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Opioid Prescribing - The Swinging Pendulum

The following article was published in House Calls Magazine, a print publication by the Alachua County Medical Society. Here Dr. Jesse Lipnick of Interventional Pain Management discusses creating a standard for compassionate and safe treatment of pain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dr. Ariane Harris Joins SIMEDHealth Rehabilitation Medicine

SIMEDHealth is proud to welcome our newest Physical Medicine & Rehabilitation physician Ariane Harris, MD!

A native of Gainesville, FL, Dr, Harris earned her undergraduate and MD degree from the University of Florida. Dr. Harris completed both her residency in Physical Medicine and Rehabilitation and her Fellowship in Interventional Chronic Pain at the University of Alabama, Birmingham. While there, she served as both chief resident and academic chief resident.

She is currently a member of the American Academy of Physical medicine and Rehabilitation and the Spine Intervention Society. In the future, she hopes to continue researching in the fields of regenerative medicine, ultrasound, botulinum toxin and spinal cord stimulators.

Outside of work, Dr. Harris is an avid equestrian. She is interested in serving her community by participating as a volunteer with equine therapy groups.

Dr. Harris is available to diagnose and treat patients with a wide variety of chronic pain issues. These including those with impaired functional mobility, amputations and performing interventional pain procedures for her patients.

 

Click here to request your appointment with Dr. Harris, or call SIMEDHealth Rehabilitation Medicine at (352) 373-4321.

Non-operative Management of Chronic Knee Osteoarthritis

 

Dr. Eric Rush of SIMEDHealth's Rehabilitation Medicine recently wrote an article for the spring/summer edition of House Calls magazine, a seasonal publication by the Alachua County Medical Society. In this article, he discusses treatment plans for Osteoarthritis of the knee that do not involve surgery. 

 Check out the full article below:

 

 

Article content:

 

Background:

Arthritis is the leading cause of disability in the US with an estimated 52.5 million adults suffering from this condition (2). The CDC denotes arthritic joint pain that severely impacts a person’s quality of life as severe joint pain (SJP) and found that of the 52.5 million adults with documented arthritis over 27% of them suffered from SJP (2). Finding ways to help our patients to live with osteoarthritis (OA) and SJP is of paramount importance, especially in our home of Alachua county which has a median age of 31.3.

Diagnosis and Workup of Arthritic Knee Pain

The beginning of an arthritis diagnosis like any other medical condition starts with a thorough history and physical examination. Ruling out inflammatory conditions (gout, pseudogout etc.) and systemic spondyloarthropathies (RA, ankylosing spondylarthrosis etc.) is important when first making the diagnosis of primary knee OA. Red-Flag Symptoms that should make you think of other causes of knee pain include, fever, weight changes, many joints involved, erythema, swelling, warmth, prolonged morning stiffness (> 1 hour), and rapid onset of knee pain. Knees which are swollen, erythematous and red should always be considered for infection, and gouty arthropathies, and fluid analysis on the synovial fluid is critical in those diagnoses.

A classic OA picture will present as a gradual worsening of symptoms, initial stiffness in the am (usually < 30 minutes), worse after rest but improves somewhat with moderate exercise, can be provoked by prolonged activity. The patient may report clicking or popping but it is uncommon for the joint to lock or become stuck with just OA. The pain is usually aching and deep in nature but can have some occasional sharp pains reported. Typical OA will develop worse in the medial compartment of the knee with a slight valgus (knees buckled in) appearance. In younger patients (<55 years old) primary patellofemoral arthritis can cause severe pain which remains localized deep to the patella and is worse with extension type activities.

Before moving forward with treatment, it is important to perform a thorough physical exam. Inspection is often overlooked but is vitally important, deformities of the knee will cause uneven stresses and can lead to more rapid progression of the arthritis and more severe symptoms. Palpation along the joint lines of the knee as well as range of motion (ROM) of the knee can give insight into general function and localization of pain symptoms. Testing of the ligaments of the knees should include varus and valgus stress testing both in full extension and at 20-30* of flexion, as well as anterior and posterior stability testing with either an anterior and posterior drawer test or Lachman test. Gait observation including limp, and comparative stride length can give insight into the impact arthritis may be having on your patient.

Further testing with laboratory studies and imaging can be beneficial when first making the diagnosis of primary knee OA. Weight bearing XR of the knee in AP, Lat and NWB sunrise views gives the best images of the knee in its functional state and can better help to establish progression of disease. Routine laboratory studies with CBC, CMP, sed-rate and/or CRP may be warranted if the patient has any of the red flag symptoms above, or you are considering pharmacologic interventions for their pain, however lab testing is usually not necessary for diagnosis of OA..

 

Non-pharmacologic Management

The first steps for managing OA knee pain are lifestyle changes with an emphasis on diet and exercise. Moderate intensity exercise of at least 150 minutes per week has been shown in several studies to have beneficial effects on slowing the progression of and disability from knee OA (4). Also, BMI of higher than 35 carries a very sharp rise in the risk of infection post joint replacement, and thus it is important that from the first sign of joint pain a push is made to combat obesity (5). Physical Therapy with strengthening programs targeting the adductors and knee extensor muscles will help to stabilize the knee and assist in OA pain deriving from patellofemoral component arthritis. Regular stretching to preserve full ROM is also important as one of the most predictive factors of knee ROM post replacement is knee ROM pre-replacement. Complementary and alternative medicines such as acupuncture, heat and ice modalities, and herbal supplements have also been shown to have benefits in small studies.

 

Pharmacologic Management

Acetaminophen should be considered first line for oral pharmacologic treatment. Doses of 650mg up to four times daily can be effective in most early cases of OA. Prolonged use of acetaminophen should prompt the physician to check liver transaminases for possible adverse events with the medication. Oral NSAID or topical NSAIDs should be considered second line. Chronic use of either should prompt a physician to check renal function every 3-6 months as well as considering placing the patient on an antacid medication to reduce risk of gastrointestinal complications. Topical agents either via gel, patch or liquids carry less risk of the systemic side effects but have been less effective in overweight patients. Use caution in using oral NSAID or selective COX inhibitors in patients with known coronary artery disease as there is a significant increased risk of cardiovascular events with prolonged use.

 

Interventional Management

If pain continues despite pharmacologic and non-pharmacologic treatments, the next step in management is interventional modalities. There are several types of injections and a multitude of mechanisms of action that can lead to reduction in arthritic pain and morbidity. Arthrocentesis should be considered for every patient on their first injection to allow for fluid analysis to rule out concomitant gout or pseudogout which may play a role in worsening the patient’s prognosis. Depending on the severity of the arthritis and the level of effusion within the joint it may be beneficial to the patient to first perform an arthrocentesis, as the amount of fluid in the injection can lead to increased intraarticular pressure and discomfort.

After simple arthrocentesis the next most common injection includes intraarticular steroid injection with or without local anesthetic. I recommend using local anesthetic when injecting steroids as it can limit some of the discomfort from joint capsule stretch from injection of all the fluid. While more recent studies show that there may be some increase in the rate of cartilage degradation post corticosteroid injection, and that long term the injections do not delay or prevent joint replacement patients often report improved symptom and impairment with these injections (1,3). Alternative injections with hyaluronic acid or viscosupplementation has shown benefits in the management of OA, however it seems to be very patient specific and at this point no clear predictive indices for who will be a responder and who will not currently exist (3). For these injections improvement of symptoms >50% at 2 weeks and continued benefit past 6 months is considered a successful treatment, and you could consider repeat viscosupplementation injections. They come in various options for injection including single dose up to 5 sequential weekly injections.

The newer options for interventional management of knee OA pain include geniculate nerve blocks which operate on a principle like medial branch rhizotomies on the back. First the patient will have a diagnostic block or two to identify if the formal rhizotomy is likely to provide relief. Then if the patient reports >50% reduction in their pain symptoms which wears off appropriately for the anesthetic they will be brought back for a radio-frequency ablation of the geniculate nerves; thus, denervating the articular surfaces of the knee. No motor function is lost in this procedure as all motor branches have been given off prior to the site of the lesion. The remaining two options include platelet rich plasma (PRP), or stem cell injections in which the patient has cells harvested from autologous tissue and then injected into the knee. The mechanism of action of this is an inflammatory process and thus patients are instructed to stop all NSAIDs and steroids prior to injections. Both last two options are still classified under investigatory by most insurances and thus are usually performed as self-pay interventions.

Ultimately, the goal of the physician in treating chronic knee OA pain is to limit pain symptoms which impair the patient’s quality of life. Doing so in the least invasive way possible is the ultimate goal. There is no treatment currently that has been shown to prevent the progression of OA or reverse damage that has already been done, and our goal should be to delay replacement as far into life as possible to prevent the need of revision and to set patient’s up for success post replacement with strengthening, ROM, and weight loss strategies if they end up needing to undergo total knee replacement.

 

To request an appointment with Dr. Rush, click here

The Migraine Treatment You Could Be Missing

38 million people in the U.S. suffer from migraines, according to Migraine.com. Of those 38 million, 11 million people say their disability is due to migraines.

June is Migraine and Headache Awareness month. With so many people suffering from migraines, it seems that we’re pretty aware of the problem. However, according to Dr. Gabriel Paulian of SIMEDHealth’s Rehabilitation Medicine, not all headaches and migraines are the same.

First, it’s important to know that a headache is defined as continuous pain, tension, or throbbing in the head and neck area. This can be caused by any number of problems such as dehydration, substance withdrawal, and side effects of another condition. A migraine is normally experienced as a headache but includes additional symptoms such as sensitivity to light and sound, nausea, blurred vision, vomiting, and more.  However, sometimes migraine symptoms can occur without a headache. A migraine can last from a few hours to a few days.

“Migraines manifest differently in every patient. There are multiple types of headaches and migraines as well,” Dr. Paulian said.

In fact, there are about 17 different kinds of headaches and about 24 types of migraines.  

“This is the reason why treatment is different for every patient,” Dr. Paulian said. “Getting a clear diagnosis is the key to guiding pain management.”

There are a number of different treatment methods for headaches and migraines that most commonly involve medications. However, if your migraines are the side effect of another condition, further medication may not be right for you. This is why Dr. Paulian recommends a lesser-known treatment for migraines, acupuncture.

Acupuncture is the process of inserting very small needles in specific locations of the body to release endorphins, the body’s natural painkillers. This process is also used to increase blood flow and stimulate nerves and tissue.

“Acupuncture for migraines is effective and one of the safest treatment options. There are no side effects, unlike other medications. The process at SIMEDHealth’s Rehabilitation Medicine clinic only lasts about 5 minutes and the pain relief is usually a few weeks,” Dr. Paulian said.

Acupuncture can also be used to treat other areas of the body experiencing pain such as the lower pain, neck, knees and other joints. 

If left untreated, headaches and migraines can affect your overall mood, sleep patterns, and stress levels. These symptoms may lead to additional physiological problems in the future as well. For complex headaches and migraines, Dr. Paulian also recommends a referral to a SIMEDHealth neurologist to find the right treatment plan. 

“If you say you are having bad headaches, you should see someone in our clinic right away,” Dr. Paulian said.

Click here to learn more about SIMEDHealth Rehabilitation Medicine or click here to request an appointment. 

Dr. Vance Elshire Featured in Local Magazine

Photo by Jimmy Ho Photography

Photo by Jimmy Ho Photography

If you flip through this month's edition of Wellness 360, a North Central Florida magazine focused on complete wellness, you may come across a familiar face. 

The Spotlight 360 section, titled "On the Quest for Adventure," features Dr. Vance Elshire of SIMEDHealth's Interventional Pain Management. Here he talks about his recent completion of the 2018 Everglades Challenge and how to live a consistently-healthy lifestyle while working and caring for a family. 

All of us at SIMEDHealth are proud of Dr. Elshire's accomplishments and excited to see where his next quest for adventure takes him.

You can read the shorter version of this article here. To view the full article and additional photos, pick up a copy of this free magazine in and around the University of Florida campus, at local retailers and at a SIMEDHealth location near you. 

 

 

Can Natural Supplements Ease Migraines?

SIMED Wellness, Migraines, Supplements, Supernatural Wellness, Interventional Pain Management, Daniel Schaffer MD
Migraines are a complex disorder characterized by recurring headaches that are usually one-sided, cause throbbing head/neck pain, are intensified with physical activity, and last 4-72 hours. Common symptoms include sensitivity to light and noise, nausea, vomiting, blurred vision, constipation, diarrhea, abdominal cramps, and food intolerance. Some individuals may have symptoms before the actual migraine which is called an aura and are most commonly visual disturbances.  SIMED Interventional Pain Management's Daniel Schaffer, MD explains more on the topic and how some natural supplements may ease the pain and frequency for some migraine sufferers.Daniel Schaffer, MD | Supernatural Wellness | SIMED Health

Migraine headaches affect about 13% of Americans every year, approximately 17% of women and 6% of men. Some may have mild or infrequent migraines, while other migraine sufferers may be dramatically impacted by their migraines. Migraines are estimated to have a cost of $17 billion annually including doctor visits, medications, and lost productivity. Headaches should be evaluated by a physician.
 

Supplements for Migraine Prevention:
A recent literature review, published in 2012 in the journal Headache, updated and combined recommendations for migraine prevention therapy. These recommendations from the American Headache Society (AHS) and American Academy of Neurology (AAN) include prescription medications, but also include various over-the-counter supplements which have proven beneficial in migraine prophylaxis in several well-designed studies. These include magnesium, riboflavin (vitamin B2), and petasites (butterbur).  Results were slightly superior in efficacy to NSAIDs.  Additional literature was evaluated regarding the use of CoQ10 with headache prevention.
 
Magnesium:
Though the exact mechanism by which migraines occur is not well understood, many theories have been suggested.  In one clinical study, 360mg of elemental magnesium was taken three times daily for two months with improvements in pain scores and reduced number of days with headache. Patients with menstrual migraines and those with low magnesium levels have been found to benefit from supplementation.
 
Magnesium is well tolerated; the most common side effects are changes in bowel habits, diarrhea, and mild hypotension. Avoid supplementation in patients taking daily tums and those with renal insufficiency.
 
Riboflavin (Vitamin B2)
Another theory of possible causes of migraine includes deficiency in energy production from mitochondria. Riboflavin is a water soluble B vitamin necessary for normal cell function, growth, and energy production. Several clinical studies have used dosages of 200-400mg of riboflavin daily for up to three months with significant reduction headache days. Groups that are more susceptible to riboflavin deficiency include the elderly, those with chronic illness, alcoholics, the poor, and vegans. Riboflavin is generally well tolerated with the most common side effect being discoloration of urine.
 
Petasites (Butterbur)*
Butterbur is a perennial shrub found primarily in Europe and some parts of North America and Asia. It may work by helping to relax the smooth muscle lining blood vessels in the brain and decrease inflammation. Dosages of 7.5mg of petasin and isopetasin per each 50mg tablet (Petadolex®), dosed at 50-75mg twice daily for up to 4 months have been studied and have shown benefit. Common side effects include: headache, drowsiness, fatigue, stomach upset, constipation, nausea, vomiting, and diarrhea. *Raw unprocessed plant may cause liver injury. However, commercially available products should have been carefully processed to eliminate the harmful components are considered safe.
 
CoQ10
CoQ10 is involved in the creation of the important substance in the body known as adenosine triphosphate (ATP). ATP serves as the cell's major energy and CoQ10 also works as an antioxidant. Primary dietary sources of CoQ10 include oily fish (such as salmon and tuna), organ meats (such as liver), and whole grains.  Minor side effects that may occur with supplementation (unusual) include a burning sensation in the mouth, loss of appetite, nausea and diarrhea.   In an open label study thirty-two patients diagnosed as having migraine with or without aura were treated with CoQ10.  No adverse events were associated with CoQ10 therapy in any of the trial participants. 61.3% of the patients treated had a greater than 50% reduction in number of days with migraine headache. Only two participants had no improvement with CoQ10 therapy in their migraine headache intensity compared with baseline (ie when the trial started). The average number of days with migraine headache during the baseline non-treatment phase was 7.34 and this decreased to 2.95 days by the end of the trial. The reduction in migraine frequency after 1 month of treatment was 13% and this improved to 55% by the end of 3 months of therapy.  The data presented suggest that CoQ10 may work within 4 weeks but usually takes 5 to 12 weeks to yield a significant reduction in days with migraine.
 
For more information or if you would like to schedule a free consultation with Dr. Schaffer please contact Supernatural Wellness at (352) 281-9355 and leave your information and you will be provided appointment options with the day.