Dr. Ajam

How to Exercise With Chronic Pain Working out may seem like the last thing someone in pain wants to do. But it can bring relief.

To find the right movement for your pain, first, get clearance from a health professional to exercise. Then evaluate your pain, life, schedule, dislikes, and finances as objectively as possible, since each influences your ideal exercise routine. The right exercise plan may include skipping certain exercises, mixing and matching exercise options, asking the right questions about why you hurt afterward, and finding the right trainer or physical therapist. It's ok to start small or in non-traditional ways. start small. Exercise isn't limited to a treadmill for a certain number of minutes or miles; exercise includes gardening or walking the dog.

To find the right movement for your pain, first get clearance from a health professional to exercise. Then evaluate your pain, life, schedule, dislikes and finances as objectively as possible, since each influences your ideal exercise routine. The right exercise plan may include skipping certain exercises, mixing and matching exercise options, asking the right questions about why you hurt afterward, and finding the right trainer or physical therapist. It's ok to start small or in non-traditional ways. start small. Exercise isn't limited to a treadmill for a certain number of minutes or miles; exercise includes gardening or walking the dog.

And remember, effort often hurts at first. Some soreness a day or so after an unfamiliar workout is normal and even desirable, since it signals the muscles are reacting as they should to the exercise. Follow the two-hour rule to make sure you haven't overdone it. If pain is worse two hours after finishing exercise than it was before starting, this is an indication that you have overdone it and should scale back the next time.

The most important thing is to move and to accumulate more active time than inactive time. Find the exercise that works for you and keep at it!

🖼 by Justin J Wee for The New York Times; Prop stylist: Caroline Dorn

How to Exercise With Chronic Pain Working out may seem like the last thing someone in pain wants to do. But it can bring relief.

Over the past two decades, as the opioid crisis has shaken the public’s view of painkillers and pharmaceutical companies have come under fire for their marketing practices, many patients are looking for alternatives. A leading contender has become treating pain with talk therapy. The Lancet went so far as to recommend education and psychological treatment as first-line interventions for chronic low back pain, before pharmacological treatment. And this is supported by research — a recent study published in JAMA Psychiatry found that two-thirds of chronic back pain patients who underwent four weeks of psychological treatment were pain-free, or nearly so, afterward. Other studies show a more modest impact with about one-third of participants seeing a significant decrease in pain.

Pain psychology is a relatively new field, and there are things patients and clinicians should know before adding this as a part of a treatment plan.

1️⃣ What does a pain psychologist do?
Pain psychologists use an array of approaches, including cognitive behavior therapy, or C.B.T., which focuses on reframing thoughts to positively affect behavior and emotions, or mindfulness, which involves learning to become conscious of feelings without reacting to them; acceptance and commitment therapy, which combines mindfulness with CBT; biofeedback, which monitors a person’s muscle tension, heart rate, brain activity or other functions in real-time to make patients aware of their stress and learn to control it; and hypnosis, which can be effective at managing pain for some people.

2️⃣ How do you find a pain psychologist?
Since this is an emerging field, finding a pain psychologist can be tough. The first stop is your primary care doctor or pain management doctor. Some insurance plans cover pain psychology, but others do not. It’s important to talk to a mental health provider first about how to get treatment covered. After that, look for specialized pain clinics by calling hospitals in your area or use the Find a Therapist function on the Psychology Today website. Search for a provider who either treats your specific condition, be it fibromyalgia or migraines, or who treats chronic pain more broadly, a specialty often referred to as behavioral medicine or health psychology. There are also online programs that are evidence-based and freely available; Dr. Aaron recommends PainTRAINER and Pain Course.

3️⃣ What should the patient expect?
Most pain therapy programs start with six to eight weekly sessions. The first session is an evaluation to learn about the pain problem and the emotional issues it may be causing. The patient might then learn mindfulness techniques to separate the physical and emotional aspects of pain and learn to reframe negative thought patterns or practice paying more attention to pleasant sensations.

4️⃣ What if you can't see a psychologist in person?
Technological advancements have made more options available. From virtual appointments to online courses to apps and even to VR, there are many new options available to patients from the comfort of their homes.

How Psychologists Can Help Treat Chronic Pain As doctors and patients worry about the effects of painkillers, therapists are finding they can be a powerful salve for suffering.

Considering bone or joint surgery? In many cases, surgery may be no more effective than options like exercise, physical therapy and drug treatments. Even when surgery has been shown to be effective, the review concluded, it may not be significantly better than nonsurgical care.

For several common surgeries, randomized trials found little advantage over interventions like exercise, weight management, physical therapy, and drug treatment. It's not that the surgeries don't work — it’s just that some don't work any better than the best nonsurgical treatments.

Lumbar spine decompression, a procedure offered to relieve the pain caused by a ruptured or bulging disk, in the lower spine showed similar outcomes. Although the quality of the evidence was low, three analyses showed that surgery and nonsurgical treatments provided equivalent improvements.

These findings suggest it's important that clinicians discuss both operative and the best nonoperative care with patients so that patients can consider all options and thereby make informed choices.

Considering Bone or Joint Surgery? You May Not Need It. For many common problems of the knee, hip, shoulder, spine and wrist, nonsurgical options may be just as good.

Glia, a set of nervous system cells once thought to be mere supports for neurons, have recently rewritten chronic pain science. Though glia take up almost half its space in the nervous system, they long received far less scientific attention than neurons, which do the majority of signaling in the brain and body.

For the 1-in-5 people, totaling over a billion people worldwide, suffering from chronic pain, your glia might be botching their pain-management job! Researchers now believe glia can drive a healthy pain network into a dysregulated state, sending false and destructive pain signals that never end. Pain then becomes not a warning of harm, but a source of it; not a symptom, but, as Stanford pain researcher Elliot Krane puts it, “its own disease.”

The Quiet Scientific Revolution That May Solve Chronic Pain New science is rewriting the book on chronic pain — and may make treatment more accessible

Lots to discuss here without discounting the positive in our specialty. I practice with many colleagues near and far who are willing to listen, even when the conversation is difficult.

Screw You Pain Management ! It's Time We Took Back Our Rights ! I have been writing about pain management since I started with DK. Before this I used to p**s and moan on FB. Through all of this I have found that I am not alone. I didn't just make a crappy ...

Pain is among the most common reasons why people visit the doctor. And it's no surprise as 1-in-5 people suffer from chronic pain and 85% of people will be affected at some point in their lives. Treatment has traditionally been viewed as either a structural problem caused by tissue damage or the result of some unseen issue. However, chronic pain is increasingly being viewed as originating in the brain. With this shift in understanding, there are more approaches to eliminating pain by altering thoughts, beliefs, and feelings rather than by changing something in the body or flooding it with chemicals. This theory is not without controversy, it is finally being proved true by science. It’s increasingly clear that chronic pain is often “neuroplastic” — generated by the brain in a misbegotten effort to protect us from danger. And that’s good news because what the brain learns, we are discovering, it can unlearn.

Pain reprocessing therapy, or PTR, teaches patients to reinterpret pain as a neutral sensation coming from the brain rather than as evidence of a dangerous physical condition. As people come to view their pain as uncomfortable but nonthreatening, their brains rewire the neural pathways that were generating the pain signals, and the pain subsides. This technique can include tools like meditation and journaling. Research backs this up too! Studies have shown that a mind-body therapy course was significantly more effective in easing persistent back pain than either a more general stress-reduction program or traditional care, like pain killers.

Read more about PRT at the link below.

Perspective | Chronic pain is surprisingly treatable — when patients focus on the brain An unexpected therapy shows results.

"I swear I’m not woo-woo, but … ”

Approximately 85 percent of back pain and 78 percent of headaches don’t have an identifiable trigger. So what’s causing this pain? Most scientists now believe that pain isn’t always something that starts in the body and is sensed by the brain; it can be a disease in and of itself. There are also social and biological reasons for pain, and for most people, it’s some confluence of all three.

Focusing on the the psychological origins of pain might be too woo-woo for some, but this approach, that both mind and body are responsible for our physical suffering, has given many the reminder that we’re not powerless to change it.

Read more at https://www.nytimes.com/2021/11/09/well/mind/john-sarno-chronic-pain-relief.html?referringSource=articleShare

🖼 by Justin J Wee for The New York Times, Prop stylist: Caroline Dorn

From party drug to wonder drug, ketamine has helped treat a variety of "stubborn conditions" like chronic pain. Ketamine increases neural connections so the brain processes pain in a healthier way. resets pain receptors, and decreases inflammation. While ketamine is not right for every patient, it can be a viable treatment option for patients with pain caused by cancer, CRPS, fibromyalgia, neuropathic pain, phantom pain, postherpetic neuralgia, sickle cell disease, and spinal injury.

https://www.tennessean.com/story/news/local/williamson/franklin/2021/05/12/wonder-drug-ketamine-infusions-help-chronic-pain-offered-franklin-tn-clinic/7318482002/

The endocannabinoid system (ECS) is a complex cell-signaling system identified in the early 1990s by researchers exploring THC, a well-known cannabinoid, and is currently at the center of new research and drug development.

The ECS regulates and controls many of our most critical bodily functions such as learning and memory, emotional processing, sleep, temperature control, pain control, inflammatory and immune responses, and eating. Endocannabinoids might target CB1 receptors in a spinal nerve to relieve pain, while others might bind to a CB2 receptor in your immune cells to signal that your body’s experiencing inflammation.

CBD and THC, which are similar to the body’s natural endocannabinoids, are being studied as treatment options for pain and other conditions, and a better understanding of the ECS could eventually hold the key to a new avenue of treatment options.

https://www.health.harvard.edu/blog/the-endocannabinoid-system-essential-and-mysterious-202108112569

📸 by Harvard Health

The endocannabinoid system: Essential and mysterious - Harvard Health Though recently discovered, the endocannabinoid system regulates and controls many of our critical bodily functions. Researchers are investigating the ECS’s role in learning and memory and in...

Wearable technology is increasingly popular, and wearables aimed at reducing pain is an intriguing new niche in a market that includes everything from cellular-enabled smart watches to rings that claim to detect illness to headsets promising to decode dog barks. While devices are still being developed, wearables have the potential to allow patients to go about their daily activities while receiving non-medication pain treatments and could help better track pain management, combine treatments, generate data to provide scientific insights, and interface with other types of wearables.

Would you consider wearable technology as part of your pain management program?

https://www.forbes.com/sites/brucelee/2017/11/05/wearable-tech-emerging-for-chronic-pain-relief/?sh=1ccf8a1b7040

📸 by Neurometrix of the Quell device

Music-induced analgesia, or pain reduction associated with passively listening to music as a result of the modulation of pain signals in response to the stimulation of brain and brainstem centers, is a new an exciting option for pain management. Studies have shown that listening to music as part of a pain management program could strengthen components of the inhibitory descending pain pathways operating at the dorsal spinal cord level and reduce pain.

Would you consider music therapy if offered by your pain physician?

https://online.ucpress.edu/mp/article/38/3/267/116127/Impact-of-Music-on-First-Pain-and-Temporal

Interesting take from pain practitioners about what's working, what isn't, and what the future of our specialty might see.

As a patient or physician, what is working for you and what isn't?🩺

Pain Management: Experts Roundtable on its History and Future [2020] Pain specialists review the past two decades (2000-2020) of pain treatments, from opioids to delivery methods to care models, and offer direction on how to achieve whole patient chronic pain care in the future.

Physical therapy might be an important addition to your pain management plan. Stretching, strength training, and light aerobic exercise could be beneficial as you manage your pain. These have been shown to decrease pain, including back pain.

Alexis Tingan, MD, Certificate of Added Qualification in Sports Medicine (CAQSM), physician at Penn Medicine, recommends physical therapy for three reason:

The first is distraction. It’s easy to say you’re going to exercise for an hour. But then the phone rings, something happens at the house, you get busy—and you get in half an hour, or don’t do it at all. Therapy is an hour of unobstructed time, with nothing to distract you from healing your body. And if you’ve already made an appointment, you will feel more obligated to go.

The second is the mechanics of the exercises themselves. It can be difficult to do the exercises on your own, and certain ones can cause more pain if they’re not done the right way. A therapist can observe you, and make sure you’re doing everything correctly.

Finally, physical therapy isn’t just a place to get better—it’s also a place to get educated. You won’t be in therapy forever, but therapy will provide you with exercises that you can take home and incorporate into your regimen indefinitely.

Talk to your physician about physical therapy as part of your pain management plan!

Read more at https://www.pennmedicine.org/updates/blogs/neuroscience-blog/2017/april/physical-therapy-for-spine-pain

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Six Tips for Safer Stretches 🤸‍♂️

🔘 Warm up first. Muscles stretch more easily (and more safely!) when warm. Stretch at the end of your workout or try marching in place with arms swinging for five minutes or dancing to a few songs. Moist heat packs or a warm shower are effective first steps, too.
🔘 Feel no pain. Stretch only to the point of mild tension, never to the point of pain. If a stretch hurts, stop immediately! Reset your position carefully, then try again. With time and practice, your flexibility will improve.
🔘 Pay attention to posture and good form. Posture counts whether you're sitting, standing, or moving. Good form translates to better gains in flexibility and less likelihood of injury when stretching tight muscles.
🔘 Focus on the muscle being stretched. You'll notice that one side of your body often is tighter than the other. Work on balancing this over time.
🔘 Breathe. Breathe comfortably while stretching, or use yoga breathing. Whatever you do, don't hold your breath while you are holding a stretch.
🔘 Practice often. You'll make the best gains if you stretch frequently-daily, or on as many days of the week as possible. At the very least, aim to do stretches two or three times a week.

Tips from Harvard Medical School/Harvard Health Publishing

Can food choices reduce pain? 🤔

According to William Welches, DO, Ph.D., patients who follow certain diets have experienced a complete turnaround in their pain symptoms. He says getting regular exercise, controlling stress, and eating healthy foods all work together to reduce inflammation and chronic pain, as diet can plan a critical role in the pain management process.

Dr. Welches recommends three principles:

🔘 Eat the rainbow: Consume eight to nine servings of vegetables each day — make a couple of those servings of fruit, if you like. Cruciferous vegetables such as broccoli, Brussels sprouts, cabbage, and cauliflower are best. 🥦 🥬
🔘 Restrict dairy and grains: Eat dairy products in limited quantities. When choosing grains, stay away from simple carbohydrates with refined sugar. Opt for whole grains, including barley, buckwheat, oats, quinoa, brown rice, rye, spelt, and wheat. 🌾
🔘 Avoid red meat: Eat red meat the way most of us eat turkey right now — twice a year, Dr. Welches says. Have it on very special occasions, very infrequently. Instead, include fish as the “meat” or eat vegetarian main dishes. Chicken is neutral — not harmful but not beneficial in the anti-inflammatory sense. 🍣 🍗 🍛

If you really want to increase the benefits, Dr. Welches suggests three other steps to make the most of a pain-reducing diet:

🔘 Get down to your ideal weight. Weight loss on its own is anti-inflammatory. 🍎
🔘 Get daily exercise in the form of walking. 🚶‍♀️
🔘 Manage stress. 🧘‍♀️

Read more at https://health.clevelandclinic.org/anti-inflammatory-diet-can-relieve-pain-age/

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Friendly reminder to take care of your back!

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Today is National Prescription Drug Take Back Day! This day addresses a crucial public safety and public health issue by providing an opportunity for individuals to safely dispose of unneeded, unused, and expired medication to prevent accidental poisonings, drug addiction, and overdoses. The April 2021 National Take Back Day collected 839,543 lbs. of medications at 5,060 collection sites!

Find a collection site near you by visiting https://takebackday.dea.gov/.

It's National Health Education Week! Today's focus is on health literacy. This is an important topic because patients need to be able to understand and use health information and services, evaluate information, and find reliable, evidence-based health information. Health literacy can help prevent health problems and protect patient health, as well as allow patients to better manage conditions and problems.

Issues of health literacy can arise when patients:
🔘 Aren’t familiar with medical terms or how their bodies work.
🔘 Have to interpret statistics and evaluate risks and benefits that affect their health and safety.
🔘 Are diagnosed with a serious illness and are scared and confused.
🔘 Have health conditions that require complicated self-care.
🔘 Are voting on an issue affecting the community’s health and relying on unfamiliar technical information.

How do you prevent issues of health literacy in your practice? Comment below. ⬇️⬇️⬇️

It's National Healthcare Quality Week (October 17 - 23)! This week is s a dedicated time to celebrate the healthcare profession and raise awareness of the positive impact healthcare quality professionals have in their organizations and communities. Amid the global pandemic, quality has taken center stage and more healthcare professionals are being called upon to do this critical work. It’s clear that quality matters … now more than ever! 👨‍⚕️🩺💉

Quick and helpful read. Three takeaways that will improve my practice: (1) Bone density can affect the movement of the cannula (2) Ablate before the BVN terminus for a bigger "burn" (3) Move caudad to cephalad when doing multiple levels to be more efficient.

Spineline - September/October 2021 - page16 SpineLine, the clinical and news magazine of the North American Spine Society (NASS), is published bimonthly to educate and inform NASS members (and

Ever heard that redheads feel pain differently from non-redheads? The MC1R gene might explain the difference in pain perceptions! 👨‍🦰👩‍🦰🧑‍🦰

The Truth About Gingers There are ALOT of stereotypes for us gingers, and the scientific truth is even weirder!Check out http://KiwiCo.com/Asap and get your first month free!FOLLOW ...

The iliotibial band, or IT band, extends from your hip to your knee along the outside of your thigh. The thick band of connective fibers is the largest piece of fascia in the human body – and often one of the biggest pains for runners and cyclists.

Here are a couple of stretches to help avoid IT band pain:

🔘 Wall or chair-supported stretch - Start in a standing position with your feet together. Cross your right leg behind your left leg. Using a wall or chair for support, lean slightly forward and to the left. Hold for 30 seconds while feeling your IT band stretch on your right side. Do the same with the opposite leg. Repeat five times.

🔘 Forward fold with crossed legs - Start in a standing position with your feet together. Cross your right leg over your left leg, setting your right foot down to the outside of your left foot. Reach down toward your left foot and breathe deeply. Hold for 30 seconds as the muscle releases. Do the same with the opposite foot. Repeat five times.

🔘 Supine IT band stretch - Lie on your back with your knees bent. Lift your right leg over your left knee, hooking your right ankle around your left knee. Then use your right leg to pull the left leg down to the right. Hold for 30 seconds. Do the same with the opposite leg. Repeat five times.

🔘 Belt/strap IT band stretch - Lie on your back. Loop a belt or strap around your right foot. Lift your right leg up straight before bringing it across your body (to the left) while keeping your hips flat. You should feel a gentle stretch along your right outer thigh. Hold for 30 seconds. Do the same with the opposite foot. Repeat five times.

🔘 Side-lying IT band stretch - Lie on your left side with your legs together and your hips and knees bent. Keeping your knee bent, move your right leg behind you and allow it to drop down until you feel a gentle stretch in the side of your right thigh. Hold for 30 seconds. Do the same on the opposite side. Repeat five times.

🔘 Foam Rolling - Start on your right side resting atop a foam roller positioned at the bottom of your outer right thigh. Bend your left leg and set your left foot down in front of your right leg. Using your arms and left leg, roll your outer thigh up and down the foam roller from knee to hip. Roll for three minutes once a day.

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Read more at https://health.clevelandclinic.org/it-band-stretches-and-treatments-to-relieve-knee-and-hip-pain/

Are you experiencing hip or thigh pain? It might be bursitis. 🤕

Bursae are small sacs of fluid cushioning your bones, tendons, and muscles near joints. Acute injury, overuse, or degenerative arthritis in your hip or back can lead to a common condition known as bursitis. Gardening, raking, jogging, cycling long distances, and playing tennis, golf, or even a musical instrument can increase your odds of developing bursitis.

Trochanteric bursitis brings warmth, swelling, and pain to your outer thigh that can spread down to your knee. Walking intensifies the pain, limping is common and climbing steps can become difficult. Tenderness on the side you're lying on may interfere with sleep.

Home treatment with rest, ice, and anti-inflammatories can help. It’s also important to avoid any activities that cause pain, including excessive standing.

📸 and info from

Read more at https://health.clevelandclinic.org/nagging-thigh-hip-pain-bursitis/

Pain management is not just for people! In June, the Humane Society of Missouri launched the first Integrated Veterinary Pain Management Center in St. Louis. Some therapies at the new center are designed to be completed within a few visits, while others attend to the long-term pain management needs of pets. 🐈 🐕

https://news.stlpublicradio.org/show/st-louis-on-the-air/2021-08-03/humane-society-of-missouris-new-center-offers-innovative-pain-management-for-pets

📸 by Lara Hamdan/St. Louis Public Radio

Unsure about when to use ice or heat for pain? Here are some considerations for deciding which option is best.

🔘 Acute Injuries (less than 6 weeks old) - Do not use heat on acute injuries because extra heat can increase inflammation and delay proper healing. Choose ice because the chill constricts blood vessels which numbs pain, relieves inflammation, and limits bruising.
🔘 Lingering Injuries (older than 6 weeks) - It's ok to use heat on these injuries, and the increased blood flow relaxes tight muscles and relieves aching joints. This is especially helpful to improve range of motion on a joint that maybe isn't moving as well.
🔘 Warm up, cool down - If needed, use heat before stretching or doing a home exercise program and use ice or cold treatment after exercise or activities to prevent any flare of inflammation.
🔘 Arthritis - Moist heat, like a soak in a tub or shower of warm-but-not-hot water (92-100°) can help.
🔘 Gout - When the sudden onset of pain and inflammation strikes individual joints, ice can calm the flare-ups while also helping to numb the pain.
🔘 Headaches - Ice, including cold masks or wraps over the forehead, eyes, and temples, can help soothe throbbing pain in your head.
🔘 Muscle strain and sprains - Start off with ice to ease inflammation (including swelling, redness, or tenderness of the injury) and numb the pain. Only after the inflammation resolves is it a good idea to switch to heat; this can help relieve any muscle stiffness at the injury site.
🔘 Tendinitis - Ice is the preferred method here as it can ease the inflammation and help numb the pain.
🔘 Tendinosis - Heat is best for relieving stiffness in the joints, but only after the inflammation resolves.

Remember to use caution on areas with decreased sensation if you have neuropathy or Raynaud’s syndrome, and extreme temperatures can damage the skin.

Read more at https://health.clevelandclinic.org/should-you-use-ice-or-heat-for-pain-infographic/

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Feeling sore after a massage meant to relieve pain? There's a reason!

Experiencing sore or tight muscles is normal after a massage, especially if it has been a while since your last massage or you’ve never had one before. Massage, like exercise, forces blood into your muscles, bringing nutrients and removing toxins. This can temporarily increase inflammation (the healing response) to areas that the body feels need attention. This inflammation can bring discomfort. However, inflammation and soreness usually only last a few hours to about a day and a half. And you can treat post-massage soreness in exactly the same way as you'd treat post-exercise soreness.

Read more at https://health.clevelandclinic.org/why-does-my-body-feel-worse-after-a-massage/

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Wondering why your pain doctor hasn't yet recommended using cannabis to manage your pain? 🤔

In February of this year, the International Association for the Study of Pain (IASP), issued a statement saying, “There is not enough high-quality human clinical safety and efficacy evidence to allow IASP to endorse the general use of cannabis and cannabinoids for pain at this time.”

In 2018, the IASP created a task force to better understand cannabis and pain. The following year, the task force commissioned a pair of reviews: One focused on previous studies that showed the potential harm of using cannabis, and one focused on randomized controlled trials of cannabis use. The results of these reviews, as well as their statement, were published in the March 2021 issue of PAIN, the IASP’s monthly journal.

Sensitive to the role pharmaceutical companies played in fueling the opioid crisis and the trauma caused by the resulting addictions, the IASP was wary of making recommendations based on claims made by people who may have other motives. After a systematic approach to reviewing studies and trials, the group found a wealth of literature demonstrating that cannabis can be an analgesic (a drug that relieves pain). They also found evidence from lab studies that cannabis and cannabinoids might, biochemically speaking, be effective in helping with pain.

However, when they looked at the evidence from clinical trials, they concluded the data that was available was of insufficient quality because too many relied on anecdotal evidence. There also isn't enough research available for cannabis because while dozens of states have legalized cannabis for medical use, far fewer have legalized it for recreational use, and at the federal level, cannabis is still classified as a controlled substance. This means there are far fewer studies available to review than with other potential medical treatments. And even then, there’s a difference between the cannabis that is studied in a laboratory and the cannabis one might buy at a dispensary.

Another area of concern is the lack of conclusive evidence about who is at risk for those negative consequences from cannabis use, like cognitive trouble among adolescents, impairment of performance and judgment, and negative connection between cannabis and mental health conditions.

The IASP recommends continued research into how cannabis and cannabinoids could potentially help patients manage pain. This will allow physicians to follow the data to make the best-informed decision based on the science.

Read the full article at https://health.clevelandclinic.org/why-using-cannabis-to-manage-pain-isnt-yet-recommended-by-pain-doctors/

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