arizona pain monthly february 2011

Arizona Pain Monthly | February 2011 Friendship is Priceless

Arizona Pain Monthly | February 2011 Don’t Lose Hope


Welcome to Arizona Pain Monthly Magazine

Welcome to the February issue of Arizona Pain Monthly. We hope you and your families are well.

As we continue into 2011, we move onto our next theme, which is FRIENDSHIP. For a chronic pain patient, there is nothing of greater value than friend-ship and companionship from others. However, it can be difficult to maintain relationships with friends and family due to chronic pain. They may not under-stand the limitations pain places on your life, and you may not want to burden them with everything that comes along with chronic pain. However, we are encourag-ing you to reach out to your friends and family members and ask them to help and sup-port you. Ask them to sit down with you so you can explain exactly what your condition is and the steps you are taking to alleviate your pain. Answer any questions they have fully and honestly and focus on not getting frustrated or negative while you talk to them.

Our focus word for the month of February is HOPE. Sometimes, it may feel as though you are lost at sea and are searching for something to guide your way. It can be difficult to find hope and to find a reason to keep moving toward something that can help you.

We are commit-ted to encour-aging you and supporting you in finding hope again. The feeling of

hopelessness can be prohibitive to healing and we truly believe that hopeful, positive patients have a far better outcome than those who feel as though there is no light at the end of the tunnel for them. We urge you to take comfort in the fact that each physi-cian and staff member at Arizona Pain Specialists has your best interests in mind, and we are here to educate you, answer your questions, and help you find hope again. Our ongoing overall theme for 2011

is Changing Lives Daily, and we are dedicated to changing your life for the better.

This month’s issue includes recipes that feature anti-inflammatory foods. Oranges, quinoa, lime and mint all have anti-inflammatory properties among other health benefits. Chiro Corner focuses on exercise, specifically yoga and tai-chi, and explains the benefits of imple-menting a consistent exercise routine. Studies have consistently

shown that chronic pain patients who regularly exer-cise will have more good days, and will benefit from the better health and attitude that can come with an exercise program.

We hope that this issue is educational and infor-mative. We thank you for your continued loyalty if you are a long-standing patient, and we welcome you to the Arizona Pain Specialists family if you are a new patient.

Until next time, remember at Arizona Pain Spe-cialists, we believe you can be pain free.

Blessings to you and your family,

Dr. Tory McJunkin & Dr. Paul Lynch

Please contact us at [email protected] if you have questions or comments.

The doctors had so much fun at their Friendship photo shoot, we decided to share some of the best pictures with you!


Hope


With Dr. Jonathan Carlson: I had back surgery several years ago, and now the

pain has returned. Does this mean I may need another back surgery?

Ask the Expert

Great question! I receive this question from many of my new patients almost on a weekly basis. As with many questions in life, the answer is not always black and white. The quick answer is, “It depends.” The answer is usually found as we delve into the office visit, which involves obtaining a history, performing a physical exam, and doing additional studies. I also ask the patient if they have recently seen the spine surgeon that did their back surgery. Once this information is gathered and a diagnosis is made, then I can often direct my patient on implementing the proper treatment plan. While treating my patients at Arizona Pain Specialists, the process in finding the best answer to this question usually involves these steps:

History: I obtain a thorough history about their recurring back pain and symptoms. How did the symptoms return? Was there a fall or some type of accident that brought the symptoms on? Are the symptoms the same as before? If there is no inciting event, and the symptoms are of similar nature pri-

or to the back surgery, then more than likely there is not new pathol-ogy with the spine. This, of course, is not always the case, so further information is always needed. In my history, I also inquire about any radiating “tingling” or “numbness” sensation down the lower ex-tremities. Is there weakness? Does the pain feel “burning”? Serious symptoms could include bowel or bladder incontinence and/or new weakness.

Physical: I then conduct a physi-cal exam to assess if there are any new neurological symptoms. Prior to the exam, I attempt to acquire a baseline exam from old medi-cal records as well as in the new consult visit. Did the patient have a foot drop before the surgery or is it new? I look for abnormal re-flexes, sensory deficits, and loss of strength. If there are any of these findings, then my patient might have new pathology of the spinal cord and/or its nerve roots, which is also known as myelopathy. I also do an exam of the patient’s spine joints or facet joints to see if this reproduces the patient’s symptoms.

Additional Studies: Imaging, such as an MRI, CT scan with a myelogram, or simple flexion/extension x-rays can be helpful in assessing for new pathology. I might do minimally invasive; x-ray guided diagnostic blocks to the medial branch nerves. The medial branch nerves innervate the joints of the spine called the facet joints. These joints can often be a source of pain above and below an area of the spine that has been fused from a back surgery. If the patient gets relief from these nerve blocks then we know pain emanates from these facet joints. We may also have the patient undergo a nerve conduc-tion study or EMG to assess if the there might be pathology originat-ing from the spinal cord or its nerve roots versus the peripheral nerves.

Diagnosis: If the patient has new pathology and findings, then the appropriate diagnosis can be made. It could be a new herniated disc, muscle spasm, or compression of the spine, called a vertebral com-pression fracture.

continued on page 13


Minty Lime Quinoa Salad

• 1 cup dry quinoa• 4 fresh mint leaves, finely chopped• 2 garlic clove, finely diced• Juice from 2 medium size limes• 2 tablespoons olive oil• 1 small handful fresh chopped cilantro•Salt and pepper to taste

Rinse quinoa in a finely meshed strainer, then move to a small pot. Add 1 1/4 cups cold water, bring to a simmer, and then reduce heat to low. Cover and continue to cook for 30 minutes, then remove from heat and let sit 5 minutes.

Remove quinoa to a medium sized bowl, fluff with a fork. Add all other ingredients, stirring together and fluffing quinoa as you mix. Serve hot or cold - flavors will improve on refrigeration for a day or more.

Did you know? Quinoa (pronounced keen-wah) is anti-inflammatory and very high in protein. While quinoa grows, the stalks produce vibrantly colored grains that become brown upon maturity.

Baked Cranberry Apples

• 4 apples, any variety• 2 teaspoons butter• 1/3 cup apple juice• 1/4 cup brown sugar• 1/3 cup dried cranberries• 1/2 teaspoon vanilla extract

Preheat oven to 450 degrees.

Cut a small piece off the bottom of each apple so they will stand in the baking dish. Remove the top of the apple, and then remove the core with a grapefruit spoon, leaving a solid wall of apple on all sides.

Mix cranberries and brown sugar in a small bowl, then fill apples equally with mixture. Place 1/2 teaspoon butter on the top of each apple, and place in a baking dish. Pour apple juice into the bottom of the dish, cover the dish with foil and bake for 30 minutes. Uncover, baste the apples with the juice, and then bake uncovered for 10 min-utes more.

Spicy Citrus Chicken

• 4 boneless, skinless chicken breasts• 1/2 cup orange juice• 1/2 cup lemon or lime juice• 1 small handful fresh chopped cilantro• 2-4 garlic cloves, finely diced• 4 tablespoons olive oil• 1-3 diced chipotle peppers in adobo sauce• 1/2 tablespoon adobo sauce (from the same can as the peppers)

In a medium bowl, whisk together all ingredients except chicken.

Place chicken in a zip-top plastic bag, then pour the marinade on top. Leave in refrigerator for at least four but no more than eight hours.

Grill chicken on outdoor or indoor grill until chicken reaches an inter-nal temperature of 160 degrees, approximately 6-8 minutes per side.


Yoga is also a beneficial exercise program to consider. It is an ancient practice that originated in India and has gained huge popularity in the western world. It is a form of exercise that incorporates stretching with movements to encourage strengthening and relaxation. There are different styles of yoga such as Ashtunga yoga, which fo-cuses on improving flexibility with developing strength, and Hatha yoga which focuses on improving flexibility and relaxation. For those just starting out, Hatha yoga or a beginner’s Iyengar class is a good choice.

Continued practice of yoga often improves posture and makes it easier for most to hold and maintain their good posture. You may also become more aware of your pos-ture, alignment and patterns of movement. It is beneficial for those with back problems, as it provides improved strength and flexibility of the spine. Because the total body is challenged in ways that traditional exercise does not provide, yoga improves balance and coordination. Many also experience feeling more energized when yoga is practiced regularly.

Yoga positions act to increase flexibility, tone muscles and increase lubrication of the joints, ligaments, and ten-dons. The gentle stretching of muscles and joints has been said to flush out toxins of the body and encourage nour-ishment of the body’s tissues. The benefits of a better metabolism result from continued practice of yoga which helps to keep your weight in check along with providing core strengthening to improve overall body strength and help heal and reduce injuries.

Both yoga and Tai Chi provide profound physiological benefits to increase cardiovascular and respiratory ef-ficiency, musculoskeletal flexibility, increased endurance and energy, decreased pain, stress, anxiety and depres-sion, with improvement in balance, coordination, sleep and immunity. It has been well documented that weight-bearing exercises strengthen bones and help prevent osteoporosis. Both practices strengthen the mind-body connection, meaning that as you match your controlled breathing with the movements of the body, you can re-train your mind to find a place of calm and peace.

Both yoga and Tai Chi provide benefits that are apparent even after the first session. Most importantly, due to the low impact of both yoga and Tai Chi with controlled mo-tion, there is a very low risk of injury compared to other forms of exercise.

2011 is an excellent time to make a commitment to try something new or expand on what you already know. It is never too early or too late to make exercise a habit in your life. You will be rewarded with a healthy mind and body! As little as 30 minutes per day will provide you a means of enhancing your physical and mental health. Although Tai Chi and yoga are gentle exercises with few risks, if you have a health condition, it is important to con-sult with your health care provider prior to trying either of these practices.

As many of us are aware, exercise has a long list of health benefits. These benefits can be taken advantage of at any age. Exercise appears to be increasingly important the older we get. Partaking in regular physical activities can minimize or even prevent several of the problems that are often associated with aging: increased body fat, loss of bone mass, decreased muscular strength, decreased flex-ibility, and slower reaction times.

As we continue into the New Year, many of us are try-ing to stay true to our resolutions to improve our health and wellness thereby improving the quality of our lives. If this is your goal, then exercise is the way to get there. There are many ways to accomplish this and research is now highlighting the practice of both yoga and Tai Chi for men and women alike as effective home exercise options to promote health and well-being. The benefits of yoga and Tai Chi can be enjoyed by any age group and across any range of fitness and flexibility. It also doesn’t matter what level of flexibility you have.

Tai Chi has been linked to impressive health benefits in virtually everyone from youth to the elderly. It is an ideal form of exercise for those limited by chronic pain or other conditions that limit more vigorous exercise. The combi-nation of martial arts movements and deep breathing can be adapted even for those confined to wheelchairs.

This form of exercise can often times reduce chronic pain and stiffness. It can also improve strength, coordina-tion, flexibility, and can condition the body as well. Studies have shown that the practice of Tai Chi can also improve the quality of sleep when practiced regularly. There is also a psychological benefit associated with the practice of Tai Chi, which has been shown to reduce the incidence of stress, anxiety, depression, and mood disorders.

Tai Chi began as a martial art and is part of Traditional Chinese Medicine (TCM). TCM has evolved over thou-sands of years in China. Tai Chi incorporates slow and controlled gentle movements with regulated breathing and focused meditation. Research is now highlighting the many powerful health benefits that this practice provides.

Tai Chi is a low impact, weight bearing, aerobic exercise that is also relaxing. Studies are now showing us that Tai Chi promotes cardiovascular fitness while burning about 280-500 calories per hour. It can result in lowered blood pressure and improvement in immune system function-ing while providing significant improvements in balance and coordination, which may prevent falls. Because Tai Chi is one of the lowest types of impact exercise there is, many with arthritis are able to practice this form of exer-cise with little or no discomfort.

For those that have incorporated and learned to enjoy Tai Chi in their lives, it’s no surprise that they’ve reported improved quality of life. In practically every way, this an-cient practice appears to be good for you.

F


Chiro Corner: Yoga and

Tai-Chi for Less Pain


What Would You Do If You Were Pain Free?

For Jeff Grabosky, the answer is a feat of historic proportions – he is running across the United States. Over two hundred people have ac-complished this goal, however, Jeff is running alone, with no running partners and no car following him carrying his supplies. Only seventeen people before him have completed this run unsupported across the United States.

To prepare to run across the United States, Grabosky had been gradu-ally increasing the length of his runs, peaking at 210 miles in a week, which is 30 miles a day. With a train-ing schedule like that, it comes as no surprise that Grabosky found himself in pain. “I began to experience severe

leg pain,” Grabosky ex-plains. “It got to where I had to stop training, which was concerning because I was plan-ning to leave in two weeks. I needed to do something, and so I went to Arizona Pain Specialists, where I received active release therapy massage. I instantly felt so much better, and was able to get right back into training. I went from

being very nervous to very confident again.”

Grabosky has been running for years, but it wasn’t until he suf-fered great loss that he really began to make it a part of his life. “I had a pretty tough stretch where, in the span of about a week, I lost my mom to cancer and my wife left me,” Grabosky says. “Running is what gave me a sense of purpose again, and so I just started doing more and more of it. I began running marathons and through that was able to raise some money for cancer research, run a few 100 mile races and coach others.”

While he enjoyed and was rewarded by coaching others and sharing his love of the sport, Grabosky felt there

was more that he needed to do. “I thought, ‘what could

be bigger than what I’ve already

done?’ and running across the country seemed like a good

idea,” Grabosky says. “Then I had the idea for

the mission of the run. I’m not raising money specifically, and the main

reason for that is that I wanted every-one to be able to be involved as much as possible. So even though a cause like cancer research is very close to my heart, other people might have a child that was born premature, or has a relative that is suffering from drug abuse, or whatever their burden may be. By doing it this way, whatever is specifically important to a particular person, I will be running for them.”

On average, he will be running thirty to thirty-five miles per day, with some days as high as fifty or sixty miles, depending on the distance between towns on his route. When the journey is over, Jeff will have run approximately 3,700 miles. Grabosky left Oceanside, California on January 20th, and plans to arrive in New York City around May 20th.

Grabosky speaks eloquently of the similarities between running and life. “I have found running to be a saving grace for me,” he says. “There is so much between life and running that creates a parallel. Through overcom-ing difficulties in running, you can see that you are strong enough to get through the bad things in life and vice versa. It’s actually a really great circle.”

“The more I talk to people, the more I see that everyone struggles with something,” Grabosky continues. “It may be big or it may be small, but everyone has something. I want to help people see that if you look at what you have instead of what you don’t have, it makes a big difference in your daily attitude. It’s amazing how a smile or a small act of kind-ness toward someone else can really make your own day, and can actually give you the strength to continue on.”

Jeff will be updating the staff at Arizona Pain Specialists during his run. Check www.ArizonaPain.com for personal updates from Jeff!

Page 10 Friendship is Priceless

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The term “degenerative disc dis-ease” can be misleading, as this is not truly a disease, but a grad-ual breakdown of the discs that comes naturally with age or other contributing factors. While de-generation can happen through-out the spine, it is most common in the neck (cervical spine) or in the low back (lumbar spine).

Degeneration of the discs may have multiple contributing fac-tors. The natural process of aging can break down the fluid inside the discs, making them less spongy, and thus lessening their effect on cushioning the spine. With the loss of fluid, the discs will begin to become thin-ner and will cause the vertebra of the spine to grow closer and closer together, which can begin to cause chronic pain.

Spine arthritis can also occur as a result of degenerative disc disease as the mechanics of the spine change and the disc loses its height and elasticity. A good example of this could be seen if the air was let out of all of your car tires. If you drove around on flat tires for a month it would cause many other mechanical problems to appear.

Disc bulges or herniations can cause the onset of degenerative disc disease. Bulges and hernia-tions can also cause instability within the discs, leaving the ver-tebra lacking support and cush-ioning. Those who are obese or are employed in positions which require repeated lifting may

also develop degenerative disc disease.

Treatment for pain due to degenerative disc disease usu-ally starts conservatively with non steroidal anti-inflammatory medications (known as NSAIDs) such as ibuprofen and aspirin. Cold and hot therapy can also be applied to the painful areas. Your physician may recommend physical therapy, chiropractic care, disc decompression (trac-tion) or specific exercises that can help alleviate pain and help restore range of motion and flexibility.

If DDD causes spine arthritis, a diagnostic procedure called a “medial branch block” might be performed to diagnose if this is the source of your pain. If it is in fact found to be the source of your pain a longer lasting proce-dure called radiofrequency abla-tion is often considered.

If disc bulge or herniation is the cause of degenerative disc dis-ease, an epidural steroid injec-tion may be discussed. An epidu-ral steroid injection is another effective procedure to treat pain due to degenerative disc disease. These injections are minimally invasive procedures that can of-ten lead to nearly complete pain relief. Epidural steroid injections consist of a steroid with anti-inflammatory properties, which will reduce the irritation and pain associated with inflamed nerves. If conservative measures fail, percutaneous disectomy may

Causes and Treatments

be considered. This is a surgical minimally invasive procedure that is intended to remove the bulging or herniated disc mate-rial, which effectively relives pain due to the bulge or herniation.

Degenerative disc disease often cannot be prevented, but mea-sures can be taken to promote and maintain a healthy spine. Special care should be taken to lift heavy objects properly, and, since there is a link between obesity and degeneration of the discs, maintaining a healthy weight will help immensely in the long run.

This MRI image depicts degeneration of the discs. Where the discs are dark, they have not yet experienced degeneration. Where the discs are white, degeneration has occurred.


It could be an enlargement of the main ligament in the back of the spine lead-ing to a narrowing of the spinal canal, which is is called spinal canal stenosis. It might be faulty surgical hardware, although this is less common. If the patient has no new pathology, then the diagnosis of post laminectomy pain syndrome is usually made. This is simply pain that persists after spine surgery.

Treatment: As a general rule, I have the patient re-evaluated by the spine surgeon who did the initial surgery. I explain to the patient that this does not necessarily mean that they will have to have another back operation. It is an important step in the diagnos-tic and treatment plan process. If the patient has significant new pathol-ogy and is at risk for permanent spi-nal cord injury, then a second surgery may be needed. If the patient has a diagnosis that is non-surgical, then many different treatment options can be explored. A good spine surgeon and pain specialist will work in con-cert together, along with the goals and desires of the patient, to determine if a re-operation is best.

Conservative treatment measures such as physical therapy and medica-tions that include non-steroidal anti-inflammatory drugs (NSAIDS), mus-cle-relaxants, and pain medications may suffice. Chiropractic care and acupuncture are options. Treatment to fix vertebral body fractures can be done by placing cement in the bones through a procedure called vertebro-plasty. Facet joint pain can be allevi-

ated by cauterizing the nerves to the joints utilizing a procedure called ra-diofrequency ablation.

The remainder of my answer will fo-cus on the diagnosis of post laminecto-my pain syndrome. Minimally invasive procedures can be highly successful in treating this type of pain. Contrary to popular belief, some patients still receive periodic epidural steroid in-jections after their back surgery to treat recurring “sciatica” or radiating leg pain. The thinking behind this is that although the disc may be stabi-lized or a majority of it removed, there may still be some inflammation of the nerve(s) from the spine. This may be from direct mechanical compression, adhesions (scar tissue), or inflamma-tory agents released from the disc. The steroid from the epidural may help alleviate this inflammation and, in essence, “calm” the nerve. Another highly successful procedure that I can do for my patient is a procedure that I learned from Professor Dr. Gabor Racz while I was doing my pain fellowship at Texas Tech. It is called an epidural lysis of adhesions or the Racz proce-dure. It is also minimally invasive and involves the chemical and mechanical breakdown of the scar tissue that can result from back surgery. This proce-dure typically works best when done within a year of the surgery. Lastly, if all conservative and minimally inva-sive avenues are exhausted and the patient’s pain still persists, I may sug-gest implanting a spinal cord stimula-tor (SCS). Post laminectomy pain syn-drome is the number one reason why this procedure is done in the United

States. One of my favorite aspects of this procedure is the fact that you get to try it out (called an SCS trial) to see if it works for you before any kind of surgical inter-vention. An SCS trial is very similar to an epidural, but instead of medications being placed through the needles, a small flexible lead is placed through the needle and steered with x-ray guidance to the right location. The device is then tested and there is an exchange of the painful transmissions for a mild mas-saging sensation in the patient’s area(s) of pain. The needles are then removed and the small leads are taped to the skin. The patient tries the device for 3-5 days, and if the patient has more than 50% re-duction in their normal pain symptoms, they are a candidate to have the perma-nent device placed. Unlike many other surgeries, SCS has a “try it before you buy it” option. If the patient is convinced that this device will help them, the de-vice is permanently implanted like a pacemaker and is sometimes called a “pacemaker for pain.”

Pain after spine surgery can be com-plex to diagnose and difficult to treat, but hopefully with the right pain spe-cialist and surgeon, you can find the best options for you. I hope this article is in-formative and takes you down a path of being pain free with improved quality of life!

Please feel free to contact myself or one of my partners at Arizona Pain Spe-cialists for a consultation to discuss this question in more detail, as we are all ex-perts in these types of interventions.

-Dr. Jonathan Carlson

Ask the Expert Continued from page 6


Lisa is a nurse practitioner in the Scottsdale office. She is dedicated to the patients and loves to be able to help people get back to their lives and be pain free!

See what you have in common with Lisa!

Favorite activities: Sewing, knitting, gardening and hula hooping.Favorite TV shows: Grey’s Anatomy and NCIS. Favorite sports team: The Arizona Diamondbacks.Favorite food: Pizza. Favorite movie: Breakfast at Tiffany’s.Favorite location in the world: Switzerland.Favorite location in Arizona: Bisbee. Favorite thing about Arizona: The beautiful desert landscape, the sunsets, and the fact that it isn’t 115 degrees all the time. Favorite bands: Social Distortion, Sublime, Bad Religion, and Modest Mouse. Favorite book: One Flew Over the Cuckoo’s Nest. Famous person you would like to meet, dead or alive, and why? Audrey Hepburn. She was just such an incredible actress!Unknown fact about you: I’ve been to Burning Man five times. Unknown talent: I can fire dance, and I’m a pretty good tap dancer. What celebrity do people say you look like: Jennifer Grey. As a child, what did you want to be when you grew up? A veterinar-ian or a professional tap dancer. Where are you from originally: Phoenix, Arizona.

Cheyenne works as a medical assistant in the Scottsdale office and has been with Arizona Pain Specialists for a year.

Cheyenne originally became a medical assistant because she has a special needs daughter, and enjoyed learning the medical tasks required to care for her. She admired the medical staff that helped her daughter on a regular basis and was inspired to enter the medical field.

Cheyenne loves her job, and says the best part of working at Arizona Pain Specialists is getting to see patients who were in extreme pain get significant relief from a procedure we were able to provide. She enjoys seeing her patients, happy, pain-free and motivated!

Her advice to patients is this: “Humor has healing power! I un-derstand at times it is hard to find humor in your life when you are in pain, but laughter has healing properties and can reduce your pain - our bodies will produce pain-killing hormones called endorphins in response to laughter. So laugh more!”

Employee of the Month at APS

Meet Lisa P., Nurse Practitioner

arizona pain monthly february 2011

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friendship photo shoot