Dr. Susana Duncan

The Ecstasy (and Agony) of Sushi

2010-06-29T06:44:00.000-07:00

      Several years ago, a young woman came to me with neck and back pain, which had not yielded to acupuncture or physical therapy. There were tight bands in her neck and upper back muscles, yet trigger point injections, which usually alleviate this source of pain, provided no lasting relief.
      Reviewing her life style, I noted that she was a self- described "sushi addict," eating it as much as five times a week. Her blood work then showed abnormally high mercury levels. A call to the New
York City Board of Health confirmed there were unacceptably high levels of mercury in some fish, affecting sushi served in restaurants.
     Eureka, a diagnosis: mercury poisoning. Mercury is a heavy metal that is found in the earth's crust of rocks and soil. It is released into the atmosphere by burning coal, by burning and improper disposal of manufactured products containing mercury, and from personal products such as batteries. As it gets into water, bacteria can change it into a highly toxic methylmercury, which builds up in fish, shellfish and animals that eat fish. As it moves up the food chain, with larger fish eating smaller ones, mercury can become highly concentrated. Sushi from fish at the top of the food chain, such as Tuna, Salmon, and Tile fish, can cause problems associated with mercury poisoning, which is often overlooked as it takes a while to manifest. Absorbed through the gut, methylmercury can alter critical enzyme function and affect muscles function and nerve cells in the brain and spinal cord. The result can be a gait disorder, back and neck pain, and mental-psychological problems.
     Once diagnosed, the solution was straightforward. My patient modified her sushi intake, and restrict her choices to sushi at the low end of the feed chain, such as squid, shrimp, and abalone. She was also put on high fluid intake to help flush out the stored mercury in her body tissues. Her symptoms of tightness and pain subsided.
    While mercury poisoning is relatively rare in my practice, finding the source of pain often requires detailed review of a patient’s life: sleep, work ergonomics, exercise and diet. After all, when it comes to pain, we often suffer the unanticipated consequences of our life-style .

The Advantages of Ultra Sound

2010-06-11T13:21:00.000-07:00

An ultrasound image can evaluate the nature and severity of an injury
to soft tissues, such as tendons and muscles, and thus determine the
next step in treatment without having to leave the office, or
recourse to costly MRI or CT imaging which, like X-ray,
exposes the patient to radiation. Ultrasound can "see" a foreign body,
such as a splinter, and can also see a needle, and so is used in
guiding injections, such as steroid, into tendon sheaths to reduce
inflammation in tendinitis, and joint spaces for treatment of
arthritis pain. Without imaging the needle may miss its intended
placement. Ultrasound can also detect change in blood flow, clot
formation or narrowing in arteries of the limbs and neck. For both patient and doctor, it is a great advance in sports medicine.
　
　

Botox and Rehabilitation Medicine

2010-05-17T06:15:00.000-07:00

Botulinum toxin A, or Botox as it is commonly called, is used in
medicine to block unwanted, awkward and painful muscle contraction,
such as in childhood spasticity, wry neck or eye lid twitching. In
1989 it was FDA approved for medical purposes, and its early use
was in children with a "wandering" eye strabismus, where one eye
does not look at the object being viewed. The botox molecule
interferes with muscle receiving nerve signals to contract. The
muscle paralyzing feature of Botox , when used beneficially, has
proven to be useful in more than 50 pathological conditions, and in
2002 received FDA approval for cosmetic use.
The injection technique guides a slender needle toward the belly of
the muscle where nerve endings are known to enter. The more botox
molecules deposited the more effective the block. Its therapeutic
qualities led to its being used for muscle problems seen in later
life, such as spasticity after stroke; and its therapeutic benefits
were expanded to relieve neck and back spasm, headaches due to
muscle tension, and to control spasticity following spinal cord and
brain injuries. The doctor, who trains in Physical Medicine and
Rehabilitation to become a Physiatrist, Pain or Sports Medicine
specialist encounters these injuries frequently and is in the front
line helping the person to manage pain and recover function. The
Rehabilitation physician is first and foremost trained in the
anatomy of the body in motion -- a functioning, moving entity,
which means muscles and nerves as well as joints, tendons and
ligaments. And Botox is an essential tool she learns to handle. To
skillfully identify the problem muscle and direct the needle to the
optimal site are essential skills and take time to develop.
Successful practice of Rehabilitation also requires the ability to
understand the person with the problem; ability to listen and to
assess that person's wishes, and potential to meet them. In
Rehabilitation one frequently must make aesthetic recommendations
for a patient, for example whether a surgical procedure is needed,
not only for pain relief, but also, as in rheumatoid hand deformity
or a bent arthritic knee, for cosmetic reasons. It is a natural
and a short step to offer this capability to patients concerned by
their facial appearance. A detailed interview to understand the
person's wishes and a careful examination of the facial bone and
soft tissue structure leads to a treatment plan. Injected into
certain small muscles of the face Botox can soften, even remove
unwanted deepened expression lines. This particular therapeutic
application, is now commonly called aesthetic Botox. Practitioners
of this often do not have background in its medical therapeutic
uses, and have trained recently and exclusively in its aesthetic
use. By contrast, the pain management and sports medicine and
rehabilitation medicine physician has familiarity with the placement
of needles for all parts of the body, and known dexterity. In my
case, I have more than twenty years experience with muscle, joint
and ligament injections. This experience, with my knowledge of
anatomy, empathy and aesthetic sense, greatly enhance my ability to
provide aesthetic Botox.
　
　
　

Ultra Sound And Sports Medicine

2010-05-14T12:43:00.000-07:00

Ultra Sound is proving to be an incredibly effective way of diagnosing and guiding treatment of sports and dance injuries. Unlike X-rays and CT scans, it does not exposes patients to radiation and is harmless, painless, non-invasive, and relatively inexpensive.
Sports injuries are most commonly caused by contusion arising from sudden or wrong movement, weight lifting, or falling down on the leg, arm or some other part of the body. Extremity muscles are more prone to injury because of the short tendon combined with a wide muscle body and fast contraction. The observable signs are pain, swelling , and function loss, but clinical examination, as good as it might be, does not allow complete assessment of the changes of the muscles, vessels and other soft tissues, which is why other diagnostic methods are needed;.
Here is how cutting edge Ultra Sound works. Muscle fibers are bound together with capillaries surrounded by fine connective tissue, with .muscle fascia spreading between muscle fibers, and, at the end, the muscle is transformed into a tendon. Ultra sound waves produce imagery that allows the diagnostician to visualize and differentiate with great precision these structures beneath the surface and even soft tissues. Once the problem is diagnosed, ultra sound can be used to guide injections and other treatments towards solving it.