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Friday, September 14, 2018

Preventing Seizures with Sphenopalatine Ganglion Blocks

The Sphenopalatine Ganglion Block had many uses in the past many of which became forgotten medicine with the onset of new pharmaceuticals.  Seizures were once treated with SPG Blocks as described in "Sparer W. Cessation of convulsive seizures following injection of alcohol into spheno-palatine ganglia. Three Cases."

Sphenopalatine Ganglion Blocks are safe, easy to administer and still have a place in treatment of seizures resistant to medications and in patients where medication may be inappropriate.

Self-Administration allows patients to self administer the blocks at home for prevention of seizures.  This avoids the more invasive alcohol block.

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posted by Dr Shapira at 9:07 AM

Wednesday, April 18, 2018

HATE YOUR CPAP? Get INSPIRED! New Device Treats Sleep Apnea successfully


INSPIRE is a new therapy for Sleep Apnea.

CPAP  and Oral Appliances have been the first line treatments for mild to moderate sleep apnea and CPAP is the gold standard for severe sleep apnea.

While CPAP is extremely effective only 25% of patients actually utilize t as prescribed and 60% of patients refuse or fail CPAP completely.

Oral Appliances have been the choice of most patients who do not tolerate CPAP but these new studies show that there is a new effective treatment.  Studies have shown that over 90% of patients offered a choice of CPAP or an Oral Appliance chose the Oral Appliance therapy.  Chicago testimonials for Oral Appliance Therapy can be found at:  https://thinkbetterlife.com/category/blogs/

Now that there is a new player and patients have more choices, a very positive development.

Morbidly obese patients are probably still going to need CPAP but just as oral appliances are used with CPAP to lower pressure cotreatment with inspire will probably be possible as well.

Inspire or Hypoglossal nerve stimulation (HNS) therapy is the newest player on the block.

There are three new studies (abstracts below) on the use of Upper Airway Stimulation with the Inspire device.  This is GOD NEWS for patients who HATE CPAP!

North Shore Health System is the first in Chicago to offer Inspire Therapy.
https://www.northshore.org/sleep-center/procedures/inspire-therapy/

While there are risks associated with this therapy, they are low and the risks of untreated sleep apnea are much greater.


Conclusions in Upper Airway Stimulation for Obstructive Sleep Apnea:  5- Year Outcomes. showed Improvements in sleepiness, quality of life, and respiratory outcomes are observed with 5 years of UAS. Serious adverse events are uncommon. UAS is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure.  The study showed the responder rate was 63% at 5 years and that there was a 6% rate of serious device-related events related to lead/device adjustments.

The study in  2018 Mar 2. pii: S0196-0709(18)30077-2. doi: 10.1016/j.amjoto.2018.03.003. "Uvulopalatopharyngoplasty vs CN XII stimulation for treatment of obstructive sleep apnea: A single institution experience.  tShowed that Inspire was more successful than traditional UP3 surgery with 65%  HNS patients achieving an AHI of under 5  ie HNS is  "curative" in the majority of patients. "For select patients, HNS therapy provides excellent objective improvement in outcome measures."





 2018 Mar 1:194599818762383. doi: 10.1177/0194599818762383. [Epub ahead of print]

Upper Airway Stimulation for Obstructive Sleep Apnea: 5-Year Outcomes.

Abstract

Objective To present 5-year outcomes from a prospective cohort of patients with obstructive sleep apnea (OSA) who were treated with upper airway stimulation (UAS) via a unilateral hypoglossal nerve implant. Study Design A multicenter prospective cohort study. Setting Industry-supported multicenter academic and clinical trial. Methods From a cohort of 126 patients, 97 completed protocol, and 71 consented to a voluntary polysomnogram. Those having continuous positive airway pressure failure with moderate to severe OSA, body mass index <32 kg="" m="" span="" style="font-size: 0.8461em; line-height: 1.6363em; position: relative; top: -0.5em; vertical-align: baseline;">2
, and no unfavorable collapse on drug-induced sleep endoscopy were enrolled in a phase 3 trial. Prospective outcomes included apnea-hypopnea index (AHI), oxygen desaturation index, and adverse events, as well as measures of sleepiness, quality of life, and snoring. Results Patients who did and did not complete the protocol differed in baseline AHI, oxygen desaturation index, and Functional Outcomes of Sleep Questionnaire scores but not in any other demographics or treatment response measures. Improvement in sleepiness (Epworth Sleepiness Scale) and quality of life was observed, with normalization of scores increasing from 33% to 78% and 15% to 67%, respectively. AHI response rate (AHI <20 and="" events="" hour="" per="">50% reduction) was 75% (n = 71). When a last observation carried forward analysis was applied, the responder rate was 63% at 5 years. Serious device-related events all related to lead/device adjustments were reported in 6% of patients. Conclusions Improvements in sleepiness, quality of life, and respiratory outcomes are observed with 5 years of UAS. Serious adverse events are uncommon. UAS is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure.

KEYWORDS:

cranial nerve; device; device apnea hypopnea index; hypoglossal nerve; implant; long term; obstructive sleep apnea; polysomnogram; quality of life; sleep; sleepiness; surgery; upper airway stimulation
PMID:
 
29582703
 
DOI:
 
10.1177/0194599818762383

Upper Airway Stimulation for Obstructive Sleep Apnea: Results from the ADHERE Registry.

Boon M, et al. Otolaryngol Head Neck Surg. 2018.

Abstract

Objective Upper airway stimulation (UAS) is an alternative treatment option for patients unable to tolerate continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea (OSA). Studies support the safety and efficacy of this therapy. The aim of this registry is to collect retrospective and prospective objective and subjective outcome measures across multiple institutions in the United States and Germany. To date, it represents the largest cohort of patients studied with this therapy. Study Design Retrospective and prospective registry study. Setting Ten tertiary care hospitals in the United States and Germany. Subjects and Methods Patients were included who had moderate to severe OSA, were intolerant to CPAP, and were undergoing UAS implantation. Baseline demographic and sleep study data were collected. Objective and subjective treatment outcomes, adverse events, and patient and physician satisfaction were reviewed. Results The registry enrolled 301 patients between October 2016 and September 2017. Mean ± SD AHI decreased from 35.6 ± 15.3 to 10.2 ± 12.9 events per hour ( P < .0001), and Epworth Sleepiness Scale scores decreased from 11.9 ± 5.5 to 7.5 ± 4.7 ( P < .0001) from baseline to the posttitration visit. Patients utilized therapy for 6.5 hours per night. There were low rates of procedure- and device-related complications. Clinical global impression scores demonstrated that the majority of physicians (94%) saw improvement in their patients' symptoms with therapy. The majority of patients (90%) were more satisfied with UAS than CPAP. Conclusions Across a multi-institutional registry, UAS therapy demonstrates significant improvement in subjective and objective OSA outcomes, good therapy adherence, and high patient satisfaction.

PMID

 29557280 [ - as supplied by publisher]


 2018 Mar 2. pii: S0196-0709(18)30077-2. doi: 10.1016/j.amjoto.2018.03.003. [Epub ahead of print]

Uvulopalatopharyngoplasty vs CN XII stimulation for treatment of obstructive sleep apnea: A single institution experience.




Abstract

OBJECTIVES:

Hypoglossal nerve stimulation (HNS) therapy is an emerging surgical treatment for select patients with obstructive sleep apnea (OSA). This study aims to compare outcomes in patients with moderate to severe OSA who underwent HNS surgery (Inspire Medical Systems) and those who underwent traditional airway reconstructive surgery, specifically uvulopalatopharyngoplasty (UPPP).

METHODS:

Patients who underwent HNS implantation (n = 20), all with moderate to severe OSA, inability to adhere to positive pressure therapy, and compliant with previously published inclusion criteria, were compared to a historical cohort that were intolerant of CPAP with similar inclusion criteria who all underwent UPPP (n = 20) with some also undergoing additional procedures such as septoplasty/turbinate reduction. Data including body mass index (BMI), pre- and post-implant apnea-hypopnea index (AHI) were assessed.

RESULTS:

For patients who underwent HNS, mean preoperative BMI was 28.0. Mean AHI decreased significantly from 38.9 ± 12.5 to 4.5 ± 4.8. All patients achieved an AHI < 20 post implant with 65% (13/20) with an AHI ≤ 5. For patients who underwent traditional airway surgery, mean preoperative BMI was 27.5; mean AHI decreased from 40.3 ± 12.4 to 28.8 ± 25.4.

CONCLUSION:

While both traditional surgery and HNS are effective treatments for patients with moderate to severe OSA with CPAP intolerance, our study demonstrates that HNS is "curative" in normalizing the AHI to <5 excellent="" for="" hns="" improvement="" in="" majority="" measures.="" objective="" of="" outcome="" p="" patients.="" patients="" provides="" select="" the="" therapy="">

KEYWORDS:

Apnea hypopnea index; Hypoglossal nerve stimulation; Obstructive sleep apnea; Upper airway surgery; Uvulopalatopharyngoplasty
PMID:
 
29540289
 
DOI:
 
10.1016/j.amjoto.2018.03.003

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posted by Dr Shapira at 1:33 PM

Thursday, March 29, 2018

Management of Cluster Headaches with Sphenopalatine Ganglion Blocks. What is the Best Mode of Administration of SPG Blocks for Cluster Headaches.

What is the best method of delivering a SPG Block?  There are many alternatives for delivering SPG Blocks, I personally feel that self-administration is the best approach for the majority of patients.  I utilize a wide variety of methods in some circumstances.
An excellent new article "Sphenopalatine Ganglion Block (SPG) in the Management of Chronic Headaches" in Current Pain and Headache Reports by Jeffery Mojica, Bi Mo & Andrew Ng does an excellent job in discussing both pathogenesis and treatment of Cluster Headaches utilizing Sphenopalatine Ganglion Blocks.
This article will discuss only that portion of their article dealing with Cluster Headaches but the article concluded in part that ", SPG blockade is a safe and effective treatment for chronic headaches such as cluster headaches, migraines, and other trigeminal autonomic cephalalgias"
Cluster Headache is one of the Trigeminal Autonomic Cephalgias. According to the article  "The autonomic symptoms of the various forms of headaches mimic the activation of the SPG. Therefore, the SPG has become a therapeutic target of interest. Symptoms such as lacrimation, conjunctival injection, nasal congestion, rhinorrhea, forehead sweating, and periorbital edema are common autonomic manifestations of trigeminal autonomic cephalalgias (TACs). The presence of these symptoms suggests that SPG may be a key structure in their pathogenesis."
TACs include cluster headache (CH), paroxysmal hemicranias (PH), short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), Long-lasting autonomic symptoms with hemicrania (LASH), Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)and hemicrania continua (HC).
"Cluster headache is the most common type of TACs. CH is characterized by unilateral headaches in Maxillary Division of the Trigeminal Nerve distribution that are classically associated with parasympathetic disruption, causing lacrimation, conjunctival injection, nasal congestion, and rhinorrhea."
The Sphenopalatine Ganglion has a very long history in the treatment of chronic headaches, migraines and Cluster headaches.  It was originally described by Greenfield Sluder in 1903 in case now thought to be a cluster headache.  The Sphenopalatine Ganglion (SPG) has many names including Sluder's Ganglion, the Nasal Ganglion, the Pteryggoalatine Ganglion named for its location in the Pteryggopalatine fossa, anr Meckel's Ganglion.
The Sphenopalatine Ganglion is the largest parasympathetic ganglion of the head and in addition to parasympathetic fibers it also carries somatosensory fibers and sympathetic fibers.  According to the article "The sphenopalatine ganglion is activated when the superior salivatory nucleus receives stimulation from the trigeminal afferent nerves. This results in parasympathetic activation of the meningeal vessels, lacrimal glands, nasal, and pharyngeal mucosa. This signaling pathway is referred to as trigeminal-autonomic reflex."  The Vascular and Neurogenic type headache pain is secondary to the release of vasoactive peptides.
This review cited five studies on SPG Blocks for Cluster Headache.  The first by Devoghel looked at 120 patients treated with Sphenopalatine Blocks by Supra-Zygomatic injection.  103 (94%) experienced complete relief and 17 reported no relief.
The second study looked at was by Barre of 11 Cluster headache patients treated with Intranasal cotton-tipped application of cocaine or lidocaine. All of the patients in this smaller study  reported a minimum of than reduction in headache intensity.  This study utilized the same technique originally described by Sluder in 1903.
The third study was by Kittrelle et al. was small with only 5 patients and utilized 4% lidocaine delivered by intranasal droplet.  4 of the 5 patients experienced a 75% decrease in headache intensity.
The fourth study by Robbins looked at 30 patients where 4% lidocaine was deliered by intranasal spray and 16 or slightly more than half experienced mild to moderate relief.  14 of the patients experienced no relief.
The last study by Costa et al.was a double-blind, placebo-controlled study  with rhinoscopic-guided bilateral intranasal cotton-tipped application of 10% cocaine or 10% lidocaine.   All patients reported complete relief with application of both lidocaine and cocaine.  This technique again utilized Sluder's original application technique.
There are three newer FDA approved catheter devices for delivering Sphenopalatine Ganglion blocks as well.
There is no question about the effectiveness of of Sphenopalatine Ganglion Block in the treatment of Cluster Headache.  What is amazing is that the Sphenopalatine Ganglion had become what is called "Forgotten Medicine"  Many excellent techniques get "lost" when newer techniques come along.  The era of polypharmacy approach to headaches has been over 50 years in the making.  Research and research money is spent looking for the "Magic Cure" or "magic pill" to treat  specific issues and doctors are never trained in old techniques.
The SPG Block is a perfect example of "Forgotten Medicine"  This is a video of a physician who had a severe disabling headache as a young boy and was treated with an SPG Block.  This boy decided to become a physician because of this experience, he wanted to help others as he had been helped.  Unfortunately, he was never taught or learned about SPG Blocks and after 10 years in practice he quit because he was unable to help patients in the manner he was helped.  He became an artist and makes magnificent trees.  This video was taken the day he learned what a SPG Block actually was.
https://www.youtube.com/watch?v=Sn46l_nH9-A&t=30s

The history of SPG Blocks began with Greenfield Sluder in 1903.  He published many articles on these blocks and wrote two books.   The first in 1918"Concerning Some Headaches and Eye Disorders of Nasal Origin" and the second "Nasal Neurology, Headaches and Eye Disorders" while he was a clinical professor and Director of the Department of Oto-Laryngology at Washington University School of medicine in St Louis.
There was a great deal of interest in these blocks and in 1930 Hiram Byrd MD and Wallace Byrd AB. wrote a paper published in the Annals of Internal Medicine (JAMA) on Phenopalatine Phenomena" that looked at 10,000 blocks in over 2000 patients.
This amazing block almost disappeared but in 1986 a book was published "Miracles on Park Avenue" by Albert Gerber about the medical practice of Milton Reder MD a world-famous New York City Otolarymgologist whose entire practice was utilizing SPG Blocks to treat a wide variety of chronic pain disorders with extreme success in thousands of patients including senators, generals, magnates, kings, Hollywood and Broadway stars and many prominent medical practitioners.  Dr Reder and this book written about this "Miracle Block" probably saved this treatment from the dustbin of obscurity.
I originally learned the technique in 1986 when a patient gave me a copy of the book and asked me to find someone in Chicago who used this technique.  I read this book in one sitting and found there was no one using it.  I finally found a colleague in the TMJ field in Kansas City who knew the technique, Dr Jack Haden and learned it from him.
I have been using this remarkable block since 1986.  Initially, I used a 10% cocaine solution but later switched to 4% and the 2% lidocaine.  I used the same technique as both Sluder, Byrd and Reder but later switched to a cotton-tipped catheter that allowed continuous capillary release of anesthetic.
Looking at these studies you will see that they use either lidocaine or cocaine and both are effective.  The applicator is more effective than drops which are more effective than the sprays of lidocaine.  Devoghel  used an injection technique utilizing alcohol which is longer lasting than  lidocaine or cocaine but carries more risk.  This was described by both Sluder and Byrd in their publications.
I believe the best approach is to teach patients to self-administer SPG Blocks with cotton tipped nasal catheters that continually provide anesthetic to the mucosa over the ganglion.    Some nasal passages are difficult to negotiate.  There are three new devices made to deliver SPG Blocks, they are the Sphenocath, the Allevio and the TX 360.  They are all nasal catheters used like "squirt guns"  They care all more effective than lidocaine spray or drops.  They are relatively expensive devices, $75.00 for a single use.  Physicians typically charge $750.00 per bilateral block.
I teach patients to Self-Administer SPG Blocks with cotton-tipped applicators but for some difficult access noses I teach patients to self-administer with a Sphenocath device which can be reused by a patient.  Patients can also self-administer with the TX 360 but it is strictly a single use device.
The use of Afrin (oxymetazoline ) spray can shrink mucosal membranes making self administration easier and I supply patients with spray bottles for lidocaine so they can numb nasal mucosa prior to self administration of SPG Block.
The advantage to self-administration is it is available to the patient on an as needed basis.  This allows the patients to avoid repeated trips to the ER or physician offices.
SPG Blocks can also be utilized to treat other pain disorders like Fibromyalgia. This video is a disabled Israeli veteran who suffered for nine years from Fibromyalgia before trying SPG Block.
https://www.youtube.com/watch?v=A5xUFtuZe_Y

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posted by Dr Shapira at 1:26 PM

Thursday, March 22, 2018

Anxiety And Migraine: Management with Sphenopaltine Ganglion Can Prevent or Eliminate Migraines

Migraine, Anxiety and Depression can all be sucessfully and treated with "Self Administered Sphenopalatine Ganglion Blocks"

Migraine and Anxiety are linked by the involvement of the Trigeminal Nerve and particularly the sympathetic autonomic nerves that pass thru the SphenoPalatine Ganglion (SPG).  The American Migraine Foundation believes that the majority of Migrainers (50-60%) also have anxiety disorders.  Migraine patients who do not have anxiety disorders frequently will experience anxiety during a migraine attack or even with prodromal symptoms.

Anxiety and Depression are also related and about 25-30% of Migraine patients have both Anxiety and Depression making treatment and management of migraine far more difficult.  Special care should be exercised in these patients who are at high risk for progressing to Chronic Migraine as well as Intractable / Refractory Chronic daily headache or New Persistent Daily Headache.

These patients often present with symptoms of Sympathetic Overload or Autonomic Dysregulation which can cause:
  • Shortness of breath
  • Increased heart rate
  • Chest tightness
  • Sensation of throat closing
  • Vertigo
  • Dizziness
  • Nausea
  • Double vision
  • Sweating
  • Difficulty thinking
  • Cold hands and feet

Hypervigilance and  Catastrophizing often leaves patients consumed with fear and feelings of hopelessness.  Depression can become severe and suicidal ideations may occur but are often denied by patients.  The stimulation or blocking of this ganglion

The SOAP approach to diagnosis can help overcome these issues but due to insurance issues and financial obstacles most doctors are typically rushed for time.
S. or Subjective considerations are often the most important part of an evaluation      and require a significant amount of face to face physician patient time.
O. or Objective findings are usually secondary.  CAT Scans, MRIs, Blood Panels       and other objective tests based on Subjective Evaluation are ordered.
A.  Assessment is the actual process of integrating both the subjective &             objective data.  Unfortunately, both objective tests ordered and assessment  
are compromised due to insufficient time spent gathering Subjective data.
P.  Plan is the method to address these issues.  

Medication Management has become the "Norm" for treating these problems but an older procedure called a SphenoPalatine Ganglion Block (Pterygopalatine Ganglion, Nasal Ganglion or SPG) may be the best first line treatment.  Prior to the explosion of pharmaceuticals available this procedure was routinely used to treat and eliminate a wide variety of conditions including Headache, Migraine, Cluster Headache, Sluder's Neuralgia, Trigeminal Neuralgia and a variety of ear pains, eye pains and sinus pains.

The Sphenopalatine Blocks have also been shown to treat anxiety and depression as well as PTSD.  Another Autonomic block the Stellate Ganglion Block has shown promise as a "One Shot Cure for PTSD"

The SPG Block was the subject of a 1986 book called "Miracles on Park Avenue" about Milton Reder who utilized only SPG blocks and treated patients from around the world.  In 1930 Hiram Byrd MD wrote an article called Sphenopalatine Phenomena detailing the amazing results of over 10,000 SPG Blocks in over 2000 patients.  Dr Greenfield Sluder first described the Sphenopalatine Ganglion Block in 1903 and in 1918 wrote the book "Concerning Some Headaches and Eye Disorders of Nasal Origin" and in 1927 the  book "Nasal Neurology:  Headaches and Eye Disorders"

These blocks have resurfaced in 21st century medicine after the introduction of three new FDA  devices to deliver the blocks, the Sphenocath, the Allevip and the TX 360.  They are utilized for treating Intractable and refractory headaches and Migraines, https://www.sphenopalatineganglionblocks.com/intractable-headaches-migraines-sphenopalatine-ganglion-spg-blocks-may-fastest-safest-treatment/.

Self Administration of Sphenopalatine Ganglion Blocks have enormous potential for decreasing and eliminating pain and anxiety and many other problems.  The effect on quality of life is exceptional because patients are now in control of their pain without dangerous or addictive medication.  The vale of eliminating trips to the ER and time spent in hospital and physicians offices waiting for treatment is incalcuable.

A recent editorial declared the Sphenopalatine Ganglion Block a medical miracle that is vastly underutilized. 
https://www.sphenopalatineganglionblocks.com/sphenopalatine-ganglion-block-underutilized-tool-pain-management/

Another recent article showed that SPG Blocks could eliminate about a third of Essential Hypertension cases.  https://www.sphenopalatineganglionblocks.com/new-studies-point-common-etiologic-cause-migraines-essential-hypertension-spg-blocks-missing-piece/

An article in December 2017 did a complete review of the science and treatments associated with the Sphenopalatine Ganglion..
https://www.sphenopalatineganglionblocks.com/sphenopalatine-ganglion-block-radiofrequency-ablation-neurostimulation-systematic-review/

Neuromuscular Dentistry has always been extremely predictable in treating chronic head and neck pain associated with TMJ and occlusal causes.  Much of the success in Neuromuscular Dentistry in eliminating headaches and migraines is probably due to the fact that the Myomonitor, which relaxes muscles innervated by the facial and trigeminal nerves also acts as a Neuromodulation device on the Sphenopalatine Ganglion.  

The Myomonitor has an incredible history of safe use for over 50 years to relax muscles and modulate the Sphenopalatine Ganglion.  It is not sold or marketed for Neuromodulation of the Sphenopalatine Ganglion.

I routinely treat a wide variety of issues relating to TMJ disorders, MPD and Orofacial and Craniofacial Pain with Neuromusclar Dentistry, beginning with a diagnostic orthotic. I teach these  patients to Self Administer Sphenopalatine Ganglion Blocks with cotton tipped nasal catheters in my Highland Park, Il office..Visit www.ThinkBetterLife.com to learn more.

This link is to 32 patient testimonials of patients who utilize SPG Blocks. 
 https://www.youtube.com/playlist?list=PL5ERlVdJLdtllxAN1QwD7JU7Qo_ISoqvt


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posted by Dr Shapira at 8:50 AM

Tuesday, March 20, 2018

Learn to Self Administer SPG Blocks in Chicago

WHERE CAN I LEARN TO SELF ADMINISTER SPHENOPALATINE GANGLION BLOCKS?

Dr ira L Shapira teaches patients to Self-Administer SphenoPalatine Ganglion Blocks in his Highland Park, Il office.

CONTACT DR SHAPIRA THRU HIS WEBSITE:  WWW.THINKBETTERLIFE.COM

LEARN MORE ABOUT SPG BLOCKS:  WWW.SPHENOPALATINEGANGLIONBLOCKS.COM

Sphenopalatine Ganglion Blocks were first decribed by Sluder in 1903.

Hiram Byrd wrote "Sphenopalatine Phenomena" in 1930 which was published in 1930 and reported phenomenal success in 10,000 SPG Blocks in 2000 patients

Forgotten Medicine:  New Medications and procedures become available and marketed but sometimes valuable medical procedures are forgotten in the process..


DR SHAPIRA'S STORY

In 1986 I learned about Sphenopalatine Ganglion Blocks from a patient who brought me the book, "Miracles on Park Avenue" and wanted me to find him a doctor who did the procedure in Chicago. I was amazed when I read the book and was dismayed when I could not find anyone in the Chicago area who did the procedure.

I learned the procedure from Dr Jack Haden in Kansas city that same year and I have used it ever since. Initially I did a lot of intra-oral injections through the greater palatine foramen because it was a "comfortable" injection for me to give in an area I routinely gave anesthetic. Later, I learned techniques for extra-oral injections which were initially outside my comfort zone. I have embraced them over the years for their ease and predictability.

 My Blog at www.SphenoPalatineGanglionBlocks.com has a wide range of information about Sphenopalatine Ganglion Block including indications and history of this "Miracle Block".
I also took a while to be comfortable with doing the trans-nasal block because it was outside my aera of comfort. I have done thousands of these over the years and have adapted my techniques. In the beginning I always brought the patients in to my office for me to do the SPG blocks.

I have always had long-distance patients who traveled to see me for TMJ treatment and neuromuscular treatment and UI would teach my patients how to treat and eliminate their pain between visits with Travell Spray and Stretch techniques. This was life-changing for my patients who could now turn off severe head, neck and facial pain as well as migraine without a trip to my office. This was initially difficult because pharmacies did not understand the prescriptions and vapocoolant spray was often hard for patients to buy.

Over time, it became routine for me to automatically offer this to all patients. I would also teach them the basic principles so they could relieve pain anywhere in their body.

Empowering patients to take control of their pain without prescription medications resulted in better patient care, fewer visits both to my office and to other physicians and emergency rooms in hospitals.
I later began utilizing home ULF-TENS (Myomonitor) units to my patients for home use rather than just in my office and againfound a tremendous improvement in my ability to care for my patients and in their quality of life.  The Myomonitor also acts as an at home on demand Neuromodulation device for the Sphenopalatine Ganglion.  The Myomonito has over a 50 year safety record.

Every time I empowered patients to self-care I was rewarded with great patient appreciation for my efforts. The same level of pain relief with fewer doctor visits improved the quality of thei lives. Truth is, "Quality of Life Sucks when you are in a Doctor's office or waiting in an ER.

Success rates for treatment improved with fewer visits and lower costs.  This link is to videos of patients who have experienced SPG Blocks.
 https://www.youtube.com/playlist?list=PL5ERlVdJLdtlk8PbufsI0l_MzHo4oOb6g

I used the Sphenopalatine Ganglion Block initially only as a measure of last resort, when other treatments were not working well. My patients who received SPG Blocks taught me that they did better when I did the blocks and the number of visits decreased while their quality of life increased. I remember when I first began to teach patients how to self-administer it was with great trepidation and I did blocks twice a day in the office for two days before teaching them to self-administer because I was worried about adverse reaction, even though they never occurred. Twice a day administration drastically improved the positive effects of the blocks as the blocks appeared to have a cumulative action and increased exposure in frequency and duration increased effectiveness.

I no longer reserved these for patients with TMJ and Facial pain but began to use them for Anxiety, depression and for problems like dental phobias and that were either difficult to treat or resistant to treatment. Gradually, I began to teach self administration to all my patients and found they appreciated having control.

Recently several devices have received FDA approval for delivering anesthetic to the area of mucosa overlying the Sphenopalatine Ganglion and physicians began to bring patients in for a series of 10 treatments (every two weeks) for $750.00 per treatment or $7500 for a course of treatment. (Blue Cross / Blue Shield recently stopped paying for these blocks calling them experimental but in reality I think they became too expensive) These devices are the Sphenocath, the Allevio and the TX 360. All devices are expensive and a single use device costs a physician about $75.00.
When I teach patients to self-administer SPG Blocks I no longer use the cotton-tipped applicators but have switched to cotton-tipped catheters that supply continual capillary feed to the mucosa over the Sphenopalatine Ganglion. This has, in my opinion increased the effectiveness far beyond any of the commercial catheters.

The Sphenocath, the Allevio and the TX 360 are all basically "squirt guns" that shoot a small amount of anesthetic over the mucosa covering the Sphenopalatine Ganglion. Ideally patients will remain supine for 10-20 minutes to increase absorption time.

The cotton-tipped catheter in contrast delivers a continual flow of anesthetic to the mucosa and can be kept in place for 20 minutes to several hours and can be refilled as needed. Due to the continual flow there is no reason to stay supine (on back) but with acute severe pain an initial supine position may increse speed of onset. The size of the cotton-tipped nasal catheter is larger than the other devices and there is certainly cases where I use a Sphenocath or TX360 in my practice. If I teach self-administration I have my patients use the Sphenocath because it is reusable at home. The TX360 can esily be utilized for self administration but is a single use device only.

The cost to the patient of doing a bilateral SPG block with cotton-tipped nasal catheters after initial appointments is less than $1.00. This is an enormous cost saving to the patient and to insurance companies and makes it far less expensive than almost any of the prescription medications available for treating migraine and chronic daily headaches.

In addition there are virtually no side effects from medication. I generally use 2% lidocaine that is extremely safe and has anti-inflammatory properties.

The biggest savings is in time and medical expenses as patient no longer have to leave work for medical visits or suffer long ER waits and thousands of dollars of expense. The biggest savings is TIME. It is the one thing that if we spend it we can never get it back.

I usually will start the self-administration protocol as twice daily for multiple reasons. The two main reasons is it offers better immediate control of even severe pain and secondly if a patient is doing it twice daily they rapidly develop a high level of expertise and can do it without problems in the future. In patients with tight nasal passages they tend to become easier to navigate over time with repeated applications.

I have taught patients from across the United States as well as International patients how to Self-Administer Sphenopalatine Ganglion Blocks.

This link is to over 100 videos of patients treated with Neuromuscular Dentistry, Trigger Point Injections, Sleep Apnea Appliances and SPG Blocks: https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

I used to use SPG Blocks only for patients with the most difficult problems, I was wrong.  I now believe it should be part of the diagnostic work-up for all headache patients before they receive medications and injections like BOTOX.

Chicago Metropolitan area has three airports: O'hare Airport, Midway Airport and Mitchell Field just south of Milwaukee.  O'hare and Mitchell are the most convenient to my office.  The office is also located on the North Line of Metra (Union Pacific to Kenosha) at the Fors Sheridan Train Station.

#spgblocks, #spgblockstrigeminalneuralgia, #spgblockmigraine, #spgblockclusterheadache, #selfadministrationspgblock, spgblocksideeffects, spgblockindications

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posted by Dr Shapira at 10:41 AM

Monday, March 19, 2018

Tension-Type Headache: AKA: Tension Headache, Muscle Contraction Headache, Psychomyogenic Headache, Stress Headache, Ordinary Headache, Essential Headache, Idiopathic Headache and Psychogenic Headache.

Tension-Type Headaches are extremely common affecting the majority of the public at some time during their lifetime.  It is commonly associated with Stress or more accurately how patients react to stressful periods. 

There is often considerable cross over between Tension-Type headaches and Medication Overuse Headache.

Tension-Type Headaches can be mild, moderate or severe to very severe and frequently patients refer to them as "my Migraine".  Migraine in Children are often misdiagnosed Tension Type Headaches associated with Myofascial Trigger Points.  Because Migraine pathogenesis is also not well understood there is a great deal of crossover diagnosis.  

This recent study;  2018 Feb;22(2):385-392. doi: 10.1002/ejp.1127. Epub 2017 Sep 26.  "CHILDREN WITH MIGRAINE:  PROVOCATION VIA PRESSURE TO MYOFASCIAL TRIGGER POINTS IN THE TRAPZIUS MUSCLE?"  is an excellent example of research which confuses or fails to clarify migraine and tension-type headaches.  The article is excellent looking at headaches from triggerpoints in the Trapezius muscle.  (abstract below at ent of post)

To understand Tension-Type Headaches I believe it  is extremely important to understand and know all of the referral patterns identifies in MPD or Myofascial Pain.  Any physician or dentist is compromised in their quality of care without this knowledge and is likely to  prescribe excessive or inappropriate medications.  

 I believe it is impossible to make a proper diagnosis in many patients until both  active and latent  trigger points have been identified and managed.  This is an essential step in the differential diagnosis and should be completed prior to medication prescriptions for triptans and other medications.

The website www.TriggerPoints.net is an excellent resource for patients and physicians dealing with Tension-Type Headaches and Migraines.  It is taken from the testbook "Myofascial Pain and Dysfunction: A Trigger Point Manual"  

I recommend that my patients buy this book to better understand their pain patterns, how they can prevent myofascial trigger points from forming and how they can improve the pain from these trigger points. 

The precise mechanisms of Tension-type headaches are not well understood.  There are many discussions that differentiate central and peripheral mechanisms.

The first known fact about Tension Headaches (and Migraines) is that they are primarily disorders of the Trigeminal Nervous System and the Trigeminal Vascular System.

There is also no question that the autonomic nervous system plays an enormous role especially the Sympathetic nervous system and the balance between the sympathetic and parasympathetic nervous system.  

Chronic Tension Type Headaches are a serious condition that can severely decrease quality of life and cause considerable disability.  

All patients with Tension-Type headaches of a severe or chronic nature should have the effects of the autonomic nervous system evaluated as part of the diagnostic work-up with a minimally invasive Diagnostic Sphenopalatine (Pterygopalatine) Ganglion Block.   https://www.sphenopalatineganglionblocks.com/managing-chronic-headaches-spg-block-sphenopalatine-ganglion-block/

The use of self-administered Sphenopalatine Ganglion (SPG) Blocks can often have almost immediate relief of even severe pain and sometimes spontaneous remission of the underlying headache with repeated use.

These blocks reset the autonomic nervous system and help with stress response (sympathetic) turning off "Fight or Flight Reflex" and turn on the Parasympathetic Reflex ie "Feed and Breed or Eat and Digest Reflex"

There is an incredible histor of pain relief including a 1930 scientific article by Hiram Byrd on "Sphenopalatine Phenomena" and a 1986 popular book "Miracles on Park Avenue" documenting the practice of Dr Milton Reder who exclusively utilized SPG Blocks to treat patients varied types of pain.

Dr Ho published an extensive review Sphenopalatine Ganglion Blocks and Modulation in a 2017 paper.  https://www.sphenopalatineganglionblocks.com/sphenopalatine-ganglion-block-radiofrequency-ablation-neurostimulation-systematic-review/

The concept of Neuromodulation is extremely important because it helps explain the amazing successes of neuromuscular dentistry in treating and eliminating headaches and migraines.  A basic concept in Neuromuscular Dentistry is utilizing the Myomonitor to relax muslces inervated by Trigeminal and facial nerves to find neuromuscular rest and occlusion which serves to give a healthy reset to the trigeminal nervous system as a patient functions and swallows.

The Myomonitor also acts as a Neuromodulation device of the Sphenopalatine Ganglion.  There is an incredible 50 year safety record of Sphenopalatine Stimulation with the Myomonitor when used by Neuromuscular Dentists.

Understanding how these processes work is important.  It is also important to hear patients stories.  This is a link to over 100 patient videos who have been treated with Neuromuscular Dentistry and SPG Blocks for Tension-Type Headaches, Migraines, TMJ disorders, Myofascial Pain and referred headaches and related sleep disorders.

https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

PubMed Abstract
 2018 Feb;22(2):385-392. doi: 10.1002/ejp.1127. Epub 2017 Sep 26.

Children with migraine: Provocation of headache via pressure to myofascialtrigger points in the trapezius muscle? - A prospective controlled observational study.

Abstract

BACKGROUND:

The objective was to evaluate a supposed clinical interdependency of myofascial trigger points and migraine in children. Such interdependency would support an interaction of spinal and trigeminal afferences in the trigemino-cervical complex as a contributing factor in migraine.

METHODS:

Children ≤18 years with the confirmed diagnosis of migraine were prospectively investigated. Comprehensive data on medical history, clinical neurological and psychological status were gathered. Trigger points in the trapezius muscle were identified by palpation and the threshold of pressure pain at these points was measured. Manual pressure was applied to the trigger points, and the occurrence and duration of induced headache were recorded. At a second consultation (4 weeks after the first), manual pressure with the detected pressure threshold was applied to non-trigger points within the same trapezius muscle (control). Headache and related parameters were again recorded and compared to the results of the first consultation.

RESULTS:

A total of 13 girls and 13 boys with migraine and a median age of 14.5 (Range 6.3-17.8) years took part in the study. Manual pressure to trigger points in the trapezius muscle led to lasting headache after termination of the manual pressure in 13 patients while no patient experienced headache when manual pressure was applied to non-trigger points at the control visit (p < 0.001). Headache was induced significantly more often in children ≥12 years and those with internalizing behavioural disorder.

CONCLUSION:

We found an association between trapezius muscle myofascial trigger points and migraine, which might underline the concept of the trigemino-cervical complex, especially in adolescents.

SIGNIFICANCE:

In children with migraine headache can often be induced by pressure to myofascial trigger points, but not by pressure to non-trigger points in the trapezius muscle. This supports the hypothesis of a trigemino-cervical-complex in the pathophysiology of migraine, which might have implications for innovative therapies in children with migraine.
PMID:
 
28952174
 
DOI:
 
10.1002/ejp.1127

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posted by Dr Shapira at 10:49 AM

HEADACHES due to Prevertebral Muscles and Retropharyngeal Tendonitis: Headaches often related to turning head upwards.

The prevertebral muscles and tendons are difficult to address and oftey interfere with healing and recovery.  They are frequently injured in whiplash injures and symptoms can linger for years or even decades.

"Headache attributed to retropharyngeal tendonitis" is classified by "The Third Classification of Headache Disorder, 3rd addition" 
Diagnosis Code 11.2.2

Raising of the eyes by tilting of the head can cause both referred pain, aching and headache.  These muscles and tendons extend over the top 3-4 vertebrae to the skull.   There is a frequent involvement of the upper cervicl complex.

While Neuromuscular Dental Orthotics address the majority of head and neck symptoms by  restoring structural and muscular balance NMD does not correct upper cervical vertebrae.

These can be addressed by specially trained osteopaths and chiropractors.  Atlas-Orthoganol chiropractors wok on the first vertebre (the Atlas) and the second vertebrae (the Axis) and their relation to the skull.   They deliver a precice adjustment to the upper cervical region.  NUCCA chiropractors address the same area utilizzing different techniques.  Both work well as does the osteopathic approach.

It is important to have a stable neuromuscular orthotic before doing the adjustment (on combination cases) and it is often necessary for a patient to have both adjustments on the same day.  Typically, the nuromuscular orthotic is corrected after the A/O adjustment.

I work closely with Dr Mark Freund on patients requiring upper cervical corrections.  https://www.northshoreatlas.com/atlas-orthogonal.

Addressing the fascial and muscular disorders of the prevertebral region is usually started by a very gradual passive gentle stretch with the patient laying on the floor with a very small towel roll under the shoulders allowing the head to extend and tip backwards.  If there is pain or discomfort the size of the towel roll is reduced.  Typically 20 minute sessions that also combine very slow diaphragmatic breathing will let these muscle release their taut bands and tension.  Overdoing the stretch impedes progress.

The scalene muscles are usually also involved in  creating problems but they can be addressed with ULF-TENS (Myomonitor), Spray and Stretch techniques, correction of paradoxical breathing issues and other physical modalities.

Sufficient Magnesium and calcium levels are important for muscle relaxation.
Feldenkrais and Alexander techniques work well in patients with these disorders as do Paul St John techniques.

All of these techniques work best with well balanced neuromuscular orthotics.  The Aqualizer appliance is a self balancing hydrostatic appliance that can also be extremely useful.  Italian studies show it relaxes muscles throughout the body.

I frequently have my patients walk and run up and down stairs in these appliances to let the body and spine unwind and the muscles relax prior to adjusting neuromuscular appliance.

Aqualizers are almost a necessity when having A/O adjustments for patients traveling from one office to another.

Cranial Manipulation is another instance where the Aqualizer is incredibly useful as a patient goes from cranial doctor to have his Neuromuscular Orthotic adjusted.

Dr Mark Freund also utilizes Cranial work.   https://www.northshoreatlas.com/cranial-suture-release

His Highland Park office is across the hall from my Highland Park office:
www.ThinkBetterLife.com

Prevertebral muscle and tendon issues can be very difficult and working with multiplle professionals is key to success.



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posted by Dr Shapira at 9:38 AM

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