Info & FAQ

FAQs — Frequently Asked Questions & Articles of Interest

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Physiatrists, or rehabilitation physicians, are medical doctors who are:

  • Experts at diagnosing and treating pain
  • Restore maximum function lost through injury, illness or disabling conditions
  • Treat the whole person, not just the problem area
  • Lead a team of medical professionals
  • Provide non-surgical treatments
  • Explain your medical problems and treatment plan
  • Work not only on treatment but also prevention

Physiatrists are nerve, muscle, and bone experts who treat injuries or illnesses that affect how you move. Rehabilitation physicians have completed training in the medical specialty physical medicine and rehabilitation (PM&R).

Rehabilitation physicians treat a wide range of problems from sore shoulders to spinal cord injuries. Their goal is to decrease pain and enhance performance without surgery. Rehabilitation physicians take the time needed to accurately pinpoint the source of an ailment. They then design a treatment plan that can be carried out by the patients themselves or with the help of the rehabilitation physician’s medical team. This medical team might include other physicians and health professionals, such as neurologists, orthopedic surgeons, and physical therapists. By providing an appropriate treatment plan, rehabilitation physicians help patients stay as active as possible at any age. Their broad medical expertise allows them to treat disabling conditions throughout a person’s lifetime.

Rehabilitation Physicians May Treat:

  • Amputations/Prosthetics
  • Arthritis
    • Osteoarthritis
    • Rheumatoid Arthritis
  • Back Pain
  • Brain Injuries
  • Cardiac Rehabilitation
  • Geriatric Rehabilitation
  • Neck Pain
  • Nerve Pain
    • Radiculopathy
    • Ulnar Neuropathy (Wrist Pain in Bicyclists
  • Osteoporosis
  • Pediatric Rehabilitation
  • Post-Polio Syndrome
  • Spinal Cord Injuries
  • Sports-Related Injuries
  • Stroke
  • Women’s Conditions
    • Female Athlete Triad
    • Pelvic Pain
    • Pregnancy and Back Pain
  • Work-Related Injuries

A Nonsurgical Ligament Reconstruction & Treatment For Chronic Pain

Prolotherapy uses a dextrose (sugar water) solution, which is injected into the ligament or tendon where it attaches to the bone. This causes a localized inflammation in these weak areas which then increases the blood supply and flow of nutrients and stimulates the tissue to repair itself.

First, it is important to understand what the word prolotherapy itself means. "Prolo" is short for proliferation, because the treatment causes the proliferation (growth, formation) of new ligament tissue in areas where it has become weak.

Ligaments are the structural "rubber bands" that hold bones to bones in joints. Ligaments can become weak or injured and may not heal back to their original strength or endurance. This is largely because the blood supply to ligaments is limited, and therefore healing is slow and not always complete. To further complicate this, ligaments also have many nerve endings and therefore the person will feel pain at the areas where the ligaments are damaged or loose. Tendons are the name given to tissue which connects muscles to bones, and in the same manner tendons may also become injured, and cause pain.

Prolotherapy Is Useful For What Conditions?

The treatment is useful for many different types of musculoskeletal pain, including:

  • Arthritis
  • Fibromyalgia
  • Carpel Tunnel Syndrome
  • Ligaments & Cartilage
  • Sciatica
  • Back Pain
  • Sports Injuries
  • Chronic Tendonitis
  • Degenerated or Herniated Discs
  • Neck Pain
  • Unresolved whiplash injuries
  • Partially Torn Tendons
  • TMJ

Historical review shows that Hippocrates first used a version of this technique on soldiers with dislocated, torn shoulder joints. He would stick a hot poker into the joint, and it would then miraculously heal normally. Of course, we do not use hot pokers today, but the principle is similar—get the body to repair itself, an innate ability that the body has.

How Long Will It Take For Treatment?

The response to treatment varies from individual to individual, and depends upon one's healing ability. Some people may only need a few treatments while others may need 10 or more. The average number of treatments is 4-6 for an area treated. The best thing to do is get an evaluation by a trained physician to see if you are an appropriate candidate. Once you begin treatment, your doctor can tell better how you are responding and give you an accurate estimate.


Answers to Common Questions About Back Pain
Questions and Answers by Dr. John Liguori

Q. My doctor told me that there was nothing left that he could offer to reduce my back pain. What should I do?
A. Get the opinion of another doctor who specializes in the treatment of back pain. Sometimes a fresh look at an old problem reveals effective treatments.

Q. My doctor told me to “learn to live with the pain”. How can I do this?
A. When this is all that is left, you need to know what relieves your pain and what makes it worse. Only you can determine this. If cutting the grass causes 24 hours of bed rest, find someone to cut your grass. You may find that resting each afternoon reduces your pain. Do whatever you can to reduce your pain without increasing your dependence on medication.

Q. When are narcotic pain medicines appropriate?
A. Narcotics include percocet, methadone, tylox, etc. In some cases when more conservative medications have failed, narcotics may be necessary. Narcotic pain medication can reduce your perception of pain and if dosed properly can increase your level of function.

Q. I am concerned about addiction to narcotic medications, will this occur if I take prescription narcotics?
A. Although addictions occur in some cases, the majority of people treated with narcotics do not become addicted. In many cases where other treatments do not help, narcotic pain medicines are very appropriate and safe.

Q. What is Osteoporosis?
A. Osteoporosis is a progressive problem of bone in which the mineral that makes the bone strong (calcium), leaves the bone. It is most often seen in postmenopausal women.

Q. What role does osteoporosis play in back pain?
A. Osteoporosis by itself is usually not a cause of back pain. However as bone weakens it becomes more vulnerable to fractures. These fractures can become extremely painful. Most women should begin treatments to prevent osteoporosis at an early age. For specific treatments, see your doctor.

Q. What is scoliosis?
A. Scoliosis is a condition of the spine in which the spine bends left to right or right to left.

Q. Is scoliosis serious?
A. Scoliosis can be serious and if it is proven to be rapidly progressive, surgery may be necessary. When scoliosis is discovered in an adult it is usually a stable ( non progressive) type and surgery is usually not necessary.

Q. My neighbor received trigger point injections (TPI’s) and her back improved. What are TPI’s?
A. TPI’s are injections of medication into trigger points. Trigger points are areas of muscle that when compressed by the examiner, feel very painful and pain travels to an additional nearby part of the body. In some cases, TPI’s can greatly reduce symptoms.

Q. My doctor prescribed a muscle relaxer for my back pain. What should I expect?
A. First of all, not every doctor aggress that muscle relaxers are effective in reducing pain or even relaxing muscles. Many muscle relaxers have significant side effects including sleepiness, light headedness, low blood pressure, and confusion. .Muscle relaxers should be reserved for people only when they clearly have overactive muscles and the muscles are causing the pain. In addition, no one should drive a car while on muscle relaxers. One muscle relaxer, SOMA, has few documented benefits and is very habit forming.

More Answers to Common Questions About Back Pain
Questions and Answers by Dr. John Liguori

Q. What is the most effective treatment for back pain?
A. The treatment depends on what is causing the pain. There are many different causes of back pain. Most require a specific treatment. Success occurs when a treatable cause of back pain is matched with an effective therapy. When the diagnoses and treatment are mismatched, treatment fails.

Q. How can my doctor determine what is causing my back pain?
A. By asking you questions, listening to your answers, and examining you. Each different cause of back pain presents with a characteristic “fingerprint” of symptoms and findings on physical exam. Most of the time the correct cause can be determined, sometimes it is not clear. The doctor treating you must be able to accurately interpret these findings. He also needs to know which treatment is effective for your particular diagnoses.

Q. Are X-Rays, MRI’s, etc., necessary?
A. Not always. X-Rays, MRI’s, etc, are extremely helpful if a patient presents with a very specific group of findings on examination or if the patient has specific symptoms. Testing is used to confirm diagnoses or to establish a new one. In many cases, the diagnosis is clear after the doctor listens to your symptoms and examines you. When this is the case, additional testing is not necessary.

Q. I have back pain, why won’t my doctor order an MRI?
A. When indicated, MRI’s are a very valuable tool. However, over 30% of healthy, pain free volunteers have abnormal back MRI’s. Abnormal findings on MRI’s can lead a doctor away from the correct diagnoses and treatment.

Q. My back MRI showed a bulging disc. Is this serious?
A. Scoliosis can be serious and if it is proven to be rapidly progressive, surgery may be necessary. When scoliosis is discovered in an adult it is usually a stable ( non progressive) type and surgery is usually not necessary.

Q. My doctor prescribed physical therapy for my back pain. Can I go to the gym and work out instead?
A. No. If your doctor has accurately diagnosed the cause of your back pain and referred you to a physical therapist, he/she has a specific treatment in mind. Physical therapy can be extremely beneficial and sometimes curative.

Q. Do all physical therapists treat back pain effectively?
A. P.T’s specialize just like doctors. Some PT’s are terrific treating back pain; others are terrific treating sports injuries. It is important to receive treatment that is specific for your unique problem. When it comes to treating back pain, routine treatment is successful only for routine problems. One size does not fit all.

Q. Will I need surgery for my back pain?
A. This depends upon your unique situation. Sometimes surgery is the only appropriate treatment option. However, it is advisable that you first exhaust all appropriate non-surgical treatment options for your back.

Why Visit A Rehabilitation Physician?

Rehabilitation physicians are nerve, muscle, and bone experts who treat injuries or illnesses that affect how you move. By taking the whole body into account, they are able to accurately pinpoint problems and enhance performance - without surgery. Consider seeing a rehabilitation physician if:
  • You had an accident or you have an injury or chronic condition that has left you with pain or limited function
  • You’re contemplating or recovering from surgery
  • You have an illness or treatment for an illness that has diminished your energy or ability to move easily
  • You’re recovering from the effects of a stroke or other problems related to nerve damage
  • You have chronic pain from arthritis, a repetitive stress injury, or back problems
  • Excess weight makes it difficult to exercise or has caused health problems
  • You think you’re too old to exercise
  • Life changes such as childbirth or menopause have created new challenges to your physical function

Getting started

A rehabilitation physician will thoroughly assess your condition, needs, and expectations and rule out any serious medical illnesses to develop a treatment plan. A clear understanding of your condition and limitations will help you and your rehabilitation physician to develop a treatment plan suited to your unique needs.

Tailoring your plan

You need the right type of exercise to effectively overcome fitness obstacles. A runner may have gained weight after being sidelined by a knee injury. A rehabilitation physician can prescribe tailored, low-impact activities that burn calories without aggravating the injury, simultaneously prescribing physical therapy and use of a brace to strengthen and support the knee. Another patient may be suffering from chronic neck pain. The rehabilitation physician might prescribe medication, stretching, and massage for short-term pain relief, as well as strengthening exercises to prevent future pain. If surgery is a necessity, rehabilitation physicians work with patients and their surgeons before and after surgery. By directing your treatment team and collaborating with other health care professionals, a rehabilitation physician is able to specially design a treatment program tailored to you.

Understanding and identifying your goals

Do you want to strengthen an injured muscle, find relief from chronic pain, or walk up the stairs without being winded? A rehabilitation physician can work with you to determine realistic short- and long-term goals. Along the way, he or she will help you to find relief from pain, achieve successes in rehabilitation or exercise programs, overcome your setbacks, and reassess your goals if necessary.

Source: American Academy of Physical Medicine and Rehabilitation

Why Do People Respond Differently to Pain?

A common experience:
I worked the same job for over 20 years. I was a good employee, hardworking, professional, and dedicated. Also, all of my life I have been a fairly physical and active person. I played sports; went to all of my children’s games, plays, and recitals; and was very involved in the community and church. Of course I had aches and pains but normally just shrugged them off to declining age and a hard physical life. But my pain steadily got worse. Doctors frequently told me I had a pulled muscle or arthritis. And for 10+ years of going to the chiropractor, numerous massages, and months of physical therapy my pain was manageable with some degree of improvement. But one day I rolled over and could barely move. The pain was just unbearable. X-rays suggested something about degenerative disc disease and bone spurs, supposedly pressing on nerves causing severe pain. In attempts to avoid surgery, I again participated in physical therapy, tried epidural and cortisone injections, and numerous other medications, but nothing was completely helping my pain. It is hard to believe the doctors cannot find exactly why I hurt and fix it. And now they are suggesting that I see a psychologist; don’t they believe I hurt? It’s not all in my head.

For many the origination or cause of pain may differ but the process that one goes through is common. The experience of ongoing pain and reaction to disability not only affects the individual but also those around them. Many report feeling hopeless, totally dependent, and angry at what their pain has done to them and their family. No, it was not suggested that you see a psychologist because someone thinks the pain is all in your head. By and large, whether you were in an accident, experience pain following multiple surgeries, or suffer from disease, the experience of pain is a psychological experience (Smith, 2004). There is no simple correlation between the severity of an injury and the pain that many of us experience.

Some severe injuries produce no pain at all, while absent limbs may provide a person with excruciating pain and discomfort. Thus pain is not merely a simple matter of transmitting impulses along nerve pathways to some specific pain center in the brain. There is no such location. Instead when pain is experienced many brain areas are involved, ranging from the frontal lobes, motor and sensory areas, to the midbrain, and cerebellum. Pain perception is the response of the whole brain and not just one area (Campbell, 2000). As a result pain is easily affected and intensified by varying emotions, stressors, hormonal changes, and thought processes, just to name a few.

Some 45 million Americans are plagued by headaches. Up to 80% will experience back pain during their lifetime. Over $4 billion is spent each year on over-the-counter medications alone. This being said, pain issues are prevalent and are the most common reasons patients either enter healthcare settings and/or self-medicate (Smith, 2004). Generally pain functions as a protective device alerting us to danger or injury, and priming us for escape. So if I burn my hand or even bang my elbow, pain would signal me to remove my hand from the hot object or my elbow away from the obstruction. This type of pain is commonly referred as acute pain.

When we are out of danger or the tissue damage has healed pain diminishes. However this is not always the case. There are a number of situations where pain persists or is thought in excess of identifiable injury and tissue damage. Examples are often seen with back pain, headaches, arthritis, and angina (Smith, 2004; Eccleston, 2001). When pain becomes chronic it is more than just a physical and minor emotional impediment. It typically results in disability, which can be physical, emotional, and financial. Most if not all activity stops.

We experience various emotions ranging from anger, anxiety, and depression, and often a sense of loss. We perceive ourselves as completely disabled, unable to do or be the person we once were. We may push away those we care about, feeling like we are nothing but a burden to others. As our pain persists we become more and more inactive. We may see ourselves at the complete mercy of our pain, no longer feeling any sense of control over our lives. We are stressed financially too, unable to work and dependent on a system of disability or worker’s compensation. We often feel that, if only we could end the pain then all would return to normal; the depression would lift and we would be the person we once were. But this is rarely the case. The question is asked, which came first, the pain resulting in loss then depression, or did underlying depression cause the pain? Many would easily say that one’s pain and disability led to loss and depression, as well as other emotions, but researchers and healthcare personnel believe that this is not easily determined.

But why do people respond differently to pain? Why is it that some individuals who received seemingly minor injuries become totally inactive and dependent, while others who may be more severely hurt appear to take a positive attitude and are better able to manage their pain? Without attempting to settle this question of the “chicken or the egg,” many would agree that when someone experiences stress and/or has tremendous emotional baggage associated with physical pain, healing is an extremely slow process.

In conjunction with ongoing medical care, psychological treatment is often introduced to assist with the emotional toll one experiences from daily pain. Often goals are designed to help manage the pain cycle. Pain from increased activity. To develop skills to minimize pain.

To learn to maximize activity and positive life experiences despite physical limitations. Techniques typically used may involve traditional psychotherapy, cognitive-behavior treatment, biofeedback, hypnosis and relaxation, and/or fundamental breathing exercises. Factors such as disability, financial stress, loss of work, and problematic family dynamics are also frequently a part of treatment. Given all of these aspects of pain and disability, not to mention the chemical processes associated with emotions and hormonal levels, it is easy to see how pain, especially persisting and enduring pain is indeed psychologically based. The course of treatment to best address these many factors would be a multidisciplinary approach, focusing on physical limitations, pain, and related psychological issues.

**Campbell, 2000. Book review of P. Wall, Pain: The science of suffering.
**Eccleston, 2001. Role of psychology in pain management. British Journal of Anaesthesia. Vol. 87.
** Smith, 2000. Pain: Double trouble. Psychology Today. July/August, 2004.

What is Sacroiliac Pain?

There are many potential causes of back pain. Effective treatment of back pain almost always follows an accurate diagnosis. When an accurate diagnosis is followed by appropriate treatment that is specific for that condition, the outcome is usually very favorable. One of the potential causes of back pain is sacroiliac joint dysfunction.

The sacroiliac joint is one of the largest joints in the body. It forms a space between the sacrum, or base of the spine, and the ileum or wing of the pelvis. The sacroiliac joint is crossed by very strong ligaments which hold the joint together. The joint is further stabilized by the front of the pelvis. There, a much smaller joint known as the pubic symphysis is located.

In the majority of people, the sacroiliac joint moves only to a small degree. The joint surfaces are very different from the surfaces of the shoulder joint or hip joint, which are very smooth. The sacroiliac joint surfaces are irregular. The surfaces are not unlike the irregular surfaces that we see in corrugated cardboard. One side matches up with another and sliding within the channels occurs. This can happen while we are changing positions in bed, standing from the sitting position or doing most any other activity of daily living. However, when the joint moves in an unusual position, pain can occur.

The theory associated with this joint as a generator of pain is that the bone on one side of the joint can slide out of position with respect to the bone on the opposite side of the joint. When this happens, it can be present for just a few moments or it can last a long time.

Symptoms usually include the following:

  • Pain over the side of the back, low in the back, on the same side as the sacroiliac joint problem.
  • Pain can be referred from this joint down into the buttock or back of the thigh.
  • People can feel as if there is a rotation of their hip joint and that their leg, on that side, has turned as well.
  • In some situations, pain can be felt at the front of the pelvis, down near the pubic bone.
  • The individual with this condition can also complain of pain that is brought about by movement or lifting.

In addition to changes in the position of the joint that precipitate pain, an actual inflammation in the joint, similar to an arthritis can cause pain. In these situations, there may be no changes in the position of the joint itself, but the pain is generated because of the inflammation. Symptoms in this situation would more likely be limited to pain in the low back on the side of the sacroiliac joint and possibly referred to the buttock.

Sacroiliac joint dysfunction is diagnosed by physical examination and history. On physical examination, if there is a change in the joint itself, it can usually be measured right in the doctor's office. Changes or shifting in the pelvis can be felt with the doctor's hands and some of these changes can be confirmed by leg lengths which appear to be unequal. Tenderness over the sacroiliac joint is also a very common finding.

Treatment for the sacroiliac joint problems can be very effective. The first line of treatment following an accurate diagnosis is usually made through an attempt to put the joint back, as it belongs. This can be done by a physician, but is often done by a physical therapist. Stretching and maneuvering the patient can also reposition the joint. When this occurs, there is usually a significant reduction in symptoms.

Once these bones have gone back into place, the job is not done. Efforts must follow that keep the joint where it belongs. A very specific home exercise program is prescribed for the individual and the goal is to stabilize the joint so it does not slip out of position again.

If the joint does slip back out of position, the therapist or physician try to reposition the joint again. If the joint will not hold where it belongs, external support in the form of tight corset or a pelvic belt can be very helpful. If the joint can remain in position, it is likely that the internal ligaments will become tight enough to stabilize the joint.

If the above does not help or if the pain is coming from an inflammation of the joint, an injection of medicine into the joint can also be very helpful. Sometimes, an injection can resolve the problem entirely. Injections into the joint are technically difficult, because the joint is very narrow. A specialized x-ray machine is needed to confirm the placement of the tip of the needle in the joint and also that the medication was delivered where it needs to be.

In most cases, a combination of physical therapy and this type of injection is effective. In case it is not, another line of treatment could include performing a procedure to eliminate the ability of the nerve endings in that joint to transmit the sensation of pain. As a last resort, for a chronically unstable joint, surgery can be performed to permanently immobilize the joint in the proper position. This can be very effective as well. But again, it is reserved only as a last resort.

In our practice, a significant percentage of the people who we see with back pain, have the diagnosis of sacroiliac joint dysfunction. It is much more common than many people think. If you think that you may have this condition, please ask your physician about this. We are able to diagnose and treat this condition at the Independence Back Institute.

What Is Radiofrequency Lesioning?
Questions and Answers by Dr. Ben Wall, M.D.

Q. What is Radiofrequency Lesioning?
A. Radiofrequency Lesioning is a safe, proven means of effectively providing lasting relief from chronic pain.

Q. What is the procedure for Radiofrequency lesioning?
A. Radiofrequency Lesioning is performed by a physician in a hospital or a surgical center, or on an outpatient basis.

Following the administration of a local anesthetic, your physician will use fluoroscopy to guide a small insulated needle into the general area where you are experiencing the pain.

Then your physician will stimulate the nerves near the tip of the needle to make sure it is correctly placed. When the correct site has been found, Radiofrequency Lesioning treatment will begin.

During treatment, a Radiofrequency Generator transmits a small radiofrequency current through the insulated needle, to disrupt the specific nerve sending pain signals to your brain. More than one area may need to be treated to achieve optimal pain relief.

Q. Is the procedure painful?
A. Unlike surgery, there is no incision and the procedure is not particularly painful. A local anesthetic is used before the procedure to reduce any discomfort during treatment.

Q. Is there pain after the procedure?
A. You may experience some discomfort at the site of the Radiofrequency Lesioning. However, this discomfort usually subsides and can be treated with medication during this short period of time. Icing to the local areas can decrease pain post procedure.

Q. Am I a candidate for Radiofrequency Lesioning?
A. If you have chronic pain, only your physician can decide whether this procedure is right for you. Your physician may use nerve blocks to see if you might respond to Radiofrequency Lesioning.

Q. How long does the pain last after Radiofrequency Lesioning?
A. Radiofrequency Lesioning treatment should provide the pain relief you need, to allow you to resume your daily activities. Pain relief usually lasts 3-12 months.

On occasion, your body may regenerate the nerve responsible for sending pain signals to your brain. If this occurs, Radiofrequency Lesioning treatment can be performed again.

Q. Are there risks associated with Radiofrequency Lesioning?
A. As with any medical procedure, however minor, there are certain risks involved. Please consult your physician for more details.

Radiofrequency lesioning is now being performed by Dr. Ben Wall at the Independence Back Institute in Wilmington. Dr. Wall is Board Certified in Physical Medicine and Rehabilitation

Electromyogram (EMG) and Nerve Conduction Studies

An electromyogram (EMG) measures the electrical activity of muscles at rest and during contraction. Nerve conduction studies detect how well and how fast the nerves can send electrical signals. These tests assist in detecting muscle weakness, muscle disease and damaged nerves.

EMG testing is typically done when you have these symptoms:
  • Tingling
  • Numbness
  • Muscle weakness
  • Muscle pain or cramping
EMG results are often necessary to help diagnose or rule out a number of conditions:
  • Muscle disorders
  • Diseases affecting the connection between the nerve and the muscle
  • Disorders of nerves outside the spinal cord (peripheral nerves), such as carpal tunnel syndrome or peripheral neuropathies
  • Disorders that affect the motor neurons in the brain or spinal cord, such as amyotrophic lateral sclerosis or a herniated disk in the spine

Dr. Peter Gemelli does the EMG/nerve conduction studies for Independence Back Institute. If you have further question, please call our office at 910-794-8892.

Botox For Pain
By Dr. Ben Wall, M.D.

As a physician specializing in Physical Medicine and Rehabilitation, I constantly strive to uncover the latest and most effective therapies for reducing or eliminating pain. The use of Botox (botulinum toxin A) injections for the treatment of pain is one of the most exciting and innovative developments in recent years.

Most people are aware of the cosmetic applications for Botox; however, it is not widely known that Botox has been used for other conditions. As a rehab provider I have personally treated stroke and brain injury patients with Botox injections, thus witnessing the life-changing results Botox has provided these patients. As I move forward in providing Botox injections for my patients suffering from incapacitating pain from muscle spasm, I have been pleased to observe the same overwhelming results.

Here is how Botox injections work. Botox blocks the release of the neurotransmitter acetylcholine creating a disruption in the signals from the nerves to the muscle. The result of this process is the local elimination of muscle contractions. By manipulating these processes to control muscle spasms, pain resulting from the muscle spasm can be significantly reduced or eliminated.

A Retrospective Study by the Pain and Evaluation Treatment Center in Tulsa, OK, found that 70% of patients with myofascial pain in the back and extremities who received Botox injections over a two-year period reported good to excellent pain relief lasting 2.5 to 3.6 months. This finding is consistent with my experience that most patients will need a follow-up injection approximately every 3-4 months for continued pain relief.

Additional studies have found that low back pain can be safely and effectively treated with Botox injections even when the patient has experienced no relief through conventional therapy. Studies have proven Botox injections to be superior and longer lasting than traditional steroid therapy, as well. In addition, Botox injections have proven effective in the treatment of headache, neck, back and shoulder pain.

Funding through most insurance companies requires preauthorization, however Medicare will provide coverage for Botox injections as a treatment for pain in the appropriate circumstances.

As with any therapy, there should always be a physician consultation to ensure that one is an appropriate candidate for a Botox injection

Golf and Back Pain
By Dr. John C. Liguori, M.D.

O.K. it is Saturday morning. Your regular group has an 8:30 tee time at your favorite course. You worked hard over the last few days at the driving range to get your swing under control. When you went to bed last night, you were convinced that today was going to be the day that you would shoot a new low. Somewhere in your brain, you imagined your friends congratulating you for your heroic performance as you finally conquered the game of golf. Then, you roll in bed and feel the pain. Your back is hurting. You get up, do some exercises that help your friend treat his back and things only get worse. You get dressed, hoping that things quiet down. You take your Tylenol, Ibuprofen, get to the course and almost collapse on the first tee.

Or, you may be someone who has chronic pain and stiffness. By about the 4th or 5th hole, you might be moving better. You might be worse. If this sounds familiar, read on.

Back pain is a common problem. It effects an overwhelming majority of all people including golfers. There are as many different causes of back pain as there are golf swings. Understanding your back and your limitations are very important to successful treatment, and your enjoyment of the game.

Probably, the most common cause of back pain is wear and tear arthritis involving the joints of the spine. These are common findings in all people who are mature enough to remember the days when Roadrunner cartoons were considered the cutting edge violence and too much for your youth.

Symptoms that go along with this wear and tear arthritis include an aching type pain in the back and possibly the buttocks, but rarely, if ever, into the legs. The pain is usually worse with activity such as the take away and follow through of a golf swing. It is also worse when someone bends forward at the waist to lift a ball out of a cup, tee up a ball or carry a golf bag.

More disabling causes of back pain can also include leg pain. This can be caused by a compressed or pinched nerve in the back. Between every pair of back bones, two nerve roots exit from the spinal cord. These nerve roots pass out of the spine through windows between the bones. They then travel down to the buttock and legs. Compression of these nerve roots, can result in severe burning pain, tingling, numbness and even weakness of the legs.

This is a more serious condition. Playing with a plain backache due to wear and tear type arthritis usually does not result in significant long term deficits such as weakness. On the other hand, continuing to play through the pain associated with compressed or pinched nerve roots can.

With regard to the regular run of the mill backache, there are several structures that can generate pain in the back and the pelvis. The treatment for each of these "generators of pain" can be different. Some of the universal treatments for back pain that can get you back on the tee box include the following:

Standard doses of Tylenol before, during and after the round. If you have no medical problems such as kidney disease or stomach ulcers, the use of medications like Ibuprofen can also help a great deal. These medications could be taken before, during and after a round. If you are already taking other medications in the same category of Ibuprofen, such as Bextra, Celebrex or Vioxx, you should not mix these medications.

The application of an ice pack before and after the round can also help a great deal. The ice is usually applied for 20 minutes and then removed for at least 40 before it is reapplied.

One of the most universal concepts that can help all people with backaches include increasing your flexibility.

When someone has restricted movements of their spine, between two arthritic joints, the take away and follow through, during a golf game can still take place. Instead of sharing the burden of motion evenly, among all the joints of the spine, extra stress is put upon the joints that are most able to move. This can cause problems as these joints are asked to contribute more than they are able.

Stretching before, during and after a round can help greatly. A safe and effective way to stretch includes sitting on the chair and maintaining good posture. Place your right hand at the outside of the left knee and use your shoulders to rotate to your left, keeping your buttocks and thighs as still as possible, (sounds like a golf swing). Move slowly to the left and then slowly back to the midline. Then, place your left hand over the outside of your right knee and rotate your shoulders to the right.

A good golf turn results in a 90 degree rotation of the shoulders to the right. This can be simulated and enhanced by this exercise.

There are many effective treatments for back pain and for nerve root compression or radicular pain in the legs. It would be impossible for anyone to recommend specific and effective treatment without examining the individual golfer.

The take home messages today include:

  1. Try to stretch, before, during and after a round.
  2. Use Tylenol and occasional medications like Ibuprofen as long as there are no medical reasons to avoid these medicines (see above).
  3. Ice before and after a round.
  4. If your problems include pain shooting down to the legs or feet, this can indicate a more serious problem that needs to be evaluated by a physician.

If you feel limited by your back or leg pain, see your doctor. It is more likely than not that you can enjoy the game again, either pain free or with greatly reduced pain. No one can guarantee that you will be carried off the 18th green on your partner's shoulders, as the club house admires your record setting performance. However, playing a round without pain can be almost as rewarding.

Fluouroscopic Guided Injections
Questions and Answers by Dr. John Liguori

Q. What are spinal injections?
A. Spinal injections are procedures in which a doctor injects medicine into a part of the spine or in an area near a nerve root. We provide fluoroscopic guided injections for chronic pain sufferers. We have a new state of the art C-Arm as well as full X-Ray services and can provide SI, Epidural, Facet, Translaminar, Transforaminal, Lumbar injections, as well as other procedures. We can treat a new referral within one week!

Q. Why are the injections done?
A. When more traditional treatment has failed, a spinal injection could help. Injections can not only treat problems with the spine but also assist the doctor to establish the diagnosis.

Q. How do the injections help the doctor establish a diagnosis?
A. One of the difficulties in treating people with back pain is that there are numerous structures that can be "sick" and generate pain. These pain generators may not always be obvious during an exam or even an imaging study such as an X-ray or MRI. Successful treatment depends upon the identification of the pain generator. The medicine injected into the spine includes a numbing medicine similar to the medicine a dentist uses. If the injection into a part of the spine suspected to be a pain generator relieves your pain even temporarily, the pain generator has been found. Appropriate treatment can often follow.

Q. So the injection finds the pain generator. Once the medicine wears off I'm in the same spot right?
A. Not necessarily. Only one of the medicines injected is a numbing medicine. The numbing medicine is mixed in a syringe with an anti-inflammatory medicine, usually a steroid. The steroid is responsible for decreasing the inflammation in that area. If successful, long lasting relief can follow and often does.

Q. My aunt had steroids for lung disease. She is very ill from complications of the steroids. Will I get sick from the steroids in the spine injections?
A. Although in rare cases, some people respond negatively to spinal injections the amount of steroid placed specifically in one tiny area of the spine is tremendously less than the steroids people take in pill form. Also, the injections are limited in number whereas people who take oral steroids usually take these medications daily. It is important to remember that although oral steroids have side effects, they are often the only treatment available to treat certain diseases.

Q. If I get spinal injections, will the steroids make me muscular or grow hair?
A. No. the steroids that do those things are a different type of steroids.

Q. Are injections the answer to my back pain?
A. Only your doctor can answer that question. It is unusual for one or a series of injections to be curative. In most cases injections are just one aspect of treatment which could include Physical Therapy, exercise and a healthy diet.

Q. What conditions can be helped by injections?
A. The conditions that can be helped include arthritis of specific joints of the spine and pinched nerves.

Q. Which joints could be involved?
A. In my practice the most commonly involved joints which benefit from injections include the facetjoints (small, paired joints on the posterior spine), sacroiliac joints (large joints on either side of the sacrum) and the joints between the vertebrae themselves which contain the discs.

Q. How are spinal injections done?
A. Since the joints in the spine are usually narrow and small, most of them can only be entered with confidence if the doctor uses an imaging machine to localize the needle tip. Special X-ray machines or CT scans can confirm the location of the needle tip before the injection occurs. This not only increases effectiveness but safety as well. Some doctors safely perform a type of spinal injectioncalled epidural steroid injections without CT or X-ray guidance. Others prefer to use a special X-ray machine.

Q. I have had back pain for years. A doctor gave me epidural steroid injections in the past and they didn't help. Could these other injections help me?
A. It is possible that they could. Epidural steroid injections are specific for certain types of back problems but not all of them. Often, an epidural steroid injection may be of no benefit, then a facet or sacroiliac joint injection may help tremendously. With injections and all procedures, a correct diagnosis combined with effective treatment usually results in improvement or recovery.

Q. Are there procedures done by doctors other than these injections that are designed to reduce back pain?
A. Yes. Doctors with special training and equipment can use devices to deactivate the tiny nerve branches that transmit the sensation of pain.

Q. How would I know if I am a candidate for injection therapy?
A. Candidates meet most of these criteria:
  1. They have pain that has not responded to more conservative treatment (Physical Therapy, medicine, spine mobilizations).
  2. A specific pain generator has been identified and it is treatable with an injection.
  3. There are no medical reasons to avoid an injection.

Q. I feel that an injection may help me. How can I be evaluated for this?
A. Ask your doctor or request a referral to a medical doctor who performs these procedures.