Orthopedic Medicine: A Non-Surgical Approach To Chronic Pain

Lawrence Cohen, MD

When asked what I do, I hate to say “I’m in pain management,” because the focus of my practice is really pain resolution. By the time someone reaches a pain specialist, they have failed standard interventions such as physical therapy, medication and even more invasive procedures such as epidural steroids. They have persisting pain that leaves them less effective in the home, at work, and in their personal relationships. I was trained with a physical medicine education to utilize medications, physical or occupational therapies, psychology, and a few injection techniques for tendons, bursae or muscle trigger points. This approach proved inadequate for so many of my patients. I began searching the alternative medicine world for treatments that worked.

This led me to the field of Orthopedic Medicine, a group of physicians who are utilizing alternative techniques to deal with complex pain problems. The direct cost savings can be tremendous; just think of the cost of one back or neck surgery that might be avoided or the cost of years of chiropractic care, Physical therapy, or physician and emergency room care. Indirect savings can be greater when adding the return to work someone who otherwise might be out on disability or worker’s compensation for life.

The focus of this therapy is on the structural component. This might be the sprained or strained ligament, tendon or muscle- or the “somatic dysfunction” of the chiropractor or osteopath. One of the most important lessons regarding structure is that the underlying problem may not be where the pain is. The injured area is typically tender only to careful examination, and may be quite distant from the area where pain is actually felt.

I see many patients involved in car accidents with persistent neck pain and headaches who have undergone expensive and unnecessary MRIs, EMGs, physical therapy and chiropractic treatment aimed at the cervical spine, when careful examination might have focused treatment at the real source of their pain elsewhere.

In some instances the perpetuating problem results when the head is whipped to the side, the scalene muscles yank on their insertion into the first rib and pull it up out of alignment. This results in a super sensitive spot where the first rib attaches to the T1 spine, and muscles around it remain severely triggered, referring pain up the neck to the head, down the medial scapula and down the arm. In this case, osteopath mobilization followed by Prolotherapy to the ligament that joins rib to spine and trigger point injections of the remaining triggered muscles, will resolve the head, neck and shoulder girdle complaints.

For others, the problem occurs following an accident in which they bounce back into the car seat at their mid thoracic spine. This can depress one or two segments of the thoracic spine, reversing the normal kyphotic curve. Here, the posture changes to compensate, straightening out the cervical curve and shortening the paraspinal muscles. Restriction and triggering at mid-thorax refer pain up to the skull and neck. The pain is felt in the neck and head-not in the back! When asked to flex their neck, patients typically cannot reach their chin to their chest. Osteopathic mobilization, often facilitated by Neural therapy block to the paraspinal musculature, will allow resolution.

In another common accident scenario , the person is jamming on the brake with the right foot while the left foot is hanging loose and the seat is tethering the pelvis. This may displace the right cuboid (a small bone in the foot) or, worse, may cause a torsion that shifts the pelvis out of alignment with respect to the two iliac bones, or to the sacrum that sits between. The low back may be painful with either one of these conditions, yet the foot, where the injury really occurred, rarely is. Either one of these conditions can alter the patient’s posture, gait and stance, resulting in chronic head or neck pain. Osteopathic mobilization and occasionally Prolotherapy is necessary to obtain correction and relief.

Finally, there are pain patients where the structural problem is in the neck. These patients typically are okay as long as they keep seeing the chiropractor or physical therapist every few days, but they can’t resolve the pain. X-rays may show some arthritis, spondylosis, and degenerative disc changes, which frequently get the blame for the pain.

Here the structural problem involves the ligament and tendon attachments to bone. There may be a strain or sprain (micro avulsion or rupture of fibers as the insert into bone), with local tenderness on palpitation, causing reactive muscle triggering, which generates much of the pain a patient feels. In addition, recurring somatic dysfunction in the cervical spine returns within hours or days after each chiropractic or PT treatment.

The most effective treatment is prolotherapy, a way of repairing the ligament and tendon injuries and shutting down the “C” pain fiber irritation present. In prolotherapy, a hyperosmotic 12 percent dextrose and lidocaine solution (which may be combined with a chemical irritant as well) is injected in small amounts at the attachments of tendon and ligament to bone. This induces the body’s healing inflammatory response to repair strained and frayed ligament, or merely tighten existing ligaments, made lax by narrowing of disc or joint spaces through degenerative processes. Through repeated injections, the treated ligaments can have as much as 140 percent the strength of controls (in animal studies). Prolotherapy can be used at the neck, low back, knee, shoulder (Prolotherapy to the shoulder video), or any joint to prevent progression of arthritis and eliminate pain.

© Lawrence Cohen, M.D.
The opinions expressed here does not necessarily reflect the views of the other member physicians of getprolo.com.

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