Center for Functional Medicine

Overview
Pain is the body’s way to signal to us that something is not going well. It is a call to action, asking for you to make that body part function better. For patients with chronic pain, their health problem is like having a foghorn signal blown in their ear each day. Chronic pain is defined as acute pain, which never leaves after six months. For some people it starts as an insidious ache that worsens with changes in weather, humidity, and barometric pressure. Pain is described by some as the emotional, subjective response to a noxious or irritating condition. Pain medicine is a primary medical specialty based on a distinct body of knowledge and a well-defined scope of clinical practice that is founded on science research and education. It is concerned with the study of pain, the prevention of pain, and the evaluation, treatment, and rehabilitation of persons in pain. A comprehensive evaluation incorporates the physical, psychological, cognitive, and socio-cultural contributions to pain. The treatment protocol may include pharmacological, interventional, behavioral, cognitive, rehabilitative, and complementary strategies provided in a concurrently focused and patient specific manner.

INTERVENTIONAL PAIN MANAGEMENT

Often you are referred by your physician for diagnostic or interventional nerve or joint blocks. In this case, your family physician or surgeon is asking for assistance in helping with the source or diagnosis of your pain, or even co-management your treatment plan. These injections are done in any part of the body, but particularly the spine. These injections are being done to evaluate whether the disc is irritating the nerves, or if the nerves are irritated by osteoarthritis of the spine along the little joints that help our spine move called the zygopophyseal joints or facet joints. These injections are considered safe, but do not assume that a cascade of events ranging from reaction to the medicines used, inadvertent injection in the blood vessels or in the nerve sac, or infection or blood clot could, in extremely unfortunate chain of events cause death. As scary as it is, we should consider that each day that we drive our car, a similar series of events could cause us to die and indeed this happens every day. Thus, once you are satisfied that the risk and benefits of the procedure has been discussed and understood, the injection would then be a way to find out if pain can be treated without surgery or by any other means. Technological options such as pain medicine pumps or pain altering spinal stimulation electrical wiring are useful in a small number of patients and while Dr. Fortier-Bensen was one of the first physician to place these in patients in the early 1990’s, he does not perform these treatments anymore.
Radiofrequency is a way to alter the nerves to the spinal joints in the spine and has helped for a temporary but substantial time period (3-9 months), by essentially cauterizing or stunning temporarily the nerves to that joint. There are many hypotheses about the mechanism of action, importantly; it may be causing collagen modulation. There are some supporting studies that do show these treatments are helpful.

Epidural space steroid injections, or epidural, as it simply called is the use of a small layer around our spinal cord and nerves to assess if the pain can be calmed down or erased by the use of a small amount of cortisone placed near the irritated nerve root. There are studies which both prove epidurals do work, and some that show it works well, but not as well as surgery. Every attempt will be used to try and relieve the pain without the use of medications, but sometimes both are needed to deal with the every day pain.

Dr. Fortier-Bensen is board certified in Anesthesiology, and in Pain Medicine, and was asked to submit questions for the certification process for the boards. Dr. Fortier-Bensen is a considered an expert in the field of Pain Management, although he prefers being an Integrative Physician, or a Functional Medicine doctor. This type of medicine looks at you as a person and thus a personalized program is tailored to your body, your mind, and your biochemical individuality. Pain is the secondary issue, the larger consideration is to look for the underlying cause, and only, a patient’s inability or unwillingness will stop Dr. Fortier-Bensen from looking for that cause. Only a devoted dogged determination by the patient as well as the physician to find a cause of the pain, and a staff who offer an attitude of compassion, hope, and faith, can a treatment plan that truly works.

Helping patients to find answers

Whether it is spinal pain, fibromyalgia, chronic fatigue or joint pain, the evaluation of a chronically ill patient is very challenging. Foremost, because patients have variability within themselves, that is called biochemical individuality, which makes for an interesting, if not difficult, assessment. It requires a broad and at times, a subjective, interpretative assessment of the disease process and how that person reacts individually to it. Within this context is family systems transgenerational energetic, or psychosocial sensitivity, secondary mental or psychological factors affecting or manifesting a physical condition, including depression, anxiety, insomnia, and psychiatric or personality disorders.

Many of the following underlying causes that may cause the cascade of chronic pain or illness are as follows:
• Accumulation of physical injuries, or postural aberrations which make for mechanical, structural stimulation of mechano-pressure induced pain
• Alterations in the immune system Th-1/Th-2 abnormalities, allergies, food or other sensitivities
• Infections of all types.
• Coagulation and blood circulation dysfunction
• Nutrient depletion, transport problems across endplates, and free radical overload
• Environment both heavy metal, and organic toxins
• High velocity accidents, trauma, and surgery which affects structural or nervous component
• Hormonal deficiency
• Genetic polymorphisms or defects
• Abuse of any kind causing psychiatric disorders
• Congenital disorders
• Altered biochemical or biological processes
• Stress, both emotional, physical, and insomniacally related
• Inflammation
• Sympathetic nervous system alterations, nervous tissue dysfunction
• Family system problems or Transgenerational Energetics

Treating patients is altered mostly not by what is scientific, but what is reimbursed by the insurance industry. The pain management techniques employed by physicians are variable, but include crudely, a psych clinic where pain is ignored, (it is all in your head), a block clinic, don’t tell me your concerns, let me suppress your nerves function, or do continuous cortisone steroid nerve blocks on you, and if they do not work, well learn to live with it. Finally, the integrative model, that includes a comprehensive, methodical approach using current technology that are safe and effective, as well as a patient centered plan.
There are those who believe that chronic pain is a maldynia model. That is, the person has an altered sense of pain sensation.

The inputs of pain are variable and require an integrative approach including a consideration of the list previously discussed. But what happens to those patients that neither surgery, nor injections fail to relieve the pain. Or advanced technology is disappointing. The intellectually honest physician uses what means are available, seriously making with the patients a decision with known risk. Other physicians say they do not use narcotics, but they do prescribe them. By not prescribing pain medication, it allows them to avoid the moral dilemma of treating pain when injections, surgery, or pumps have failed, or health insurance for procedures run out. All drugs, hormones, chemicals, and even natural substances will down regulate a person ability to gain the same effect from repeated uses of the item. You will note this, when you smell perfume long enough, you temporarily lose the ability to smell it. Another example is when you need more and more coffee to get the same wake-up buzz you did initially. Tolerance is a built in, primitive biological system to help one deal with too much of any substance to protect the receptors. Only specific drugs that can treat pain without causing tolerance are without this principle. All these are in research mode, and currently, all we have is a more general treatment with drugs that are not specific.

That big issue which so polarizes the body of physicians is that of prescribing opioids, or narcotics. Some will prescribe them willingly based on their trust of the patient and compassion, others will not write them at all, feeling it is a dirty business, because of all the drug diversion and abuse issues. Others use the idea that even if opioids have beneficial effects, they do not prescribe these medications so as to leave the doctor an exit strategy of the case. What do you think they would with if they had advanced, unrelenting pain? An analogy to the use of fire is appropriate, it heats our food, keeps us warm, provides light, but it can kill, maim, destroy forests and our homes. Hippocrates used opioids, but warned them to be used judiciously, that perspective is still the same today. Some patients have in a fit of anger, often wished their doctors would have chronic pain just for a while and maybe that unsympathetic attitude would change. I explain that whenever I have taken care of physicians, when they hurt, they ask for medicine. Most injured physicians however end up on disability, never entering their personal experiences to their practice. A sage retired doctor from Mississippi once said all physicians should have chronic pain for just a little while if only for them to be sympathetic to their patients. Pain researchers are beginning to elucidate which patients may have a predisposition to abusing anything, as well as alcohol, narcotics etc. and these patients with chronic pain presents a difficult management problem.

Nevertheless, new studies are elucidating that certain people with high levels of a certain substance called TNF-alpha tend to have severe neuropathic pain from degenerating disc disease, whereas other will barely even notice their discs dying. Neuropathic pain is very difficult to treat and despite all the antidepressants, anti-seizure, neuroleptic, and anti-inflammatory medicine none of these treat the multiple pathways of pain. Narcotics are at least, a general treatment with some efficacy, and until we can find a drug which is multipurpose and selective, it is all we have. Dr. Fortier-Bensen notes that if he never had to write another medication, opioid or otherwise, but instead use natural approaches, he would be content, but life is not that easy. Once pain begins to stress the body, cortisol levels are raised up, DHEA is depleted, sex hormones are catabolized, and eventually the body goes into a fatigue state where secondary depression, anxiety, and insomnia take it toll. Psychological factors affecting physical conditions then become an issue with pain, the more stress the more pain, the more fatigue and depression. It is clearly obvious, that coping skills, whether it be from a psychiatrist or psychologist need to be addressed to help with this problem.

All patients who obtain medication of this type will have to sign an agreement that they understand the risks and benefits of medication and realize that the DEA is the final authority as they give physicians the right to offer these medications to chronic pain patients. I often use this guideline to help with the trial period of patients on these medications. Those who are in pain take these medications to live, those who are abusers live to take these medications, and those who take these medications to sell to those abusers, will have their day in court sooner or later.

All options will be considered in trying to relieve suffering and keep the patients functional, while all diagnostic and treatment modalities are investigated. A number of treatments may be needed such as chiropractic, manual therapy, acupuncture or even surgery to help with a patient’s pain management when addressed earlier in the course of the process. The process of chronic pain is in a feed forward loop and little can be done to stop the process after the process has been ignored for so long. This is why it is so very important for the patient and doctor, physical therapist, chiropractic to work together as a team early on to address and hopefully improve the patient’s health. You must look for answers in science articles being reported in the research world, but many of us are not reading the research, among other places.

Our Integrative Approach

Our approach involves connection to multiple physicians, manual therapists, chiropractors, massage therapists, kinesiologists, psychologists, acupuncturists, nutritionists, naturopaths, pharmacists, dentists, nurses, psychiatrists, surgeons, and counselors including religious. A “clinic without walls concept” that brings the best of the best practitioners in a network close to you, without being forced to see only the practitioners that are available at the office, or the doctor’s favorite golfing buddy.

We are happy to help you with your health needs, and will offer you all that are safe and effective, with an agreement, that, we can not help you, if you do not help yourself. You must love yourself and respect yourself enough to be willing to change if you want success in this integrative patient-centered model of the Center for Functional Medicine. Contact us about any therapies, second opinions, or as a patient advocate to help you with your decisions in your health.

Some of the common symptoms patient complains of which their head hurting include the following:

Pressure behind the eyes or side of the head
Dizziness
Vision changes
Migraines
Light sensitivity
Barre’-Lieou Syndrome
Eagle and Ernest Syndrome
C1-C2 joint dysfunction

Tension Headaches are often a problem of the muscles of the neck, head, face, and shoulder,
Disequilibrium of the muscle support relationship, poor posture or dissymmetry will cause persistent problems.

Migraine, both classical and nonclassical have causes which are still under research. There are a spectrum of causes, which can range from dysfunction of the vessels in the brain, hormones changes during cycles, estrogen, etc, food intolerances, detoxification abnormalities, and structural defects to name just a few aetiologies. After complete workup by a neurologist, these lesser known causes are where Dr. Fortier-Bensen will concentrate. Posterior cervical pain syndrome, more commonly known as whiplash, can alter the soft tissue in the neck and cause headaches. This can be from a trauma or an occupational position which causes an alteration of the normal relationship of the muscles.
There are other types of headaches, or cephalgia, which can be related to atypical facial pain. Bruxism
can cause this type of headaches. TMJ as well can cause headaches. Boot, which Dr. Fortier-Bensen was one of the first to use this as a treatment for muscular causes will help this problem.

Neck pain: The neck consists of three large areas which contribute pain to the neck; the cervical discs, the cervical facets, and the ligamentous components. Spurs and arthritis of the spine, muscular dysfunction and small nerves also contribute to neck pain. Finally the shoulder can present a confusing picture of neck pain.
Location of the pain generators and treatment will follow once it can ascertain that the cause of the problem is where the patient feels it and not a distant referral pattern from somewhere else.

Back pain: There are two areas which predominate in causing back pain; these are the disc which when degenerative or inflamed will cause pains in the lower extremities, or in the back, axial or lumbar facet pain are often noted when one is told they have arthritis in the spine. The lumbar spine initiates the locomotion movement we call walking, and surgery, such as laminectomy or fusion will alter the mechanics and hence aggravate the Sacroiliac or hip derangement or motion. Continual assessment of the back must be done in intervals after treatment of any type as the REAL cause of the spine or lower back pain may as of yet not be elucidated. Additionally, there are many other causes of back pain which will not be assumed by the surgically trained physician, or by interventionalists. Because of these two types of pain, physicians refer them as neurogenic back pain, caused by nerves, and mechanical back pain caused by the wear and tear of the spinal joints, and ligaments.

The thoracic spine is problematic as it is often has referred pain from the neck or from the lower lumbar spine; ribs can also cause back problems and is usually not considered from other interventionalist. The postvertebral joints can cause a great deal of pain.

Shoulder pain: The shoulder is often a reason why neck pain does not get better after surgery, and it will often give a referral pattern that will confuse the patient thinking the neck pain, carpal tunnel syndrome and inability to sleep on one side is all coming from the cervical spine only.

Wrist and arm pain can be a hidden fracture, or a muscular and ligamentous problem, or it may be signs of what is called sclerotomal, dermatomal or myotomal referral patterns from the spine. Chronic Sprains and strains will mask as radiculopthies from the neck but are really signs of a weakness in these smaller joints.

Hip or sacroiliac joint pain: These joints work together and often a degenerative hip can cause back pain, the Sacroiliac does not normally fuse and is under extreme forces in walking, sitting, and standing. The key point here is the patient cannot do any of these activities for too long. The experts with these joints are often manual therapist and chiropractic physicians, occasionally another physician with osteopathic training will understand the relationship, but in general, most other family physicians are going to overlook the mechanics, because they have little or no training, and most have little interest in learning it.

Knee pain: The knee is under extreme forces above and below it, it is under the influence of the muscles and often the REAL problem with the pain of the knee joint will be secondary to a derangement, dissymmetry, and weakness in the forces above and below it. As noted in past studies, arthroscopy can help some of these problems, but often it only documents a more complex problem, but does not fix this.

Ankle and Foot pain: While these can be source of referral pains from the spine, mechanically speaking, the problems with joints, and the spine can often be attributed to past injuries, derangements, and weakness of the ankle and the foot. People who claim they fall because they are clumsy, are underestimating themselves, they fall because of an unstable motion in the ankles, and feet.

There are treatments, which may help alleviate these problems with these symptoms, for more information call either (985. 626.6174 or 228. 897.2337).