<![CDATA[Spine Pain Diagnostics Associates - Specially Trained Physicians to Diagnose and Manage Pain - BLOG]]>Thu, 02 May 2019 01:34:32 -0500Weebly<![CDATA[Whiplash and Whiplash Related Disorders]]>Wed, 01 May 2019 17:03:11 GMThttp://www.paindiagnostics.net/blog/may-01st-2019Many people suffer from a condition commonly known by the name “whiplash injury”.  This condition is caused by a sudden acceleration/deceleration of force; the head and neck are hyper extended when whipped backward and immediately following, the head and neck are thrown forward and hyper flexed. This motion is usually caused by car accidents, falls, horseback riding, snowboarding, skiing, and contact sports. Following such an incident, the muscles and many other structures of the neck are sometimes left damaged. The symptoms involved with this condition include pain in the neck, shoulder, back, jaw and/or arm; headaches, dizziness, and weakness are common as well.
Often, the pain from whiplash injury doesn’t start until hours or even days after.  But once it arrives, it can partner with other strange symptoms, including dizziness, ringing in the ears, hearing loss, insomnia, the loss of concentration, fatigability, memory loss, jaw pain, chest pain and even fever.  The combination of any of these symptoms with a known whiplash injury is called whiplash associated disorder.
The trauma caused by whiplash injury can be very elusive. Consequently, it is not uncommon for X-Rays, MRIs, and CAT scans to not show the source of the problem.  In order to properly treat whiplash, it is important to understand the progression of a patient’s symptoms.  The multiple factors revolving around the injury make management of the pain highly variable from patient to patient. Our physicians will listen closely to the patient and may also rely on advanced minimally invasive spinal interventions to locate the exact source of the pain.  Once the source has been determined they can develop an appropriate treatment plan. Nerve blocks under imaging guidance are a specific interventional technique that aid in both the identification of the pain source and its subsequent treatment. 
Evaluation and treatment of all whiplash related pain is recommended as soon as symptoms appear. If the condition is ignored, whiplash pain has the potential to become chronic. 

If you or a loved one is suffering from whiplash injury, contact Spine Pain Diagnostics Associates today.  We have over 45 years of combined experience in treating whiplash injuries and can help you find relief from your lingering pain.  Don’t continue suffering and masking your pain with pain medications, let the physicians at Spine Pain Diagnostics Associates treat it at the source so you can get back to enjoying life.
For more information or to schedule an appointment, you can visit our website at www.paindiagnostics.net or call us 1-888-PAIN.DRS.  In most cases, no referral is necessary and we accept most major insurances.
<![CDATA[Spinal Stenosis]]>Thu, 28 Mar 2019 20:01:34 GMThttp://www.paindiagnostics.net/blog/spinal-stenosis​Back pain, specifically low back pain, is the leading cause of disability in the country.i  More than depression.  More than diabetes.  Low back pain is the number one contributor to years of life with disability. 
Spinal stenosis is an abnormal narrowing of a space in the vertebra.  Nerves, arteries and other non-bony tissues pass through these spaces.  When this narrowing interferes with these tissues you can have pain, numbness and, if sever, poor muscle control.  The disease typically occurs in the low back or neck, and is more common in older patients.
One of the hallmarks of spinal stenosis of the low – a.k.a. lumbar spinal stenosis – is shooting pain from the buttocks to down the leg that gets better when bending forward or sitting.  A second hallmark is pain in the leg that worsens when walking.  There may be numbness, and the pain remains even when you stop walking.  It’s not until you sit or bend forward that you find relief. 
There are a number of good treatment options available for spinal stenosis:  activity, modification, epidural steroid injections, decompressive laminectomy, microdecompression and interspinous spacer.ii  Activity modification includes things like using a cane and bending forward.  Epidural steroid injections are one of the more familiar interventional pain management treatments applies anti-inflammatory medicine to the suspected source of pain.  Decompression laminectomy and microdecompression are spine surgeries that have been performed primarily by spine surgeons, but can also be done using minimally invasive techniques.  And finally, interspinous spaces are like drywall anchors that keep two vertebrae from narrowing the suspected spinal stenosis.  It is not a new concept – spacers have been around since the 1950s – but the device took a hiatus from the therapeutic tool chest for the past 40 years to receive an engineering upgrade.  They have recently seen an uptick in use as more spine pain physicians become trained in them.
All these treatment options have been shown to improve symptoms in some patients, but there is no resounding conclusion on which is the best for whom.  We do know, however, that in patients’ with the hallmarks of spinal stenosis conservative therapies focusing solely on exercising and occasional over the counter pain-relievers do not relieve these symptoms.  And so the practice is really to secure a specific diagnosis, identify the patient’s goals and functional health, and match a suitable treatment option.iii
i The stat of US health, 1990-2016: Burden of Diseases, injuries and risk factors among US States.  The US burden of disease collaborators.  JAMA.  2018;319(14):1444-1472.
doi: 10.1001/jama.2018.0158
ii Markman JD. Lumbar spinal stenosis:  current therapy and future direction.  Current therapy in pain.  Saunders/Elsevier; 2009:316-322
iii Lurie J, Tomkins-Lan C; Management of lumbar spinal stenosis.  BMJ 2016; 352 :h6234
more information
<![CDATA[Obesity]]>Thu, 27 Sep 2018 16:39:46 GMThttp://www.paindiagnostics.net/blog/obesityMost middle-aged adults in America are overweight, and 35.1% are classified as obese. That means, every third person is obese.* In 1962, every 10th person was obese.[i] What happened?!
We don’t have an answer. Most scientists think it’s a combination of genetics, lifestyle factors and changes in food access (e.g. more sedentary work, more restaurant dining, more TV, daily soda and sugary drinks, and thrifty-genes). [ii] But there are also other theories including disrupted sleep, exposure to exogenous hormones and things called endocrine disruptors, changes to your gut bacteria, oppression, and sunlight exposure. There are even theories about infectious disease causing obesity.
With so many obesogenic forces at play, you would think that we would have a battery of interventions. But we don’t. For the most part, we leave it to the patients and doctors to deal with it on an individual level.
And the treatment? Eat less! Yep. Fifty years of obesity research and the resounding conclusion is that you need to take in less calories than you burn in order to lose weight.[iii] Even with bariatric surgery and medications, the end goal is to help the patient eat fewer calories. But, anyone who has dieted knows this is very hard. If people could just “eat less,” we would not have an obesity epidemic.
What makes losing weight hard? At a biological level, it’s your fat cells. They don’t like to disappear. You get a set of fat cells when you are born, and then another set when you go through puberty. By the time you are in your early twenties, you should pretty much have all the fat cells you can generate. [iv] So weight gain mostly leads to filling up those fat cells. But something in the past 50 years has changed (re: the second paragraph from the top) where more fat cells are being generated into adulthood, leading to obesity. And it’s really hard to get rid of them. Even with liposuction—the most popular cosmetic surgery in the world[v]—fat cells return!
Fat cells aren’t all bad. They do great things like release important hormones and regulate reproduction. But in obesity**, it’s as if they can’t stop sending signals, so you are constantly fighting the urge to feed yourself.
However, there is hope. A high-intensity, in-person intervention provided by a behavioral specialist, nutritionist or other trained profession with at least 14 sessions in 6 months is effective. The components of the intervention are no surprise: reduced-calorie diet, increased physical activity and strategies to trouble-shoot dieting challenges. When this isn’t possible, food-tracking seems to be effective, too. But you have less personal support. Free online apps like Lose-it and MyFitnessPal are popular.
There may be a future when we’ve figured out all the environmental causes of obesity and coordinated a really effective population-based treatment. In the meantime, we should try our very best to pack half of our plates with fresh fruits and veggies at every meal, and to exercise everyday. And if you are obese or overweight, don’t be afraid to ask your doctor or healthcare provider for help. They want to help. It’s what they are there for. Your whole health is important to them.
*The term obesity means fatness, and the most common way we measure it is by the body mass index, a.k.a. BMI. That is equal to your weight in kilograms divided by your height in meters-squared. A BMI greater than or equal to 30 is considered obese. Sometimes the BMI can be high because of a lot of muscle, but for most people it is due to fat composition.
** Obesity has been debated as to whether or not it is a disease in itself. Regardless, it can be a cause of heart problems, blood clots, diabetes, joint problems, social problems, breathing and sleeping difficulties, and cancer.

[i] Fryar CD, Carroll MD, Ogden CL. Prevalence of overweight, obesity, and extreme obesity among adults aged 20 and over: United States, 1960–1962 through 2011–2014. National Center for Health Statistics Data, Health E-Stats, July 2016. https://www.cdc.gov/nchs/data/hestat/obesity_adult_13_14/obesity_adult_13_14.htm
[ii] Williams, E.P., Mesidor, M., Winters, K. et al. Overweight and obesity: prevalence, consequences, and causes of a growing public health problem. Curr Obes Rep. 2015). 4: 363. https://doi.org/10.1007/s13679-015-0169-4
[iii] Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society. Obesity. 2014;2:S5–39. doi: 10.1002/oby.20821.
[iv] Rosen ED, Spiegelman BM. What we talk about when we talk about fat. Cell. 2014 Jan 16;156(1-2):20-44. doi: 10.1016/j.cell.2013.12.012. Review. PubMed PMID: 24439368; PubMed Central PMCID: PMC3934003.
[v] http://www.isaps.org

<![CDATA[Spinal Cord Stimulation]]>Tue, 03 Jul 2018 18:00:00 GMThttp://www.paindiagnostics.net/blog/spinal-cord-stimulationPain activation
Why is it when you aren’t feeling well, having someone rub your back makes you feel a little bit better? Or, when your knees ache, you automatically rub them? It may be that this instinct actually helps dull the pain in part by activating other senses—such as touch and vibration.
For our brains to detect sensations, we have receptors throughout the body that, when activated, transmit signals up the nervous system. The ones that detect touch and vibration are known as mechanoreceptors. Other ones include thermoreceptors, chemoreceptors, and photoreceptors. But the notorious one is the nocireceptor because it is the one that senses pain.
Using electricity as medicine
Some receptors, like the mechanorecptors in the skin, require less stimulation to be activated than other receptors. Activating these lower threshold receptors may interfere with the activation the higher threshold nocireceptors. This idea is famously known as the “gate control theory of pain.” And though not a complete
picture of the neurophysiology of pain, doctors used this idea in the 1960s to treat patients with chronic pain. They designed a device that had a small electrical generator connected to an electrode, and implanted the electrode near major nerve centers.
Like a pacemaker for the spinal cord
The device transmitted varying frequencies of electrical impulses. It functioned like a pacemaker in the heart, but for the nervous system. When it was implanted near the spinal cord, known both as both a dorsal column stimulator and spinal cord stimulators (SCS), it appeared to interfere with the sensation of pain.  Neurosurgeons and interventional pain specialists now use them consistently to treat chronic pain. Patients can use an external controller to modulate electrical impulses. 
SCS is indicated for many chronic pain syndromes
SCS is supported in the treatment of multiple disorders, but the best—at least 50% improvement in pain symptoms for the first year post procedure—seems to be for neuropathic limb pain.   It is also indicated in aiding in the management of chronic pain associated with the following: 
  • Postlaminectomy pain
  • Multiple back operations
  • Unsuccessful disk surgery
  • Peripheral causalgia
  • Epidural fibrosis
  • Arachnoiditis or lumbar adhesive arachnoiditis
Usually, SCS is a near-last line of treatment for chronic pain.  Only you and your physician can determine if you are a candidate.  You may call us at 888.724.6377 to learn more or to find out if you may be a candidate. 

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<![CDATA[The ASIPP and the Opioid Epidemic]]>Mon, 12 Mar 2018 13:13:01 GMThttp://www.paindiagnostics.net/blog/the-asipp-and-the-opioid-epidemicEveryone is affected by the opioid crisis. For many of us, the crisis has been personal. Illicit drugs, prescription drugs and mental health have all played their part. Some argue that the crisis started with an effort to treat pain, codified in hospital protocols.[i] Others said that drug companies played down the addictive effects of opioid prescriptions and incentivized prescribing them.[ii] In response, the medical community has tried to help. There is now renewed focus on mental health and substance abuse treatment.[iii] Unfortunately, there has been a history of naiveté amongst many physicians, especially two decades ago when prescribing opioid long term for chronic pain was much more common. However, at least one physicians group sounded the alarm very early on, and dedicates much of its time towards advocating for opioid prescription accountability.
That group is the American Society of Interventional Pain Physicians, also known as ASIPP. Members of ASIPP are mostly interventional pain physicians, but also include allied healthcare professionals. “Interventional” means that the doctors rely on noninvasive and minimally invasive diagnostic and therapeutic tools to treat chronic pain. They also prescribe oral medical therapies. These doctors often see patients who have already been prescribed long-term oral opioid medication, and that puts them in a unique position to see the effects of opioid addiction. Since the 1990s, this society has been at the forefront of the fight against the opioid crisis.
Tackling opioid addiction, abuse and misuse is challenging and cannot be done alone. That is why interventional pain physician leaders created a bill to help states with health-oriented drug monitoring programs share information across state lines. This was not a policing program, but rather a way for doctors to improve public health by preventing opioid overuse and misuse. Spearheaded by Dr. Laxmaiah Manchikanti, MD, this bill was called the National All Schedules Prescription Electronic Reporting, NASPER for short, and was the first and only physician drafted bill to be passed by the U.S. Congress.[iv] Since the bill’s passage in 2005, many states have received grant funding from the U.S. Health and Human Services to build and enhance an opioid drug-monitoring program. This has empowered health professionals to control some of the supply of drugs, and hold inappropriate prescribers accountable. More on state prescription drug monitoring programs here: https://www.deadiversion.usdoj.gov/faq/rx_monitor.htm#10
This month ASIPP will hold its annual conference in Florida, and Dr. Vijay Singh, the medical director of Spine Pain Diagnostics Associates, will be receiving a lifetime achievement award for his leadership in interventional pain medicine. This award is for his commitment to his specialty and even more so, for his compassion as a doctor; one who took on a public health crisis before we were even calling it a crisis"

[i] https://www.nytimes.com/2017/10/26/us/opioid-crisis-public-health-emergency.html

[ii] https://www.mccaskill.senate.gov/opioid-investigation

[iii] Department of Health and Human Services, Centers for Disease Cont
rol and Prevention, CDC Guideline for Prescribing Opioids for Chronic Pain –United States, 2016
(Mar. 15, 2016)  (www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1er.pdf).

[iv] http://nasper.org/

<![CDATA[Stem Cells Part I]]>Sun, 28 Jan 2018 06:00:00 GMThttp://www.paindiagnostics.net/blog/stem-cells-part-i“Wild fire.”  That was how Dr. Paul Knoepler—a well-known American cell and molecular biologist—phrased the up swell` of direct-to-consumer stem cell clinics. In less than nine years, the number of new stem cell clinics has gone from two to about 600, with new clinics more than doubling every year. Here’s a youtube video showing how the map has changed over time: https://www.youtube.com/watch?v=7U-WMKr1K3w .
*Direct-to-consumer means patients see advertisements of different treatments for themselves, like seeing an ad banner online, rather than hearing about it from their doctor during a regular office visit.

These private clinics cater to a growing market of patients—ranging from curious to desperate—who often seek stem cell treatment for joint disease, pain, and nerve damage. They use stem cell products that are neither FDA-approved nor approved for a special status that allows doctors to use them for possibly life-saving treatment. So, then, why do these clinics continue to crop up and use unapproved products? Most likely because no one told them it was wrong.

Since 2009, less than one warning letter per year has been issued from the Food and Drug Administration (FDA), the organization responsible to monitoring drug and biologic product safety. This inaction, according to Dr. Knoepler, may have “inadvertently enabled the US commercial space for unproven stem cell interventions.” However, the FDA may be starting to pick up the pace on its review of clinics and stem cell manufacturers. Just this past month a major warning letter was sent to a company in New Jersey. Many of the complaints were related to the processing of the stem cell product, which is derived from a patient’s own fat tissue and currently the most popular non-FDA approved stem cell product in the market. https://www.fda.gov/ICECI/EnforcementActions/WarningLetters/ucm591225.htm . It’s unclear yet what the consequences will be for not complying the letter, but the tone suggests that the FDA’s patience has run out.

But why go through all this trouble? So many doctors are using stem cells. Shouldn’t it be safe? What is a stem cell, anyhow? And if stem cells are retrieved from one’s own body, what harm is there in injecting them back into the same body? More on this next.  



<![CDATA[The Shutdown]]>Sat, 27 Jan 2018 15:22:42 GMThttp://www.paindiagnostics.net/blog/the-shutdownIt’s happening. The federal government is partially shutting-down. And though there are endless summaries of what will happen, the truth is no one can really predict it. That’s because each federal agency has it’s own contingency plan. And these plans, just like any plan you might make for, say, an unpredicted house fire or bad weather, can be adjusted by the leadership of each agency as deemed prudent.  

For example, if part of an employee’s work is deemed essential but another part is not, can that employee still do the other nonessential work? According to page 9 of the official memorandum by the White House Budget Office ( https://www.whitehouse.gov/wp-content/uploads/2017/11/m-18-05-Final.pdf ), it seems like the answer to this is “yes” as long as it is completed within a day. However, what constitutes essential and nonessential work also varies between agencies. So, in order to help you better understand what might happen, or what has happened, or what should have happened, is your very own official guide on the “Causes, Processes and Effects” of a government shut down: https://fas.org/sgp/crs/misc/RL34680.pdf. This official publication by the Congressional Research Service outlines in detail the history of recent shutdowns (there have been 18!), the specific order of furloughs and the multiple unresolved issues related to federal grants and national security.  

But why does the government even have to shut down? Well, it turns out that there is a law called the Antideficiency Act that states an agency must cease operations if there are no appropriations (planned budget) for the year, except in certain situations when law authorizes continued activity. The idea is that this would help the government run responsibly. A summary of some things that might change during a partial shut down can be found here: https://www.voanews.com/a/during-government-shutdown-what-closed-who-affected/4216433.html/  

In healthcare, the big federal entities that see immediate changes are the National Institutes of Health Clinical Center, which has to stop accepting new patients for clinical studies (https://cc.nih.gov/), and the Centers for Disease Control and Prevention, which has to stop surveillance activities including answering their disease hotline. The VA should operate as normal, and clinics and hospitals expecting reimbursements from Medicare and Medicaid should still see payments made on time. However, because employees who help answer billing questions might be furloughed, there might be delays in solving payment problems or correcting billing errors.  

If you haven’t tired of yet another piece on the federal shut-down, then here are additional links to writings on what has happened ( https://www.natlawreview.com/article/effect-government-shutdown-medicare-medicaid-and-other-affordable-care-act-aca-relat ) and what might happen https://www.whitehouse.gov/omb/agency-contingency-plans/  

​Angelie Singh  ​
<![CDATA[Dangerous Cold]]>Fri, 19 Jan 2018 14:42:09 GMThttp://www.paindiagnostics.net/blog/dangerous-cold
Heat waves steal headlines for their deadly spikes, but, globally, more deaths are caused by the cold than heat. When it comes to heat, our bodies do a pretty good job of regulating our core temperature without any help. But when the temperature drops, even to a mild 60 degrees F, our bodies rely on heaters and extra clothes. This human weakness is especially dangerous in subzero temperatures, where a few minutes in wet clothing or little clothing can cause severe hypothermia or even death if left untreated. Tragically, this past week nine Wisconsinites lost their lives to hypothermia.

Doctors divide hypothermia into three stages: mild, moderate, and severe. But what we call mild hypothermia is a already drop in the body temperature below 95 degrees F (normal body temperature is about 98.6) and not actually very “mild.”
Unlike heat stroke or other problems with high temperature, mild hypothermia has more subtle symptoms. You might just feel off or slow, have some memory loss and confusion, or feel angry and become combative. You also might notice the skin on your belly or inner thigh feeling cooler, and even if you don’t notice this, your brain will detect the low temperature and start sending signals to make heat by shivering.
Shivering jacks up your metabolism 4 to 6 times, so it costs a lot of energy and isn’t a good long-term solution. Your breathing and heart rate speed up to help fuel the shivering and also to make sure the rest of your organs are getting enough oxygen. But once the core body temperature gets below 91.5 degrees F, your brain starts to malfunction. This is known as the “transition zone.” Everything starts to slow down, including your heartbeat and breathing. This is a time when arrhythmias—abnormal heart beating that could lead to death—are likely to occur. It’s a very dangerous emergency that could require intensive care in the hospital.
If you or someone you know has been outside or in wet clothes and appears confused, is slowing down mentally and physically, and/or is shivering, take a temperature. If the temperature reads 95 degrees F or below, GET EMERGENCY HELP immediately. While you wait for help, or if the temperature is above 95, take off any wet clothing and wrap the person in warm, dry blankets. Prioritize keeping the core warm rather than the arms and legs. Do not take a hot bath as this might actually cause the temperature to drop further (known as the “after drop”). If the person is talkative or interactive, encourage drinking fluids. Do not force any drinks down if the person is losing consciousness.
For older adults, a slight decrease in temperature can be even more problematic because the body’s shivering mechanism is weaker, and the perception of cold may be less sensitive. In addition, older adults are more likely to have other medical problems that are exacerbated by slight fluctuations in temperature.
Here are three non-commercial websites with more information about hypothermia prevention and care.
For all age groups: https://www.cdc.gov/disasters/winter/staysafe/hypothermia.html
For older adults:
Frostbite is when the skin or another part of the body temperature reaches 32 degrees F, literally freezing. Unlike hypothermia, frostbite should be rewarmed with warm water (99 to 104 F). Rewarming a frost bitten hand can be very painful as sensation returns to the hand.
Some patients with chronic pain sense that things are worse when there is a sudden temperature change. And in the winter they seem to be extra sensitive to cold air. Well, a research team in Australia was interested in looking at this topic and asked the question: do chronic back pain suffers have a lower threshold for pain from cold or heat than other people without low back pain?
Turns out that pain sensitivity from cold stimulation may be worse in those patients with chronic low back pain when compared with patients with no chronic pain. By using a cold stimulus that gradually got colder, a thermometer, and a button, subjects would push when they wanted the pain to stop, researchers measured the difference in cold pain tolerability. When the cold stimulus was on their arm, subjects with chronic back pain asked to stop the cold stimulus at 57 degrees F, on average, while subjects without low back pain averaged at 46 degrees F. And this difference was statistically significant.


The above does not constitute professional medical advice. Please contact your doctor or health care provider for personal medical attention. Seek immediate medical help for anyone with suspected hypothermia or frostbite. Call 911 if you suspect severe hypothermia or notice any change in mental alertness.

Angelie Singh, MD, MPH, MS