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Managing Pain Fall 2013


Autonomic Disorders: Finding and Treating that Ever Elusive Cause of Pain

When we think of pain, we most often associate it with nerves, joint inflammation or traumatic injury. We might think of a pinched nerve or chronic arthritis. But pain management specialist Daniel Callahan, MD, explains that some pain is a result of autonomic disorders.

“The autonomic system is the part of our nervous system that controls all of our involuntary actions such as the movement of blood through our bodies and the digestion of our food,” says Dr. Callahan. “Autonomic nervous system disorders can occur alone or stem from another disease. Diagnosing them and finding the underlying cause of the pain can take testing and a process of elimination.“

Dr. Callahan joined the Cleveland Clinic Pain Management team at South Pointe Hospital in May, bringing another perspective to the team of physician pain management specialists. He is a neurologist who subspecializes in interventional pain management through procedures including nerve blocks, botox injections and spinal cord stimulation.

He says that autonomic disorders can be genetic or degenerative and can cause symptoms including headaches, sweating, blood pressure problems, gastrointestinal pain, heart issues and trouble with breathing. Dr. Callahan can help pinpoint the autonomic reason for these disorders and then treat the pain and discomfort associated with these issues. He will often do this in concert with other physicians in different specialties.

Autonomic nervous system disorders can result from diseases such as complex regional pain syndrome (CRPS), Parkinson’s disease or diabetes. Some autonomic nervous system disorders get better when the underlying disease is managed. But many times, because there is no cure, the goal of treatment is to improve symptoms through pain management.

On a visit to Pain Management, patients will have a complete history taken and undergo a physical exam. Then the pain specialists may use X-rays, MRI, EMG (electromyography), nerve conduction studies and nerve blocks to localize the pain source and help to formulate a diagnosis and treatment plan.

“So we use imaging technology, neurophysiological studies [electromyography] and injections to determine where the injury is/was, where the source of the pain is and where the pathology is coming from,” Dr. Callahan explains. “Every test has meaning in the context of the patient. And because chronic pain has a psychosocial impact, a clinical psychologist is often involved in the diagnosis and treatment process as well.”

This comprehensive approach can help patients get to real underlying issue of their pain so they can receive the treatment they need to have a better quality of life.

To make an appointment with Dr. Callahan or another Pain Management specialist at South Pointe Pain Management, call 216.445.7370.


All about Neck Pain, What You Want To Know

Pain Management specialists Benjamin Abraham, MD, and Philippe Berenger, MD, help hundreds of patients each year in dealing with neck pain issues. Here, they provide answers to some basic questions about neck pain to help you understand when it is serious enough to visit a physician and what you can do to avoid or alleviate it.

What is the most common cause of neck pain?

In general, axial neck pain is caused by muscle strain or bone/joint problems. Muscle strain can happen just from sleeping in the wrong position, sitting at a computer all day, from a sports injury or from whiplash. Genetics, age and injuries can also lead to arthritis of the neck/spine. Neck pain might also be part of a more generalized condition such as fibromyalgia or other inflammatory condition.

What are the best ways to manage neck pain if it is caused by simple muscle strain or arthritis?

If neck pain is caused by muscle strain or arthritis, regular exercise and movement are important. Your doctor might prescribe physical therapy and anti-inflammatory medications, including NSAIDs (nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen).

What are other causes of neck pain?

Radiculopathy, or cervical radiculopathy, refers to neck and arm pain caused by a disk or bone impinging or pressing on a nerve root as it exits the spinal canal. The pressure and inflammation on the cervical spinal nerve can cause pain, weakness or numbness. Depending on which spinal nerve is affected, the pain will be localized to a specific part of the arm, forearm or hand. If a disk herniates, moves or bulges, pressure can be exerted on the nerve from the disk. Often patients describe this pain as aching or burning pain.

When is neck pain severe enough that I should see a physician?

In general, you should see a physician when there are neurological changes or when symptoms are severe. Red flags include pain that wakes you up at night, pain or weakness in an arm, or a history of associated cancer, weight loss, fever/chills or if you have used IV drugs at any time in your life.

What will the doctor do to diagnose my neck issue?

First, the doctor will get your history to find out if it is being caused by muscle strain or if you have a history of trauma. If the symptoms have been present for several weeks, he/she may have you get an X-ray. If you have weakness in the arm (or other red flags) or if symptoms persist without responding to physical therapy and anti-inflammatory medications, the doctor will most likely have you get an MRI to determine if there is a structural problem.

Depending on the MRI findings, your clinical exam and response to prior conservative measures, you may require pain management, therapeutic or diagnostic injections or a surgical evaluation.

How can I avoid neck pain?

Get regular exercise and keep your weight in a normal range. Also, avoid cigarette smoking. If you have had neck pain in the past and participated in physical therapy, continue with a regular home exercise program. All of these things will make neck pain less likely for you.

To make an appointment with Drs. Abraham and Berenger, or another Pain Management specialist call 216.444.PAIN (7246).


Pain Relief through Alternative Care

In addition to the standard treatment, which includes nerve blocks, epidurals and other treatments, pain management doctors offer a variety of alternative therapies, including guidance on diet and lifestyle changes and osteopathic manipulation.

Of all the alternative therapies available, acupuncture has proven one of the most effective in treating a large number of diseases and painful conditions. In fact, many patients have said it is “life-changing” allowing them to sleep better and more fully enjoy time with friends and family.

“Acupuncture can treat just about any condition you can think of,” says Pain Management specialist William Welches, DO, PhD. “It is holistic, and considers the entire individual in the treatment. It doesn’t replace traditional medical treatment, but complements it.”

How does acupuncture work?

Medical acupuncture is performed by physicians who have been trained in this ancient Chinese medical art. They select from hundreds of acupuncture points to treat local, regional or global (body-wide) pain. Pain management specialists stimulate or calm these points on the body by gently inserting needles at acupuncture points and electrically stimulating acupuncture points.

The needles stay in place for a few minutes to as long as 20 minutes. They help to trigger the release of brain chemicals (natural painkillers) that can block or decrease pain signals.

The number of acupuncture treatments varies, but a typical course of treatment is one or two sessions a week for five to six weeks. You should try at least five acupuncture treatments to give acupuncture a chance to work.

Who can benefit from acupuncture?

You may benefit from acupuncture by our physicians if you have:

  • Chronic low back pain
  • Migraines or cluster headaches
  • Chronic neck or muscle pain from stress or whiplash
  • Shoulder pain from stress, sports injuries or trauma
  • Severe menstrual cramps or female abdominal pain
  • Medical acupuncture may also be used to treat severe osteoarthritis, facial pain and irritable bowel syndrome (spastic colon).

Your medical acupuncture treatments may be combined with physical therapy. You may receive education from our doctors about adopting the heart-healthy Mediterranean diet and other wellness habits. If appropriate, they may combine acupuncture with osteopathic manipulation for low back pain.

For an appointment for a pain evaluation with a Pain Management specialist and/or acupuncture, please call 216.444.PAIN (7246).


Managing Your Pain Following Orthopaedic Surgery

Fear of pain may have stopped many in the past from having the orthopaedic surgery they needed. But today, patients don’t need to fear the severity of pain, says Loran Mounir Soliman, MD, of Cleveland Clinic’s Anesthesiology Institute. In recent years, there have been many advances in relieving post-surgical pain. One example is a new portable pump that provides continuous nerve block medication.

“Following surgery we are helping patients get through physical therapy with minimal pain and minimal side effects from their pain meds,” says Dr. Mounir Soliman. “We want to get people home within a day or two after an orthopaedic surgery so that they can spend time with family, sleep better and feel better faster.”

He explains that in years past, patients often needed to stay in the hospital for five or more days following an orthopaedic procedure to have their pain managed. This would involve taking pain medications and sometimes having repeated local nerve blocks. The problem was that nerve blocks would only ease the pain for 12 to 14 hours and the common side effects of pain medications—from nausea and vomiting to dizziness and drowsiness—made going home difficult or impossible.

Now, small continuous pumps are able to provide continuous ambulatory peripheral nerve blocks. The pumps are programmed for each patient at the time of surgery and for up to a week following the surgery. The nerve block is performed with insertion of an indwelling catheter near the nerve to provide a continuous flow of medication to the nerve. It is infused via tubing that is attached to a portable device (with the medicine bag) that is easily strapped around the waist. A bolus button allows the patient to get an additional dose of medication each hour if the pain becomes worse during physical therapy.

“We have been using the pumps for the last four to five years and have had great results and very positive patient feedback,” says Dr. Mounir-Soliman. “Patients also have pain meds they can take, but don’t need to take as many with the continuous nerve block medication, which works locally at the site of the pain.”

Cleveland Clinic is one of only a few healthcare providers across the country that is providing this alternative way to control pain following orthopaedic surgery. The pumps are used for most upper and lower extremity orthopaedic surgeries. Spine or pelvic surgeries are exceptions where this technique cannot be used.

A key element is the follow-up. Patients who are discharged home with a pump receive a daily follow-up phone call from Cleveland Clinic’s Acute Pain Management team to make sure that everything is going well. The team wants to ensure that the device hasn’t become dislodged and that there is no sign of infection, both of which are rare events. Then, in five to seven days, the patient can remove the catheter on their own—there is no need for follow-up appointments.

“The ease of using these pumps is a great advancement in pain management for our ortho patients of all ages,” says Dr. Mounir-Soliman. “Now, we can tell patients that they shouldn’t worry so much about pain, but rather about getting back to full strength following surgery.”

Visit our Pain Management and Orthopaedic Surgery pages for more information and treatment options.  


Could There Be a Clinical Trial That’s Right for You?

When in pain, we all seek out the best possible pain remedy. Thanks to years of clinical trials, researchers are always moving medicine forward with new and improved treatments. In general, clinical trials are used to test the safety and effectiveness of drugs and medical procedures in a human population. The results of this research help to set the standards of patient care for all.

In the Department of Pain Management, there are currently five major clinical trials going on. Each study is unique, highly regulated and focused on providing the best of care to clinical trial volunteers. Patients who volunteer for clinical trials benefit by gaining access to new research treatments long before they are widely available. At the same time, they are making a big contribution to medical advancements for the future.

“Our pain research studies are focused on specific clinical conditions and have very specific age and health condition requirements for volunteers,” says Pain Management Department Chairman Richard Rosenquist, MD. “We work with patients who volunteer to assure that they understand the details of a study, feel safe, and fit the criteria. We want it to be an excellent experience for them and to produce reliable information for the study as we seek to improve our understanding and treatment of complex pain conditions.”

Safety of Clinical Trials

Federal law stipulates that all institutions that conduct or support biomedical research involving people must have an independent review board (IRB) that initially approves and periodically reviews the research projects. This means that every clinical trial that Cleveland Clinic does is approved and monitored by an IRB committee of physicians, statisticians, community advocates and others whose objective is to ensure that the trial is ethical and that the rights of study participants are protected.

Pain Management is continuously seeking out the safest and most effective ways of treating the many sources of pain. Today, Cleveland Clinic’s Department of Pain Management is enrolling patients in a range of ongoing clinical studies.

For a complete listing of the trials currently available, visit the Pain Management clinical trials page.