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? The fact that there are abnormalities in your discs on MRI doesn't necessarily mean that the discs are the cause of your pain, without clinical correlation.

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, and specialized interventional techniques such as nerve blocks, epidural steroid injections, joint injections and 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 muscloskeletal system and the rest of the body.

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. More recently, I spent several years studying Myofascial Release with John Barnes PT, and exploring Awareness Through Movement as developed by Moshe Feldenkrais. Many of the practitioners with whom I trained incorporated the principles of Energy Medicine as well.

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. What do these techniques do? One of the major principles is to look at the whole body. With regards to 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." Examples include a patient with asthma who was able to discontnue asthma medications following correction of restrictions in the spine. Another patient with astma and back pain had sinificant improvement in his low back pain following correction of restrictions in the ribs and neck.

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.
The focus of treatment is to find the root cause of the problem. This usually involves addressing multiple areas in the body. Sometimes the root cause is not in the part of the body that hurts.
Why does this work on a longer term basis? I have found 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, etc.

This approach has a lower risk: 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. 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 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. In cases of spine surgery, it is common to have problems in spine adjacent to the operated region. Adding a holistic manual therapy approach, surgery may be avoided, and if still needed, recurrent problems may also be avoided.

Here are some exmples of techniques that are taught in my practice:
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.

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.

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 hold the stretch for 3-5 minutes. Yoga is an excellent form of stretching, as it is balanced and 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.