Pain Treatment and Management
Treating the root cause of chronic pain and related conditions.
With Dr. Smigel, she will ask why. We strive to understand and treat the cause of chronic conditions, not just the resulting dysfunction. We look at all factors that influence health and then provide a combination of therapies that tap the human body's amazing ability to heal and correct itself.
Her integrative approach utilizes both conventional and alternative methods that facilitate the body's innate healing response. She researches treatments that are proving helpful in other parts of the country and the world and bring the best of them to our patients.
To help you feel better so you can live better, Dr. Smigel will:
- Conduct a thorough review of medical records and diagnostic process.
- Look at all the factors that could contribute to your chronic condition.
- Evaluate how well your body's systems are working.
- Provide proper multidisciplinary therapy to treat the root cause of your problems.
- Chronic neck, back and spinal pain
- Degenerative joint disease
- Arthritis
- Hip, knee, or other joint injuries and pain
- Chronic ligament and tendon injuries
- Chronic fatigue
- Headache, migraines
- Abdominal pain
- Pelvic pain
- Complex Spinal Injection Procedures
- Prolotherapy - also known as Regenerative Injection or Therapy RIT
- Coordination of rehabilitation team.
Interventional Pain: History & Rationale
Due to the irreversible nature and the historically high potential for surgical failure, patients and physicians alike have always searched for less invasive and risky alternatives to surgical management of pain. Interventional pain dates back to as early as 1901 when the first epidural was performed to treat sciatic pain. Recently, with the explosion of technologic advancements in imaging techniques and pain treatment systems, there now exists a host of minimally invasive outpatient procedures that may effectively manage your pain.
Traditionally, the ability to accurately diagnose pain-generating structures was as low as 15%. With advancements in diagnostic interventional pain techniques, physicians may definitively pinpoint your pain to its exact source by temporarily blocking nerve roots, ligaments, joints, muscles or discs. This allows precise localization of painful structures in up to 85% of patients treated, which undoubtedly leads to more a focused treatment plan.
Dr. Smigel specializes in supplementing exercise, physical therapy and medication with minimally invasive procedures to effectively diagnose and manage your pain. She offers a wide array of treatments options including epidural blocks, selective nerve root blocks, SI and facet joint injections, nerve blocks, proliferative therapy, joint injections, trigger point injections, lysis of scar tissue, and Botox injections.
Read below to learn more about any specific procedure that may have been ordered by your doctor to help you more effectively manage your pain and maximize your active lifestyle.
Pain Relief / Pain Management - Spinal Injections
CERVICAL, THORACIC, OR LUMBAR EPIDURAL STEROID INJECTION:
For relief of pressure and inflammation on a nerve root, usually caused by a disc protrusion, narrowing of the nerve canal, or by scarring after back surgery.This procedure involves placing a needle under fluoroscopic guidance either into the foramen, or hole, where a specific nerve comes out of the spine or into the center of the spine where the nerves run together down the spinal canal. A combination of local anesthetic, such as lidocaine, and a cortisone like drug, such as triamcinolone, that decreases the inflammation and swelling around the nerve is injected. This combination is very effective in relieving the pain and can also help diagnose the cause of the pain when it's selectively injected in the area of specific nerve roots.
CERVICAL, THORACIC, OR LUMBAR FACET JOINT INJECTION AND MEDIAN BRANCH NERVE BLOCK:
For relief of pain in the facet joints-the supporting joints found behind and to the side of the intervertebral discs. Median branch nerves innervate the facet joints, which are a common source of pain.
This injection is used to confirm the diagnosis of facet joint pain as well as to decrease the inflammation and pain from these joints. During this procedure a needle is placed under fluoroscopic guidance into the joint and the ligaments around the joints. A combination of local anesthetic, such as lidocaine, and a cortisone like drug, such as triamcinolone, is injected. With the onset of the local anesthetic, the pain often abates almost immediately indicating that the particular facet joint injected is the cause of the pain. At other times the median branch nerve that serves the facet joint is blocked with a local anesthetic. Pain reduction after this procedure also indicates that the facet is the pain source.
Patients with this problem are often excellent candidates for prolotherapy.
SACROILIAC (SI) JOINT INJECTIONS
A SI injection is performed with a long acting steroid and local anesthetic. The sacroiliac joints are located in the back where the lumbosacral spine joins the pelvis. They are paired (right and left) and are surrounded by a joint capsule like the finger joints. The patient is given a local skin anesthetic before a small spinal needle is inserted under fluoroscopic guidance into the SI joint o/r ligaments. Local anesthetic and steroids are injected.
TRIGGER POINTS
A trigger point is a portion of the muscle that has become a source of pain and dysfunction. It usually consists of a nodule or band that can be felt by pressing the skin over the muscle. When the trigger point is pressed, it will feel sore and a cause pain which extends to another body part (for example: a trigger point in the buttocks often refers to leg). Injecting a trigger point can help to eliminate it. Without injection, it may last weeks, months or become chronic. Furthermore, if left untreated, a single trigger point can promote the development of other trigger points in nearby muscles. Based on your response to the first injection(s), you and your doctor can plan how to proceed with any future injections.
The beneficial effect of the injections depends on the adequacy of your overall treatment program, including physical therapy and your regular performance of home exercises.Some individuals, despite diligent effort to performing the exercises, experience chronic recurrences and require more injections.
Overall, this is a procedure with minimal risks, although no invasive procedure is totally risk free. Potential adverse effects include temporary muscle soreness, infection, bleeding, weakness in the injected muscles up to 45 minutes (rare), or partial collapse of the lung (extremely rare).
BOTOX INJECTIONS
BOTOX is a therapeutic muscle-relaxing agent that works at motor nerve endings (nerves that lead to muscles). It is in a class of drugs called neurotoxins. When considering neurotoxin therapy,BOTOX is a novel therapeutic agent derived from the bacterium, Clostridium Botulinum. Also known as Botulinum Toxin Type A, the brand BOTOX is produced in controlled laboratory conditions and given in extremely small therapeutic doses. BOTOX is indicated for the treatment of blepharospasm associated with dystonia in patients 12 years of age and above. BOTOX is being investigated for several conditions associated with overactive muscle activity, known as spasticity due to post strokes, spinal cord injury, brain injury and cerebral palsy. It is also used in overactive muscle activity in myofascial pain. BOTOX works to block the release of acetylcholine and, as a result, the muscle doesn't receive the message to contract. This means that the muscle spasms stop or are greatly reduced, providing predictable and reliable relief from symptoms. Effects of reducing pain and spasticity usually begin to dissipate within a few days and maximum effect is reached within 2 weeks. The effects can last up to six months.
Symptoms may vary throughout the course of the condition, and so the degree of relief and duration of effect varies from person to person. All medications have some side effects. With BOTOX?, side effects are usually transient and mild to moderate in nature. Some people notice temporary weakness of muscles or discomfort at the injection site. Other less common side effects may include low grade fever, or flu-like symptoms for the first 24 hours. If you have any questions regarding the use of BOTOX? treatment, please consult your physician.
PLASMA RICH GROWTH FACTORS (PRGF)
When people say their pain makes them feel older it's because it's true: their pain truly does make them physiologically older. When you're in pain, you breathe less, you exercise less, you sleep less, and your hormones fall out of balance.
A new treatment for pain is becoming popular among orthopedic and pain specialists: the injection of platelet rich plasma (PRP).
Most everyone thinks of blood platelets as being responsible for blood clotting after injury which is true. What many people do not know is that blood platelets serve two other important functions. Blood platelets are responsible for bringing white blood cells to the injured area to clean up the remains of dead and injured cells. Most importantly to this discussion, blood platelets release growth factors that are directly responsible for tissue regeneration. These substances are called cytokins and include platelet derived growth factor, epithelial growth factor, and other important growth factors.
PRP has been used for years in surgical centers around the US and abroad to improve the success of bone grafting (especially in dental surgery) and also by cosmetic surgeons for speeding healing time and decreasing the risk of infection after surgery. Only in the last few years have doctors and surgeons been experimenting with injecting PRP for the treatment of chronic pain. Tennis elbow, plantar fasciitis, Achilles tendonitis/tendonosis, rotator cuff tears, meniscal tears, osteoarthritis and chronic low back and neck pain are all being treated with the injection of PRP with the goal of regenerating degenerated connective tissue with reports of success.
A PRP treatment looks like this: a patient's blood is drawn and placed into a special collection kit. Using the person's own blood eliminates the risk of transmission of any blood-borne disease. This kit is placed in a centrifuge for 15 minutes and the platelets and plasma are separated from the red and white blood cells. Two thirds of the plasma is removed and discarded and the remaining plasma is mixed with the platelets. This higher than normal concentration of platelets is what gives us platelet rich plasma. The PRP is drawn into a syringe. The area to be treated is injected with a local anesthetic and after waiting five minutes for the anesthetic to take effect, the PRP is injected.
The injection technique is identical to prolotherapy/regenerative injection therapy, only the solution injected is different. Same instrument, different sheet music.
People generally report two days of being sore and then usually pain relief occurs within the first week and continues to improve over a period of months. To date, my experience is that one PRP treatment is the therapeutic equivalent of three or four prolotherapy/regenerative injection therapy treatments using dextrose. One of the attractive aspects of this treatment is the use of a person's own blood to eliminate the risk of the transmission of disease. The same lab that has developed the preparation kit for production of PRP has also developed a method to collect a person's own stem cells which eliminates the need for embryonic, umbilical or placental stem cells. This procedure is much more invasive as it requires a bone marrow biopsy and it is quite expensive compared to PRP which is safe, easy and inexpensive.
Dr. Smigel is receiving training for this procedure and will be doing this in the future.
