Category: Painful Conditions

PIRIFORMIS SYNDROME

Overview

The piriformis, located deep within the buttocks, is a large muscle with two large sections. The sciatic nerve is a large nerve running from the base of the spine down through the back of the leg and passes through the two piriformis muscle bundles. If the muscular tissue or the connective tissue around this muscle becomes inflamed or swollen, it can irritate the sciatic nerve and cause pain that reaches from the buttocks down through the leg. Some patients will complain of lower back pain as well. Typically pain is worse while sitting and especially while driving a car.

Diagnosis

During a physical examination the piriformis muscle is tender. Stretching the muscle will often cause a painful reaction. The neurologic exam is usually normal.  Symptoms of piriformis syndrome can be similar to symptoms for spinal disorders that affect the sciatic nerve such as a ruptured disk. X-ray studies of the spine such as a CT scan and a MRI are used to insure there is not a spinal pathology causing the pain. MRI scanning of the piriformis area itself can sometimes show enlargement of the piriformis muscle with compression of the sciatic nerve. An injection of anesthetic medications around the piriformis muscle and sciatic nerve helps confirm the diagnosis. A biomechanical screen performed by the physical therapist can also help confirm the diagnosis.

Treatment

Many patients will find relief  from  the pain with injection therapy around the piriformis muscle and sciatic nerve. Physical therapy is also very important in treating this syndrome. Patients with piriformis syndrome will be asked to perform exercises to stretch and condition the large muscles in the gluteal region. This will help reduce the number of muscle spasms and irritation of the connective tissue around the sciatic nerve. For some patients the use of behavioral therapy, including biofeedback techniques, helps control some of the excess muscle irritability and reduces the pain. This permits the patient to progress more efficiently through their course of physical therapy. In extreme cases of piriformis syndrome, surgery is considered, but only after conservative measures have failed.

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OSTEOARTHRITIS

Overview

Osteoarthritis is a disorder affecting our joints; causing pain and gradual deterioration of function. Every joint is composed of two bones with a gap between them. Lining the bone on either side of the gap is a smooth material called cartilage that allows the joint to move freely. In the gap between the two cartilage surfaces is joint fluid. Around the joint is a capsule called the synovium. It contains the joint fluid. Overlying the synovium are ligaments and muscles keeping the joint intact and the bones in place.

In osteoarthritis there is a progressive loss of the smooth cartilage, exposing the rough bone underneath. The bone will compensate by increasing its growth. This causes spur formation where the ligaments and capsule attach to the bone. This combination of exposed bone and spurs make the joint stiff and painful. The causes of osteoarthritis are:

• Joint overuse
• Obesity
• Fractures
• Trauma to the soft tissues (cartilage)
• Genetics

Diagnosis

The primary symptom of osteoarthritis is joint pain and stiffness. Sometimes the pain can be directed to some other area of the body that has a nerve connection with the joint. Patients with osteoarthritis of the hip may actually feel pain in their groin or knee. Patients with osteoarthritis of the spine may feel pain in the hip. If these symptoms are present, the doctor will order an X-ray, test the joint fluid and order blood tests to make sure there is no other disease present.

Treatment

Treatment of osteoarthritis should include medications, strength training, weight loss, minimal joint impact and surgical replacement of certain joints when necessary. Strength training is extremely important in patients with osteoarthritis. Avoiding physical activity causes the muscles around the joint to decrease in size or atrophy. As the muscles atrophy, the joint becomes less stable and that can have a negative effect on osteoarthritis. It is important to keep our body weight at ideal levels. Excessive body weight puts additional stress on the joint causing more pain. Using a walker or cane can make the joint feel better.

Your doctor may prescribe certain medications. There are over 17 different drugs, called non-steroidal anti-inflammatory agents (NSAID) that are useful in the treatment of osteoarthritis. These drugs include medications such as ibuprofen, aspirin and Naprosyn. It is important to realize these drugs have significant side effects such as ulcer formation, water retention, increased blood pressure and increased stress on the kidneys and liver. Your doctor will want to monitor your response to these drugs very closely.

Depending on the location of the arthritis, injections can sometimes be given into the joint or adjacent nerve to help relieve the pain associated with a sudden flare up. The injection may require the use of an X-ray machine for accurate placement. If the injection is painful to administer, a light intravenous sedative such as Valium can be used to make the procedure comfortable. In some patients the joint function deteriorates so badly that surgery is the best option. Surgery is commonly used to replace the joints of the knees, hips and fingers. Other joint replacement surgeries such as the shoulder are being developed and with time may be as successful as hip and knee replacement.

It is important to remember to stay very active despite the osteoarthritis. Non-impact exercises such as bicycling and swimming are ideal. Strength training is very beneficial when done appropriately.

Prevention

• Maintain ideal body weight
• Low-impact activities
• Proper strength training

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FIBROMYALGIA

Overview

Fibromyalgia is a very common disorder that results in chronic pain and stiffness in various muscle groups throughout the body without active inflammation. The pain seems to originate in the tendons, muscles and ligaments, excluding the joints. It is estimated five million Americans, usually between the ages of 20 and 50, experience fibromyalgia. Fibromyalgia seems to be associated with physically unfit muscles and poor conditioning. Muscles that are unable to withstand physical demands will begin to ache and hurt. A classic example is a poorly muscled woman performing manual labor in a factory on a repetitive basis. This can cause an aching in the shoulder or between the shoulder blades due to excessive muscle demands. Smoking also tends to aggravate fibromyalgia. This is because nicotine is a muscle stimulant and increases the demands of the muscle. In addition, there seems to be links between sleep disorders and fibromyalgia. Sleep studies have shown patients with fibromyalgia have decreased rapid eye movement (REM) sleep, or dream sleep. During REM sleep, we manufacture chemicals in our brain, which elevate our pain threshold. Patients who have disturbed sleep have low levels of these chemicals and have an increased perception of pain. Stress also has a negative impact on fibromyalgia. Trauma, surgery, medical illness and emotional turmoil have all been suspected as agents that can trigger fibromyalgia.

Diagnosis

The primary symptom of fibromyalgia is pain. This can occur in any muscle, tendon, or ligament in the human body, but is most common around the shoulder girdles, neck, low back and hips. Certain areas of the muscle can become extremely tender. These are called trigger points. Trigger points are generally in the same place from patient to patient, and help confirm the diagnosis. Another primary symptom of fibromyalgia is fatigue, which may be secondary to the sleep disturbance that is common with fibromyalgia. Other common symptoms associated with fibromyalgia include headaches, irritable bowel, dizziness and bladder spasms. Upon physical examination, the doctor will note the patient to have the characteristic trigger points of fibromyalgia. Above and beyond this, however, there are no specific laboratory tests or x-rays to confirm the diagnosis. Nonetheless, your doctor may order certain tests to rule out other disorders like rheumatoid arthritis.

Treatment

There are two primary treatments for fibromyalgia; exercise and anti-depressants. Since the disorder seems to be related to poorly conditioned muscles, it is very important to strengthen muscles. This can be done with a regular exercise program involving strength training at home as well as under the guidance of a physical therapist. It is important to maintain ideal body weight so unnecessary stress is not placed on the poorly conditioned muscles. Eating a well-balanced diet low in fat is helpful.

Anti-inflammatory drugs, which have pain-relieving qualities, such as aspirin and ibuprofen, do not seem to work well in fibromyalgia. Tylenol is a better drug because it does not cause ulcers or irritate the stomach and intestines the way the anti-inflammatory drugs do. The most useful medications in the treatment of fibromyalgia are the anti-depressant drugs like Pamelor and Sinequan, which raise levels of chemicals in our brain, that are the body’s mood elevators. We now know these mood elevators are also the body’s natural pain relievers. Anti-depressants have the additional benefit of inducing deeper sleep. In severe flare-ups of fibromyalgia, injections can be used to control pain that is restricted to one area of the body like the neck and shoulder. Injections of local anesthetics and small doses of anti-inflammatory drugs can be given.    This can be very useful to control the pain and allow the patient to become more functional. Generally the injections are given as a series of two to four over a period of weeks. When the injections are stopped, the patient is observed to see how long the relief lasts. If the pain relief lasts at least a number of months, the injections can be given again in the presence of a recurrent attack.

Prognosis

The long-term outlook for patients with fibromyalgia  is generally very good. Patients do not have to worry about joint destruction or neurological damage. Moreover muscles respond well to an active exercise program. By working closely with your doctor, exercising on a regular basis, building strength and taking prescribed medications, patients with fibromyalgia can lead a normal life.

Prevention

• Avoid smoking
• Stress reduction and relaxation Proper diet
• Proper strength training Regular activity
• Maintain ideal body weight Get enough sleep

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SPINAL ARTHRITIS

Overview

Spinal arthritis is a very common disorder affecting millions of Americans. When it occurs in the neck it is called cervical spinal arthritis. When it involves the low back it is called lumbar spinal arthritis. It begins to affect many people in their 30’s. By the age of 40, 50% of people will have evidence of spinal arthritis on an X-ray or CT scan. By the age of 50, that number rises to 100 percent.

Arthritis begins as a low-grade inflammation of the soft tissues surrounding the joints. The joints are composed of a delicate tissue called articular cartilage. It is a very smooth surface and allows the two bones composing the joint to glide over one another easily. Around the articular cartilage is a capsule of soft tissue called synovium. This capsule contains the joint fluid that lubricates the articular cartilage. Inflammation first begins in the capsules. Because the capsules are composed of soft tissue, they cannot be visualized on x-ray. As the arthritis progresses, the surface of the joints becomes pitted and gradually deteriorates. As the articular cartilage erodes, the bones underneath respond to the stress by forming spurs. This erosion and spur formation is a later finding that can be viewed on X-rays.

Diagnosis

Patients with spinal arthritis will develop pain in the neck or low back. That pain can spread to the arms or legs as the inflammation from the joints begins to affect the spinal nerves next to the joints. The pain may be worse in the morning because the joint stiffens during the night. As the day progresses, the joint gradually loosens up and symptoms get better. As the pain progresses, the patient will frequently go to the doctor to see what is wrong. The doctor will conduct a history and physical exam and may order blood tests and X-rays to confirm the diagnosis. The most sensitive test is the CT scan. This is capable of picking up arthritis at a relatively early stage. However, in most symptomatic patients, a simple X-ray will suffice.

Treatment

Many patients can find meaningful relief with a combination of therapies. The initial approach to early arthritis should involve a modest exercise program to keep the joints flexible; usually non-weight bearing exercises such as water aerobics to put the spine through a gentle range of motion and to enhance its flexibility. As arthritis progresses, medications such as aspirin may be necessary. There are now over 17 different types of compounds resembling aspirin on the market. These include drugs like Motrin or Naprosyn. Many patients with spinal arthritis find excellent relief with these anti-inflammatories, however there are some troublesome side effects such as stomach ulcer formation, high blood pressure, and deterioration of the liver or kidneys. Patients on these drugs have to be monitored by their doctor with blood tests taken at least once a year.

If gentle exercises and oral medications fail to control the discomfort, the patient can try a back or neck brace to inhibit the joint’s movement and to allow it to rest for a short period of time. Wearing a brace long term is controversial because it will cause weakening of the spinal muscles, which can worsen symptoms.

In severe cases of spinal arthritis, the patient may be a candidate for nerve block techniques. With nerve blocks, anti-inflammatory medications are injected directly into the joints or nerves. Once the inflammation decreases, the pain decreases. These steroid drugs are generally given as a short series of injections, usually two or three, over a period of weeks. If the patient gets relief lasting at least a few months, the drugs can be used again if the symptoms recur.

It is important to realize spinal surgery cannot relieve the pain of spinal arthritis. Even if a surgeon removes an arthritic joint, the tendency to form arthritis is still present in all the other elements of the spine so the pain will continue. Only if there is pressure being placed on the nerve by a single spur, can surgery be beneficial. The surgeon can remove the spur, alleviating the pressure and pain associated with nerve compression. Nonetheless, the tendency to form arthritis still remains and another spur may develop in a matter of years.

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INSOMNIA

Overview

Insomnia is the inability to fall asleep or remain asleep. It is a large problem in our society, but fortunately for most people, insomnia occurs only on occasion. However, for others insomnia can become chronic. Early morning awakening can become a problem resulting in persistent sleepiness during the day. Contributing factors to insomnia consist of:

• Change of environment
• Drug abuse / alcoholism
• Depression Lack of physical activity
• Grieving the death of a loved one
• Certain medications
• Medical problems
• Caffeine consumption
• Stress
• Eating late
• Improper diet

Diagnosis

Insomnia may be related to other health problems, therefore, it is important to tell the doctor about sleep problems. A diagnosis of insomnia is based on:

• History
• Physical
• Diagnostic tests
• Sleep lab findings

Treatment

Primary treatment is to avoid those elements causing the insomnia. Long-term drugs are not appropriate because they interfere with the body’s normal rhythm and over time will decrease the restful function of normal sleep. Because patients begin to feel their sleep is poor, they may take more and more medications, entering a viscous cycle. It is okay to take a sleep-inducing drug on occasion when difficulty sleeping is anticipated, such as a business trip or stimulating vacation.

Prevention

• Reduce stress
• Avoid caffeine (especially after dinner)
• Relax two hours before bedtime e.g: read, meditate, journal. Do not go to bed tense.
• Exercise regularly.
• Move your body regularly throughout the day.
• Practice the same routine every night.
• Wake at approximately the same time of day.
• Make a quiet sleep environment.

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