Judith Kahn, M.D. P.C.
Chronic Pain
 
 
 
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Pain! Do you have to live with it?
Are you reading this article because you are in pain?
Do you have pain in your back, neck, shoulder, hip, knee, or feet; an injury from an accident or sports injury that never fully healed; sciatica, or a pinched nerve?
Have you been diagnosed with rheumatism, arthritis, or fibromyalgia?

Have you been told that these are chronic conditions, will never improve, and will only worsen with the passage of time? Have you been told that you are just getting old and that you have to live with it? Have you tried physical therapy, chiropractic treatments, and/or massage therapy with only transient relief at best? Have you been told that the only option left for you is surgery?

I would like to suggest to you that your pain may be improved or resolved with my integrative approach, which includes osteopathically based treatments including soft tissue myofascial release techniques, muscle energy therapy for joint mobilization, and craniosacral therapy. My practice specializes in helping patients who have not responded to other treatments, but are not willing to give up.

What do your diagnoses mean?
Arthritis: What is arthritis? Arthritis means joint inflammation. The typical variety is osteoarthritis, which is generally due to "wear and tear" on joints, very commonly in the knees, hips, and spine. This can often be related to weight and/or physical overuse of joints. Osteoarthritis involves a wearing down of the cartilage, with narrowing of the space between bones; There can also be extra bone deposits within joints, as a result of stress put on the joint. This narrows joint further, limiting motion and causing pain with motion due to restricted motion and bone rubbing on bone. However, research shows that there is often no correlation between arthritic changes seen on x-rays and degree of pain that the person experiences. Most people over the age of 25 show arthritic changes on x-ray, but do not necessarily have pain. When do the arthritic changes seen on x-ray cause pain? When there's marked destruction of the joint and severe rubbing of bone on bone.

What else could be causing the pain? How about sciatica or a pinched nerve? Is this what's causing your pain? Even if the MRI shows damage to one of your discs, such as a bulge or herniation (known in layman's terms as a "slipped disc", is it affecting your sciatic nerve? When MRIs are done for unrelated reasons in people with no back pain 30% of people in their 30s have been found to have disc abnormalities on MRI, and in their 60s, over 50% of people have them. These are disc abnormalities in a large number of people who have no pain in their back or legs. In other words, many of us can be walking around with these abnormalities and not have pain. So when you do have pain, the fact that there are abnormalities in your discs on MRI doesn't necessarily mean that the discs are the cause of your pain.

So what else could be causing your pain? I have found that most people have muscle spasm and joint restrictions. Most of us are aware of tension and tightness in our muscles. There may be areas of tenderness as well. Muscle spasm can limit the movements of the joints to which they are attached. You might also have sudden restriction of joint mobility from an accident or a "bad move"; which can then cause the muscles in the immediate are to have spasm as well. Muscle spasm and joint restrictions can make you feel stiff and achy. Is this arthritis? It could be, but often the degree of
discomfort does not correlate with the arthritic changes on x-ray. And, if you relieve the spasm and joint restriction, the person can be pain-free, yet the x-ray is unchanged. Sometimes, muscle spasm and joint restrictions can mimic a "pinched nerve" such as sciatica, and when the restriction is relieved, the "nerve" pain resolves immediately, even when the MRI still shows disc damage.

So, what can you do?
The first step is to get a full musculoskeletal examination to determine how your body and its joints are moving, and how much muscle spasm there is, and where it is. You may even choose to have x-rays, MRIs or electrodiagnostic studies to establish a baseline of objective anatomic images. Then you are ready to begin treatment.

Let me tell you my story?
I graduated from Einstein Medical School, and specialized in the field of Physical Medicine and Rehabilitation. Specialists in this field are called Physiatrists. We are trained to look at the joints and muscles of the body, and help patients regain function.
Physiatrists in Rehabiliation centers, such as Rusk, Kessler Institute, Burke, Helen Hayes will commonly treat patients with spinal cord injuries, strokes, amputations, head injuries, joint replacements. In private practice, physiatrists often specialize in pain management of musculoskeletal conditions such as ones we&'ve already mentioned.
We can offer physical therapy, injections, medications, referrals for surgery. Many practitioners offer specialized techniques such as nerve blocks, botulinum injections.
After finishing my training I began to explore what options I could offer my patients.

How many of you have tried physical therapy, with no results?
I've found that there is a marked difference in quality of therapy offered.
Sometimes what is done is provide heat and electrical stimulation, which relax the muscles and prepare them for treatment, but then no actual hands-on treatment is provided. When hands-on treatment is given, there is a difference in the quality of techniques used. I found that many of the better physical therapists were using techniques developed by osteopathic physicians.

Osteopathic physicians are fully medically trained doctors, who also look at the connection between the musculoskeletal system and the rest of the body.
What does this mean? One example is asthma. When osteopathic physicians treat asthmatic patients, they evaluate how the lungs are working, and provide medication to help with the breathing. But they also look at the rib and spine mobility, and relieve restrictions to help the patient breath more easily.

Osteopathy believes that the body has the means of healing itself. What this means is that you don't have to just live with your symptoms for the rest of your life. This means that you can start a process, which leads to correction of the cause of your symptom - that there is a means of recovery and healing available to the body. The body is designed to function optimally in a certain fashion, and the closer we come to the original specifications, the better we feel.

I was getting frustrated telling patients that there was nothing else I could offer them, and that they had to just live with their pain. I began to study with highly qualified manual therapists and with osteopathic physicians and found that these practitioners were getting quicker and more permanent results than standard physical therapy. Over a ten year period, I took at least one course a month studying manual therapy techniques, and spent an entire year studying the osteopathic curriculum with osteopathic students at the NY College of Osteopathy, becoming certified in their techniques.

What do these techniques do? One of the major principles is to look at the whole body. You may be familiar with the term Holistic Medicine. What does this mean? It means looking at the whole person. Well, if you take the musculoskeletal system – this means looking at the entire body, and not just the part that hurts. The term that I have been trained to use is "finding the area of greatest restriction".

I already mentioned asthma as an example. One patient who I've treated with this approach has not needed any of her asthma medication for 10 years. Another patient was in a nursing home. He had undergone major heart and chest surgery two years previously, and now had been hospitalized after he stopped breathing due to asthma. I saw him for back pain, but found that his ribs were very tight. After treating him once, and loosening up his rib and spine, his back pain resolved over the next few days, and his breathing improved as well. Notice, he didn't come to me for his breathing problem. He was being seen in physical therapy for his back, and had been getting several weeks of therapy for the back with no relief. I took a complete medical history, so I knew about his breathing problem. But the main thing that I did was examine him, and determine where he was tightest - this turned out to be his ribs - so that's where I treated him first. Then, I reassessed him. The next place turned out to be his neck - well he never even mentioned neck pain. It didn't matter. That was where the tightness was, that was affecting the rest of his body. Then, I reevaluated his body again, and addressed the low back last. The key is that I did not go to where he said he hurt, or where he was having his medical problem. I was examining and reexamining his entire body, to find each area of tightness in the correct order to treat it. By the way, this first treatment took about 15 minutes all together.

Another example is someone who came to me with heel pain. All I've done is examine her, and have not started any treatment. However, this person has significant tightness in her neck, and moderate tightness in her upper back. I will suggest to you that loosening up the restrictions in these areas will address why she has tension in her heel, that resulted in heel spurs, which is extra bone deposited in the heel due to mechanical stress. She has had extensive treatment to her heels without relief, but even if there were some relief, this would not correct the underlying cause of the problem. The heel pain indicates that there is a problem in the body that causes it to put stress on the heel. For full correction, one has to address the whole body, and correct what is putting the stress on the heel.

As we go through life, we develop restrictions. It's like a car that goes over bumps, and goes out of alignment. As you keep driving, more things go out of alignment as well. It's detective work to determine what restriction is causing pain, or problem. Sometimes there are multiple layers to be corrected before the pain is relieved.

So for many years, this is what I did, and many patients got better. However, my best teachers are the patients who do not respond to all the techniques that I have to offer. So, I kept on taking more courses.

I now learned about the Energy field around the body, and how this influences the musculoskeletal system, specifically, and the body in general.

Harold Saxton Burr was a scientist at Yale University starting in the 1930s. He began to measure electrical changes in the body. He measured differences in voltage between various points on the body, starting with his laboratory staff, and found that each one had a unique readout. He found specific changes that correlated with ovulation and with tumors, and used these medically. He also studied salamanders and found a field that essentially looked like the outline of an adult salamander. He found that if he cut off one of their legs, the field still existed, and the leg grew back. In frogs, he found that if he cut off the leg, it did not grow back. However if he added an externally generated electric field around the frog's leg, it would regenerate. He was curious when this field started, and found that an unfertilized salamander egg had the field of an adult, fully grown salamander around it. Based on measurements of the energy field, he was able to predict what part of the egg would become the neural tissue, and injected a dye in that region. After fertilization, this dye appeared only in the adult salamander's nervous tissue. This shows a correlation between parts of the energy field, and physical parts of the body.

Dr. Burr suggested that there is an energy field around the body, which he called the Life Force, which is the blueprint for our body. It is what tells each of our cells what to do. Remember, all of our cells have the same DNA, the same genetic material inside. So what tells one cell to become a heart cell, another, a liver cell, and another, a brain cell? Based on the research by Dr. Burr, I would suggest to you that the energy field around our body plays an important role in this process. Could our energy fields act as templates, directing the body in its development? Our bodies are constantly remodeling and rebuilding. The cells in our digestive system are replaced every 3 days. Neural tissue can take up to 7 years to repair itself. What is the blueprint for this process? The same energy field that directs the embryo to become an adult human may also direct the repair and rebuilding process. What if this blueprint becomes distorted? Will we rebuild based on incorrect information? What if the DNA in our cells stops receiving input from this blueprint? If the lining of the intestine replaces itself every 3 days, then why will someone have Crohn's disease, or other intestinal inflammation, for 20 years? If you lose the blueprint, or the connection to the blueprint, it's like you're living in a house that you can't fix. You patch things up to the best of your ability, but you're not able to do any permanent repairs, or take corrective action to the cause of the problem. Eventually, things fall apart.

But the energy field is more than just an individual blueprint that we carry. It is an invisible background that surrounds all of us. It is similar to the network of radio waves that are all around us that we can't see, but reach our radios and cell phones. There is some wonderful research about how the energy field around us affects us, and how we can connect to this field intentionally, and use it to our benefit. Some of the scientific research that explains this involves quantum physics. There is also evidence that information is transmitted through this field. Some of the research into these phenomena involved connecting plants and trees to lie detector machines and reading changes in the output in response to various events in their environment. This was done by Cleve Bakster, a lie detector expert, and by Dr. Burr.

It is postulated that the way that this energy field affects us is through the water in our bodies. There is work from Japan about the shape of water molecules. We all know that snowflakes have unique crystalline shapes. When you freeze water and look at it under a microscope, you can see shapes that are similar to snowflakes. A Japanese research, named Masuru Emoto, looked at the drinking water in several Japanese cities, and found that none of them formed good crystal shapes. He looked at spring water from a variety of locations, and found that they all formed good crystals. He then took water from these different locations, and did a number of experiments with them. He wrote words, such as "I love you" or "I hate you" and taped it onto bottles of water. He also exposed the water to various types of music. Polluted water formed beautiful crystals when exposed to positive messages and classical music. Spring water lost its crystals when exposed to negative messages and to heavy metal music. We are over 70% water. Messages that are transmitted to us by our environment and by our thoughts, may affect the structure of our internal water.

There are many techniques, loosely referred to as Energy Therapy, which allow the body to reconnect with the energy field, that is our blueprint. They also allow participants to become more aware of the energy fields around them, and the effect that our internal and external environments can have on our well being. Some of these techniques have to be provided by a practitioner, and some can be supplemented by, or performed by the patients themselves.

For a period of time, I focused more on the energy field in my treatments, and less on the body itself. I have now come to understand that both approaches are needed in parallel.

There is also a very important role played by the MIND. People are talking a lot about Mind-Body Connections. What does this mean? It means that our brain produces chemicals that travel throughout the body, and have effects remote from their source.
Medicine is now starting to acknowledge the connection between our minds and how our body functions. Candace Pert has identified chemicals created in the brain that affect how our entire body functions. The production of these chemicals is related to our emotional state, and may serve as the agents of the mind/body connection.

Why are illicit drugs so popular? They make you feel good. Did you know that the body can produce similar substances, called enkephalins. These are responsible for the "runner's high" that many athletes strive for. Well, how about adrenalin? Have you heard of the "fight or flight response?" When we face danger, our bodies prepare to fight the enemy or to run away. Part of this preparation involves the release of a chemical called adrenalin, which speeds up our hearts, expands our lungs, shuts down our intestines, and tenses muscles in preparation for action. Think about your lives, and the pervasive levels of stress that we have all become used to: the noise, the crowds, the fast pace, the deadlines; and the limitation of options available to us. We can't kill our boss, in the same way that a cave man could kill a mountain lion. So, instead we seethe internally, with the adrenalin flowing, but with no output.

We also use a lot of body imagery in our language. We "eat our guts out". Someone is a pain in the neck, or other unmentionable parts of our anatomy. We "shoulder a burden". We are told to "grit our teeth" and bear it. One patient, with unremitting facial pain, told me how a business client had been unnecessarily mean to her, and had "mashed her face in it". I will suggest to you, that our bodies respond to these unconscious images, which contributes to our pain.

So, what can you do?
After you've had a proper evaluation, the next step is treatment.
As I mentioned, in my practice, I've found that a combination of manual therapy and energy techniques provide the best result. The focus of treatment is to find the root cause of the problem. This usually involves addressing multiple, successive layers. Sometimes the root cause is not in the part of the body that hurts. Sometimes, it is in the energy field around the body, and not in the body itself.

Why does this work on a longer term basis? I believe, and have found in my practice, that this approach gives more lasting results since it addresses the cause of the problem, and not just the symptom.

How fast will results be? Sometimes one treatment is enough. Sometimes, a person feels better after one or a few treatments, but their pain recurs. Typically, the pain is not as intense or as prolonged. Sometimes, the perceived pain is unchanged, but the body is moving better and the person can do much more activity. Why does this happen. The part of the brain that perceives chronic pain, called the thalamus, is relatively primitive, and will flash up the same pain "picture" or "message" even when part of the problem is resolved. It seems that sometimes, a certain threshold has to be crossed, before the thalamus is convinced that the problem is going away. Typically, younger patients will require fewer sessions for more complete results - basically they haven't driven their "car" for as many miles, so there's less that's gone out of alignment.

What role do medications have in this process? I typically do not prescribe a lot of medications. They rarely address the cause of the problem, and are typically not curative. They may manage one's symptoms, and help keep a person comfortable during the recovery process. This has to weighed against the side effects of pain medications, which can include stomach ulcers, sedation, constipation, and so on.

Lower risk of this approach over other approaches: All you have to lose with this approach is your pain. This may sound like a joke, but in fact, some people are defined by their pain, and become very threatened by a reduction in their symptoms.

Specifically, the approach that I have outlined can be used in combination with other medical approaches, but offers the possibility of relief in cases where people have been told that there is nothing that can be done for them.

It also offers an alternative to surgery. If someone tries this approach before neck or back surgery, or hip or knee surgery, there is generally nothing to lose. Obviously, if there is a situation of an unstable spine, which is relatively rare, emergency surgery is needed. Otherwise, there is no harm in delaying, and seeing if conservative, integrative, holistic management can correct the problem. If, not surgery can still be done. In some cases, surgery may still ultimately be needed, but if the mobility is restored to the rest of the body, the outcomes are much improved. In the example of heel spurs mentioned above, surgery can be done to remove the spur, but without looking at and addressing restrictions in the rest of the body, the spur is likely to recur. Sometimes, the approach that I outlined can allow the body to resolve the spur on its own. Other times, surgery may still be needed, but the person is less likely to have a recurrence. In the case of arthritis involving the hips and knees, the pain can sometimes resolve on its own with this approach, and the body can repair itself. In other cases, surgery may still be needed. However, if you have corrected the stresses in the rest of the body, then the body is much less likely to damage the artificial joint in the years following the procedure. With spine surgery, it is common to have problems in spine adjacent to the operated region. With this approach, surgery again can be avoided, and if still needed, successive problems may be avoided.

Here are some exmples of techniques that are taught in my practice:
Relaxation/meditation/breathing:
These techniques are not the same as falling asleep in front of the TV, or unwinding with friends. This involves a quieting of mental activity, and withdrawal of the body and mind from external stimulation. It's like "erasing the blackboard" of all mundane concerns in preparation for contacting deeper layers of the mind. It allows us to think and feel again. This is often very difficult for Americans. Out constant mental diet of advertising, noise, violence and media stimulation makes it very difficult to endure even a few moments of inactivity and quiet. We have created a wall around ourselves to block out this deluge. In the process, we also stop feeling, and the quiet can be threatening. One of my patients, who was critically ill, was willing to travel abroad for very experimental treatments, but was not willing to sit quietly and turn inward - she said she had no time left for this.

Relaxation: The goal is to reach a light trance state, which is the first step in hypnosis, biofeedback, yogic meditation. You can find a wonderful review of this in The Relaxation Response by Herbert Benson. He is affiliated with Harvard, and has done studies on relaxation lowering blood pressure, and other ways that it positively affects health. Typically, there is a step-wise approach of tightening and relaxing muscles, working from your head to your feet.

Meditation: This is a method where we can stop listening to the pressures and distractions of everyday life, and are able to listen to and acknowledge our deeper thoughts and feelings. Some techniques use a symbolic sound or word, called a mantra, or an image, such as a candle flame. Others focus on the ebb and flow of the breath, or gently restrain the mind from following the thoughts that flicker across its surface. The end result is ultimately the same: a deeply restful emptiness, that strengthens the mind by freeing it from its accustomed turmoil.

Breathing:
A recent study shows that doing independent breathing exercises had the same outcome as a course of intensive physical therapy in relieving chronic low back pain (more than 3 months duration) at 6 months follow-up.

Exercise:
There are different types of exercises: Aerobic; stretching and strengthening.

Aerobic activity is wonderful for cardiac fitness, and for mental health. It helps you sleep better. I highly recommend that everyone exercise at least 30 minutes 3x/week in a way that will raise your heart rate. The safest way to do this is keep your heart rate at a level where you can still carry on a conversation. If you have been inactive and are over 40 years old, you should check with your internist before starting this type of program.

Stretching exercises are helpful, but I generally find that they are most helpful when combined with some manual therapy such as what I've described above, in order to help loosen up the areas of greatest restriction. Often, people overstretch, which results in tearing muscles. You just want to go to the point where you feel a slight pull, and stay there for a few seconds. Yoga is the best form of stretching that I know about. First of all, they have you balance everything well, by going in 2 directions for every stretch. Also, it incorporates breathing, which helps quiet the mind, and facilitates more effective stretching.

Strengthening exercises are also very important. This is also most helpful in combination with treatment to loosen the areas of greatest restriction. What often happens is that people overuse certain muscles, and underuse others. The most important muscles to pay attention to are the thigh muscles. When these are weak, people will overuse their back muscles, and develop chronic low back pain. Another important role of strengthening exercises is in the prevention of falls and of hip fractures in the aging population.