Information on chronic pain and addicton

Christopher Frandrup, M.D., DABPM, FIPP

Month: August 2016 (Page 1 of 2)

FDA requiring boxed warning about serious risks and death when opioid pain or cough medicines combined with benzodiazepines

FDA review has found that the growing combined use of opioid medicines with benzodiazepines or other drugs that depress the central nervous system (CNS) has resulted in serious side effects, including slowed or difficult breathing and deaths.  Therefore the FDA is adding Boxed Warnings, its strongest warnings, to the drug labeling of prescription opioid pain and prescription opioid cough medicines, and benzodiazepines.

The agency issued a Safety Alert noting that it has conducted and reviewed several studies showing that serious risks are associated with the combined use of those drugs, other CNS depressants, or alcohol.

If these medicines are prescribed together, it recommends limiting the dosages and duration of each drug to the minimum possible while achieving the desired clinical effect.  Further, prescribers should warn patients and caregivers about the risks of slowed or difficult breathing and/or sedation, and the associated signs and symptoms. 7619349538_25d476aa12_o

If you or someone you know is taking a benzodiazepine and an opioid, schedule an appointment with us to discuss your options.

Exercise Is Really THAT Important For Lower Back Pain

Exercise Is Really THAT Important For Lower Back Pain |

Exercise Is Really THAT Important For Lower Back Pain

If you suffer from back pain as an estimated 80 to 90% of people in the U.S. will in their lifetime, you know how hard it can be to keep moving when the pain flares up. Lower back pain can be especially difficult to move through, but the numbers don’t lie. Exercise really is that important for lower back pain. Here’s why.

Targeted exercise for lower back pain reduces pain

While it may seem like a contradiction, working the specific muscles that support and move the spine – the ones that may be painful – actually helps reduce lower back pain. This type of exercise is called motor control exercise. Motor control exercise begins with simple functional movements guided by a physical therapist and gradually adds more complex actions.

In a meta-analysis of 29 studies involving over 2,400 patients with lower back pain, researchers at the Cochrane Library found that those patients who participated in this type of targeted exercise. They found that they experienced greater improvement in pain and less disability than those patients with minimal interventions.

Physiotherapist Bruno Saragiotto, lead author from The George Institute at the University of Sydney, believes that this approach offers a cost-effective and positive treatment option for patients with lower back pain, noting:

“Targeting the strength and coordination of muscles that support the spine through motor control exercise offers an alternative approach to treating lower back pain. We can be confident that they are as effective as other types of exercise, so the choice of exercise should take into account factors such as patient or therapist preferences, cost and availability.”

Exercise for lower back pain can include intimacy

Many couples with a partner experiencing back pain will put intimacy (including sex) on hold rather than risk more pain. While this may seem like a good idea, many couples may find that celibacy for long periods of time affect the relationship in negative ways. In excellent research news, scientists have used X-rays and other techniques to find the best ways that partners can remain intimate while one partner is experiencing lower back pain.

For the 84% of men and 73% of women who report a significant decline in sexual intercourse during episodes of lower back pain, this research is welcome news. As always, patients need to read the research and find out what works for them. Natalie Sidorkewicz, a PhD candidate at the University of Waterloo in Canada and lead author on the paper, believes that this research can help improve the quality of life for patients experiencing lower back pain, saying:

“For the first time ever, we now have very solid science to guide clinicians on their recommendations for patients who suffer debilitating back pain, but still want to be intimate. This has the potential to improve quality of life — and love-life — for many couples.”

Exercise for lower back pain reduces pain

It turns out many patients prefer pain relief over increased mobility. A study from the University of Rochester Medical Center indicated that when surveyed, patients experiencing spinal stenosis overwhelmingly chose pain relief over increased mobility.

John Markman, M.D., director of the Translational Pain Research Program in the University of Rochester Department of Neurosurgery and lead author of the study believes that this makes clear the direction of pain relief, noting:

“There has long been a debate in the medical community over striking the right balance between pain relief and physical function. While physicians have leaned toward the need to increase mobility, this study shows that patients have a clear preference for pain relief.”

While the University of Rochester study indicated patient preference for immediate relief, often in the form of steroid injections. The fact remains however that for long-term pain relief, exercise reduces lower back pain. One researcher at the Sahlgrenska Academy, University of Gothenburg conducted a small-scale study of 109 patients with lower back pain to see if exercise or rest were more effective.

One group of patients was advised to continue to move as much as possible, and the other group was advised to adjust their activity level based on the pain. Both groups kept a pain diary for a week, recording the number of steps they took and their general activity levels. Both groups also completed an exercise to determine if they felt depressed or not.

Across the board, the group that moved more recovered more quickly and felt less depressed than the group that restricted their movement. Olaya-Contreras, a researcher at the Sahlgrenska Academy’s Department of Orthopaedics, noted that some patients who normally experience depression may feel a heightened pain sensitivity. This can be exacerbated by limited physical activity:

“I think that if you’re suffering with acute low back pain you should try to remain as active as possible and go about your daily business as well as you can. If you don’t keep moving, it’s easy to get locked into a downward spiral, as inactivity combined with pain can, in a worst case scenario, turn into long-term disability and an inability to work that, in turn, can lead to depressed mood and more pain.”

Exercise reduces the risk for lower back pain

If exercising to help reduce lower back pain when it flares up isn’t enough, how about preventing pain in the first place? A new review of clinical research by Daniel Steffens, Ph.D., of the University of Sydney and coauthors looked at 21 clinical trials with nearly 32,000 participants. They found that, when combined with education, exercise reduces the risk of lower back pain. They also found that exercise alone was indicated as effective in preventing lower back pain as well.

Although the evidence for exercise alone (without education) was not as strong, Steffens noted that both have a preventative effect on lower back pain, in both the short- and long-term, saying:

“Although our review found evidence for both exercise alone (35 percent risk reduction for an LBP [low back pain] episode and 78 percent risk reduction for sick leave) and for exercise and education (45 percent risk reduction for an LBP episode) for the prevention of LBP up to one year, we also found the effect size reduced (exercise and education) or disappeared (exercise alone) in the longer term (> 1 year). This finding raises the important issue that, for exercise to remain protective against future LBP, it is likely that ongoing exercise is required.”

It is clear from the research that, as challenging as it may be, exercise is a great way to help prevent and treat lower back pain. To incorporate exercise into your treatment plan for lower back pain, talk to your doctor today.

Vestibular Migraine – Migraine With Vertigo

Vestibular Migraine - Migraine With Vertigo |

Vestibular Migraine – Migraine With Vertigo

Migraine is one of the most common chronic conditions, with migraine sufferers outnumbering both asthma and type 1 diabetes sufferers in the U.S. While many use the term migraine to identify every severe headache, there are actually seven types of migraine headaches. Some of those can then be broken down into other types, often by their symptoms. This week we are looking at a rare sub-category of migraine: vestibular migraine.

What is a vestibular migraine?

Migraine headaches in general share some symptoms. Most migraine sufferers experience four distinct phases of migraine headache:

  • Prodromal: This is the days or hours before a migraine. Symptoms could include fatigue, irritability, and mood swings.
  • Aura: Not everyone will experience the aural stage, but if they do, sensory changes occur, as does sensitivity to sound and light.
  • Attack: The attack phase is the acute period of migraine. Symptoms such as pain, fatigue, and nausea occur.
  • Postdromal: After an attack has passed, sufferers may feel a sense of euphoria. They may also be tired.

Vestibular migraine is a type of migraine headache that adds a complicated symptom: dizziness and vertigo. The causes of this type of migraine are unclear, but there is a connection between migraine and the inner ear. The inner ear is the organ that affects balance and equilibrium. For a person who sufferers from vestibular migraine, this equilibrium is thrown off during a migraine. Instead of pain being the main symptom of migraine, dizziness is most prominent.

Other symptoms of vestibular migraines include:

  • Vertigo
  • Poor balance
  • Muted hearing
  • Ringing in the ears (tinnitus)
  • Extreme motion sensitivity

Any of these symptoms can lead to fatigue and nausea, but in general pain is not present. A vestibular migraine can last anywhere from days or hours.

Dr. Susan Broner, an attending neurologist at Roosevelt Hospital’s Headache Institute in New York City, describes the symptoms of this migraine like this:

“Vestibular migraine is a variant of migraine in which instead of headache being the most predominant feature, dizziness is. Patients usually say that out of nowhere they got extremely dizzy and don’t feel like they’re on even ground. Some describe a spinning or rocking sensation. They have light or sound sensitivity and get nauseous or throw up.”

Causes of vestibular migraines

There are several theories as to what causes vestibular migraine.

  • Blood vessel spasm: Vascular spasm in the brainstem may cause vertigo.
  • Changes in the neurotransmitters: As with most migraines, patients with vestibular migraine often have changes in serotonin levels.
  • Disturbance in the cerebellum: Changes in the metabolism of the cerebellum may be a cause of vestibular migraine.

Patients who are extremely sensitive to changes in sensory detail – sound, light, and movement – are more likely to experience vestibular migraine than any other type.

Women are three times more likely to experience any kind of migraine than men, leading researchers to hypothesize that fluctuations in hormones play a role in causing migraines. A genetic predisposition may also be a cause of this type of migraine.

Getting a diagnosis for vestibular migraines

Diagnosis of vestibular migraine can be complicated. As with most migraines, accurate patient reporting is key. In the case of vestibular migraine, there may be a misdiagnosis of Meniere’s disease or benign positional vertigo. Dr. Broner pointed out that although these conditions share similarities, these migraines are not quite the same, noting:

“There may be an overlap between Meniere’s and vestibular migraine. With vestibular migraine, people are exquisitely sensitive to motion, but they seem to be more sensitive to migraine triggers like fluorescent lighting or drinking wine. All the migraine triggers affect these patients; vestibular migraine is a disorder of exclusion—you have to rule out seizures and structural abnormalities—so it’s one of the clues.”

In other words, vestibular migraine is often diagnosed by process of elimination. In order to do this, doctors take a thorough patient history that includes any family incidence of migraine of any type. They may administer a CT scan or MRI to look for brain activity that indicates vascular involvement.

Because this type of migraine can involve the areas in the ear that deal with balance, patients may be referred to an otolaryngologist (ear, nose, and throat doctor) or an audiologist (to test for hearing loss or other symptoms of vestibular migraine).

Treatments for vestibular migraine

There are two types of treatments for this condition: preventative and reactive treatments.

1. Preventative

Preventative treatments for this type of migraine include identifying potential migraine triggers and removing them. These triggers can include:

  • Food: Certain aged cheeses, chocolate, and salt can be triggers for vestibular migraine.
  • Additives and preservatives: The additives and preservatives that keep processed foods shelf-stable can sometimes trigger migraine headaches. Monosodium glutamate (MSG) in particular has been associated with migraine, but other preservatives like sulfites and nitrates are also common culprits.
  • Drinks: Caffeine and alcohol should generally be avoided.
  • Stress: Chronically high stress levels can cause a number of different health problems, including vestibular migraine.

Other preventative measures for frequent or chronic vestibular migraine include the following medications:

2. Treatment for acute attack

For this type of migraine, many treatments during the attack phase include anti-emetics to control nausea and muscle relaxants.

Other treatments may include:

Vestibular migraine can be a seriously debilitating condition for those who suffer from it. Because it does not generally occur with pain, it is often misdiagnosed or underdiagnosed.

If you feel like you may be experiencing the symptoms of vestibular migraine, talk to your doctor about possible treatment options.

6 Moves for a Stronger Upper Back

Gym-goers are notorious for only working the muscles they can see in the mirror. That’s a strength-training cardinal sin because you miss out on arguably the most important quadrant of the body for strength and size: the upper back.

Building a big back isn’t easy, but it also isn’t complicated. You only have to do a few things:

  • Pick up heavy things off the floor
  • Pull heavy things toward your body
  • Pull yourself up off the floor

With those three types of movements in mind, here are the six best exercises to build an upper back worth showing off:

1. Deadlifts
No other exercise hits more muscle groups at once than the deadlift. The upper back plays a crucial role in stabilizing the weight during deadlifts, making them an essential choice if you want a big, strong upper back. Aim for 2–3 sets of 8–10 reps.

You can perform them with a barbell:

If you’re newer to the exercise, try them with a kettlebell and a sumo stance.

2. Barbell Bent-Over Rows
Using a barbell lets you add more weight, leading to greater strength and muscle gains. The bent-over row will also improve your deadlift strength because the mechanics of the two exercises are similar.

Here’s how to do a bent-over row with a barbell:

Perform 2–3 sets of 5–12 reps with moderate to heavy weight. Do these at the beginning of your workout because they challenge the entire body, and doing them in a fatigued state makes it difficult to keep good form.

3. Single-Arm Dumbbell Rows
The dumbbell row is one of the most versatile back exercises because you can use any weight you want for low reps, high reps or anywhere in between. Plus, it’s plenty safe for your lower back because you can support yourself on a bench with your opposite hand and leg.

Two to three sets of 8–12 reps per arm work best, but you can do as many as 20 reps per side for a deep burn. Do these after your heavier back exercises such as bent-over rows and deadlifts.

4. Standing Single-Arm Cable Rows
Cable rows add a level of versatility to your upper back training because you can alter the angle of your elbow and wrist as you pull, letting you hit your back muscles from different angles. The standing position also enforces core stability, as you have to use your abs to resist rounding or arching your lower back.

Stick with higher reps and lighter weight for these, opting for 2–3 sets of 8–15 reps per arm. If you don’t have access to a cable machine, wrapping a resistance band around a stationary object works too.

5. Pull-Ups
Pull-ups are one of the best back exercises in existence, but until you have a certain level of strength and can do 10 or more bodyweight pull-ups, your back muscles won’t get much stimulation from the move. So, to reap the benefits, you need to practice your pull-ups and increase the number of reps you can do.

Stick with the previously mentioned exercises first, and practice them 2–3 times per week with multiple sets of low reps (3–5 reps per set) with band-assisted pull-ups to build your technique. Once you’re proficient with the exercise, pull-ups can then be a valuable upper back builder.

6. Inverted Rows
The next-best body-weight alternative to pull-ups is the inverted row, which lets you use the resistance of your own body to strengthen your upper back. Simply grab a barbell set up in a power rack at about hip-height, and you’re good to go.

The key to effective inverted rows is keeping your body in a straight line from head to toe. Make sure to squeeze your abs and glutes so your hips don’t sag toward the floor. Do 2–3 sets of 8–20 reps, and get a tight squeeze in your shoulder blades at the top of each rep.

Back to Basics
Building a strong upper back is entirely possible with a few basic exercises. Pick the deadlift and row variations that work best for you, and you’ll be on your way to a bigger, better upper body.

5 Proven Ways to Prevent and Treat Knee Pain

Injuries are among the biggest concerns when starting a workout plan. In particular, knee pain is an issue that many people encounter at the outset of a new physical-activity program. But when you’re armed with a bit of knowledge on how to prevent and treat knee pain, you’ll be better equipped to stick with your workouts.

While there are a variety of culprits when it comes to knee pain, osteoarthritis is the most prevalent. In fact, the Centers for Disease Control and Prevention estimates that 1 in 2 people will experience knee osteoarthritis by age 85. Obesity and lack of activity only will increase your chances of developing the condition.

Another oft-cited source of knee pain is patellofemoral pain syndrome, aka
“runner’s knee.” This condition, which is used to describe general pain in front of the knee and around the kneecap, can afflict everyone from marathon runners to those just starting to exercise. Regardless of the cause, knee pain can knock you off your workout program, not to mention have a negative effect on your overall quality of life.

Here are a few methods of prevention and treatment that have been proved through academic research. Whether you’re looking to head off problems in the first place or you’ve already encountered some knee pain, the results of these recent studies may be the answer to your knee-related afflictions:

1. Strengthen your thighs.

Research suggests that weak front thigh muscles, also known as your quadriceps, can lead to knee pain. When you strengthen those muscles, your knees are stabilized and better able to handle the load that is involved with weight-bearing activities. Since doing the wrong types of strength work can actually lead to increased knee pain, the Journal of Orthopaedic & Sports Physical Therapy released guidelines for quadriceps exercises. The two main strength moves they suggest for pumping up your thigh muscles are squats and leg extensions. Here’s how to perform both moves safely:
  • Squat: With your feet pointed forward and shoulder-width apart, lower your backside down, keeping your back straight. Start by lowering to 45 degrees from a standing position, and progress to 90 degrees as your strength increases.
  • Leg Extension: While sitting on a chair with good posture, flex your foot and lift your leg upward, straightening it out in front of your body. If you have trouble getting it straight, start by raising it to 45 degrees until you build more strength.

2. Strengthen your hips.

In addition to strengthening your quadriceps, increasing strength in the muscles around your hips has been shown to reduce knee pain. One recent study published in the Clinical Journal of Sport Medicine found that 12 weeks of hip-strengthening exercises done 3–5 times a week decreased pain and improved quality of life for those with knee osteoarthritis.

Similarly, research has revealed that hip strengthening can be effective in reducing knee pain in patients with patellofemoral pain syndrome. While there are a whole host of hip-strengthening exercises you can do, here are two that are often recommended by trainers and coaches:

  • Side Leg Raises: Lie on your side with your legs straight. Slowly lift one leg toward the ceiling until you reach a 45-degree angle. Lower back down and repeat.
  • Bridges: Lie on your back with your knees bent and your feet flat on the floor. Carefully lift your backside upward until it is in line with your knees. Hold for two seconds, and lower back down.

3. Move more.

A 2015 review looked at more than 50 studies on the subject, finding that any type of land-based exercise can help lessen knee pain and improve function for those with knee osteoarthritis. While it’s always best to consult your doctor regarding what type of activity to engage in, land-based exercises can include everything from walking or jogging to cycling. The key, according to research, is that you stick with exercise for the long haul. If you are already experiencing knee pain, that can be tough, which is why it is important to consult with your physician on the type and amount of activity you should be doing.

4. Change your footwear.

While the jury is still out on what type of footwear may decrease knee pain, it appears that shoes can definitely play a role. Studies have looked at everything from rocker-soled shoes tominimalist “barefoot” footwear in hopes of identifying which might reduce pain. There are also studies that look at whether adding an insole or orthotic to your shoes might cut down on pain. For instance, lateral wedge insoles with arch support, which keep you from excessively rolling to the outside of your feet when you walk, have been shown to reduce pain related to knee osteoarthritis.

What’s more, studies have also demonstrated that insoles can be effective in treating pain caused by patellofemoral pain syndrome. The key is to experiment with various footwear options and see what works for your individual condition. If you’ve had these issues in the past, consider visiting a podiatrist at the outset of an exercise program for help with custom-made orthotics and shoe recommendations.

5. Get in the pool.

A wide variety of aerobic and strength exercises are proven to help prevent and treat knee pain, but hydrotherapy may be one of the best. A 2014 study published in the Annals of Applied Sport Science demonstrates the benefits of aquatic exercise: It provides a low-impact cardiovascular workout that also offers the opportunity to build strength and mobility. When researchers tested a group of people who suffered from knee osteoarthritis, aquatic exercise training done three times per week for six weeks was also shown to reduce knee pain.

Indeed, another study carried out by Chinese researchers found that aquatic exercises had the potential to increase range of motion and mobility. In terms of preventing knee pain, hopping in the pool to swim laps or do water aerobics a couple of times a week can be a great way to jump-start an exercise program before you commit to higher-impact activities.

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