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Interventional Pain Management
When other more common approaches fail and you still have pain, we can intervene with a limited number of special procedures. The medical specialty of interventional pain management may involve various minimally invasive procedures, though mostly injections. Within this specialty, our greatest focus at NMPM is on procedures that stimulate the body's own ability to permanently regenerate, regrow and repair damaged, degenerated tissues responsible for your pain.
And, it should be mentioned that interventional pain management and all of the treatment services discussed here are only as good as the diagnostic methods that guide them. At NMPM we emphasizes thorough interview and detailed orthopedic physical examination as the core of our practice, regardless of the treatment eventually recommended. Detailed evaluation is the key to effective pain management, orthopedic injury treatment, or any high quality medical care.
And, it should be mentioned that interventional pain management and all of the treatment services discussed here are only as good as the diagnostic methods that guide them. At NMPM we emphasizes thorough interview and detailed orthopedic physical examination as the core of our practice, regardless of the treatment eventually recommended. Detailed evaluation is the key to effective pain management, orthopedic injury treatment, or any high quality medical care.
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Overview
We permanently re-grow
Ligaments are straps that limit bone movement within safe, pain-free boundaries. Worn, loose ligaments are themselves painful, and they cause their own referred pain. Additionally, their laxity eventually hurts surrounding structures, causing disc herniation, nerve compression, damage to tendons, damage to cartilage, and osteoarthritis.
Tendon breakdown may be felt as local pain, referred pain, or as pain and dysfunction in the muscle that the tendon connects to bone.
Cartilage and fibrocartilage (meniscus, labrum) are damaged with injury or worn down in loose ligamented, dysfunctional joints. As cartilage gets thinner, movement irritates surrounding bone edges and eventually leads to bone spurs and other degenerative bone changes.
Breakdown of these spine and joint tissues is a key source of pain.
Procedures that re-grow these tissues can eliminate chronic pain permanently.
We intervene with minimally invasive procedures that do not involve open surgery. We precisely inject natural substances that attract your body's own growth factors and stem cells. This is done in some series of monthly procedures, with each procedure re-growing more and more of the damaged tissue, filling in broken fibers, gradually returning integrity and safe, pain-free function to the joint or spinal region being reconstructed. It is an incremental, natural process that is, literally, gardening or farming of collagen, the substance that ligaments, tendons and cartilage are made of.
However, no medical procedure can solve all medical problems. Not every patient is a candidate. Your eligibility for our methods can be preliminarily assessed in a scheduled phone conference. If you are a candidate, then a lengthy, thorough initial evaluation and examination in our office will detail how we may be able to help.
- ligaments - bone to bone connectors
- tendons - muscle to bone connectors
- cartilage - cushioning, gliding surfaces within joints.
Ligaments are straps that limit bone movement within safe, pain-free boundaries. Worn, loose ligaments are themselves painful, and they cause their own referred pain. Additionally, their laxity eventually hurts surrounding structures, causing disc herniation, nerve compression, damage to tendons, damage to cartilage, and osteoarthritis.
Tendon breakdown may be felt as local pain, referred pain, or as pain and dysfunction in the muscle that the tendon connects to bone.
Cartilage and fibrocartilage (meniscus, labrum) are damaged with injury or worn down in loose ligamented, dysfunctional joints. As cartilage gets thinner, movement irritates surrounding bone edges and eventually leads to bone spurs and other degenerative bone changes.
Breakdown of these spine and joint tissues is a key source of pain.
Procedures that re-grow these tissues can eliminate chronic pain permanently.
We intervene with minimally invasive procedures that do not involve open surgery. We precisely inject natural substances that attract your body's own growth factors and stem cells. This is done in some series of monthly procedures, with each procedure re-growing more and more of the damaged tissue, filling in broken fibers, gradually returning integrity and safe, pain-free function to the joint or spinal region being reconstructed. It is an incremental, natural process that is, literally, gardening or farming of collagen, the substance that ligaments, tendons and cartilage are made of.
However, no medical procedure can solve all medical problems. Not every patient is a candidate. Your eligibility for our methods can be preliminarily assessed in a scheduled phone conference. If you are a candidate, then a lengthy, thorough initial evaluation and examination in our office will detail how we may be able to help.
Grafting
One of our most powerful methods for growing new tissue is platelet-leukocyte autografting.
How does it work? Your blood is drawn and processed here on-site over about an hour. The resultant platelet, white blood cell and stem cell concentrate is then immediately grafted to within the damaged tissue via injection. Intelligent regeneration of the broken tissue fibers and fibrils ensues. Growth and repair continues for up to a month. Some series of monthly procedures is usually necessary.
The result is new, healthy, natural young tissue that is permanent.
- Platelets are blood cells that carry a pouch of growth factors. Growth factors are the complex proteins in our bodies that act as contractors and subcontractors to initiate and organize the growing of tissue.
- Leukocytes are white blood cells, several kinds of immune system cells that are also key to tissue growth.
- Stem cells are cells that divide to leave one stem cell and another cell of whatever kind may be needed by the growth factor contractors to make new structures. By concentrating the blood we are concentrating some amount of stem cells natural to the blood. The injection of this blood cell concentrate has also been shown to attract a large additional amount of stem cells to the repair site.
- Grafting is taking tissue or cells from one place and putting it in another place where it is needed.
- Autografting is using the tissue or cells from one's own body.
How does it work? Your blood is drawn and processed here on-site over about an hour. The resultant platelet, white blood cell and stem cell concentrate is then immediately grafted to within the damaged tissue via injection. Intelligent regeneration of the broken tissue fibers and fibrils ensues. Growth and repair continues for up to a month. Some series of monthly procedures is usually necessary.
The result is new, healthy, natural young tissue that is permanent.
Plasma Therapy
Plasma is the straw colored fluid in the blood. It is also secondarily bio-active and useful in stimulating growth. It contains two growth factors, substances that act like contractors to organize and signal tissue repair. Plasma also contains two important adhesion factors, substances that help the area being repaired to hold together while new tissues grow in. In has some lesser capacity for attracting stem cells. It is another substance from your own blood that we utilize in making growth of new tissue occur in areas where you are experiencing pain due to degeneration or injury.
Tendon \ Fascia Remodeling
A first step in gardening is breaking up the soil. With painful, broken down tendons, just breaking up the tissue in a calculated manner gets the growth process off to a good start. This process of tendon remodeling is called tenotomy; in cases of fascia it may be called fasciotomy. After anesthetizing the given area, needling of the tendon or fascia does several things:
The medical term for such needle stimulation of tendon is "tenotomy." Such needle stimulation of fascia is "fasciotomy."
This treatment may be useful alone or best in a series of interventions that may later include other types of injection. Recent studies have provided strong medical evidence of the effectiveness of tenotomy or fasciotomy in repair, regeneration, and pain management.
- breaks up any calcium deposits in the tendon that would be in the way of growing healthy tissue
- breaks up foreign fibrocartilage tissue that often infiltrates degenerating tendons, making way for growing healthy tendon tissue
- breaks up some of the irregularities on the degenerated bony surface where the tendon must reattach; this may be compared to cleaning off old dried glue that has failed before re-gluing an object to a surface
- immediately brings blood to the area - blood carries growth factors and stem cells
- stimulates development of new, extra blood vessels in the area for increased nourishment during the healing phase
The medical term for such needle stimulation of tendon is "tenotomy." Such needle stimulation of fascia is "fasciotomy."
This treatment may be useful alone or best in a series of interventions that may later include other types of injection. Recent studies have provided strong medical evidence of the effectiveness of tenotomy or fasciotomy in repair, regeneration, and pain management.
Introduction
While our above described tissue regeneration procedures are our greatest emphasis, in the right situation the other interventional procedures listed below can be very meaningful. They may have significant temporary effect in controlling pain, they may have permanent effects in and of themselves, or they may be part of a process that also involves tissue regeneration procedures.
Neurolysis
It is a common strategy in interventional pain management to destroy some nerves that are causing pain. The nerves do grow back over part of a year and hopefully behave better. We believe such strategies have a place, yet we approach this process of neurolysis or neuroablation with some caution. We use milder, safer versions of these techniques in a few clinical situations. For example, a Morton's neuroma is a painful enlargement of nerve tissue in the foot near the toes. We find neurolysis to be a reasonable strategy for this disfigured nerve. While destruction of the neuroma is sometimes attempted all at once using stronger methods with risk of surrounding tissue damage and side-effects, we use a mild 4% alcohol injection, repeated comfortably over several occasions, to accomplish the same goal more safely.
Autonomic Nerve Blocks
There are two nervous systems
somatic nervous system - normal motor and sensory nerves that most people are familiar with. It is organized like a centralized federal government, with the brain and spinal cord in charge.
autonomic nervous system - another very extensive system that controls blood flow, sweating and many other secretions, digestion, heart beat and other organ functions. It also has significant influence on pain. It is then divided into two parts.
somatic nervous system - normal motor and sensory nerves that most people are familiar with. It is organized like a centralized federal government, with the brain and spinal cord in charge.
autonomic nervous system - another very extensive system that controls blood flow, sweating and many other secretions, digestion, heart beat and other organ functions. It also has significant influence on pain. It is then divided into two parts.
- The parasympathetic nervous system is the autonomic nerves that help us relax, secrete and digest.
- The sympathetic nervous system is the autonomic nerves that stop secretion and peripheral blood flow in response to fight or flight situations, or perhaps just greater situational stresses.
Somatic Nerve Blocks and Tissue Bed Blocks for Regional Anesthesia
On some occasions we may use local anesthetic blocks for anesthetizing the region where a tissue regenerating procedure will occur. This is not always necessary, but if we decide to seek such pre-anesthetization, it may be locally (called a tissue bed block) or upstream on the nerve that innervates the region to have a procedure (somatic nerve block). Because we seek to keep local anesthetic volumes modest, and because we preferably try to avoid motor block (the ability to subsequently use the limb in question), the amount of block that we chose to effect may be partial.
Somatic Nerve Blocks for Pain Management
The nerves that people usually think of are somatic nerves. Injection of these nerves with local anesthetic can block nerve impulses to some degree. Blocking pain impulses in a nerve may have some value in management of pain. After the somatic nerve block wears off, the pain will most likely return unless the cause of the nerve pain is addressed. Thus we emphasize tissue regeneration procedures as longer-term solutions. However, the good news is that after nerve blocks some of the time the pain upon return of nerve function may be less, at least for some period of time. And it is reasonable to repeat such somatic nerve blocks at some time after the pain escalates once again.
Each situation is unique. The nerve in question, the patient's overall medical condition, and other factors may determine how aggressively we chose to block the nerve in question. Our preference is for lesser, milder blocks for a number of reasons, but each unique situation has to be considered as it presents itself.
Each situation is unique. The nerve in question, the patient's overall medical condition, and other factors may determine how aggressively we chose to block the nerve in question. Our preference is for lesser, milder blocks for a number of reasons, but each unique situation has to be considered as it presents itself.
Scar Release
We soften and reduce scar tissue from cuts, scrapes, burns and surgery. Such scars may not be a problem for some people, but in some cases the scars may be painful or they may subtly or frankly limit full and easy motion of the involved body part.
Furthermore, autonomic nerves spread through the body like rivers or networks of thinner and thinner wires. If they bump up against a scar they have been known to continue building up a hundred fold near the dead scar tissue. In the case of such small autonomic nerves, they may not hurt locally but may send strong signals back to their regional office (autonomic ganglion). Acting on this strong feedback, the ganglion may alter blood flow or other functions on erroneous information coming from the scar. In other words, some scars can be responsible for pain or other symptoms in distant areas of the body. While it is difficult to verify if such feedback is occurring or altering regional function, this possibility increases our reasons for considering your scars when we build a plan to ameliorate your pain.
Many substances can be injected into the scars: water, local anesthetic, or a scar tissue dissolving agent such as a natural enzyme. Patients often don't feel a needle going into scar tissue.
Furthermore, autonomic nerves spread through the body like rivers or networks of thinner and thinner wires. If they bump up against a scar they have been known to continue building up a hundred fold near the dead scar tissue. In the case of such small autonomic nerves, they may not hurt locally but may send strong signals back to their regional office (autonomic ganglion). Acting on this strong feedback, the ganglion may alter blood flow or other functions on erroneous information coming from the scar. In other words, some scars can be responsible for pain or other symptoms in distant areas of the body. While it is difficult to verify if such feedback is occurring or altering regional function, this possibility increases our reasons for considering your scars when we build a plan to ameliorate your pain.
Many substances can be injected into the scars: water, local anesthetic, or a scar tissue dissolving agent such as a natural enzyme. Patients often don't feel a needle going into scar tissue.
Trigger Point Release
Trigger points are muscle knots that most adults have experienced in places such as the upper back. The knots are contracted muscle tissue where the muscle's pulling action is more focused. And, such knots are always part of a taut band that extends from one end of the muscle to the other. Such trigger points are a problem for at least the following reasons:
For a variety of reasons, we feel that injections are often the most effective means of releasing these taut bands and trigger points.
Like any medical method, such injections have some limitations. Stretching may also be needed right after, and perhaps long after, most such injections. We avoid trigger point injection in some areas because of greater technical difficulty or risk. In some simple situations release of trigger points with injection may lead to long or seemingly permanent relief, but more commonly the causes of the stress on the muscle also need to be studied and treated.
- local pain at the trigger point
- referred pain from the trigger point, even far from the trigger point
- muscle shortening
- muscle weakening and atrophy because the muscle can't be used and strengthened through its full range of motion
- simple or complicated dysfunction of other muscles and joints in the region effected by the dysfunctional, shortened muscle
For a variety of reasons, we feel that injections are often the most effective means of releasing these taut bands and trigger points.
Like any medical method, such injections have some limitations. Stretching may also be needed right after, and perhaps long after, most such injections. We avoid trigger point injection in some areas because of greater technical difficulty or risk. In some simple situations release of trigger points with injection may lead to long or seemingly permanent relief, but more commonly the causes of the stress on the muscle also need to be studied and treated.
