A Path to Wellness NYC

16May 2017

Pudendal Neuralgia

Imagine experiencing pain, severe sensitivity, numbing or a mixture of these symptoms in your most intimate and private areas but feeling too embarrassed to seek help.  Or, worse, taking the brave step to seek medical help only to find that they may not be knowledgeable or comfortable in evaluating and treating your genital/pelvic pain and discomfort.  

Either situation is far from ideal, which unfortunately, is the case for many suffering from a condition with these symptoms called Pudendal Neuralgia, a type of pelvic pain.

Do you have these symptoms?

  • Pain while sitting, which may be relieved on standing/walking
  • Progressive pain during the day
  • Burning pain in the pelvic area
  • Numbness in genital area
  • Increased sensitivity to touch or pressure (hyperesthesia or allodynia)
  • Knife-like or deep aching pelvic pain
  • Feeling of a lump/swelling present internally
  • Twisting/pinching pains in the pelvis on certain movements
  • Painful intercourse and/or sexual dysfunction
  • Urinary retention (bladder does not empty fully) or increased urgency/frequency of urination
  • Straining or burning with bladder and bowel movements

A person with Pudendal Neuralgia may experience some but not all of the above.1,2  

Symptoms for this condition, as illustrated, can be wide-ranging.

What is it and how is it caused?

The genitals, anal area and urethra1 send and receive sensory, autonomic and motor signals (“messages”) via a network of nerves. The pudendal nerve is a prominent part of this network, located in the pelvis. Should this nerve become inflamed — as a result of an autoimmune disease, a virus, or through mechanical damage/trauma to the nerve — Pudendal Neuralgia may result1,2,3.

With regard to mechanical damage1,2 to the pudendal nerve, it can occur from

  • nerve entrapment (by a ligament or muscle pressing on the nerve as it passes),
  • childbirth,
  • a fall landing onto the buttocks, or
  • after sacral surgery such as a sacroiliac fusion.

Pudendal neuralgia may also be accompanied by musculoskeletal pain in other parts of the pelvis such as the lower back, coccyx (tailbone), piriformis or sacroiliac joint2,4.

So, who can get it?

Unfortunately, anyone can present with Pudendal Neuralgia. It can be experienced by both men and women, although it has a higher prevalence in women5. For women, areas affected may include the clitoris, mons pubis, vulva, lower aspect of the vagina and labia. In men, the penis and scrotum may be involved1.

However, there is some research to suggest that certain individuals may be more prone to developing the condition.

These can include those who:

  • Sit or who drive for prolonged periods of time2,3
  • Participate in sports/activities involving repetitive hip flexion such as heavy weight lifting, cycling2
  • Have anatomical differences in pelvic structure, ligament or muscle alignment2

How is it diagnosed?

  • Detailed history surrounding medical history, the pain and activities relating to the pain2,3
  • Physical Examination2
  • A pudendal nerve block under fluoroscopy or CT guidance can act as a diagnostic tool2 in addition to a treatment

What treatments are available for this debilitating condition?

There are various treatment options available such as neuropathic pain medications and pelvic floor physical therapy4, which may be tried before any injections like the pudendal nerve block. This pudendal nerve block may also be completed to assist in the diagnosis of Pudendal Neuralgia. Pudendal nerve blocks are a minimally invasive, non-surgical treatment for chronic pain with a growing body of evidence for their beneficial effects on reducing the sensitivity of the nerve and improving function and quality of life2,5. If the symptoms are quite severe, a nerve block may be more appropriate before any physical therapy is attempted.

If conservative management is unsuccessful, more invasive treatment options include neuromodulation4 and decompression surgery2.  It is important to remember that no two patients will present exactly the same which is why our team of physicians, nurse practitioners and physician assistants here at The Spine & Pain Institute of New York will complete a comprehensive evaluation and create an individualized treatment approach for each  patient presenting with these symptoms.

I have these symptoms but I feel embarrassed… Will it resolve itself? What if I do not get treatment for Pudendal Neuralgia?

Unfortunately, Pudendal Neuralgia tends not to resolve without seeking medical help. If left untreated, Pudendal Neuralgia may cause both worsening bladder and bowel incontinence, chronic constipation and sexual dysfunction2,3. It can lead to debilitating, constant pain, even when you are in a standing or lying position (not just seated)2,3.

Our team here in the Spine & Pain Institute of New York are highly trained and experienced in diagnosing and treating this condition and, as with any patient, you will be assessed and treated with the utmost sensitivity, confidentiality and care.

For further information on Pudendal Neuralgia or to schedule an appointment to discuss your symptoms with one of our Physicians, please click here.

Sources:

  • Labat et al 2007. Diagnostic Criteria for Pudendal Neuralgia (Nantes Criteria)
  • Hibner et al 2007. Pudendal Neuralgia, A review Article.
  • Gupta et al 2015. A multidisciplinary approach to the evaluation and management of interstitial cystitis/bladder pain syndrome: an ideal model of care.
  • Mamlouk et al 2013. CT guided for Pudendal Neuralgia: Diagnostic and Therapeutic Implications

___________________________________________________________________________________________________

Marie Geraghty, Medical Assistant        Casey Grillo, Nurse Practitioner         Kallback, Marketing Manager

WRITER                                                       EDITOR                                                    EDITOR

 

10May 2017

MAY IS LUPUS AWARENESS MONTH! – MAY 10, 2017 IS WORLD LUPUS DAY! – JOIN ME AND PUT ON SOME PURPLE!

From the Desk of “Dr. Maggie” Cadet

I can remember the first time I heard the word “systemic lupus erythematosus” (SLE or lupus).

DRCADETIn my first blog, I briefly shared the story about meeting a girl during my time at medical school who had complained of several months of joint pain and swelling, extreme fatigue, and mild hair loss.  She told me that she had been diagnosed with lupus.  At that point in medical school, I barely knew the details of this disease.  From lectures, I recalled that it was considered to be a type of autoimmune disease.

Autoimmune diseases are illnesses that occur when the body’s tissues are attacked by its own immune system.  Patients with autoimmune diseases produce proteins or antibodies in their blood that target tissues within their own body rather than foreign infectious agents like viruses and bacteria, resulting in inflammation.

I could tell that this young woman was in disbelief about her diagnosis. Moreover, she was given a therapeutic regimen that consisted of steroids and other medications. She never fully understood the extent of her disease. For example, she was unaware of the association of early heart disease, lung disease, brain involvement or kidney damage, that can occur with SLE if early and aggressive treatment is not taken to control disease activity.  I also didn’t understand how serious this disease could be, or I would have tried harder to persuade her to follow up with doctors and take her medications regularly.  Sadly, I received the tragic and surprising news that she had passed away from complications of the disease.

Over the years, I have met numerous women and men who come from different countries and have never heard about this disease and have limited knowledge about diagnosis and treatment.  Raising awareness in different ethnic groups especially African Americans, Afro-Caribbean, Hispanics, Native Americans, Native Hawaiians, Pacific Islanders and Asian females is very important to me and has been a focus in my clinical practice over the years.

I have so many positive stories of people who live with this diagnosis every day and are living incredible lives.  Several years ago I was invited to a cosmetic workshop in NYC.  After the workshop, the women were paired off with a makeup artist from one of the biggest beauty brands.  I was immediately taken to a woman who appeared to be so energetic, vibrant, and not to mention gorgeous. We instantly connected as we started to chatter.  Sometime in the middle of the conversation, I told her what I did for a living.  When I told her that I was a rheumatologist, her eyes widened with amazement and told me that she has been living with SLE for many years.

We proceeded to talk for the next hour about how she grew up coping with the disease and how she refused to let this disease control her life.    She continued to tell me how she was diagnosed in college and she had complaints of joint pain and chest pain from inflammation around her heart.  Her disease was complicated by kidney failure requiring weekly dialysis and eventually two kidney transplants because her first one was complicated by a blood clot.  She told me that she had a successful second kidney transplant and had been treated with several years of steroids, chemotherapy (cyclophosphamide) and other agents.

The last time I saw her she was on a regimen of low dose steroids and anti-rejection medications.    It was so great to see this amazing, forty-something, married, professional in one of the best cosmetic companies of the world stand before me after enduring two kidney transplants.    At the end of my makeover, we exchanged our contact information.  This woman was a perfect example of how aggressive treatment, a healthy lifestyle, a supportive physician and social network, and a positive outlook on life can help control the disease despite flare ups.

Last summer, I cared for another young, beautiful and successful legal professional who had moved to NYC to pursue a job opportunity and move forward in her relationship.   She had a history of kidney disease related to her lupus, but was in remission. She was taking an immunosuppressant called mycophenolate and living her life to the fullest.

Although I have seen the ugly side of this disease, I have also witnessed many success stories.  I mainly see women, but men as well, who live with the strength and courage to wake up every day and fight this disease by keeping their disease activity in remission with the help of caring physicians, potent medications and healthy lifestyle modifications. There are effective therapies to help women and men live productive lives, but the benefits and risks must be discussed with a physician.

There are so many role models living with SLE in today’s world.   In recent years, the attention to lupus has been increasing. Sensational singer and actress Selena Gomez told the public in 2015 that she was diagnosed with lupus and took some time away from the spotlight to treat her lupus with chemotherapy (which can be used to help control inflammation for this disease).  Rapper Snoop Dogg’s daughter was seen on the “View” many years ago opening up about her battle with juvenile lupus.  Toni Braxton has spoken candidly on Dancing with the Stars and mainstream media about her battle with lupus and early heart complications.  Since being diagnosed with lupus and nephritis (kidney disease) in 2012, entertainer and television personality Nick Cannon has also taken the opportunity to educate more people about this complex disease.

Every day when I go to work, I keep the faces of the individuals that I have cared for in my mind and in my heart.  These patients inspire me to increase awareness about the clinical symptoms, diagnostic evaluation, and complications like heart disease and diabetes associated with this disease.  Thank you for taking the time out to read this story and share it with any male or female that may have symptoms suspicious for lupus (see below).  That individual should be referred to a rheumatologist and follow up every few months.   Most people can live normal and productive lives but the disease is chronic and can be challenging in terms of activity limitations and quality of life with flares.  Individuals must take an active role in their treatment plan and find support with family, friends, health care professionals or other individuals living with the disease.  There is so much hope for a future cure!

You may have Lupus…

if your doctor finds that you have at least four of these problems:

  1. Rashes
    1. malar rash- butterfly shaped rash over the cheeks (spares nasal  creases)
    2. discoid rash- round or disk-shaped lesions that can be scaly and thick. Lesions may be red or can become discolored and scarring over time.
    3. photosensitive rash  (rash with sun exposure in sun exposed areas like face, neck, arms, legs)
  2. Mouth or nasal ulcers/sores, lasting at least a few days or more
  3. Heart or lung inflammation. Pleurisy/pleuritis- swelling of the tissue lining the heart (pericarditis) or lungs that can result in chest pain with deep breaths.
  4. Kidney problem (Nephritis). Blood or protein in urine can be detected, facial or leg swelling, kidney function can be abnormal
  5. Pain and swelling lasting several weeks to months in more than two joints
  6. Neurologic problem. Stroke, seizure, confusion, memory difficulties or other mental health problems like psychosis, depression
  7. Abnormal blood tests
    1. anemia, low white blood cells or platelets counts
    2. positive proteins or antibodies called antinuclear antibodies (ANA) that may cause the body to attack different organ systems. Present in many lupus patients but are also found in healthy individuals
    3. complement proteins (part of the immune system, complement 3 and complement 4)
    4. other specific antibodies that show an abnormality in the immune system
    5. anti-double stranded DNA
    6. anti-Smith
    7. antiphospholipid antibodies
    8. false positive blood test for syphilis (no actual syphilis infection)

    Individuals may also note fever for more than a few days, extreme fatigue for days to weeks despite sleep, sudden unexplained hair loss.

    Complications of Lupus

    1. Early and or accelerated heart disease/atherosclerosis, heart attack. This is a MAJOR COMPLICATIONand leading cause of death among people with lupus.
    2. Stroke
    3. Miscarriages, pregnancy complications like preeclampsia (high blood pressure in pregnancy), premature birth
    4. Areas of gastrointestinal system may be affected (liver, pancreas, bile ducts)
    5. High blood pressure and loss of kidney function
    6. Higher risk for miscarriages or premature birth
    7. Blood clotting (thrombosis)
    8. Blood vessel inflammation called vasculitis
    9. Infection
    10. Diminished blood supply to bone causing bone tissue death (avascular necrosis)

    Healthy Lifestyle Modifications

    1. There is no specific diet but maintain a well-balanced diet with fresh fruits, vegetables (spinach, broccoli), and whole grains. Possibly consider incorporating omega 3 fatty acids (flaxseed oil and fish oil) and adequate calcium and vitamin D (which play a role in bone health and immune function).  Steroids can worsen bone quality.
    2. Reducing stress (meditation, walking, yoga, pilates)
    3. Stop smoking
    4. Wearing sunscreen and sun protective clothing against UVA and UVB light
    5. Stay active with exercise.
    6. Rest during the day and establish good sleep regimen
    7. Discuss herbs and dietary medications, vitamins with your physician first

    There is no cure for lupus but there are some treatment options that can help individuals live a productive life despite the challenges. Sometimes other specialists like a nephrologist, cardiologist, gastroenterologist, hematologist or OBGYN may get involved and be part of the medical team since lupus may affect multiple organ systems.

    Treatment Options

    There must be a discussion about benefits and risks of a specific medication, as well as a review of an individual’s medical history with a rheumatologist first!

    Common treatment options that a rheumatologist may consider are:

    1. Nonsteroidal anti-inflammatory drugs (NSAIDS)
    2. Antimalarial drugs (hydroxychloroquine)
    3. Steroids (prednisone, methylprednisolone, prednisolone)
    4. Immune suppressants
      1. Azathioprine (Imuran)
      2. Methotrexate (for predominant joint symptoms)
      3. Cyclophosphamide (Cytoxan)- a form of chemotherapy in lower doses to control inflammation
      4. Cyclosporine (Neoral)
      5. Mycophenolate mofetil (Cellcept)
      6. Biologics (newer drugs that block certain chemicals)
          1. Belimumab (benlysta)- FDA approved medication for active but not severe lupus adult patients
          2. Rituximab (Rituxan)- a form of chemotherapy
          3. Abatacept (Orencia)

        Note: Some of these treatments are already approved for other rheumatic diseases like rheumatoid arthritis and may be an option for some individuals.

        For more information on Lupus, please check out these websites:

        I am involved with this wonderful nonprofit organization which helps individuals who are living with lupus and other autoimmune diseases connect to each other and feel that there is an online support community.

            • ebook Lupus: Real Life, Real Patients, Real Talk by Marisa Zeppieri-Caruana

        Read some of my personal experiences with lupus patients.

27Apr 2017

An Introduction to Platelet Rich Plasma (PRP) Treatment

What is it?

UntitledPeople living with conditions affecting cartilage, tendons, ligaments, and bone, such as  tendinopathy and osteoarthritis1,2, stand to benefit from Platelet Rich Plasma (PRP) Treatment. The aim of PRP is to give a biological “boost” to the natural healing process in the body.

As it is a treatment created by the patient themselves, it is a low risk option with possible benefits in terms of healing.  PRP is not known to have any adverse effects, unlike the commonly used non steroid anti-inflammatory drugs (NSAIDs) that are known have effects on the gastrointestinal, cardiovascular and renal systems of certain populations2.

Key words

Platelets : a type of cell whose function is to help clot the blood

Liquid plasma: the fluid part of the blood

Centrifuge: a piece of laboratory equipment which separates the blood into different parts

How it’s done?

PRP is actually produced from the patient’s own blood. The blood itself has different parts including platelets and liquid plasma – both critical components for healing and repair in the body1. A blood sample is obtained from the patient and is placed in a centrifuge. PRP is collected from the centrifuge and treated before being injected in the patient’s body, under ultrasound guidance.

What to do? The Before and After

The goal of of PRP treatment is to optimize the initial inflammatory response of healing, where nutrients and oxygen are in greater to supply to the affected tendon/ligament, thus helping it to help. For this to occur, anti-inflammatory medications (which prevent this inflammation) should be stopped prior to and after the PRP treatment3. It is important for the patient to avoid exercise for a short time after the treatment before resuming their rehabilitation program. However, your physician will guide  you on regarding these medications and exercise for this type of treatment on an individualised basis.

Is it effective?

To date, in terms of evidence and clinical trials in the use of PRP, there are few well designed, high quality studies evaluating PRP1,2. More trials are needed to assess the effectiveness of PRP in different body structures. For example, weight-bearing tendons like the Achilles tendon (at the ankle) may require different treatment parameters to non-weight bearing tendons, like those in the shoulder.  

Is it for you?

Although more studies need to be completed, it is a low-risk option that could be explored by patient candidates and attending physicians due to the potential for some pain relief and the possibility of increased rates of healing. Tanzina Khan, M.D., M.P.H., our newest physician at The Spine & Pain Institute of New York, has a special interest in this option for pain management. Learn more about Dr. Khan who is accepting new patients at our New Hyde Park office in Long Island by visiting her biography, here. For further information on PRP or to arrange an appointment, please call (516) 209-2357 or email us at Help@SpinePainNY.com.

 

SOURCES

  1. P Halpern et al. The Role of Platelet-Rich Plasma in Inducing Musculoskeletal Tissue Healing, HSSJ (2012) 8:137–145
  2. Zhou and Wang. PRP Treatment Efficacy for Tendinopathy: A Review of Basic Science Studies. BioMed Research International (2016) 7: 1-8.
  3. https://www.painscience.com/articles/platelet-rich-plasma-does-it-work.php

 

21Apr 2017

image2[20][1]The Spine & Pain Institute of New York welcomes Dr. Khan to our “family!”

To help us all get to know Dr. Khan, we asked her a few questions:
1. Why Medicine?
When I was a kid, I went to a conference with my mom for Bangladeshi doctors. On the last night of the conference, they had a dinner where they awarded an American Orthopedist for his work in Bangladesh during the 1970’s and 80’s. This Orthopedist used his talent to develop low cost, practical solutions to help amputees who were wounded during the war for independence. What he thought to be his routine work turned out to help hundreds of people regain their ability to participate in daily life, and to help families recover from the years of war and violence. I thought that night that if I could help people — even if it was only a fraction of the work that this doctor had accomplished — it would be my greatest achievement.

2. What are your special clinical interest areas?
Before my fellowship in interventional pain, I studied regional anesthesia and acute pain management at Columbia University Medical Center. Since mastering ultrasound was the cornerstone of that fellowship, I was able to integrate those skills and knowledge into my pain management practice, as well. Therefore, from my earliest days learning interventional pain, I have been able to use ultrasound for various treatment injections, especially for joints and peripheral nerve blocks. Ultrasound is another method of viewing the body to guide injections but it is important to note that it is not appropriate for every procedure or body part, especially the back which is why we use the x-ray machine (fluoroscopy) to take pictures. However, an advantage of ultrasound is that it provides another approach to some of the peripheral joint injections (shoulder, hip, knee). For example, sometimes the x-ray machine cannot be used for positioning reasons or we are unable to see an important structure using the x-ray machine. Ultrasound also reduces radiation exposure and, at times, is easier to monitor the injection as the ultrasound provides real-time imaging.

3. How does the M.P.H. influence your practice as a physician?
Having a Master’s in Public Health (M.P.H.) really helped me to achieve a greater global perspective on my practice. My background in population health informs me as to how my patients deal with the healthcare system and the challenges they may face in receiving healthcare or living a healthy lifestyle. These challenges can range from smoking cessation to achieving a healthy weight with the correct nutrition and exercise.

4. How do you balance your time between being a physician and a mother?
I believe mothers go through “trial by fire” when it comes to multitasking. I think this is especially true when working outside the home. So, being organized, having schedules and having an excellent support system helps me immensely. Plus, I try to remind myself that although the list of tasks at work and for the kids never ends, I can prioritize and tackle what needs to get done one step at a time. Although I may have serious commitments in and out of my home, I think this motivates me to be a better physician as I like to think of my patients as an extended family. As I tell my patients, I wish to treat them as I would my own family members.

image3[20]5. Any advice for those interested in becoming a physician and specializing in Anesthesiology and Pain Management?
I would advise anyone pursuing this field to always be mindful that patients are not defined by their condition. They have full lives and responsibilities. They have important relationships. Mostly, patients come to pain management to figure out ways to function in their lives after suffering from injuries or degenerative conditions. So, we treat the whole patient and come up with new strategies to achieve the best outcome for the patient.

When not working, Dr. Khan will be found spending quality time with her husband, two young children and extended family on Long Island. She enjoys cooking and is an avid traveler having visited many countries including Bangladesh, Kenya, India, United Arab Emirates, Spain, Morocco, Singapore, Costa Rica, Canada and Thailand to name a few. Dr. Khan has a future goal of completing trails in the Himalayan Mountains. In addition to English, Dr. Khan also speaks Spanish and Bengali.
Dr. Khan is now accepting new patients in our New Hyde Park, Long Island office. Learn more about Dr. Khan by visiting her biography, here. For further information or to arrange an appointment, please call (516) 587-5500 or email us at Help@SpinePainNY.com.

18Apr 2017

image001

IS IT FOR YOU?
If you have back pain and are found to have a vertebral compression fracture, that is, a break or collapse of the vertebral bones, the minimally invasive procedure known as Kyphoplasty may be recommended as a treatment option for you. According to one of our pain specialists, Dr. Kenneth Chapman, “If you can grin and bear it, then that is the first option. The least invasive option is always the best route. What needs to be considered is to what degree the pain causes disability. An inability to function normally can lead to loss of muscle mass, deep vein thrombosis, weight loss, depression and can lead to falls, which can lead to further fractures. The risk of developing these secondary effects of pain and disability far outweighs the risks of the Kyphoplasty procedure.” The pain from a vertebral compression fracture can range from mild, and can be confused with a simple backache, to severe and debilitating, leading to hospitalizations resulting from the pain. Pain from a broken bone in the spine can heal. Time, rest, anti-inflammatory medications (Ibuprofen, Alleve, Naprosyn), opioids medications, and sometimes a brace are the first line treatments for a fracture. However, when the pain is too severe, the disability from the pain is too limiting, or a patient’s improvement is not moving quickly enough, there may be a need for an intervention.

HOW DID WE GET HERE?
Vertebral compression fractures can occur for several reasons. Something so trivial as lifting a laundry basket or opening a window may be the culprit. Or, it may result from a traumatic event such as a fall. Most commonly, however, it occurs as a consequence of Osteoporosis, which is the loss or decrease of the mineral constituents of the bones. These bones are thus ‘softened’. Weakened bones are the primary cause of painful fractures. When a compression fracture occurs, it may involve the collapse of one or more vertebrae in the spine that results in pain, hunched back, loss of height, numbness, tingling, weakness, incontinence, and other unpleasant symptoms that may vary from patient to patient. Kyphoplasty is designed to relieve the pain, to stabilize the bone, and to restore lost mobility. An important portion of the procedure is taking a biopsy of the collapsed bone. This assures us the fracture is from Osteoporosis and not other possible causes of bone weakness. “More often than we would like, we find other causes of compression fractures like multiple myeloma or a metastatic cancer. A compression fracture can be a presenting symptom in these diseases — and it’s our job to find that,” says Dr. Chapman.

HOW IT’S DONE
kyphoplasty-spine-surgery-2The kyphoplasty procedure is performed through trochars (larger needles) with the patient awake or sedated. One of the benefits of our specialists performing this procedure is that you do not need general anesthesia, which most Kyphoplasty that an orthopedic or neurosurgeons perform require. “Avoiding general anesthesia is one of the biggest benefits of us performing the procedure. We, as pain specialists, are used to patients being awake and talking during the procedure. Surgeons tend not to be used to that. The risk of a general anesthetic can outweigh the benefits of the procedure in this compromised, often elderly population” adds Dr. Chapman. Be sure to see a specialist regarding the severity of your back pain. It is also important that if you are not getting treatment for Osteoporosis, that you should see a specialist for an evaluation. “It’s never too late to change your lifestyle and/or potentially start treatments for the condition,” according to the doctor. If you or a loved one are found to have a compression fracture and have pain you can consult one of our physicians to determine if Kyphoplasty is right for you. The board-certified pain specialists at The Spine & Pain Institute of New York are regarded as experts in the field and are available for consult and more information on Kyphoplasty and related procedures.

05Apr 2017

Dealing with knee pain as an avid runner.
– Magdalena Cadet, M.D. – Rheumatologist
IMG_3752“Spring is officially here in NYC and the weather is starting to get nicer. Some runners have been loyal to their outdoor regimen and managed to brave the cold during the winter season. Some of us who are not fans of the frosty weather took a little hiatus, but now it is time to get back to the GRIND!  My love of running ignited when I attended Georgetown University and I decided to pick up this form of exercise after I gained more than the “Freshman 15” pounds. I was getting adjusted to a schedule at college that didn’t involve daily ice skating or ballet practices and we can all remember late night snacking during those college years. I found running a stimulating sport where my priority was focused on improving endurance and speed while trying to maintain good joint function and prevent injury. This activity also served as a peaceful outlet as my mind escaped from the day’s reality. I loved running by the amazing Lincoln and Jefferson Memorials as well as the other famous sites in Washington D.C. when I was younger. In NYC, running through Central park and down the West Side highway by the Hudson River has become one of my favorite activities. As I have begun to slowly start my running routine again this season, I’ve noticed some aches and pains that are creeping in. With repetitive running and other aerobic exercise during the last thirty years, there have been periods in my life where I have complained of knee pain. Sometimes it may just be a simple runner’s injury, but we all still need to pay attention to our bodies and explore the causes for knee pain.” – Dr. Cadet

 

 

Look for these symptoms in your knees:
• Stiffness in the knee
• Locking
• Grinding
• Snapping
• Catching
• Warmth
• Swelling

It is very important to seek medical attention when:
• there is significant swelling or fever with the knee pain
• the knee can’t support the body’s weight
• if the knee locks up and doesn’t relax
• if falls occur from the knee pain

After a complete history and physical examination by a specialist, some of the common reasons for knee pain may include:

• Chondromalacia Patellae – This condition also known as patellofemoral syndrome results from softening or irritation of the smooth cartilage under the knee cap which can result in the knee cap rubbing against the thigh bone with movement pain. Younger individuals may complain of pain on top of the knee, especially runners. Pain may be noted when climbing and descending stairs or with squatting, kneeling, and standing up from chairs after prolonged sitting.
• Ligament injuries of the anterior cruciate ligament tear (ACL), posterior cruciate ligament (PCL) and medical collateral ligament (MCL) often occur in younger individuals who are involved in athletics.
• Meniscal Tear – The meniscus is an important part of the knee cartilage by distributing a person’s body weight across the knee joint. Runners may have decreased ability to move their knees or hear a “popping” or “clicking” noise in the knee. Meniscal or cartilage tears can be seen in both older and younger patients.
• Bursitis (prepatellar) – This often occurs in individuals who often kneel for their occupation or are involved in tasks, which involve kneeling for a significant period, like cleaning or getting your little one to crawl. There is a small sac of joint fluid of the kneecap and fluid can accumulate to cause pain and swelling.
• Patellar Tendonitis – It is referred to as “jumper’s knee”. The patellar tendon is located over the front of the knee and may become inflamed with overuse and may result in pain. This condition often occurs in people who engage in sports like running, soccer, volleyball, and basketball.
• Baker’s or Popliteal Cyst – Knee pain may arise from swelling that occurs in the back of the knee. Sometimes the cyst or swelling may become so large that the cyst ruptures and causes significant pain in the knee and calf. A baker’s cyst may be a sign that there is an underlying problem, such as osteoarthritis, rheumatoid arthritis, or meniscal tear.
• Osteoarthritis – It is often referred to as “wear and tear” arthritis, since the cartilage which cushions the joints breaks down with aging and results in the bones of the joint rubbing together. This breakdown of cartilage may cause knee pain, swelling, and stiffness lasting less than thirty minutes.
• Rheumatoid Arthritis is a debilitating arthritis associated with inflammation, joint destruction, and possibly involvement of other organs in the body.
• Post Injury or Trauma Arthritis can result in knee pain from cartilage damage, ligament tears or bone fractures.
• Gout- a type of arthritis linked to an increase of a substance in the body called uric acid. When there is a large buildup of uric acid in the body, crystals form and may settle in the joint causing severe pain, redness, and swelling at first. Pseudogout, which is often found in women in their mid-forties to sixties, can result from an accumulation of calcium crystals in the body and cause knee pain.
• Hip conditions like Iliotibial (IT) Band Syndrome may also sometimes refer pain to the knee. This specific condition which is often seen with runners and cyclists can cause pain on the outside of the knee with overuse of the band of connective tissue (iliotibial tendon) that extends from the outside thigh to the knee. When the band tightens and rubs across the hip bone, inflammation may occur.
It is very important for the physician to consider other conditions such as an infection (septic arthritis) or a neurologic condition if these other causes are not suspected. It is very important for you to clearly tell their physician the details of their knee pain in order for a complete evaluation to be initiated.

Here are some SIMPLE MEASURES that may help with knee pain.
• Avoid tasks that involve kneeling or squatting for several hours, lifting heavy objects, excessive climbing stairs or prolonged walking!
• Scale back on engaging in sports that require repetitive direct impact on the knee joint such as basketball, soccer, or excessive running. Participating in stationary cycling for up to 15 minutes a day may be a better alternative to these high impact sports. This may be difficult to do for some of us but it may be time to try that Soul cycle or Fly Wheel class!!
• Keeping the knee relaxed and avoiding overextension may also help with knee pain.
• Sometimes massaging the knees by slowly rotating the knee cap or patellae can be beneficial.
• If the pain is due to an overuse syndrome or an acute injury, try resting the joint first for a few days to weeks. Avoid the activity that aggravates your knee pain. Heat and Ice are often initially recommended to decrease the initial inflammation and swelling.
REMEMBER “RICE”: Rest, Ice, Compression, & Elevation
13-Natural-Treatments-for-Osteoarthritis-01-722x406For any female or male who is overweight and imposes a risk of developing knee osteoarthritis or a ligament/cartilage injury, weight loss and lifestyle modification is necessary. For every pound that an individual is overweight, additional excess weight and force is applied to the knee joint.  “Now that I’m in full swing of my running regimen and half marathon training as some of you may be, I’ll be making a solid effort to pay attention to my knees. I’ll keep you posted on the training and stay tuned for my next blog on different treatments and exercises for knee pain. Keep that knee strong and fit!” – Dr. Cadet

 

If you are interested in learning more about Dr. Cadet, please feel free to email or call one of our offices for a consultation. She would be more than happy to discuss your condition and treatment options for an individualized treatment plan. www.OsteoCenterNY.com

29Mar 2017

By Magdalena Cadet, M.D. – Rheumatology

shutterstock_128950370A few months ago, a professional female in her late thirties walked into my office complaining of several months of joint pain in both of her wrists, hands, knees and feet and she also reported feeling “achy and stiff.” As she went on to describe her symptoms of joint pain, swelling, stiffness that lasted into the middle of her workday, loss of energy, and occasional dry eyes, I started to focus on a diagnosis of rheumatoid arthritis (RA). She had been married for a few years and had started to think about having a baby but because of this recent development in her health, she wanted to have an evaluation before thinking about family planning. She couldn’t believe that she was having arthritis at her age and was very anxious about it. The difficulty with typing and writing was making her job harder and her fatigue posed a challenge since she had to be vigilant for her office meetings and work events. She was sent to me by her primary care doctor because her lab tests were abnormal and she revealed feeling fearful of having RA.

In the past, I would see individuals who had extensive hand deformities and immediately knew that they had RA. Patients used to fear a diagnosis for rheumatoid arthritis because they pictured a very disabling type of arthritis. Now, newly diagnosed individuals may develop symptoms early and not have any joint deformities. The outlook for these patients has dramatically improved. Treatment advances have made it possible to stop or slow the worsening of joint damage. My patient was so disappointed when she walked into the office that day because in RA, the cells of the immune system may not function properly and start attacking healthy tissue in the joints and other organs by releasing chemicals. I reassured her that her diagnosis was like any other chronic medical condition like high blood pressure, diabetes or thyroid disease and may require lifelong treatment and that she was lucky to have an early diagnosis and treatment could start immediately if there were no major contraindications.

joint-with-rheumatoid-arthritisRA is a chronic autoimmune disease that causes pain, stiffness, swelling and limited range of motion and function. Usually this type of arthritis is associated with inflammation. Middle-aged females (fourth and sixth decades) are more commonly affected, but RA can occur in any age group and in males. Small joints are commonly affected like in my former patient and stiffness is usually worse in the morning and can last from one hour to all day. Joint damage can happen because the chemicals that are released by the immune system can destroy the cartilage tissue that cushions the space in between the joints and bone. Most people don’t realize that although inflammation is commonly seen in the joints, other organs such as the eyes, lungs, blood vessels, liver, heart, and skin can be affected. Once a diagnosis for RA is made by clinical history, physical exam, X-rays and other imaging and blood work, frequent checkups with a rheumatologist are crucial to strive for remission. The goal of RA therapy is to improve the individual’s symptoms, prevent or stop joint damage, and prevent complications from the disease, such as accelerated heart disease, osteoporosis and cancer (lymphoma).

The positive side of this condition is that there are so many medications out there today that can help women and men with this disease. Before taking a medication that suppresses the immune system, a thorough discussion should take place between the doctor and individual to discuss benefits and risks of the medication. In addition to medications, making healthy dietary changes, cutting back on smoking and alcohol intake, and establishing good exercise and sleep habits can help with feeling better but cannot treat RA alone. For those individuals that are interested in alternative therapies such as acupuncture, yoga and massage, these interventions can help with some symptom relief but should not replace the need for treatment with conventional medicines. I always encourage my patients to KEEP MOVING since a common mistake for many patients living with RA is to stop using their joints and stop exercising because of the pain and stiffness.

Several months after the initial consultation, that young lady returned for a follow up visit. After finding the right medication combination and making certain lifestyle changes such as resuming some aerobic exercise and modifying her diet to include more omega 3 fatty acids and less gluten, it was great to see her walk into my office with a smile and proclaim that she began feeling like herself again. She still wanted to be in remission before discussing having a baby again, but I knew she was on the road to living well with rheumatoid arthritis.

For more info on Dr. Cadet and the Bone & Joint Health and Osteoporosis Center of The Spine & Pain Institute
of New York, please visit: www.OsteoCenterNY.com

References:
American College of Rheumatology (www.rheumatology.org)
www.everydayhealth.com

22Mar 2017

osteoporosis2“Osteoporosis is my passion. It is important to know the facts about this common disease, which can affect the quality of life for so many individuals, particularly post-menopausal females.”
– Magdalena Cadet, M.D. – Rheumatologist

Osteoporosis, is defined as a disorder of low bone mass causing bones to become thin, weak and brittle. This condition is not acutely life threatening, but can lead to debilitating fractures of the hip, spine and wrist along with various complications. Some of these fractures result from low trauma such as coughing, sneezing or tripping after losing balance. Complications from an osteoporotic fracture may significantly impact a person’s daily activities and quality of life.

Some of the risk factors for osteoporosis include age, family history, history of previous fracture, race, vitamin D deficiency, low body mass index, excessive alcohol intake and smoking history, certain medications like steroids and specific diseases such as rheumatoid arthritis. Males are also at risk as well as some younger individuals who may have medical conditions such as lupus, seizures, inflammatory bowel disease or thyroid disorder, and are taking treatment that may affect bone quality.

ostoeporosisAt the American Society for Bone and Mineral Research Annual Meeting in 2016, there was a discussion focusing on the “call to action” by numerous bone health-related organizations to increase the screening, diagnosis and treatment of individuals who are at high risk for fractures. The annual meeting emphasized the need to adequately treat osteoporosis around the country and the world. Dr. Kenneth Saag, the president of the National Osteoporosis Foundation spoke about the upward projection of increases in hip fracture in men and women by 2050 as compared to the past. This increase will be likely due to a significant decline in the rate of bone density (DXA) testing therefore resulting in the decline in diagnosis and treatment of high risk patients. Dr. Saag also pointed out that 2016 data surprisingly showed half as many patients were placed on an osteoporosis regimen compared to the mid-2000s.

As a rheumatologist, it is imperative to assess an individual’s risk for osteoporosis and fracture. This is done by:
• Obtaining a thorough clinical personal and family history
• Performing bone density testing (DEXA)
• Obtaining blood work to check for calcium, vitamin D, parathyroid and thyroid levels
• Using an online tool called FRAX to quantify an UNTREATED individual’s ten-year probability of a hip or major osteoporotic fracture.

Once this assessment is completed, physicians should discuss lifestyle changes to help prevent this bone disorder. A few of these tips include:

• Stop smoking today! Get on some type of nicotine replacement with the advice of your doctor as soon as you can. It is no surprise that nicotine consumption can generate free radicals that destroy bone cells and increase cortisol levels that accelerate bone deterioration.
• Limit the excessive (more than 2-3 ounces a day) alcohol intake. Alcohol interacts with bone forming cells and can affect the liver and pancreas which play a role in calcium and vitamin D absorption.
• Engage in balance and flexibility training and strengthening (weight bearing) exercises to stimulate estrogen production and bone formation. Swimming, walking, yoga and Tai Chiu are encouraged.
• Get some adequate calcium and vitamin D into the diet. Good sources of calcium can be found in milk, yogurt, nuts (almonds), cheese, dark green vegetables, orange juice, sardines and soy milk. Vitamin D sources may include cod liver oil, fish oil, eggs, fortified dairy products and over the counter supplements.

Sometimes women and men may develop worsening bone density despite their participation in good lifestyle modifications, and may require medications to increase their bone density and strength. Some of these medications aim to help build bone mass and increase bone strength, and other medications aim to prevent further bone loss. Other drugs affect the interaction of the different cells involved in the bone remodeling process. Estrogen has also been used to help protect the skeleton by promoting calcium absorption and preventing the death of bone forming cells. Every person is different and must discuss the options with his or her physician and evaluate the comfort level with the drug side effect profile before making a final decision. Keep in mind that not treating osteoporosis is risky and may lead to disability. No therapy is permanent.

“I hope that with more education about this public health concern, people will empower themselves to take measures to improve their bone health!” – Magdalena Cadet, M.D. – Rheumatologist

For more info on Dr. Cadet and the Bone & Joint Health and Osteoporosis Center of The Spine & Pain Institute of New York, please visit: www.OsteoCenterNY.com

www.nof.org (National osteoporosis Foundation)
www.rheumatology.org (American College of Rheumatology)
Highlights from American Society for Bone and Mineral Research Annual Meeting September 16-19; Atlanta

17Mar 2017

shutterstock_107831294Nurse Practitioners and Physician Assistants: Who are they and what do they do?

With the increasing demands on healthcare services and Physicians in particular, healthcare roles such as a Physician Assistant (PA) and Nurse Practitioner (NP) have evolved and developed over recent years. In the past, these roles were known as “mid-level” healthcare providers; however this term can portray these highly qualified and skilled healthcare professionals to only provide an average or mediocre service to patients which is far from the truth! In fact, NP’s and PA’s undergo extensive and rigorous education and clinical training followed by robust state examinations before attaining a license to practice and treat patientsa,1.

Let’s look at the table below, which outlines the similarities and differences between their extensive training and their roles as healthcare professionals in patient care.

Screen Shot 2017-03-17 at 10.46.46 AM

Although their training is different, both NP’s and PA’s can work in private practice, hospitals, ambulatory centers and can specialize within a particular field of medicine or population1,3. NP’s blend clinical expertise in their assessment, diagnosis and treatment of health conditions with disease prevention and health education resulting in a comprehensive health care plan1. PA’s assess, diagnose and treat health conditions focusing on their clinical and scientific expertise and experience3. A point that is often forgotten but fundamental to quality healthcare is the time spent with patients. NP’s and PA’s often have more time with patients – thus increasing the value and quality of the care patients receive. Casey Grillo, one of our NP’s sums it up with a simple but fitting thought: “Nurse Practitioners… The heart of healthcare.” Here at The Spine & Pain Institute of New York, our highly qualified and skilled NP’s and PA’s work alongside our attending Physicians as a team; assessing and treating each patient based on their individual needs. Each patient case is discussed in detail using the best available evidence. Combining these backgrounds provides a platform for our patients to receive the highest quality of care. So… whether you are seen by our NP’s, PA’s or attending Physicians during your visits with us, rest assured you will receive the most advanced, beneficial and appropriate treatment and care available!

References

  1. aanp.org (American Association of Nurse Practitioner’s)
  2. Criteria for Evaluation of Nurse Practitioner programs, 2012, 4th
  3. aapa.org (American Association of Physician Assistant’s)
09Mar 2017

headshot8Since my childhood, I have always been fascinated by the power of musculoskeletal system and the amazing things it can do.  As a current long distance runner and former competitive figure skater and dancer, I have become fascinated by the interplay of bones and joints with ligaments and tendons.

I had a few other poignant experiences during my medical journey, which led me to the field of rheumatology.  During my second year of medical school, I met a girl who had complained of several months of joint pain and swelling, fatigue, weight loss, hair loss, and a rash. She came to me one day and told me that she had been diagnosed with lupus (SLE). At that point in medical school, I had never heard of this disease and I believed that arthritis only affected older patients and only involved the joints. I later learned that this was a myth. She never fully understood the extent of her disease. She was not aware of the co-morbidities, such as early heart disease, lung disease, or kidney damage, that can occur with SLE and other rheumatologic conditions if early and aggressive treatment is not taken to control the disease activity. Several months after her diagnosis, I received the sad news that she had passed away from complications of her disease.

I also watched my best friend’s father who is a physician battle with moderate to severe psoriatic arthritis. He had to temporarily walk away from his medical practice for several years until his joint pain, stiffness and physical function improved after receiving treatment. During my years as a rheumatologist, I’ve seen many more patients who have touched my heart and left the same imprint on my mind. I see some patients struggle with daily common activities like brushing their teeth, combing their hair, or walking a block due to their arthritis.  Arthritis and other musculoskeletal and autoimmune diseases can affect one’s physical and emotional functioning.  My goal is to encourage individuals to take an active role in their disease management by first educating themselves about their condition. I also encourage all individuals living with arthritis or autoimmune diseases to engage in a healthy lifestyle such as exercising, watching their caloric intake and being aggressive about their treatment plan and follow up care.

If you are interested in learning more about Dr. Cadet, please feel free to email or call one of our offices for a consultation. She would be more than happy to discuss your condition and treatment options for an individualized treatment plan. www.OsteoCenterNY.com

01Mar 2017

SCS-implantA spinal cord stimulator, also known as SCS, is a surgical implantable device that sends electrical pulses to the spinal cord nerves for the management and relief of chronic pain.

SCS is an alternative therapy typically recommended for patients who have been unresponsive or failed conventional therapies. Such therapies include but are not limited to, oral medication and steroid injections. SCS can also benefit patients who have underwent and failed more aggressive procedures such as back surgery, patients who suffer from residual pain after surgery, patients who suffer from chronic peripheral neuropathy or plexopathy, and patients who have been diagnosed with illnesses like Multiple Sclerosis, just to name a few.

SCS is an innovative technology that targets some of the most difficult pain problems a person can be challenged with. This technology has given patients a second chance to experience a normal pain free life, resuming everyday activities, without many restrictions or pain related worry. It has allowed patients to regain control of their lives.

“For the appropriate patient, the application of spinal cord stimulation can dramatically decrease pain and restore quality of life” says Dr. Kiran V. Patel, Pain Management Specialist at The Spine & Pain Institute of New York.

If you are interested in learning more about SCS for your chronic pain, please feel free to email or call one of our offices for a consultation. Our award winning physicians at The Spine and Pain Institute of New York would be more than happy to discuss your condition and treatment options for an individualized treatment plan.

(Anthony H Wheeler, MD;  Kim J Burchiel, MD  2015)
http://emedicine.medscape.com/article/1980819-overview

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