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Thread: Any comments to ribs compression?

  1. #1
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    Any comments to ribs compression?

    My friend's wife suffered C3/4 fracture disslocation with complete spinal cord injury for 7 months. Recently,she feels stiffness and compression under her breasts and along her ribs. Her medical doctor could not explain satisfactorily to her ordel. Does anyone has the same experience to share with her? Thanks!

  2. #2
    Senior Member Tara's Avatar
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    I get that too. I was told that my ribs were out of alignment or something. A good physio or chiropractor might be able to help.

  3. #3
    Vincent,

    The pain may be either musculoskeletal or neuropathic. Musculoskeletal pain is likely only if your friend's wife has touch or pressure sensation in her thorax. However, if she has no inducible sensation where she is having the pain, it is likely that this is related to neuropathic pain.

    As many other postings on these forums have indicated, a significant minority of people with spinal cord injury suffer from neuropathic or neurogenic pain. This pain is classified into four types:
    • below the injury level
    • at and around the level
    • above the injury level
    • visceral pain

    The first is the most common and may be present to some degree in a majority of people with spinal cord injury. It is frequently characterized as pressure, burning, freezing, or vibratory, often waxing and waning with a regular schedule.

    Pain at or above the injury level tends to manifest with increased spasms and spasticity of the arms and shoulder, the presence of allodynia (hypersensitivity to touch). This type of pain is frequently aggravated by sensory input and is often associated with other causes of pain (such as shoulder, neck, or back pain).

    Visceral pain is much less understood but usually is deep and pressure related. It may involve the thorax (as you are describing for your friend's wife, bowels, bladder, or pelvic region). If she does not have touch or movement induced sensation in the area where the pain seems to be coming from, it is very likely to be neuropathic.

    What are possible therapies? Usually, what doctors start with is amitryptaline (Elavil). This is an antidepressant but the doses that are given for neuropathic pain are considerably lower than those use to relieve depression, i.e. 20 mg per day rather than 100 mg per day. At these low doses, the side-effects should be minimal. About a third or half of the people say that it takes the edge of the pain and makes it more tolerable.

    Usually, the next line of therapy is an anti-epileptic drug called neurotin (gabapentin). This drug is actually not that effective as an anti-epileptic agent but was noted to reduce neuropathic pain. The problem is that people accomodate rapidly to the drug and the common story is that the drug relieves pain for several days or weeks and then the effect goes away. However, if the person has minimal side effects, the dose can be increased to as high as 3200 mg per day. Some people find that this is effective.

    Beyond these two treatments, the remaining therapies are more controversial and have less evidence of efficacy. I will list them in sequence:

    • Baclofen. This is of course the traditional anti-spasticity drug. It is not clear why it should have effects on neuropathic pain. One possibility is that it may modulate opioid receptors like the glutamate receptor blockers (see below). I think that because over 50% of people with spinal cord injury are taking baclofen, it may already be suppressing mild neuropathic pain. There are some reports that intrathecal baclofen reduces neuropathic pain as well.

    • Glutamate receptor blockers (particularly metabotropic receptor blockers) have been reported to reduce neuropathic pain in animal models and in at least one clinical trial. A recent study suggests that glutamate receptor increases opioid receptor sensitivity. In people that have severe neuropathic pain from cancer, low-dose oral ketamine has proven to be effective. This is a glutamate receptor blocker; in low oral doses, its side-effects may be acceptable.
    http://carecure.org/forum/showthread.php?t=36663
    http://carecure.org/forum/showthread.php?t=23450

    • Opioids. Unfortunately, people accomodate rapidly to morphine, oxycontin, and other opioids, requiring higher and higher doses that have undesirable side-effects. There is a drug called Ultram which apparently has both opioid and anti-depressant effects. Again, accomodation is a problem. One of the ways that doctors have been getting around this issue is to use a morphine pump where the morphine is directly injected into the intrathecal cavity. Higher local doses can be achieved with less side effects.

    • Electrical stimulation. A number of studies have shown that spinal cord or even peripheral stimulation can alter the balance of neurotransmitters in the spinal cord and can reduce neuropathic pain. Unfortunately, the precise stimulation location, rates, and approaches are not well defined.

    • Acupuncture. I believe that this provides some relief but unfortunately the relief tends to be temporary. I was visiting the China Rehabilitation Research Center in Beijing about two years ago and asked the head of the acupuncture unit there what he thought the role of acupuncture was. He said that it does work in many people but the effect last perhaps a day or so and that it is not practical or economic to do acupuncture in people daily. In any case, I have heard many people say that acupuncture provides relief.

    I am sure that I am providing more information here than you want to know. If it is clear that your friend's wife does not have sensation in the area where the pain in emanating, this suggests that it is neuropathic pain. If she does have sensation and the pain is movement or position dependent, her doctor needs to try to find out the cause. I would suggest first Elavil and see if it helps. If that does not help, Neurontin is the next line of therapy to try. If that does not help or the side-effects are unacceptable, I would suggest trying electrical stimulation; you will need to find an experienced pain clinic with expertise in the use of spinal cord or peripheral stimulation. If all three do not help, then I would start thinking about adding a glutamate receptor blocker to the mix, morphine pump, etc.

    Finally, of course, for people with intolerable pain that is refractory to non-invasive therapies, surgeons have long used a variety of surgical procedures. I would not recommend surgery until the above have been exhausted. The surgical procedures are not completely effective either and may produce neurological loss. If your friend wants to know about the surgical procedures, I can dig up the information but it will take some time because there is a lot of conflicting information on the subject.

    Wise.

  4. #4
    Senior Member crashgirl246's Avatar
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    Dr,Young? on Meds.

    Ok ..i use to take Elivil (10mg @bedtime) i thought this was for the burning,tingling feeling of pain? am i right or wrong onthat one? AND Im on Neurontin 3x a day (300mg/pill) this I know is for the pain. I also am on Zanaflex this i thougth was for spasims??. I have Really bad Leg spasims, so bad they fling me around in the chair, make me spill stuff on myself etc.. Being newly injuried im a little confused on what the heck pills work for what. I was put on Baclafln in the hospitola ndit made me very nauses. i took one dose again the other night and ended up with the shits all day the next day, and in the middle of the night. HOWEVER< i may also have a UTI. So, the question is, is the uti causing the diahrera(spelling sorry) or the Baclafln? Is there anything else i can take for spasims ? I havent taken the Elevil in about 2-3 months becaseu the perscription ran out, and i thought if it wsa for teh pain rather then spasims, then i didnt need it seeinghow imon Neurontin for that stuff. Im confuseed!
    Help!

  5. #5
    crashgirl, baclofen and tizanidine both are for spasticity, not spasms. Spasticity is stiffness and increased reflexes of muscles. Spasms are organized and usually spontaneous movements like the ones that you describe.

    At high doses, these two drugs can weaken muscles sufficiently so that spasms are not as strong. Both drugs also may reduce pain, particularly of the burning variety but not always. Neurontin or gabapentin (generic name) is for neuropathic pain.

    I personally believe that anti-spasticity drugs should not be taken at such a high dose that all muscle tone is gone. The dose should be titrated until there is some muscle tone because this tone reduces muscle atrophy. Note that not all doctors feel this way.

    Doctors use all three types of drugs to reduce pain and spasticity. For example, most people can tolerate only up to about 100-120 mg of baclofen a day and 6-8 mg of tizanidine per day. In fact, the manufacturers suggest that no more than 80 mg per day of baclofen be taken. The combination of the two drugs at lower doses may be more effective. People tend to accommodate to gabapentin over time (weeks) and may need higher doses. Some people with severe pain take as much as 3200 mg of gabapentin a day.

    Tizanidine tends to lower blood pressure while baclofen and neurontin should not. It may also cause fever; loss of appetite; nausea and/or vomiting; nervousness; pain or burning while urinating; sores on the skin; tingling, burning, or prickling sensations; yellow eyes or skin.

    The most common side effects of baclofen are confusion; dizziness or lightheadedness; drowsiness; nausea; unusual weakness, especially muscle weakness. The diarrhea that you describe is unusual but possible.

    Wise.

  6. #6
    Senior Member crashgirl246's Avatar
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    New meds?

    Thank you dr.young. My dr. had my liver tested today. she wants to put me on a drug starting with teh letter "D"...for the spasims??she doesnt know whatelse to put me on i guss. depending on my liver functions will depend on if she will start me on the new meds. any info?? thank you for your response!

  7. #7
    Senior Member Scorpion's Avatar
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    Originally posted by crashgirl246:

    Thank you dr.young. My dr. had my liver tested today. she wants to put me on a drug starting with teh letter "D"...for the spasims??she doesnt know whatelse to put me on i guss. depending on my liver functions will depend on if she will start me on the new meds. any info?? thank you for your response!
    It's probably Dantrium. I was on that in rehab, but it can cause liver failure and they have to constantly monitor your blood for possible liver damage.

    ~Rus

    "We are not brave because we are free. We are free because we are brave." ~ Rich Ward (Stuck Mojo / Sick Speed)

  8. #8
    Senior Member TD's Avatar
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    Originally posted by Wise Young:

    I personally believe that anti-spasticity drugs should not be taken at such a high dose that all muscle tone is gone. The dose should be titrated until there is some muscle tone because this tone reduces muscle atrophy. Note that not all doctors feel this way.

    Doctors use all three types of drugs to reduce pain and spasticity. For example, most people can tolerate only up to about 100-120 mg of baclofen a day and 6-8 mg of tizanidine per day. In fact, the manufacturers suggest that no more than 80 mg per day of baclofen be taken. The combination of the two drugs at lower doses may be more effective. People tend to accommodate to gabapentin over time (weeks) and may need higher doses. Some people with severe pain take as much as 3200 mg of gabapentin a day.

    The most common side effects of baclofen are confusion; dizziness or lightheadedness; drowsiness; nausea; unusual weakness, especially muscle weakness. The diarrhea that you describe is unusual but possible.

    Wise.
    I am on 1200 mg of neurontin and 400 mg of Ultram per day and this combination seems to help with my pain. I also have the baclofen pump because I was taking 160 mg of oral baclofen a day without results. I balance the dosage so I still have some spasms which has reduced the atrophy in my legs. There is one side effect for neurontin that others have reported as well. I call it "eye dancing" because my eyes seem to jump around while reading.
    "And so it begins."

  9. #9
    Senior Member crashgirl246's Avatar
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    Dantrim?maybe

    Dantrim sounds familuar. maybe thats it. Humm..liver failure or spasims so bad they flig me from my chair??I cant deal with it anymore. they throw mw all over the place. trying to self cath is a freaking wrestling match with my legs. they will tighten up so bad i cant even pry them open!ill keep you all posted. thanks

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