What you should expect when you come to my clinic.
I will do a careful review of your history and the diagnoses that have been assigned to you. We will work together to understand how the pain started and how things have progressed and the effects of treatments and surgeries tried on you. We will review all the medications and interventions that you are currently using, not just your pain medications.
Next, I will do a careful examination to identify the muscles that are likely causing your pain. Once we have done this, we can start treating them.
I perform trigger point injections directly into the effected muscle segments that are locked up. The injection fluid contains local anesthetic (freezing) that will temporarily stop the muscle pain. Stopping pain, even temporarily, allows you and I to know that we have injected the nutrients into the pain-causing muscles. The pain relief is often almost instant and can be permanent.
Although your pain will likely come back within hours, days or weeks, it is usually coming from muscles that were not injected. These muscles (secondary trigger points) also have too much acid but were not as bad as the main (primary) trigger points and thus ignored by the spinal cord and brain. As the spinal cord lowers the acid threshold for pain, the “new” muscles are recognized as causing pain. I will work with you to get all of your muscles back to optimal health as quickly as possible.
It is imperative that you optimize muscle chemistry, blood flow, posture and exercise. I may ask you to stop taking certain drugs (statins for cholesterol, diuretics for blood pressure) that are known to predispose you to muscle pain. I will ask you to stop taking any calcium supplements. In turn, I will ask you to take a high dose magnesium supplement every day and will usually combine this with other calcium and magnesium controlling factors such as vitamin D and K2.
Expect to come to see me on average four to five times before your pain-free state is maintained. Everyone is different. Generally, the longer you have had your pain, the more drugs you are on, surgeries you have had and the older you are, the longer it may take to fully get back to normal. It may take up to a year to pay back your magnesium debt incurred by your muscles as they may have been giving up magnesium over many years to maintain your blood levels at a livable level. If you have been on a high dose of calcium (1,500mg/day) for many years it will also take longer to restore balance. Restoring normal muscle mitochondrial function after statin (cholesterol lowering drug) use can also take up to a year.
I sometimes prescribe a muscle relaxant called dantrolene that very specifically helps keep Ca++ in its storage sites in muscle cells. Clonidine is sometimes useful to decrease sympathetic nerve tone and thus increase blood supply to muscles. Cialis may also help by increasing nicric oxide levels in muscle blood vessels and increasing blood flow.
As we work to treat all of your muscle pain, we may find that some other disease process has been missed which may require other investigations and treatments from other physicians. I will, and quite often do, make referrals for help. I am usually able to expedite this process directly to a physician with a strong interest and skill in that particular problem.
I will not take over your opioid prescribing. I do not believe these drugs have a role in the treatment of chronic pain, especially where the patient is not expected to die soon. They are suitable for treating cancer pain in palliative (dying) patients. I will help you get off the opioids once your pain is better.
There are no charges for injections done in my clinic. Charges are levied for letters written on your behalf. I do send a letter to your family physician after every visit made to my clinic at no cost to you. You may use this letter for legal purposes.
There is a high demand for all chronic pain clinic services and I ask that you keep your appointments or give the clinic adequate notice of your intention not to attend, so that we may get someone else in.
I encourage you to read widely and ask as many questions as you wish. Bring a partner, caregiver or relative with you, especially to your first few visits. They are welcomed and encouraged to be part of your diagnosis, treatment and recovery. Chronic pain affects the whole family!
Lastly, the big question and stumbling block for muscle injections – how badly does it hurt?
Penetrating skin with a needle can be done with little pain if the skin is pulled tight and the needle is pushed through with a rapid motion. Once through skin, the needle does not hurt, until it comes in contact with bone or a trigger point. Normal muscle does not hurt when a needle passes through it. This is key to my ability to be able to locate the abnormal segment of muscle and place the tip of the needle within that segment and infiltrate (inject) it with the fluid that I believe restores it to normal health.
Although all patients experience pain with the injections, almost all of them (including teenagers and young men!) are able to tolerate the procedure and enjoy the benefits. Most patients comment that the injections were not as bad as they were expecting and certainly not as painful as those received at other pain clinics.
The main difference is the inclusion of sodium bicarbonate into the mixture to neutralize both the acid in the local anesthetic and the muscle tissue. This also significantly reduces the incidence of rebound pain. Rebound pain occurs in the injection site after the local anesthetic effect has worn off.
Patients can expect some pain to return at or near the site of injection. Occasionally the pain is worse than before. The pain then starts to settle after a few days and relief can last for days, weeks or months. At the follow-up appointment, I most often find trigger points in different sites from where the injections were last made