells (MPCs) – adult stem cells derived from bone marrow that will be directly injected into the lumbar disc.  The minimally invasive procedure may offer an alternative to back surgery for eligible patients with chronic pain from degenerative discs.

An estimated 30 million people in the United States suffer from back pain. Degenerative disc disease is the most common cause of low-back pain, which develops with the gradual loss of a material called proteoglycan, which cushions the bones of the spine and enables normal motion.

Most patients with low-back pain respond to physical therapy and medications, but in advanced cases, artificial disc replacement or spinal fusion — removal of the degenerated discs and the fusion of the bones of the spine — is necessary. However, these surgeries often are not entirely effective.

J. Scott Bainbridge, M.D. is the lead researcher providing spinal injections for the study, and Gary Ghiselli, M.D. is the principal investigator. Both doctors agree on the critical need for a minimally invasive solution to a common, debilitating condition.

“The study is the first of its kind in the United States and we are very excited by the potential of these adult stem cells to provide a novel therapeutic approach,” said Dr. Bainbridge.

Researchers will enroll approximately 100 study participants. About 10 – 20 participants will be enrolled at the Denver site and the rest at 11 other medical centers throughout the United States.  The trial is scheduled to last for three years.

DenverSpine is enrolling study participants suffering from moderate low-back pain for a minimum of six months and whose condition has not responded to other, conventional treatments.

Once enrolled, patients are randomly assigned to one of four treatment groups:

  • One group will receive a high dose of MPCs, plus hyaluronic acid, a substance that facilitates the localization and retention of the stem cells;
  • A second group will receive a lower dose of MPCs, plus the hyaluronic acid;
  • A third group will receive the hyaluronic acid alone;
  • A fourth group will receive only the saline solution.

Patients will receive a single injection of their assigned test agent directly into the center of the target discs within their spine and will be monitored for safety.  Patients will also be monitored using imaging to identify any changes in their disease condition or disease progression. Use of pain medications, self-reports of pain, subsequent surgical interventions and assessments of disability, quality of life, productivity and activity will be evaluated. Repair of the disc and reduction of chronic back pain will be assessed in each patient.

Promising results have been observed in prior research using animal models when stem cells were investigated for the repair of damaged spine discs. The cells were well tolerated in these study animals.

This study is sponsored by Mesoblast Limited, a world leader in the development of biologic products for the broad field of regenerative medicine.  Mesoblast has the worldwide exclusive rights to a series of patents and technologies developed over more than 10 years relating to the identification, extraction, culture and uses of adult Mesenchymal Precursor Cells (MPCs).  The MPCs are derived from young adult donors’ bone marrow and are immune tolerant.

For more information, go to stem cell treatment for low back pain.

For additional information on the clinical trial, please see the listing on www.clinicaltrials.gov  study identifier number NCT01290367

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