Browsing articles tagged with " Pain"

69. Occipital Headache, How Can Acupuncture Treat It?

Mar 7, 2017   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

News Letter, Vol. 8 (2), March, 2017, © Copyright

Jun Xu, M.D., Hong Su, C.M.D., Lic. Acup.

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

How Can Acupuncture treat Occipital Neuralgia?

 

Linda, a 45-year-old female dental assistant, came to me complaining of severe headaches that started at the back of her head and continued down a portion of her neck.  The pain also radiated up to her scalp, around her ears and sometimes into the bilateral temporal area.  The pain was off-and-on, but occurred every day.  The pain ranged from dull to sharp, and was sometimes located directly behind the right eye.  As a dental assistant, she constantly turned her head to the right when dealing with patients.  This caused the headache to become more severe, and she was frustrated that it interfered with her daily work.  She had consulted several doctors about her condition, and had been prescribed Naprosyn, Percocet and Neurotin, but none of them alleviated her condition.

These headaches intensified when Linda was under stress, which was often because of her job: if she had many patients waiting for her and felt under pressure, the headaches worsened.

When I examined Linda, I discovered that when I pressed her scalp at the base of the skull and suboccipital area, the pain radiated to the back, front and side of her head, and also to the right side of the eye.  When I pressed hard on the suboccipital area (the base of the skull) the pain was exacerbated and I could feel the bilateral temporal artery palpating.

The patient probably suffers from occipital neuralgia, which is a cycle of pain spasms originating in the suboccipital area, caused by an inflammation of the occipital nerves.  The two pairs of occipital nerves (each nerve contains a greater and lesser occipital nerve) originate in the second and third vertebrae of the neck.  These nerves supply areas of the skin along the base of the skull and behind the ear, but are not always connected directly with the structures inside the skull. However, they do interconnect with other nerves outside the skull and continue into the neuro-network.  Eventually they can affect any given area along the scalp, mainly on the bilateral temporal area behind the ear and sometimes connect to the nerve branch on either side of both eyes.

Occipital neuralgia may occur continuously, often as the result of the nerve impingement, especially from arthritis, muscle spasm, or as the result of a prior injury or surgery.  Sometimes these conditions will impinge the occipital nerve root, leading to severe headaches at the back of the head, leading to muscle spasm.  Linda exhibits the severe form of occipitical neuralgia, most likely because her profession causes her to tilt her head in the same manner for a good part of her day. This stress causes the occipital nerve to be impinged, sending a constant signal to the nerve network in her scalp, leading to headaches and the pain behind her right eye.

The clinical diagnosis of this condition is based on palpation by the doctor of the bilateral occipital nerve root, which will induce or trigger the headache. Doctors currently use various treatments.  One option is to inject 1% lidocaine 5cc into the occipital nerve root, which decreases or relieves the pain, confirming the diagnosis.  A second option is to use surgery to cut or burn the nerve with a radial wave probe.  A third option is to use a small injection of Botox or a similar medication.  Western medicines include anti-inflammatory or narcotics such as Percocet or Darvocet, Naurontin, anti-epilepsy medication, etc.  For the majority, these medications do not work well, though occasionally they can reduce the occurrence and frequency of the occipital neuralgia.

Some patients respond to physical therapy and massages to decrease the spasm of the neck muscle, which might temporarily relieve the occipital neuralgia.  Though doctors may recommend surgery, many patients resist this type of treatment.

According to Traditional Chinese Medicine, occipital neuralgia belongs in the category of the side headache, i.e. the Shao Yang Gallbladder meridian headache.  Gallbladder meridians are distributed around the sides of the head, and excessive heat in the gallbladder can lead to headaches.  The gallbladder meridian originates from the outside of the eye, and continues up the temporal nerve area, around the lateral skull area, down the occipital nerve area, down through the trunk and to the outside of the leg.  If there is excessive heat along this meridian, there will be an imbalance of yin and yang.  For example, if the patient undergoes stress, muscle spasm or arthritis, the nerve and the gallbladder meridian will be impinged.  This, in turn, will cause the gallbladder to heat up, leading to excessive heat, an imbalance of yin and yang and a severe headache.

Another meridian identified in occipital neuralgia by Traditional Chinese Medicine is the urinary bladder meridian, which starts from the inside corner of the eye, continues through the middle and the top of the scalp, and follows down the back of the trunk and into the back of the leg.  Due to the connection between the gallbladder and urinary bladder meridians, heat in one will cause heat in the other to rise, generating pain around the eye, the temporal area and the scalp, and making the ensuing headache severe and highly unbearable.  Therefore, the principal acupuncture treatment is to relieve this excessive heat in the gall bladder and urinary tract.

The main acupuncture points used for treatment are: Du 20 Bai Hui, GB 20 Feng Chi, GB1 Tong Zi Liao, GB 8 Shuai Gu, Extra point Tai Yang, GB 34 Yang Ling Quan, SI 3 Hou Xi, Lu 7 Lie Que, Kid 6  Zhao Hai, Li 3 Tai Chong.

Linda underwent my treatment three times a week for one month, resulting in immediate, short-term relief of her headaches.  However, the headaches continued to plague her because of her strenuous work.  In addition, her irregular menstrual cycle and hormonal changes led to more severe headaches.  Thus, I also treated her for hormonal changes by utilizing a Chinese herb Da Zhi Xiao Yao San.  The combination of acupuncture and herbal therapy seemed to be effective and, after about two months of treatment, Linda reported that her headaches occurred only infrequently and were very mild, and that she was satisfied with her treatments.

Usually, acupuncture, with or without the addition of herbal supplements, can alleviate the problems and pain associated with these headaches.  However, sometimes it is best to combine acupuncture with a nerve block (utilizing 4cc of 1% lidocaine plus 10 mg Kenalog mixed together) injected into both sides of the occipital nerve origin.  One month of this combined treatment should give the patient 95% relief from his/her symptoms.

Tips for acupuncturists:

  1. You should identify the location of the pain and tenderness, and treat the headache accordingly.  For example, the frontal headache belongs to the Yang Ming meridian; the temporal side headache belongs to the Shao Yang meridian; the top scalp headache belongs to the Jue Ying meridian.
  2. Always use Du 20 Bai Hui for all the different types of headaches. This is based on my personal experience over 20 years of practice.

Tips for patients:

  1. You should be very specific when describing the tender points on your head because each tender-point location belongs to a different meridian, and treatment varies based on each location.
  2. Massaging the Tai Yang and UB 20 Feng Chi points for 20 minutes, 2 to 3 times a day, will greatly decrease the headache.

 

67. Dr. Jun Xu’s calling from West Africa

Mar 5, 2017   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

Dr. Jun Xu went to Leprosy village in 2013, 2014 and 2016, soon he will go to the leprosy village on March 31, 2017.

In 2013, there was no a single room being used for treatment in the leprosy village, Dr. Xu and his team had to use a tent. The temperature was around 125 Fahrenheit degrees.

The leprosy patients were waiting for their turn to be attended. Dr. Jun Xu saw about 200 patients a day.

Typical leprosy patient:
Early Stages
Spots of hypopigmented skin- discolored spots which develop on the skin
Anaesthesia(loss of sensation) in hypthese opigmented spots can occur as well as hair loss
“Skin lesions that do not heal within several weeks of and injury are a typical sign of leprosy.” (Sehgal 24)

Progression of disease

“Enlarged peripheral nerves, usually near joints, such as the wrist, elbow and knees.”(Sehgal 24)
Nerves in the body can be affected causing numbess and muscle paralysis
Claw hand- the curling of the fingers and thumb caused by muscle paralysis
Blinking reflex lost due to leprosy’s affect on one’s facial nerves; loss of blinking reflex can eventually lead to dryness, ulceration, and blindness
“Bacilli entering the mucous lining of the nose can lead to internal damage and scarring that, in time, causes the nose to collapse.”(Sehgal 27)
“Muscles get weaker, resulting in signs such as foot drop (the toe drags when the foot is lifted to take a step)”(Sehgal 27)

Long-term Effects
“If left untreated, leprosy can cause deformity, crippling, and blindness. Because the bacteria attack nerve ending, the terminal body parts (hands and feet) lose all sensations and cannot feel heat, touch, or pain, and can be easily injured…. Left unattended, these wounds can then get further infected and cause tissue damage.” (Sehgal 27)
As a result to the tissue damage, “fingers and toes can become shortened, as the cartilage is absorbed into the body…Contrary to popular belief, the disease does not cause body parts to ‘fall off’.” (Sehgal 27)

Every year, Dr. Jun Xu and his team bring around $300,000 worth of medicine donated from his team members and Americares in Stamford, CT to treat the leprosy and other patients in Senegal and Guinea Bissau. http://www.americares.org/, in 2017, his team also received medicine donation from Direct Relief in California, https://www.directrelief.org/.
Dr. Jun Xu and his team finally established a clinic in the leprosy village, one building for the clinic, and another building for the living of doctors and nurses.

Leprosy village people were celebrating the opening of the clinic.

There are 8 wards, which could hospitalize the patients if it is medically necessary.

Dr. Jun Xu’s team usually stay in Senegal for 10 to 14 days, these are the foods his team brought from US in order to keep them health and safe. They do not dare to eat street food.

The above are the coolants contained food Dr. Jun Xu’s team brought from US

Dr. Jun Xu and his team from US in 2006.
If you are interested in joining Dr. Jun Xu’s team or donating to his work in Senegal, please address your check payable to AGWV, and send to
Jun Xu, MD, 1171 E Putnam Avenue, Riverside, CT 06878, USA.
Dr. Xu promises that all your donation 100% will go to Senegal and his team will nerve use a penny from your donation. You will receive the tax deductible receipt. Any amount is a great help for Africa patients.
For more info, please visit our websites at
http://www.drxuacupuncture.co/ and http://www.africacriesout.org/

49. Acupuncture and Post-Treatment Lyme Disease Syndrome

Jan 25, 2013   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

News Letter, Vol. 5 (1), January , 2013, © Copyright

 

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Fax: (203)637-2693

 

Post-Treatment Lyme Disease Syndrome

My dear friends,

Before you read my case discussion, please read the following ,

I was the president of American Traditional Chinese Medicine Society  (www. http://atcms.org)  between March 2010 and March, 2012. Now, I am honorary  president of ATCMS.  On behalf of ATCMS,  I advise you sign the petition to  urge Obama Administration recognize acupuncturist  as  healthcare providers  and allow Medicare to pay acupuncture treatment.

Thank you for your support! Please sign the petition now!

Jun Xu, MD

Recognize Acupuncturist as Healthcare providers

Despite overwhelming evidence of the positive impact acupuncturist have on patient health, they are not recognized as healthcare providers under the Social Security Act and, therefore, cannot be paid by Medicare for therapy management.

Please visit the website at: https://petitions.whitehouse.gov/petition/recognize-acupuncturist-healthcare-providers/NTNpVFnp, and sign this petition to urge President to recognize acupuncturists as Medicare providers. We do need at least 25000 signatures by February 10, 2013, in order to get a response from the White House. Please forward this email to your family members, friends, and patients, and ask them to do so. Your participation will make a difference.

Thanks for your efforts and participating!

American TCM Society (ATCMS)

 

Fig 1-1

 

Janet, a 36 year old woman, came to me with complaints of body aches and multiple joint pain for the past 6 months.  Janet reported, “Every inch of my body is achy, I am depressed.” She reports having a tick bite about ten months ago, while she was playing with her son in the backyard of her house.  A dead tick was found on her neck close to her hair line with a bull’s  eye rash prompting her to see her physician immediately and receiving antibiotics (doxycycline) for three weeks. She felt fine at that time. However, after one month, she started to develop some flu like symptoms; feeling fatigue, poor sleep, stomach cramps and poor appetite. She took advil for 2 weeks without any improvement. She also felt poor concentration along with severe headaches. Later she developed bilateral knee joint swelling, difficulty walking, a tingling like snake sensation at both legs and hands. She went to many different doctors for her symptoms, though no one could give her a definite answer and treatment, therefore, she came to me for help.

Janet is most likely to have Post-Treatment Lyme Disease Syndrome

Approximately 10 to 20% of patients treated for Lyme disease with a recommended 2–4 week course of antibiotics will have lingering symptoms of fatigue, pain, or joint and muscle aches. In some cases, these can last for more than 6 months. Sometimes it is called “chronic Lyme disease,” this condition is properly known as “Post-treatment Lyme Disease Syndrome” (PTLDS).

The main symptoms of PTLDS are listed as following,

  • Arthritis. After several weeks of being infected with Lyme disease, approximately 60% of those people not treated with antibiotics develop recurrent attacks of painful and swollen joints that last anywhere from a few days to a few months. The arthritis can shift from one joint to another; the knee is most commonly affected and usually one or a few joints are affected at any given time. About 10% to 20% of treated patients will go on to develop lasting arthritis. The knuckle joints of the hands are only very rarely affected.
  • Neurological symptoms. Lyme disease can also affect the nervous system, causing symptoms such as stiff neck and severe headache (meningitis), temporary paralysis of facial muscles (Bell’s palsy), numbness, pain or weakness in the limbs, or poor coordination. More subtle changes such as memory loss, difficulty with concentration, and a change in mood or sleeping habits have also been associated with Lyme disease. People with these latter symptoms alone usually don’t have Lyme disease as their cause.

Nervous system abnormalities usually develop several weeks, months, or even years following an untreated infection. These symptoms often last for weeks or months and may recur. These features of Lyme disease usually start to resolve even before antibiotics are started. Patients with neurologic disease usually have a total return to normal function.

  • Heart problems. Fewer than one out of 10 Lyme disease patients develops heart problems, such as an irregular, slow heartbeat, which can be signaled by dizziness or shortness of breath. These symptoms rarely last more than a few days or weeks. Such heart abnormalities generally appear several weeks after infection, and usually begin to resolve even before treatment.
  • Other symptoms. Less commonly, Lyme disease can result in eye inflammation and severe fatigue, although none of these problems is likely to appear without other Lyme disease symptoms being present.

 

The exact cause of PTLDS is not yet known. Most medical experts believe that the lingering symptoms are the result of residual damage to tissues and the immune system that occurred during the infection. Similar complications and “auto–immune” responses are known to occur following other infections, including Campylobacter (Guillain-Barre syndrome), Chlamydia (Reiter’s syndrome), and Strep throat (rheumatic heart disease). In contrast, some health care providers tell patients that these symptoms reflect persistent infection with Borrelia burgdorferi. Recent animal studies have given rise to questions that require further research, and clinical studies to determine the cause of PTLDS in humans are ongoing.

Regardless of the cause of PTLDS, studies have not shown that patients who received prolonged courses of antibiotics do better in the long run than patients treated with placebo. Furthermore, long-term antibiotic treatment for Lyme disease has been associated with serious complications. The good news is that patients with PTLDS almost always get better with time; the bad news is that it can take months to feel completely well.

If you have been treated for Lyme disease and still feel unwell, see your doctor to discuss how to relieve your suffering. Your doctor may want to treat you in ways similar to patients who have fibromyalgia or chronic fatigue syndrome. This does not mean that your doctor is dismissing your pain or saying that you have these conditions. It simply means that the doctor is trying to help you cope with your symptoms using the best tools available.

It is normal to feel overwhelmed by your ongoing symptoms. Some things that may help you manage your PTLDS include:

  • Check with your doctor to make sure that Lyme disease is not the only thing affecting your health.
  • Become well-informed. There is a lot of inaccurate information available, especially on the internet. Learn how to sort through this maze.
  • Track your symptoms. It can be helpful to keep a diary of your symptoms, sleep patterns, diet, and exercise to see how these influence your well being.
  • Maintain a healthy diet and get plenty of rest.
  • Share your feelings. If your family and friends can’t provide the support you need, talk with a counselor who can help you find ways of managing your life during this difficult time. As with any illness, Lyme disease can affect you and your loved ones. It doesn’t mean that your symptoms are not real. It means that you are a human being who needs extra support in a time of need.
  • Being strong mind, if you know the mechanism of your illness and have strong mind to fight this illness, you will finally get out of the control of the disease.

It is important to note that people with a history of Lyme disease have more musculoskeletal impairments when compared to those without a history of the disease.  Physical Therapy is very effective at treating musculoskeletal impairments such as pain and muscle spasms though multiple means of massage, heat, ultrasound, electrical stimulation.  Muscle weakness and limited endurance are other symptoms that can be greatly improved with treatment.

A common impairment is decreased standing balance and impaired gait pattern that a routine of lower body strengthening, core training and balance exercises would help to restore.  Functional limitations would include difficulty with stair negotiation; sit to stand transfers and the inability to continue to work.  It is important not to over stress yourself with exercise or daily activities to prevent from exacerbating your PTLDS

A few exercises would be a light general warm-up that is easy on the knees being the exercise bike at low-moderate intensity taking breaks as needed.

 

Fig 1-2 http://visionfitness.mercola.com/exercise-bikes.aspx

After warmed-up, a whole body exercise that also works on a common ailment of decreased transfer ability with sit to stands would be chair squats.  With this exercise it is important not to allow your knees to track beyond your toes and to barely allow the hips to touch the seat before standing back up again.  Start with 10 pain free reps and working up to 30 reps total.

 

 

Fig 1-3 http://holistichealthgurus.com/blog/body/squats-with-chair-facing-the-wall/

 

 

Balance is another ailment that can be worked with exercise.  Start out on a flat surface with eyes open for one minute, once that becomes easy start to challenge yourself by closing your eyes only as long as you are standing in front of a couch or table that you can grab hold of if needed.  Continue to progress by then standing on a foam pad to make the surface uneven or stay on the flat surface and stand on one foot at a time with eyes open and then closed.

Fig 1-4 http://www.acefitness.org/certifiednewsarticle/687/designing-balance-exercise-programs-for-older/

A light stretching routine is encouraged to decrease joint stiffness and improve range of motion.  Shown is a simple stretch that if held for 1 minute on each leg will loosen muscles around the most common effected area with PTLDS being the knees.

Fib 1-5 http://www.livestrong.com/slideshow/558801-finding-the-fitness-30/#slide-2

Acupuncture is an excellent alternative way to treat your symptoms. It has no side effects and can be combined with traditional western medicine to relieve your symptoms. The choice of acupuncture treatment of PTLDS  is as following,

  1. Common used points: Du20 Bai Hui,  GB8 Shuai Gu, UB9 Yu Zhen, Ht7 Shen Men, GB20 Feng Chi, UB15 Xin Shu, UB20 Pi Shu, UB18 Gan Shu, UB23 Shen Shu, St6 Zu San Li, Sp6 San Yin Jiao, Lv3 Tai Cong, UB2 Zan Zhu, Kid3 Tia Xi.
  2. Arthritis: Shoulder: LI 15 Jian Yu, SI 9 Jian Zhen, SJ 14 Jian Liao, SI 10 Nao Shu, SI 11 Tian Zhong, LI 16 Ju Gu  Wrist: LI5 Yang Xi and SJ 4 Yang Chi.    Knee: LI 4 He Gu, LI 11 Quchi, St 35 Du Bi, Nei Xi Yan, Sp 10 Xue Hai, St 34 Liang Qiu, He Ding, UB 40 Wei Zhong,  ,
  3. Neurological Symptoms: Fatigue, Depression and Poor Sleep: Major points: St 36 Zu San Li, PC6 Nei Guan,  LI4 He Gu, Ht7 Shen Meng, Sp6 San Yin Jiao, GB20 Feng Chi, Du20 Bai Hui, EX-HN1 Si Shen Cong, assistant points: Du14 Da zhui, Ren12 Zhong Wan, Ren14  Ju Que, Ren6 Qi Hai, Ren4 Guang Yuan, UB21 Wei Shu and UB23 Shen Shu.
  4. Bell’s Palsy: GB14 Yang Bai penetrating  Ex Yu Yao, and Si Bai, Tai Yang  penetrating  St7 Xia Guan, St4 Di Chang penetrating  St6 Jia Che, LI20 Ying Xiang, UB2 Zan Zhu, Ren24 Cheng Jiang.
  5. Heart Palpitation: PC6 Nei Guan, Ht7 Shen Men, UB15 Xin Shu, Ren14 Ju Que, UB14 Jue Yin Shu
  6. Dizziness: Si Shen Chong, Du20 Bai Hui, Du12 Shen Zhu, UB12 Feng Men, UB43 Gao Huang, Sp6 San Yin Jiao, St36 Zhu San Li, LI11 Qu Chi.

Janet’s Treatment:

Janet was treated with me for 2 x per week for 8 weeks. I first try to decrease her pain at the joints and body with the points of group 1 and 2 , then, I used the group 3 points to help her to improve her fatigue and depression, after about 2 month’s treatment, Janet felt much improved. Her pain scale decreased from 9/10 to 2/10. She then had maintenance treatment for once a week for another 2 weeks, she finally discharged without pain.

Tips for Patients:

  1. Early diagnosis and early treatment: Always suspect you might have Lyme disease if you have exposed to wild environment with skin rash. Early treatment is the key to reduce the rate of  Post Treatment of Lyme Disease Syndrome.
  2. Multiple Therapy is the best way to treat PTLDS.  Anti-inflammatory Medication, Physical Therapy and Acupuncture Treatment together will help you a lot.

Tips for Acupuncturists:

  1. Treat your patients as a whole person, you not only treat their pain symptom, but also their stress, fatigue, and depression. To relieve the mental stress is the key for the effects of your acupuncture treatment.
  2. Encourage your patients to have at least 8 weeks treatment. It is very important to have a long term treatment to achieve the best results.

 

 

References

Reviews of human research

Marques, A. Chronic Lyme disease: a review. Infect Dis Clin North Am 2008; 22:341–60.

Feder, et al. A critical appraisal of “chronic Lyme disease”. New Eng. J. Med. 2008; 357:1422–30.

Non-human research

The following publications refer to studies in mice and monkeys. Please note that while animal studies are helpful, further research is necessary to determine whether these results correlate with human disease.

Barbour A. Remains of infection. J Clin Invest. 2012 Jul 2;122(7):2344–6. doi: 10.1172/JCI63975. Epub 2012 Jun 25.

Bockenstedt LK, Gonzalez DG, Haberman AM, Belperron AA. Spirochete antigens persist near cartilage after murine Lyme borreliosis therapy. J Clin Invest. 2012 Jul 2;122(7):2652–60. doi: 10.1172/JCI58813. Epub 2012 Jun 25.

Embers ME, Barthold SW, Borda JT, Bowers L, Doyle L, et al. (2012) Persistence of Borrelia burgdorferi in Rhesus macaques following antibiotic treatment of disseminated infection. PLoS ONE 7(1): e29914.

Reference resource:

http://www.webmd.com/rheumatoid-arthritis/arthritis-lyme-disease 

http://www.cdc.gov/lyme/postLDS/index.html

 

 

24. Acupuncture and Low back pain again after back surgery

Dec 19, 2010   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

News Letter, Vol. 2 (12), December, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

 

 

Dear Friends and Patients:

Happy Holidays!

This is the last newsletter for 2010. We are very happy to introduce Dr. Robert Blizzard, who recently joined in our practice. Dr. Blizzard graduated from the University of Connecticut with a Bachelor’s Degree in Exercise Science, and continued on to receive his Doctoral of Physical Therapy at Franklin Pearce University. He is a full time licensed physical therapist in RMAC. We believe his knowledge and experience will help you to fulfill your goal to be completely recovered from your injury. Dr. Blizzard joined us to write this newsletter too.

From now on, we will leave our comment space on under the news letter at our website, www.DrXuAcupuncture.com.  you are welcome to leave  your questions or comments .  We will try our best to answer your questions.

We wish you happy holidays!

Jun Xu, M.D.

Hong Su, C. M. D.

Robert Blizzard III, D.P.T.

Low back pain with failed back surgery syndrome (FBSS)


 

 

From: www.yorkshirehighlanders.co.uk

Peter is a 56-year-old male who complains of low back pain for three years.  The pain started from the low back and radiated down to the right leg, which made it difficult sitting, walking, and standing.  The pain also interferes with his sleep, especially while he changes positions in the bed, and therefore he went to his primary care physician. He was referred to physical therapy for about three months of treatment.  However, the pain was not getting better and still he felt pain is sharp and stabbing, and that radiated down to the right lateral thigh and the lower leg.  The pain was constant.  In the meanwhile, he gradually felt his leg was weak and he had difficulty standing from the sitting and driving position.

Then one day he realized his underwear was wet because he had difficultly controlling his urinary bladder and he had decreased sensation at right lateral lower leg.  Therefore, his primary care physician referred him to a neurosurgeon.  An MRI was done, which showed two large right L4/L5 and L5/S1 herniated disc with impingement of right L5, S1 nerve roots.  He was advised to have surgery, L5/S1discectomy.

However, he was afraid of the surgery, then he consulted another neurosurgeon, who suggested to have laminectomy because the MRI, which showed two levels, L5 and S1, with  severe right foraminal L5-S1 nerve impingement and  degenerative changes between L5 and S1 and S1 and S2, which are the reasons for urinary incontinence.

He was thinking, however, he would like to wait a few more months to see if this would be getting better.  He restarted physical therapy again, and also he had epidural injection at those two levels and his pain seemed  better slightly.  However, he felt the right leg is weaker, he sometimes loses control of his urine.  Therefore, he decided to have surgery.

Laminectomy was performed one year ago.  After the surgery within one month, he had immediate pain relief and also he could control his urine and the bowel movement.  The patient was very happy about the surgery.

However, after six months, he started to feel low back pain again and this time he felt the pain is a gradual onset, dull and achy without any radiating down to the leg and he had no bowel or bladder abnormalities, but he still feels some weakness and mild numbness and tingling sensation on the right lateral leg. He visited his neurosurgeon, who told him this pain sometimes occurred after surgery about 6 months, and if he continued to do the physical therapy, the pain should be getting better.

The patient started to do physical therapy again after six months and he did muscle strengthening and stretching on the low back.  However, one day, he felt the pain suddenly getting worse after waking up and the pain is like stabbing with burning sensation around the L3-L4, L5-S1 middle spine and paraspine, and since then, he has had difficulty bending forward and backward, sitting to standing, and driving.  The patient then revisited his surgeon and he was prescribed Tylenol with Codeine.  After he took this pain medication, he felt better.  However, he started to feel drowsy and he had difficulty driving and concentrating on his work, and gradually he also started craving for this drug.  If he did not take for one day, he felt uncomfortable not only in the low back but the entire body and also he felt depressed and low energy.  Therefore, he came to me for evaluation and treatment.

I performed  physical examination, I saw the scars on the both sides of the L4, L5, and S1 para-spine, by palpation,  there was tenderness around L3-L4 and L5-S1 para-spine.  There was no palpation pain at bilateral sciatic areas.  He can bend his low back forward only about 40 degrees and bend his back backward only about 10 degrees.  He had no problem to walk on tippy toes and heels.  He had no decreased sensation at both legs.  I compared the MRI of presurgery and postsurgery,  There was no impingement of the nerve roots anymore.  Based on all the above information, I thought the patient was suffering with post-lumbosacral laminectomy syndrome, also called “failed back surgery syndrome” (FBSS), refers to chronic back and/or leg pain that occurs after back (spinal) surgery.

Before I introduce the Failed Back Surgery Syndrome, I would like to let you understand the basic knowledge of low back surgery;

There are seven types of low back surgery.

1.      Discectomy.

2.      Foraminotomy.

3.      Intradiscal electrothermal therapy.

4.      Nucleoplasty.

5.      Radiofrequency lesioning.

6.      Spinal fusion

7.      Spinal laminectomy, etc.

Discectomy
This is a procedure done to relieve pressure on a nerve root that’s being compressed by a bulging disc or bone spur. In order to relieve this pressure, the surgeon removes a small piece of the lamina (the bony roof of the spinal canal) from above the obstruction.

Figure 24.1

http://indiahealthtour.com/treatments/spine-surgery/endoscopic-micro-discectomy-surgery.html

Foraminotomy
This is type of surgery is undertaken to enlarge the foramen (the bony hole) where a nerve root branches out from the spinal canal. Joints thickened with age, or bulging discs, may cause the foramen to narrow, thereby pressing on the nerve. This pressure can cause pain, numbness or weakness in the extremities. In order to relieve the pressure, the surgeon removes small pieces of bone over the nerve through a small slit, which allows her to cut away the blockage.

Figure 24.2

From: http://www.laser-spine.com/spinehealth/treatments/endoscopic_foraminotomy/

IntraDiscal Electrothermal Therapy (IDET)
IDET is used to treat pain caused by a cracked or bulging spinal disc. This therapy involves inserting a special needle into the disc via a catheter. Once inserted, the needle is heated to a high temperature for approximately twenty minutes, effectively thickening and sealing the disc wall. This procedure reduces inner disc bulge and spinal nerve irritation.

Figure 24.3

From: http://www.advanced-pain-care.com/Intradiscal.htm

Nucleoplasty
Nucleoplasty is used to treat lower back pain resulting from mildly herniated or contained discs. During this procedure, a wand-like instrument is guided by x-ray imaging and inserted through a needle into the disc in order to create a channel. This facilitates the removal of inner disc material. Several channels may be made, depending on the amount of material needing to be removed. After removal, the wand heats and shrinks the tissue of the disc wall in order to seal it.

Figure 24.4

From: http://www.kcpain.com/kcp_help5c.php

Radiofrequency (RF) Lesioning
This procedure is used to interrupt of nerve conduction and the transfer of pain signals. Electrical impulses are used in order to destroy the nerves located in the affected area. A special needle is inserted into the localized nerve tissue, with the guidance of an x-ray. This area is then heated for 90 to 120 seconds, destroying the nerve tissue. This may result in cessation of pain for 6-12 months.

Figure 24.5

From: bnsmedical.com

Spinal fusion
Spinal fusion is a procedure which is done in order to support a weak spine and/or to prevent painful movements. However, spinal fusion requires a long recovery period, and may result in a permanent loss of spinal flexibility. The procedure involves the removal of the spinal disc between two vertebrae, and the subsequent fusion of those vertebrae. Methods of fusion include either bone grafting and/or using metal devices secured by screws.

Figure 24.6


From: http://skillbuilders.patientsites.com/Injuries-Conditions/Lower-Back/Lower-Back-Issues/Lumbar-Spinal-Stenosis/a~51/article.html
Spinal Laminectomy
This procedure is used to relieve pressure on the spinal cord and nerve roots. Also known as spinal decompression, this type of surgery involves the removal of the lamina to increase the size of the spinal canal.

Figure 24.7

http://www.eorthopod.com/content/lumbar-laminectomy

Treatments for Faild Back Surgery Syndrome (FBSS)

In 1992, Turner et al. published a survey of 74 journal articles which reported the results after decompression for spinal stenosis. Good to excellent results were on average reported by 64% of the patients. (Turner, J., et al., Spine 1992; 17:1-8 ) Therefore, there are about 36% of the post back surgical patients, who might suffer some degrees of back pain, usually after 6 months of surgery.  For some patients, the pain might achieve the peak intensity as pre-operation after two-year surgery.

Failed back surgery syndrome (FBSS),  is characterized by intractable diffuse, dull and aching pain or sharp, pricking, and stabbing pain in the back and/or legs accompanied with varying degrees of functional incapacitation.  Recurrent herniated disc and symptomatic hypertrophic scar can produce similar low back symptoms and radiculopathy as before the surgery. Gradually increasing symptoms beginning a year or more after discectomy are considered more likely a result of scar radiculopathy, while a more abrupt onset at any interval after surgery is more likely due to recurrent herniated disc. Multiple factors can contribute to the onset or development of FBS, such as residual or recurrent disc herniation, persistent post-operative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness and spinal muscular deconditioning.

The treatments of Failed back surgery syndrome (FBSS),  include physical therapy, acupuncture, minor nerve blocks, transcutaneous electrical nerve stimulation (TENS), behavioral medicine, non-steroidal anti-inflammatory (NSAID) medications, membrane stabilizers, antidepressants, and intrathecal morphine pump. Use of epidural steroid injections may be minimally helpful in some cases. Here, we will mainly introduce physical therapy, pain medications and acupuncture treatment.

1. Physical therapy:

Spine surgery changes the anatomy of the spine but does nothing to improve activation of deep core stabilizing muscles.  That is one of the benefits of physical therapy for re-training the body to properly activate the deep core muscles that stabilize the spine.  The two deep co-stabilizing muscles of the spine are the Transverse Abdominis (TrA) and Multifidus

Spinal braces are an option to wear especially immediately following surgery to improve recovery. A corset helps to brace the lumbar spine by increasing the pressure in the abdomen, and thus reducing the amount of weight placed through the spine.

Figure 24.8The Transverse Abdominis is often called the “human corset” as it is the only abdominal muscle attaching to the posterior spine and runs transverse around the body.

Figure 24.9

http://www.unm.edu/~lkravitz/Media/transverse.gif http://www.exerciseyourpainaway.co.uk/muscles.htm

Draw-Ins

These exercises can be performed in any position and progressed once the very important concept of TrA activation is achieved. The two starting positions are quadruped and supine.  Stabilizing the spine by activating TrA and Multifidus occurs without rotating the hips, tensing the shoulders or holding ones breath but from slowly drawing-in the deep core muscles of the abdominal wall.

Figure 24.10http://www.strattonpt.com/images/uploads/images.3.jpg

Figure 24.11

http://staceyspt.com/Exercise/LowerBack.htm

Figure 24.12http://www.sportstek.net/pressure_biofeedback.htm

Draw-Ins with Alternating Upper Extremity/Lower Extremity Movement

These movements build upon a solid foundation of spinal stabilization from the previous exercises.  Start off first by performing a Draw-In and holding that contraction while moving the Upper Extremities (UE) only, then work on the Lower Extremities (LE) finally moving on to simultaneous movement of both UE/LE.  Quadruped Alternating UE/LE Movement is also called “Bird-Dog” while “Dead-Bug” is the name of Supine Alternating UE/LE Movement.  It is important to maintain a neutral spine from hips to shoulders and for the core to take in the force when an extremity is lifted and not involve a rotation component to the opposite hand or knee.  This will occur if done improperly or rushed to without developing strength and control through the previous mentioned exercises.  Both the Bird-Dog and Dead-Bug can be progressed from a solid stable surface such as the ground or exercise mat to an unstable surface such as foam dyna-discs or a foam roller to increase the activation of core stabilizing muscles thus making the exercise more challenging and effective.

Figure 24.13 Bird-DogFigure 24.14  Dead-Bughttp://michaelwoodspg.blogspot.com/ http://www.canada.com/health/3390881.bin

Kneeling and Standing Chops/Lifts

Once properly able to stabilize the spine with Alternating UE/LE Movements, progression to more functional activities is deemed ready.  Theses moves involve working through all planes of movement while stabilizing the spine.

A resistance cable is used with the hands at arms length from the body starting over one shoulder and working diagonally across the body to the opposite knee, engaging the TrA and keeping from rounding the back forward.  In a Cable Lift the hands start at the knee and work diagonally up to the opposite shoulder.

Cable Chops

Figure 24.15

http://www.menshealth.com.sg/fitness/best-exercises-your-core

Figure 24.16

http://fms.riaguy.com/articles/fitness/2010-03-15_balanced_body_series.introduction_to_the_chop_and_lift

Cable Lifts from Kneeling and Standing

Figure 24.17

http://eas.com/training/strength/rotational-lift–split-squat-cable http://www.whatsupusana.com/2009/04/pregnancy-and-exercise.html

Soft-Tissue Mobilization

Adhesions and scar tissue development are very common following any surgery.  Development of these adhesions can lead to decreased mobility and compression on nerve roots causing increased stiffness and pain. A few simple techniques to rid adhesions/trigger points/scar tissue and improve recovery along the spine are from using a foam roller or having manual work specific to your individual needs.

Figure 24.18 Figure 24.19

http://www.foamroller.co.uk/ http://www.boulderbodyworks.com/physical-therapy.html

2.   Medications:

A. Acetaminoph: (one brand name: Tylenol) helps many kinds of chronic pain.

B. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Examples include aspirin, ibuprofen (two brand names: Motrin, Advil) and naproxen (one brand name: Aleve). NSAIDs come in both over-the-counter and prescription forms. These medicines can be taken just when you need them, or they can be taken every day. When these medicines are taken regularly, they build up in the blood to levels that fight the pain of inflammation (swelling) and also give general pain relief. Please remember that you always take it with food or milk because the most common side effects are related to the stomach.

C. Narcotics: Narcotics can be addictive. For many people who have severe chronic pain, these drugs are an important part of their therapy. If your doctor prescribes narcotics for your pain, be sure to carefully follow his or her directions. Tell your doctor if you are uncomfortable with the changes that may go along with taking these medicines, such as the inability to concentrate or think clearly. Do not drive or operate heavy machinery when taking these medicines.

When you’re taking narcotics, it’s important to remember that there is a difference between “physical dependence” and “psychological addiction.”

Physical dependence on a medicine means that your body gets used to that medicine and needs it in order to work properly.
Psychological addiction is the desire to use a drug whether or not it’s needed to relieve pain. Narcotic drugs often cause constipation (difficulty having bowel movements). If you are taking a narcotic medicine, it’s important to drink at least 6 to 8 glasses of water every day. Try to eat 2 to 4 servings of fresh fruits and 3 to 5 servings of vegetables every day.

C. Other medicines

Many drugs that are used to treat other illnesses can also treat pain. For example, carbamazepine ( Neurotin )is a seizure medicine that can also treat some kinds of pain. Amitriptyline is an antidepressant that can also help with chronic pain. It can take several weeks before these medicines begin to work well.

 

3. Acupuncture Treatment:

There are three types of Failed back surgery syndrome (FBSS) according to Traditional Chinese Medicine.

Figure 24.20

Figure 24.21

Figure 24.22

Figure 24.23

Figure 24.24

Figure 24.25

Type 1: Coldness and Wetness of FBSS:

Patients feel cold, heavy, and  pain at entire low back, difficulty turning over on the bed or standing up from sitting position, getting worse during the cold weather, stiffness at low back, hip and knee joints.

Acupuncture points: UB 25 Da Chang Shu, GB 30 Huan Tiao, UB 40 Wei Zhong, UB 60 Kun Lun, plus Du 26 Ren Zhong, GB 34 Yang Ling Quan, and UB 58 Fei Yang.

Table 24.1

Points Meridan/No. Location Function/Indication
1. Da ChangShu UB 25 1.5 inch lateral to midline of the body on the back, at the level of the spinous process of the fourth lumbar vertebraFigure 24.20 Low back pain, abdominal distension, diarrhea, constipation, muscular atrophy, pain, numbness and weakness at legs, sciatica
2. Huan Tiao GB30 At the junction of the lateral 1/3 and medial 2/3 of the distance between the great trochanter and the hiatus of the sacrum.Figure 24.23 Low back  pain, thigh pain, muscular atrophy of the lower limbs, hemiplegia
3 Wei Zhong UB 40 Mid point of the transverse crease of the popliteal fossa, between the tendons of biceps femoris and semitendinosius musclesFigure 24.23 Low back pain, motor impairment of t he hip joint, contracture of the tendons in the popliteal fossa, muscular atrophy, pain, numbness and motor impairment of the lower extremities, hemiplegia, abdominal pain,k vomiting, diarrhea, erysipelas.
4 Kun Lun UB 60 In the depression between the external malleolus and calcaneus tendonFigure 24.23 Headache, blurring of vision, neck rigidity, epistaxis, pain in the shoulder, back and arm, swelling and pain of the heel, difficult labor, epilepsy.
5 Ren Zhong Du 26 A little above the midpoint of the philtrum, near the nostrilsFigure 24.24 Mental disorders, epilepsy, hysteria, infantile convulsion, coma, apoplexy-faint, trismus, deviation of the mouth and eyes, puffiness of the face,  low back pain and stiffness
6 Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibulaFigure 24.22 Hemiplegia, weakness, numbness and pain of the lower extremities, swelling and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile convulsion
7 Fei Yang UB 58 7 inch directly above Kun Lun on the posterior border of fibula, about 1 inch inferior and lateral to Cheng Shan (UB 57)Figure 24.23 Headache, blurring of vision, nasal obstruction, epistaxis, back pain, hemorrhoids, leg weakness

Type 2: Kidney Deficiency of FBSS:

Patients’ pain demonstrate weakness,  and pain at nonspecific-pointed area, difficulty standing, feel better while lying on the bed, the pain is dull and achy, cold in four extremities

Acupuncture points: UB 25 Da Chang Shu, GB 30 Huan Tiao, UB 40 Wei Zhong, UB 60 Kun Lun plus St 36 Zu San Li, Sp 6 San Yin Jiao, and Ki 3 Tai Xi. ( Please see tables 24.1, and 24.2)

Table 24.2

Points Meridian/No. Location Function/Indication
1. Zu San Li St 36 On finger-breadth from the anterior crest of the tibia in tibialis anterior muscleFigure 24.22 Gastric pain, vomiting, hiccup, abdominal distension, diarrhea, dysentery, constipation, mastitis, enteritis, knee joint and leg pain, edema, cough, asthma, waste syndrome, poor digestion, hemiplegia, dizziness, insomnia, mania
2. San Yin Jiao Sp 6 3 inches directly above the tip of the medial malleolus, on the posterior border of the medial aspect of the tibiaFigure 24.22 Abdominal pain, distension, diarrhea, dysmenorrheal, irregular menstruation, uterine bleeding, morbid leucorrhea, prolapse of the  uterus, sterility, delayed labor, night bed wet, impotence, enuresis, dysuria, edema, hernia, pain in the external genitalia, muscular atrophy, motor impairment, paralysis and leg pain, headache, dizziness and vertigo, insomnia
9 Tai Xi Ki 3 In the depression between the medial malleolus and tendo calcaneus, at the level of the tip of the medial malleous.Figure 24.21 Sore throat, toothache, deafness, tinnitus, dizziness, spitting of the blood, asthma, thirst, irregular menstruation, insomnia, nocturnal emission, impotence, frequency of micturition, low back pain.

Type 3: Blood Stagnation of FBSS:

There is sharp, stabbing pain at specific area in the low back and buttock. The pain is very severe, so that nobody could touch the tender area, difficulty bending, sitting and standing, and turning over in the bed.

Acupuncture points: UB 25 Da Chang Shu, GB 30 Huan Tiao, UB 40 Wei Zhong, UB 60 Kun Lun plus Sp 10 Xue Hai, UB 17 Ge Shu, LI 4 He Gu, UB 57 Cheng Shan.

(Please refer to tables 24.1, 24.3)

Table 24.3

Points Meridian/No. Location Function/Indication
1 Xue Hai Sp 10 2 inch above the mediosuperior border of the patella (Knee Cap)Figure 24.21 Irregular menstruation, dysmenorrheal, uterine bleeding, amenorrhea, urticaria, eczema, erysipelas, pain in the medial aspect of the thigh
2 Ge Shu UB 17 1.5 inch lateral to the middle line of the body on the back, at the level of the lower border of the spinous process of the 7ththoracic vertebraFigure 24.20 Vomiting, hiccup,belching,difficulty in swallowing, asthma, cough, spitting of blood, afternoon fever, night sweating, measles
3 He Gu LI 4 On the dorsum of the hand between th e1st and 2nd metacarpal bones, approximately in the middle of the 2ndmetacarpal bone on the radial side.Figure 24.25

 

Headache, pain in the neck, redness swelling and pain of the eye, epistaxis, nasal obstruction , rhinorrhea, toothache, deafness, swelling of the face, sore throat, arotitis, trismus, facial paralysis, febrile dieseases with anhidrosis, hidrosis, abdominal pain, dysentery, constipation, amenorrhea, delayed labour, infantile convulsion, pain, weakness and motor impairment of the upper limbs.
4 Cheng Shan UB57 Directly below the belly of gastrocnemius muscle, on the line joining Wei Zhong UB40 and calcaneus tendon, about 8 inch below Wei Zhong UB40Figure 24.23 Low back pain, spasm of the gastrocnemius, hemorrhoids, constipation, beriberi.
  1. Transcutaneous Electrical Nerve Stimulation (TENS):

TENS is thought to disrupt the   pain transmitting to the brain delivering a different, non-painful sensation to the skin around the pain site. In essence, it modulates the way we process the pain sensations from that area, i.e. it closes the pain gate to the brain. It can also trigger the brain to release endorphins. Endorphins act as natural painkillers, and help promote a feeling of well-being.

Figure 24.26

http://www.sodahead.com

5. Local Nerve Block

An epidural nerve block is the injection of corticosteroid medication into the epidural space of the spinal column. This space is located between the dura (a membrane surrounding the nerve roots) and the interior surface of the spinal canal formed by the vertebrae.

After a local skin anesthetic is applied to numb the injection site, a spinal needle is inserted into the epidural space under fluoroscopic (x-ray) guidance, using a contrast agent to confirm needle placement. Local anesthetic and corticosteroid anti-inflammatory medication are delivered into the epidural space to shrink the swelling around nerve roots, relieving pressure and pain.

Figure 24.27

http://www.treatingpain.com

6. Intrathecal Morphine Pump

Pain pump delivery of narcotic drugs is a rather new option available to persons with cancer and non-cancer pain. It is also called intraspinal (within the spine) or intrathecal (within the spinal canal) delivery. It was first used in 1979 after the discovery of narcotic receptors in the spinal cord. The use of an implant device to deliver medications directly in the area of the spinal cord was first used in 1981 for cancer pain. Since then, the pain pump has been used for chronic non-cancer pain such as failed low back surgery syndrome and spasticity from neurological conditions like multiple sclerosis, spinal cord injury, and cerebral palsy.

Figure 24.28

http://www.eorthopod.com

 

About Peter’s Treatment:

Peter underwent our treatment with both acupuncture and physical therapy. The typical protocol was as following,

  1. Peter was first put in the bed with heating pad on the low back for about 10 to 15 mins, his low back muscles were gradually loosening, then massage was given to further relax his low back muscles.
  2. After massage, acupuncture treatment was given, the most important points were selected based on the above principal. He was given needles with electrical stimulation for 20 to 30 min, his energy flow,  therefore,  is activated and the pain is gradually decreased.
  3. He then was transferred to physical therapy area, started to strengthen his abdominal and low back muscles with the above guidance.
  4. He was given the above treatment for about 20 sessions, he felt greatly improvement after the treatment. He has had more flexibility and much less pain. His pain scale decreased to 2/10 from 10/10. He was pain free for one year, and he sometimes returns to my office for tuning.

Tips for patients who had low back surgery, but still feel a lot of pain on the low back:

  1. MRI of low back spine is necessary to check any new injuries, such as new herniated disc, degenerative changes of other levels, any loosening of the screws, and spinal stenosis.
  2. Be very cautious for the subsequent low back surgery. Sometimes, you may be advised to have the second surgery for your low back. From my personal experience, I did not see many successful cases after the secondary even third low back surgery.
  3. Try to find a physiatrist MD, who also practices acupuncture. Physiatrist MDs are trained in US for Musculoskeleton Medicine. They not only understand your problem but also more specifically treat you with acupuncture. They also could guide your physical therapist for the treatment.
  4. The combination of physical therapy, massage and acupuncture treatments are very important, because these combined treatments could not only relax your muscles but also maximize your abilities to perform core body strengthen.
  5. Different patients like different sequence  of the treatment, it is not absolutely necessary to have massage, acupuncture, then physical therapy, because everybody is different. It depends on your personal preference. The most important is that you have to have the combined treatment to benefit the most.
  6. If you drive a distance for longer than 30 min, it is wise to have the lumbosacral corset, i.e. low back brace on,  the brace will protect your low back and prevent further injuries.

Tips for acupuncturists:

  1. You must clearly understand the patient’s pathological mechanism. Some patients are not allowed to have flexion exercise, some patients not for extension exercise.
  2. Heating pad and massage are very important to induce energy and relax low back muscles.
  3. LI 4 is a very important point to increase the secretion of endorphin and inhibit the up going reticular formation to send the pain signal to the brain.
  4. Electrical stimulation on the back points is a must.

Case Discussions