Author: Frederick Littlejohn, M.D.

Sunday, August 13th, 2023

It’s been a year since I wrote anything in this blog, but I’ve had a lot of ideas I want to talk about. Today they seem to be crystalizing, so here we go…

One thing I want to talk about is my strong belief that, based on years of experience , treating patients with discomfort of one form or another, the key to success lies and modifying the way the brain and nervous system processes information. There are a number of ways to do that.

Fix the Problem

Sometimes the best way to deal with pain is to interrupt the source, for example, if you have a broken leg, meditating away the pain isn’t an option. By the time most patients get to me, the easily fixable stuff has already been done. There are certainly problems I see that can get a quick fix though. Patients with joint arthritis of the back and neck often do very well with RF ablation. People can have all kinds of weird trigger points and nerve entrapments that respond to small, carefully guided injections in the soft tissues. Patients with compression fractures can have kyphoplasty, which stops the pain almost instantly.

Modulate the Pain Signals

Sometimes the sensory organs of the body themselves are dysfunctional and the source of these signals. Simply “cutting it off” won’t work. In these instances you need to find a way to modulate (change) the pain signals in the spinal cord or brain. For example, when patients have irritated nerve roots in the spine, this can produce severe pain in an extremity. When we perform epidural steroid injections, this physically interrupts the irritation, allowing the nerves to function normally again for a period of time. In some cases, the results last for years. Another way of modulating the signals is with spinal cord stimulation. This is a procedure in which small electrodes are placed behind the spinal cord and connected to a pacemaker-like device, which functions to change the painful signals in the nervous system before they get to the brain. I find it a point of pride that I don’t do a lot of spinal cord stimulators because I can usually find other ways to manage my patient’s pain. When it’s the right tool for the job, it often works quite well.

Treat the Brain

One of the most interesting problems over of the course of my career has been treating issues of central sensitization, the most well-known being fibromyalgia, with CRPS being common in my clinic. The medications traditionally prescribed for this often don’t work very well, or produce unpleasant side effects. These medications include antidepressant class pain medications or anticonvulsants. I have become of a very big fan of using low-dose naltrexone to treat patients with these syndromes, and have seen some dramatic cases of success. It’s important to highlight this because many of these patients seemed otherwise intractable and irretrievable. As a second line agent, I frequently reach for a drug called memantine (aka Namenda) which blocks certain receptors in the spinal cord and brain that modulate the excitability of the nervous system. The results are not often as dramatic as with low-dose naltrexone, but nonetheless frequent enough to justify a trial. Ketamine is another way of getting at treatment of these receptors. The batting average, again, is not very high, but I have seen sustained recoveries in patients treated with a series of IV ketamine infusions.

Ketamine

IV ketamine for depression deserves special mention because the world seems to have gone ketamine-crazy this year. There are months-long shortages from supply companies. I have found it very useful for patients with treatment refractory depression, and have many patients now in successful maintenance being treated once every month or two. Patients are often apprehensive before beginning treatment. They’ve heard of the infamous k-hole, and don’t want to go there. Who would? Using a gentle titration, I can get patients into the therapeutic zone for the medication while still keeping them lightly alert and comfortable. It usually takes about a week of infusions to see the positive effects start to build.

PTSD and Stellate Ganglion Blockade

One of the most interesting and exciting changes to my practice since I opened Portland Pain Solutions two years ago, has been expanding my scope to include the treatment of post-traumatic stress disorder. There is often a linkage between PTSD and central sensitization type pain problems. You often see the PTSD event occur in temporal proximity to onset of the pain syndrome. For example, someone might be in a car wreck, and shortly thereafter you begin to see emergence of central hypersensitivity. This may be reflected in musculoskeletal pain, but could manifest as other unusual sensitivities. Sometimes patients will report burning or prickling sensations randomly scattered around the body. They may have unusual taste, or smell perceptions. I have also seen unusual gastrointestinal and urinary sensitivities to.

It often makes sense to treat as one problem both the symptoms of centralized hypersensitivity, and the underlying PTSD. I look at this as more of a “wiring problem“ then one of abnormal brain chemistry. These are abstractions, of course, but they are a simple way of understanding my strategy. My goal in treatment is to change the way that brain circuitry is aligned so that pre-existing maladaptive circuits are quieted, and replaced by something different- and hopefully better.

Patients with PTSD can go years without making progress using the standard array of therapies. What’s needed is a catalyst to get the brain wiring shifted in the right direction. For some patients clonidine helps (a blood pressure drug), others have found success with psychedelics, like MDMA or psilocybin. Being a pain specialist, the tools I reach for are stellate ganglion blockade, and sometimes IV ketamine.

What’s a Stellate Block?

Stellate ganglion blockade is described in detail elsewhere on my website, but in short, this is a simple nerve block performed at the base of the neck, generally on the right side, which can lead to rapid and dramatic changes in the way that the body reacts to stress. There are two things that my patients often tell me at their two week follow up visit after a stellate ganglion block. The first is that the weight of anxiety has lifted off of their chest. The second is that their emotional reactivity to stress has quieted. Stressful events will still occur, but they don’t elicit the usual fight or flight response. This leads to a productive, positive feedback loop of less reactivity, less anticipatory anxiety, and greater comfort in one’s on skin. Similar to the effects that I have seen with low-dose naltrexone in patients with hypersensitivity disorders, the results I have seen with stellate blockade are often dramatic. Even in cases that one would never imagine such gains could be possible.

Meditation

I usually assign homework to my stellate patients in the form of meditation. My own personal brand! Numerous studies have been done demonstrating the effectiveness of meditation. I am interested in its potential to build on the catalytic effects of medical treatment as a form of physical therapy for the brain. If we want maladaptive brain circuitry to simply be quiet, we need to train it to stay that way. I suspect that the core benefit to meditation lies in building a quiet brain. Not just in terms of the mind, but in terms of sensory experiences too. A quiet nervous system has lower blood pressure, fewer sensory anomalies, fewer muscle twitches, less anxiety, depression, and PTSD. I suspect it helps OCD and ADHD as well.

The instructions I give to patients are quite simple. The key ingredient, and you can’t get around this, but it is time and intensity. If you want to physically change the structure of the brain, you need to approach it, the same way that you approach exercise for the body. You wouldn’t expect to become a marathoner doing a five minute jog once a day. I take sustained effort to build the body that is needed to handle a marathon. Likewise, if you want to build a truly quiet mind, it takes time and energy.

Getting Started with Meditation

Here is what I recommend: Find a quiet place to sit where there are things to observe. This can be anywhere, but I recommend a natural setting, away from technology and transportation noise. Sit at attention with feet flat on the ground. This experience is not intended to be relaxing. Set a timer for 30 minutes and turn it away from you. Pick an object of interest in your environment, and direct your gaze towards it. Focus on every last detail of the object. For example, if it is a squirrel, observe every bristle of fur, every undulation of its movement, the full richness of its color. In doing so silence all reactive thought. Silence your inner monologue. Quiet your emotions, and reject any instinct to recognize patterns or trigger thoughts. The goal is to use your focus to completely quiet every aspect of your brain except for the part that is observing the object. If you’re finding difficulty maintaining focus, use the power of a long exhale to bring it back. Spent two or three minutes on each object before moving onto the next. At first it may be difficult to do this for more than five or ten minutes. Just like aerobic exercise, meditation can feel exhausting when you’re new to it. Build up to a full 30 minutes. For the truly motivated individual, I recommend morning and afternoon sessions for the first two weeks, and then a single daily session for the remaining six. Once eight weeks have been completed, much of the work of shifting the brain circuitry has been done. At this point, you will likely be able to maintain the benefits with just a few minutes of focused meditation where you can work it into your day.

The benefits of meditation are vast. In my personal experience, the results have been normalized blood pressure, much better sleep onset and duration, minimal anxiety, and ability to maintain a calm, objective mind when confronted by stress.

Happy Second Birthday Portland Pain Solutions!

It’s been an exciting first two years at Portland Pain Solutions. We’ve gone from only a few patients per day to seeing 10 to 15 daily. I typically reserve the early mornings for treating my stellate and ketamine patients. I spend the rest of the day seeing pain cases. The best part about this career has always been seeing my patients do well, and the challenge of getting them there is a rewarding way to spending one’s days. This is what gets me up in the morning, despite all the hassles of running a practice, and dealing with the administrative aspects of care. If you’ve made it this far, thanks so much for reading, you can always email me with comments or questions.

Get (a very small part of you) Born Again!

The next topic I want to address is regenerative medicine. We have a brand-new, state-of-the-art setup for concentrating platelet rich plasma, as well as alpha-2-macroglobulin. My guess is that you have no idea what these things are. Let’s change that. Stay tuned!

Following up on “Just Another Manic Monday”, this is an update to share a video I created with a patient who had an unusually positive response to a stellate block for parosmia (smell and taste abnormalities typically associated with COVID-19). Enjoy!

Today I want to talk about the epidemic of anxiety, post traumatic stress, and sleep disorders that plague us. From a biological point of view, I think society is suffering from an epidemic of autonomic hyperarousal. Basically, our “fight or flight” system is amped up and causing all kinds of problems.

But first, some context.

Have you noticed how nutty the world has become? Everywhere you look the sky seems to be falling. News articles repeatedly tell us how anxious and depressed we all are. Sleep disorders were already at epidemic proportions, and since the pandemic they’ve skyrocketed. Each year feels like another installment in Die Hard where the “bad guys” get badder, and we feel even less equipped to deal with them. And yet we’re living in a time of the greatest abundance, security, and comfort in history. Just scroll your Facebook feed to see the array of super-optimized products available to make our lives ever more perfect. Apparently one of the Sharks wants to sell me a butter soft shirt designed by a navy SEAL that covers my gut and makes me look like an action figure. I bought one.

So what’s underlying all our anxiety? I’m sure life in the budding “metaverse”, where all our human contact is virtual, must be a big part of it. We all live in an online echo chamber perfectly tailored to generate maximum emotional charge and get us to click things so somebody else gets paid. And conveniently, we all walk around with these little electronic devices that beg for attention wherever we go. Every time we look at our phones, we escape the real world and get back into our heads, where we bathe in our worst insecurities, fears, and regrets. Satiated, of course, with occasional hits of dopamine to keep us coming back for more. So just leave your phone at home right? Wait… digitally connected clothing is coming soon.

In addition to all the anxiety generated by life in the modern world, a shocking number of people are living with real trauma. Among my patients I hear stories of child abuse, domestic abuse, sexual abuse, workplace toxicity, and other physically or emotionally traumatic events that shred people’s nerves beyond repair.

The end result of all this anxiety and PTSD is a set of neurobiological changes that have been hell to deal with for the medical community. We have meds for dealing with these things, but they’re blunt, dirty tools, rarely a game changer, and introduce all kinds of new problems for many people. Some patients will say a drug X saved their life. Another will say taking that drug was the worst mistake they ever made.

So what are these neurobiological changes?

A simplified way of describing these changes is autonomic hyperarousal. Your nervous system has different parts. Your autonomic nervous system is the “automatic” part that runs the back office, so to speak. It’s what maintains your blood pressure, triggers salivation and digestion of food, activates sweat glands, and governs sexual function. Autonomic hyperarousal is an imbalance favoring excess sympathetic, and not enough parasympathetic activity.

This is thought to be caused by, or associated with, abnormal thresholds in the limbic system (your emotional processing function). So thinking, emoting, and body function are all intertwined. That’s why a person with PTSD can be easily triggered by a simple sight or sound. Stay with me here… The trigger leads to a thought that activates an uber sensitive limbic system, which activates an already hyper-responsive sympathetic nervous system. The response is a flood of chemicals leading to emotional terror, a racing heart, skyrocketing blood pressure, and inability to calm down. This person lives in a chronic state of heightened vigilance.

Insomnia is thought to reflect a chronic 24/7 state of hyperarousal. Insomniacs have been found to have elevated levels of cortisol and circulating catecholamines (stress hormones), along with other signs that the body does not shut down normally at night. Elevated cortisol may be a cause of insomnia, but also a consequence. So perpetual insomnia is a self-reinforcing cycle. Other research reveals a more complex picture indicating the cortisol response to stress is abnormal among insomniacs (it’s heritable too), and fails to function as a protective mechanism against inflammation.

For years I’ve practiced interventional pain medicine. Basically we provide quick and easy fixes to difficult pain problems. People don’t come to my office for advice on exercise or suggestions on meditation, although I certainly provide that all the time. They come because they want me to DO SOMETHING. That’s the focal point of every visit.

So where is all of this going?

Well, in recent years we’ve found that a procedure typically done to treat pain, can have a huge impact on hyperarousal. The procedure is a “stellate ganglion block”. I have a whole page about the procedure, so be sure to check it out if you want to know more. I also have a video of one coming up, so stay tuned. The stellate ganglion is a part of the sympathetic nervous system. It’s located at the base of the neck, and injecting it with anesthetic is pretty straightforward and mostly painless. We don’t really know how it works. My suspicion is that it breaks a cycle in the nervous system that links thoughts, emotions, and the fight or flight system. The temporary break using local anesthetic is enough to allow new brain circuits to form, and that leads to lasting recovery. It’s not uncommon for patients to return about once every three months for a top up block, and generally they’re at a better baseline than when they started. My “stellate for PTSD” patients are some of the happiest in my practice, so I’m always excited to offer it new patients struggling with PTSD and hyperarousal disorders. Patients have posted their experiences with SGB all over Youtube, so there’s no shortage of anecdotes to review. Most of my patients report a rocky first week, and then a strong calming effect that lasts. Lately we’ve been doing the procedure to treat parosmia and having some good results. I have a new blog post and a video on that coming up soon.

Have you ever had a sharp sense of “lightning” go down your leg? For most people this will be an occasional occurrence, but for some, it grows into persistent pain. When it becomes severe, it’s bad enough to send people to the ER. Today’s podcast shares some experiences my patients have had with sciatica.

The sciatic nerve is a big bundle that comes together in your pelvis, joining a number of different nerve roots from your lower lumbar spine. It travels out of your pelvis, behind the bones that you sit on (although somewhat protected). It courses through your leg muscles, behind your knee, then splits and goes through your calf and into the foot.

Pain can start as high up as the spine, for example, from a herniated disc, bony overgrowth, or scar tissue from a prior surgery. It can occur in the pelvis, from pregnancy, or a large fibroid. It can also occur where the sciatic nerve comes together and exits the pelvis, as it passes through the deep muscles of the buttock.

The pain may feel the same, but the story behind it will be different for each underlying cause. The history is very helpful diagnosing sciatica, but it’s not the entire picture. Each cause has characteristic exam and imaging findings—or lack thereof. A full discussion is beyond our scope here, but a visit to the office is the right way to begin.

Treatment starts with conservative care, and the tincture of time. For mild sciatic symptoms, core exercise and stretching learned in PT may be all that’s needed. Over the counter analgesics tend not to be very helpful. For moderate or severe sciatica, it’s wise to get help early. See your PCP, who may give you a course of oral steroids and send you to PT. If you’re still not getting better your PCP will probably order x-rays and an MRI. Depending on what’s found, a referral to a clinic like mine, or ortho/neurosurgery is next.

One of the benefits of coming to Portland Pain Solutions is that we’re a small, boutique practice. You won’t wait weeks to get in, and we are 100% focused on YOU. Expect a timely evaluation, orders for any needed imaging, and effective treatment. If you need a referral to surgery, we have contacts who can expedite your care. One of the most serious concerns our patients tell us is how they wish communication with their caregivers were more effective and transparent. My commitment to you is 100% understanding of what my thoughts are, how I am planning your care, and what to expect.

I’ve suffered with sciatica myself, so I know what it feels like. We’ll get though it together.

I did an interview with WHOM radio 94.9 yesterday. Working from home has changed our daily habits and we’re seeing an increasing number of patients with neck and back pain, headaches, and carpal tunnel symptoms. There’s much you can do to prevent these problems by adjusting your daily activities to the new rhythm of the day. Start by creating some new habits. Take time for some physical activity everyday, as well as time to de-stress. Take care of your body when you are feeling sore or have pain. I’ve provided some helpful links below. Have a listen!

Here’s a little guide to optimum work from home:
Working from home – PC Magazine

And some help with postural exercise:
Postural muscle exercises from WebMD

Wednesday, June 23, 2021

I have some relatives visiting this week. As always, that means tending to all their “small” pain problems that go unaddressed at home. Some big ones too. As I get Portland Pain Solutions ready to open in July, these mini-consults are a good reminder of my mission.

I listened to one story of a family member’s seven-month struggle with facial pain and debilitating daily headaches. He’s seen his primary care provider. He spent a month in the hospital. “He just doesn’t know what to do”, my mother in-law said. There is an important generality here. People just don’t know what to do with pain. All too often, for various reasons, patients don’t advocate for themselves, and their caregivers don’t refer them to the right people. Navigating the health system is confusing, not just for patients, but for doctors too. If your doctor can’t fix the problem, and doesn’t know the guy that can, the path of least resistance is, sadly, to get swept under the rug. In the case of this family member, he’s at his wits end- hopeless, depressed, and in daily severe pain. He’s weighing the option to continue living with this problem, or not living at all. And the latter is winning. After carefully listening to his story – the whole story – including all the bits that on the surface sound unrelated, I think he actually has two separate and difficult to treat problems. But that doesn’t mean nothing can be done. A thoughtful, skilled, and creative pain specialist could do a lot for him. I happen to know such a doctor practicing in his community, and made a referral. He’s still in pain, but at least has some hope that there may be better times ahead.

I brought two of my relatives to the clinic in Portland. My wife’s mother had been suffering with terrible knee pain that for three months has made walking very difficult for her. Her doctor ordered an x-ray and an ultrasound, which showed a small Baker’s cyst. That’s a fluid collection behind the knee. That is where her care ended. She had a diagnosis, but no plan to resolve the problem. Why is that? It took me about five minutes to remove the fluid under ultrasound. She’s been walking pain-free ever since. My brother-in-law, who I’ve treated successfully in the past for years-long sciatica, complained of persistent upper back and shoulder pain. His doctor knew about the problem, but again- no plan. We did a simple soft-tissue release injection with ultrasound, and he’s also been better ever since.

So this week has been a good reminder of my mission: restore hope and quality of life by making medical care easy to access, compassionate, transparent, and effective.

Just call me and we’ll fix the problem.

Thursday, May 6, 2021

If you’ve never been to a “pain clinic” before, you might wonder what goes on in these places. Everyone knows what to expect when they go to the dentist. Pain is an unusual specialty in that it focuses on a sensory experience that is not even one of the five senses! There are no “smell clinics”, or “taste clinics”. Not in the way a pain clinic exists. We start with the symptom, wherever it happens to be, and go to work. So we’re an unusual field, to say the least.

Some history: The field of interventional pain medicine goes back over 100 years, and started with nerve blocks for pain relief. It’s since evolved and melds together a complex array of knowledge and skills found in multiple medical specialties: anesthesiology, neurology, physiatry, orthopedics, neurosurgery, psychology, and psychiatry. Doctors who identify as pain specialists come from all backgrounds, although anesthesiology, neurology, and physiatry are most common.

So what should you expect at your appointment?

Expect to be interviewed and examined, then presented with an assessment of your condition. A plan should follow, which may be simple, or have multiple components. The plan may include further assessment, imaging, tests, or a referral to another specialist. It may also include medications, physical therapy, recommendations for exercise, referral to a pain psychologist, or any of a number of other options that may help manage your pain. Finally, there will probably be a plan for an interventional pain procedure. Some clinics like ours can do same-day procedures, but others will need to schedule you to come back. The procedure will be explained, and you will be asked to sign a consent.

Procedures: Interventional pain procedures usually involve some kind of injection targeting the suspected origin of the pain. We do this with image guidance, so expect a “c-arm” x-ray machine to be swung over you on the procedure table. Needle-based procedures, when performed well, are usually very tolerable, and sometimes almost painless. Occasionally, truth be told, they are very uncomfortable and can leave you sore for days. Certain procedures are more uncomfortable than others, but a bad experience is still not the rule. Let’s take sacroiliac joint injections for example. I can comfortably say that it’s not a well-liked procedure. The pressure of injecting the joint really bothers maybe 30% of patients. But that 30% is quite vocal. Even if the remaining 70% do fine, it’s not fun hurting even a few people. So it’s definitely not my favorite procedure to do, but if you need one (and I’m the doc), try not to worry. We can always slow down, add more anesthetic- or even stop!

Patient factors are a subject worth bringing up. Anxiety almost certainly affects the perception of pain. A study was done to see how far patients moved in response to an injection of local anesthetic. Prior to the injection, patients rated their anxiety. Guess which patients moved the most? Those who rated their anxiety the highest! In addition to anxiety, there is physical hypersensitivity that seems to exist independent of emotional anxiety. Physical hypersensitivity is readily apparent when I examine patients and simply palpate their back muscles. It is normal to not have any pain with this exam. Some patients, however, express a great deal of pain. That’s because they have changes at the level of the spinal cord and brain that cause normal sensations to be perceived as painful. The medical term for this is allodynia. Patients with allodynia are more likely to report significant pain with injection procedures. There are ways we can adapt procedures to make them tolerable to people with allodynia.

Sedation: Some clinics have a policy of sedating all their patients, which I find expensive, unnecessary, and inconvenient to the patient. Do you get sedated for a flu shot? I only rarely find it necessary to sedate anyone, and even then, a Valium will usually suffice. I did an epidural injection in a patient’s neck a few weeks ago, and it was his first one. He said he had been worried sick about the procedure for two weeks and “it was totally painless, didn’t feel a thing”. I never get tired of hearing that refrain!

Aftercare: You will be given advice on what, if anything, to do afterward. You should also be told when to expect pain relief. A follow-up visit will be scheduled, and you will be on your way.

When to expect pain relief: This varies, but for most procedures you will be feeling better within 5-10 days. Some people feel better immediately, for others it takes a few weeks. We’ll make a plan to re-assess your problem in light of the original goals of care, and adjust if needed, or celebrate success!

Monday, March 1, 2021

After 10 years at Northeast Pain Management, in Bangor, I decided to leave and move to Southern Maine. It was time to go. The family had needs that would be better met in Portland, but almost as important, I’ve been yearning to build something entirely my own. A place that reflects my unique personal mission for connecting with and serving patients. In ten years I’ve experienced a lot of growth, and I have my patients to thank for that. Everyone has taught me something new or refined my approach to communication, problem-solving, and the technical aspects of care. Thanks to them I listen better, notice more, empathize deeply, and have full confidence that in time the medical answers will come, even if we don’t know how. I’ve learned to meet patients on their own terms. The most startling part has been saying goodbye. In the rush of the day, it’s hard to fully appreciate and enjoy the connections I’ve had with patients. But saying goodbye has a way of making the importance of relationships starkly apparent. It’s been hard on me, as I can plainly see it has been for my patients. We’ve together written an ongoing story about our lives and shared experiences, and every visit added new lines. While I look forward to building Portland Pain Solutions, meeting new people, and connecting with new patients, I will always enjoy the indelible memories of caring for my wonderful Northern Maine patients.