By LAURIE SMITH ANDERSON-Advocate staff writer
In this story, we look at one physician's alternative approaches to treating chronic pain. Suffering from intense chronic lower back pain and barely able to walk three years ago, Peter O'Connor was ready to try anything — short of surgery — when he started seeing Dr. Paul Kramm. The 48-year-old construction manager didn't bat an eye when Kramm, a pain management specialist with Ochsner Clinic of Baton Rouge, recommended trying a series of injections using botulinum toxin and prolotherapy. Today, O'Connor is walking just fine, working out at the gym again and back at work.
Kramm, who is certified in physical medicine and rehabilitation as well as pain management, says he is often a physician of last resort for many patients and, as such, is not adverse to trying unorthodox or alternative methods to treat pain. "Pain is a good motivator," Kramm said. "I find most of my patients are willing to try something different. They've tried antiinflammatory medications, epidural steroid injections, physical therapy and, sometimes, narcotics, and they're still in pain. I don't always have the luxury of 'going by the book' because the book has been tried and it failed." Injecting patients with either Botox or Myobloc, two forms of botulinum toxin, is one option and can be used to treat any number of disorders including chronic migraine headaches, muscular pain, dystonias, scoliosis, spasticity, tremors and others.
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Botulinum toxin works by reduc-ing tension in chronically painful muscles and improving motion and activity of noninvolved mus-cles. By diminishing spasms, sensory nerves supplying the muscles convey fewer pain messages. The toxin also seems to diminish part of the inflammatory re-sponse, thereby reducing the con-centration of pain-transmitting chemicals.
Prolotherapy offers another nonsurgical treatment of chronic pain related to damaged ligaments or tendons. It involves injecting dextrose (sugar water) solution into the damaged area to cause a localized inflammation, thereby stimulating the tissue to repair itself. The concept is elegant in its simplicity, Kramm said. Prolotherapy can be used to treat different types of musculoskeletal pain including arthritis, back and neck pain, fibromyalgia, sports injuries, whiplash injuries, carpal tunnel syndrome, degenerated or herniated discs, TMJ and sciatica.
There are differences between the two types of injections, Kramm said. Botox and Myobloc are very expensive and, increasingly, aren't covered by insurance in conditions for which they are still considered "experimental," he said. "That's unfortunate because we're not talking about cosmetic purposes here," he said. Botulinum toxins can offer significant relief from pain as they work to block neurotransmitter signals; however, symp-toms usually return after a couple of months. Prolotherapy, on the other hand, actually treats the underlying condition and can offer cures for some patients, the physician said. The dextrose solution injected costs only pennies to produce compared to Botox, (which can cost $500 or more per treatment session, depending on the number of injections). That's good news and bad news, Kramm said. "There's no money to be made (with prolotherapy) so nobody's pushing for it." Furthermore, the success of both treatments lies in their proper uses by physicians trained to pinpoint exact trigger points to inject. Kramm has taught other physicians about prolotherapy and when and how to use it. Many patients receive immediate relief after an injection of Botox or Myobloc, he said. Prolotherapy, on the other hand, can actually cause pain to intensify for several days as it causes increased inflammation, but reduces pain in the long run as tissue begins to heal.
O'Connor has received both types of botulinum toxin injections and prolotherapy, though his insurance is threatening to stop covering Botox or Myob-loc. The alternative, which was major surgery, would have been much more expensive, he noted. "Dr. Kramm's ability to isolate and fix the problems in my back is amazing," O'Connor said. "I'm so much better that I'm only coming in every three months now." Kramm said he likes adding new tools to his arsenal for treating chronic pain. "It was never very gratifying to me before," he said. "Now, it's fun because I'm able to help people change their lives. "I have patients back running, hunting and fishing again. I still don't want them moving their neighbor's pianos, but if I can help them enjoy a normal life again, then that's what I'm here for."
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