About Phoenix Pain Management Multidiscipline Practice.A Phoenix pain management professional is a medical physician or doctor of Osteopathy who manages your pain caused by trauma, disease, or disorder. Although called Phoenix pain management also known as interventional pain management professionals, are typically anesthesiologists or doctors of physiatry. Phoenix pain management at Phoenix Pain Treatment Clinic is a multidisciplinary team consortium that includes your primary care physician or other treating physicians, and specialists in chiropractic, physical therapy, radiology, complementary alternative medicine, and other fields such as psychiatry, psychology, and even oncology. Education And Training Are Two Important Aspects Of All Our Phoenix Pain Management DoctorsAnesthesiology or physical medicine residency programs are the most common choices for doctors after graduating from medical school and completing a one-year internship. However, other fields such as neurology and psychiatry may also be considered for residency. Following completion of a residency program (which is typically three years in length), the doctor goes on to complete a one-year fellowship in pain medicine to receive advanced training. A large number of Phoenix pain management doctors are certified by the American Board of Pain Medicine. All of the organizations that certify anesthesiologists, physiatrists, neurologists, and psychiatrists are working together to provide the board examination for the Pain Medicine subspecialty. Specialists in pain management continue their medical education and training throughout their professional lives. Pain management specialists have a variety of options for keeping up with the latest technological and medical advances in the field, including attending society meetings and reading peer-reviewed scientific journals. Phoenix Pain Management ObjectivesManaging acute or chronic pain by reducing both the frequency and intensity of your pain is the ultimate goal of pain management medicine. An integrated pain management program may address your functional goals for activities of daily living, in addition to addressing your pain issues and other concerns. An overall goal of a pain management program is for you to feel better, be more active (including returning to work), and have less or no reliance on medication. Pain Is Treated For A Variety Of Reasons. Phoenix pain management doctors are trained to treat all types of discomfort. Acute pain is defined as severe or sharp in nature, and it may indicate that something is wrong. Acute pain is defined as pain that occurs immediately after a dental procedure. Chronic pain is defined as pain that lasts for more than six months. This type of pain can range in intensity from mild to severe and is recurring. Pain associated with spinal arthritis (spondylosis) is frequently chronic. Despite the fact that chronic pain is difficult to manage, combining various treatments frequently results in a favorable outcome.
What to Expect During a Phoenix Pain Management Appointment in ArizonaAppointments with pain management or interventional pain management doctors are very similar to other doctor appointments. However, despite the many similarities, the emphasis is on your pain, the cause or contributing factors, and quickly alleviating it or managing it. Pain medicine doctors conduct a physical and neurological examination as well as a review of your medical history, with particular attention paid to your pain history, before prescribing treatment. Many questions about your pain may be asked of you, including the following:
Most Phoenix pain management doctors employ a standardized drawing of the front and back of the body, which allows you to mark the locations of pain as well as the spread and type of pain you are experiencing (eg, mild, sharp). It is possible that you will be asked to complete the form each time you see the pain doctor. The completed drawing will aid in the evaluation of your treatment progress and outcomes. Accurate Diagnosis Is Critical to Successful Treatment Prescribed By Our AZ Pain Doctors.Pain medicine is concerned with determining the source or cause of discomfort. In order to make the proper diagnosis, you may be required to undergo an X-ray, CT scan, or MRI study in order to determine the source of your neck or back pain. During the course of treating spine-related pain (which may include symptoms in the arms or legs), other tests such as discography, bone scanning, nerve studies (including electromyography and nerve conduction study), and myelography may be performed. The ability to make an accurate diagnosis is critical to developing a successful treatment plan. It may be necessary to consult with other specialists in order to treat some spinal disorders and pain, including your PCP (primary care physician), radiologists, psychiatrists, psychology, oncology, nursing, physical therapy, and chiropractic physicians. Phoenix pain management doctors may consult with and/or refer you to a neurosurgeon or orthopedic spine surgeon in order to determine whether or not your pain problem requires spinal fusion or other forms of spine surgery. Phoenix Pain Management In A dedicated Spinal Pain Treatment Office The skillsets required for diagnosis and treatment are the building blocks of the profession. There are some essential tenets that can be used to gain a better understanding of the issues and then to develop a more successful management program. Each of these fundamentals is built on an underlying of concern, insight, and comprehensiveness. Understanding of differential diagnosis and physical examination, as well as the ability to know when to order and interpret additional tests, are the fundamentals of caring for a patient. Having the best referral medical professionals or therapists to assist with treatment is also essential, as is the ability to be a highly regarded and precise surgeon, if surgery is the preferred treatment option, is also essential. Patient satisfaction is, without a doubt, dependent on the success of the treatment. Phoenix Pain Management Doctors And Differential Diagnosis The ability to distinguish between possible diagnoses is critical. Dr. William Osler, a well-known Harvard physician, made an insightful statement that most doctors take to heart. In other words, “You see what is familiar and find what you seek.” In other words, if you don’t know what can go wrong, you won’t be able to locate it if it does exist. What causes pain or symptoms, and how to diagnose it, must be known by the caregiver [treatment provider]. Both the science and art of medicine are based on this concept. A patient can present with leg pain. The differential can include nerve pain, muscle pain, referral (sclerotomal) pain, spinal cord pain, and even poor circulation, or a blood clot. If the physician doesn’t think of the possibility of a blood clot, this could be a significant error. Even if the therapist had never had the experience of seeing a particular disorder, but has digested a significant amount of literature, he or she will be prepared to identify it. A physician has to be “on their toes” to be aware of possible misleading symptoms and have a good differential diagnosis. Diagnostic Competence Of Our Phoenix Pain Doctors Experience and comprehensive history and physical examination are the keys to diagnostic proficiency. It’s crucial to have a thorough history of the issues at hand. No, I don’t have a family history of back problems or even of non-back-related diseases like ulcerative colitis. In other cases, back pain may be caused by a comorbid condition and require a different approach to treatment. The treatment for psoriasis (a common skin condition) differs because of the potential spinal complications that can arise. In addition, it is necessary to find out whether there are any legal difficulties, such as car accidents or employment histories, and who may be to blame. Legal difficulties can cast a shadow over the past, necessitating specialized care. A thorough assessment of an individual’s health is critical. Most diagnoses for lumbago or sciatica are based only on the patient’s medical history. Physical Examination When Experiencing Pain The physical examination must be thorough, and the examiner’s abilities are critical. Light can be shone on the tiny differences between various illnesses by looking at “shades of gray.” When a patient is experiencing pain, a diagnostician may need to distinguish between the plus-2 and the plus-1 reflexes, even if this may be a little different. The ability to conduct a thorough exam requires practice, attention to detail, and patience. To be a good examiner, you need to be careful. A patient who had been experiencing leg discomfort and hurting for six weeks recently came into the office. This patient was also a chiropractor, and he or she was thinking about nerve discomfort based on the symptoms, which we also assumed. The patient had no pulse in the affected leg during the exam, despite the presence of probable nerve root pain. As it turns out, his leg was riddled with blood clots. This diagnosis could have been missed if the doctor hadn’t been careful enough in monitoring pulses. Arizona Pain Center Confirmatory Testing Additional tests (if any) can be used in conjunction with the original impression, and this is the second skill set (presumed diagnosis). A person must be able to order the correct tests as well as analyze the findings of those tests correctly. Interpreters (for example, radiologists) may not know how to interpret data if they don’t have all the clinical information. It’s possible that the results of the tests will reveal information that’s ambiguous. The studies that use imaging of the spine include:
Our AZ Pain Doctors Educate You About Your Specific Pain Expression The third and most critical quality is the ability to educate the patient about their basic disease. Patients need to be able to interpret the information in a way that is simple and straightforward. Using visual aids if necessary, this information must be given to the patient in an understandable manner. Treatment will be less successful and patient expectations for success will be clouded if a patient is unable to understand and appreciate the condition. Disabling low back pain is often shrouded in secrecy and misunderstood. Education solves this enigma and reduces the anxiety of uncharted territory. Treatment Protocol Technique Phoenix Low Back Pain Doctor Our pain doctors are highly skilled in creating a treatment plan that is reasonable, effective, and appropriate for you and your loved ones. We don’t prescribe a one size fits all treatment plan. Our Phoenix pain management doctors have unique skill-prescribing treatment protocols that will match your personal concerns as well as your personality. Even surgery may be necessary if all other options have failed or are too risky to try. Expense-effectiveness in treatment is essential due to the high cost of medical care, which continues to rise year after year. You can trust that at Phoenix Pain Treatment Center in West Phoenix AZ, our pain management doctors are very adept at ordering additional diagnostics or therapy in an interdisciplinary environment. It’s not uncommon for a chiropractic physician to act as a quarterback and make several referrals and even to a spine surgeon or a neurosurgeon. from https://phoenixpaintreatment.com/phoenix-pain-management-in-arizona/
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Medial Branch Block Vs Facet Joint InjectionSeveral different types of pain blocks are available at our Phoenix pain management clinic; how can you tell them apart? Facet pain blocks and medial branch pain blocks are two of the most common. A facet pain block is a spinal joint injection of anesthetic and steroids. A medial branch pain block is similar to a lateral branch pain block, except that the medication is injected outside the joint and closer to the nerves (the medial branch nerves). A steroid may or may not be used in medial branch pain blocks. These pain blocks are frequently used in patients who suffer from back pain, which is frequently caused by arthritis and/or mechanical lower back pain. Multiple injections may be necessary depending on the number of affected joints. Additionally, pain blocks can be diagnostic, therapeutic, or a combination of the two. These techniques can be used as diagnostic tools, as a pain block can indicate to a pain specialist whether the pain is coming from a pain-blocked facet joint. In other words, if the pain persists after the pain block is placed, the facet joint is ruled out as a possible source. An Overview of Pain ManagementPain management is a branch of medical practice that touts the reduction of pain. Pain management covers a wide range of conditions, including neuropathic pain, sciatica, postoperative pain, and more. Pain management is a burgeoning medical specialty that utilizes a multi-disciplinary approach to treating all kinds of pain. Pain management doctors treat people in pain by evaluating a patient to determine which pain treatment protocol would be best before prescribing rehabilitation protocols. Since pain management doctors utilize a multi-disciplinary model, they typically refer to Doctors of Chiropractic for spinal and manual adjustments or to a Physical therapist for rehabilitative exercises. Your general medical doctor may refer you to pain management when your pain is significant and ongoing. Medical physicians who specialize in pain management understand the complexities of pain, and a pain physician approaches the problem holistically. While treatment at a pain clinic should ideally be patient-centered, this may not always be the case due to the clinics’ limited resources. There are currently no established standards for the types of disciplines that must be included, which is another reason why treatment options vary between clinics. This article hopes to explain the difference between the Medial Branch Block Vs Facet Joint Injection. Goals of Pain ManagementWhile some types of pain can be chronic, such as headaches and others acute, we focus on auto accident injuries. Our pain management protocols specifically address the root underlying cause of your pain. This allows for the application of science and the latest advances in medicine to relieve your pain. “we now have many modalities, including medication, interventional pain management techniques, nerve blocks, Facet blocks, Trigger point injections, along with Chiropractic Care and management to help reduce your pain. The goal of pain management is to minimize pain rather than eliminate it. Integrating pain management with chiropractic adjustments provides a potent one-two punch at correcting your pain’s underlying root cause of your pain. This is because quite often, it is not possible to do away with it completely. Two other goals are to improve function and increase the quality of life. These three goals go hand-in-hand. Look for a clinic with a specialist who knows about your kind of pain. Ask if the doctor has had special training and is board certified in pain management. As with other doctors, you should also try to find someone you feel comfortable with. Your pain management specialist will treat your pain and coordinate other care, including physical therapy, rehabilitation, and counseling. A good pain program will work with you and your family to create a plan based on your goals. It will monitor your progress and tell you how you’re doing. Back And Neck Pain ProceduresAuto accidents can result in various symptoms throughout the body, depending on the mechanism of injury. Neck, mid-back and lower back pain are all common symptoms, with or without radiating symptoms down the arms and legs. After an auto accident, an initial exam is highly recommended to assess each part of the body and prevent permanent damage to the spine and nerves. Early intervention, such as epidural steroid injections or medial branch blocks, can help prevent pain from becoming chronic, thereby avoiding the need for future invasive surgeries and procedures. At Phoenix Pain Treatment Clinic in West Phoenix, Arizona, our pain specialists conduct thorough examinations and utilize state-of-the-art diagnostic testing to gain a clear picture of a patient’s injuries and how they can help reduce their symptoms with the least amount of invasive treatment possible. If you or a loved one have been involved in a car collision, you must ask your medical doctor and chiropractor the difference between a Medial branch Block Vs. and Facet Joint Injection. Facet Joint Injection ProcedureAs is the case with many spinal injections, facet joint injections are best performed with the assistance of fluoroscopy (live x-ray) to ensure proper needle targeting and placement (and to help avoid nerve injury or another injury). Facet joint injections and medial branch blocks typically contain two types of medication: a local anesthetic (which relieves pain) and a steroid (which helps to reduce swelling and inflammation). Facet joint injections and medial branch blocks both work similarly but are administered in different locations within the joint. Your doctor will inject a local anesthetic and steroid directly into your facet joint during a facet joint injection. This is done to help alleviate inflammation in the joint space. A medial branch block involves injecting a local anesthetic and steroid directly into the nerves in your facet joint that transmit pain signals to your brain. This will temporarily halt the nerve’s transmission of pain signals. The Goal Of A Medial Branch BlockBy numbing the medial branch nerves, a medial branch block can aid in diagnosing whether or not the source of your pain is the facet joints. If the medial branch block alleviates your pain, the source of your pain is more than likely a facet joint. Medial branch blocks are used to determine whether your pain originates in the facet joints and whether radiofrequency ablation (RFA) may help alleviate your pain. A medial branch block is a procedure in which your pain management specialist uses an anesthetizing drug to briefly stop the medial branch nerves from transmitting pain signals to your brain. If a facet joint problem causes your pain, a medial branch block may provide temporary relief. If you get significant pain relief through this temporary medial branch block, then you may be a candidate for RFA, which is a longer-lasting interruption of nerve impulses from the medial branch nerves. A Brief Description Of The Lumbar Medial Branch Block And Facet Injection ProcedureWhat to expect during a lumbar medial branch or Facet Injection block procedure is as follows:
Immediately Following the InjectionFacet joint injections can be life-changing for millions of people who suffer from lower back pain. Back pain sufferers can experience months of relief with this minimally invasive procedure. The injection may be beneficial if the problem is specific to the facet joints. Otherwise, alternative therapies may be necessary. Consult a physician immediately for an evaluation and treatment of lower back pain. However, as explained throughout this explanation of Medial branch Block Vs Facet Joint Injection, you may have to endure both procedures. Although most side effects of a medial branch block are uncommon, they do occur. It is common to experience temporary discomfort at the injection site. Certain patients report feelings of weakness or numbness. Occasionally, a minor infection at the injection site develops in a small number of patients. In a much smaller proportion of patients, medial branch block exacerbates pain. If you experience any unusual side effects, contact your doctor immediately. You may experience decreased pain immediately following the injection. However, this is only a temporary fix until the medication takes effect. This can take between two and seven days following the injection. If the initial injection is effective at controlling your pain, your doctor may perform additional injections. Remember that comparing the results of your Medial branch Block Vs Facet Joint Injection can make all the difference in the world for true, long-lasting pain relief. The amount of relief depends on the nature of your pain, and because the spine contains a variety of pain receptors, the injections’ long-term effects cannot be predicted. Because everyone’s pain is unique, the effectiveness of treatment will vary. The effectiveness of Medial branch Block Vs Facet Joint Injection can also vary, but that is the best way to determine your pain management journey. The Week after the Facet InjectionFacet joint injections and medial branch blocks have varying success rates. According to studies, up to 92 percent of patients experience pain relief for a brief period of time, typically 1 to 4 weeks after the injection. However, symptoms may or may not recur over time. Certain patients may require additional injections to maintain relief, while others may experience complete resolution or long-term pain relief. In individuals who experience temporary pain relief from facet joint injections, these injections can provide a window of opportunity to progress with physical therapy and other therapies. Strengthening and rehabilitating the neck or back may result in improved function and long-term pain relief. Typically, within a one to four-week period, our pain management specialists must determine which procedure or protocol is the superior choice by comparing Medial Branch Block Vs. Facet Joint Injection. You can usually resume your normal activities the next day following a facet joint injection. Indeed, some people return to work the following day. There are, however, a few things to keep in mind in the days and weeks following your injection. You should avoid strenuous activity for a few days following the procedure. Instead, gradually increase. It’s prudent to avoid driving for the first 24-48 hours. After the numbing anesthetic wears off, you may experience an increase in pain. from https://phoenixpaintreatment.com/medial-branch-block-vs-facet-joint-injection-for-pain-relief/ The Nervous System’s Mechanisms for Detecting and Interpreting Chronic PainHow does your brain determine when you are experiencing pain? How does it distinguish between the gentle touch of a feather and the prick of a needle? And how does that information make its way to your body in time for it to react? How is acute pain transformed into chronic pain? These are not straightforward responses, but with a brief explanation of how the nervous system works, you should be able to grasp the fundamentals. What the Nervous System Is Responsible ForThe nervous system is composed of two major components: the brain and spinal cord, which together comprise the central nervous system; and sensory and motor nerves, which comprise the peripheral nervous system. The names help visualize the concept: the brain and spinal cord serve as hubs, while sensory and motor nerves branch out to provide access to all areas of the body. Simply put, sensory nerves transmit information about our environment to the brain via the spinal cord. The brain communicates with the motor nerves, which assist us in performing actions. It’s as if you have a highly complex inbox and outbox for everything. The Nerves’ Role in the Identification of Chronic Pain SignalsAs an example, suppose you step on a rock. How does a sensory nerve in the peripheral nervous system determine that this is not a soft toy? Different sensory nerve fibers respond differently to different stimuli and produce chemical reactions that influence how sensations are interpreted. Certain nerves transmit signals in response to light touch, while others respond to intense pressure. When there has been an injury, or even a potential injury, such as a break in the skin or a large indentation, specialized pain receptors called nociceptors activate. (Nociceptors are responsible for sending signals to the spinal cord and brain when there is potential damage to the body.) Even if the rock does not penetrate your skin, the compressed tissues in your foot cause the nociceptors to fire. Now, an impulse is traveling through the nerve and into the spinal cord, eventually reaching the brain. This occurs in a matter of fractions of a second. The Spinal Cord’s Function in Pain Response In Acute or Chronic PainYour spinal cord is a complicated network of nerve fiber bundles that transmits a variety of signals to and from the brain at any given time. It functions similarly to a highway for sensory and motor impulses. However, your spinal cord is capable of making some basic decisions on its own. These “decisions” are referred to as reflexes. The dorsal horn of the spinal cord serves as an information hub, simultaneously transmitting impulses to the brain and returning them down the spinal cord to the area of injury. The brain does not need to communicate to your foot to move away from the rock because the dorsal horn has already done so. If the brain serves as the body’s CEO, the spinal cord serves as middle management. The Brain’s Role in Pain InterpretationWhile the spinal reflex occurs at the dorsal horn, the pain signal is transmitted to the brain. This is because pain is more complex than a simple stimulus-response relationship. Simply removing your foot from the ledge will not resolve all of your issues. Regardless of the severity of the injury, the tissues in your foot must be repaired. Additionally, your brain requires time to process what has occurred. Your brain catalogs pain, and emotions become associated with stepping on that rock. When a pain signal reaches the brain, it is directed by the thalamus to one of several different areas for interpretation. Several areas of the cortex determine the source of the pain and compare it to other types of pain with which it is familiar. Was it precise? Was the pain greater than stepping on a tack? Have you ever stepped on a rock, and if so, how was the experience? Was it better or worse? Additionally, signals are sent from the thalamus to the limbic system, the brain’s emotional center. Have you ever wondered why certain types of pain make you cry? The limbic system makes the decision. Each sensation you encounter is accompanied by feelings, and each feeling elicits a response. Your heart rate may accelerate, and you may begin to perspire. All because of a rock beneath your feet. Additional Factors Affecting the Pain ResponseWhile it may appear straightforward, the process of pain detection is complicated by the fact that it is a two-way street. It is not even a bidirectional system. Pain is more than a simple cause and effect relationship. It is influenced by the rest of the nervous system’s activity. At any given time, your mood, your prior experiences, and your expectations can all influence how pain is perceived. How’s that for perplexing? If you step on that rock following a disagreement with your wife, your reaction may be quite different than if you’d just won the lottery. Your feelings about the experience may be tainted if your foot became infected the last time you stepped on a rock. If you’ve previously stepped on a rock and nothing terrible happened, you may recover more quickly. You can see how different emotions and experiences can influence how you react to pain. Indeed, a strong correlation exists between depression and chronic pain. When Acute Pain Develops Into Chronic Pain In this case, once your foot has healed, the pain sensations will cease. This is because the nociceptors have lost their ability to detect tissue damage or injury. This is referred to as acute pain. Acute pain does not persist following the healing of the initial injury. However, occasionally, pain receptors continue to fire. This can be caused by a disease or condition that causes damage on a continuous basis. With arthritis, for example, the joint is constantly in disrepair, resulting in rapid transmission of pain signals to the brain. Occasionally, nociceptors will continue to fire even in the absence of tissue damage. Although there is no longer a physical source of pain, the pain response remains the same. This complicates the diagnosis and treatment of chronic pain. from https://phoenixpaintreatment.com/chronic-pain-101/ Whiplash, Axial Pain And Ligamentous InstabilityIn this article we going to talk about whiplash and axial pain because that is a common health issue that patients often call us about as a result of a whiplash experience. More often than not people that have suffered whiplash trauma are really struggling with Axial Pain years after the accident, like headaches and neck pain. They may say, Oh my gosh, my ears ring. I am dizzy. I have brain fog. My balance is off. In more severe cases, I have difficulty swallowing. My voice is getting worse. My tongue goes numb and really a long list of symptoms occurs post whiplash that many healthcare and the public in general just do not associate with whiplash. What is Axial Pain?Axial Pain is a type of mechanical pain that expresses itself in one specific area, spot, or region of your body. Axial pain can be depicted as dull, sharp, comes and goes, throbbing, tight, or burning. The no 1 axial pain description of whiplash is muscle tightness; however, whiplash is more expansive than muscle tightness. Spinal Ligament instability is the No 1 Cause of disability in the United StatesWhen you actually suffer significant ligament damage in your neck that then renders your neck unstable. Think of all your ligaments throughout your whole body as well, basically rubber bands that hold your skeleton together. And if the rubber bands are too loose or they are too stretched out in your neck, your vertebrae are going to shift and move more than what is considered normal. I actually had a patient describe her neck movement following whiplash injury as “I feel like a bobble-head”. Ligament Instability can actually your vertebrae shift enough that they press on adjacent nerves or blood vessels, or anything mechanical that might actually contribute to those symptoms that I listed before. More often than notw hiplash victims that suffer whiplash, right after the accident they will go to a chiropractor or physical therapy and even undergo other kinds of treatments but they quit the minute they are feeling better or feel less pain. Without Complete Treatment Over Time Your Symptoms Will ReturnWithout complete treatment over time your condition can actually get worse and become more disabling as times go on. This will also set in motion the process of Osteoarthritis in a galloping rate. Many specialists, neurologists and other healthcare experts are not trained to look for and diagnose spinal ligament instability. Meaning if you do not know what you are looking for how can you find it? What If Your “Specialist” Treatment is not improving the Functional Movement Of Your Spine Doesn’t it make sense that if none of those treatments are helping or worse yet your symptoms returned after completing your “specialists” treatment that you have to look a little farther and say, okay, what’s actually going on to the soft tissue integrity of my neck after this injury. Most people think of whiplash like, “Oh, I, I got in this huge car accident, I injured my neck” my car was totaled so I must have severe whiplash. The truth of the matter is amount of damage your car suffered does not equate to the amount of tissue damage you suffered. The idea that since you were in a “little fender bender” and there was little damage to my car, so I did not really suffer whiplash or any injuries at all is just not clinically sound. Here Is Why You May Have Suffered Spinal Ligament InjuryThe way our soft tissue system is set up is a virtual miracle. Everything in your neck except for the bones or vertebra is considered soft tissue which includes all non-bone tissues this includes but is not limited to the following muscles, ligaments, tendons, blood vessels, disc tissue, lymph tissues any organs such as your throat. The muscular system which attaches to your bones by tendons has a series of “circuit Breakers” as do the ligaments in your neck (and the rest of your body). Typically, when someone is involved in an Auto collision their neck muscles as well as most of the spinal muscles are in a relaxed state. Actually, so are the spinal ligaments except the fact that your ligamentous system is always on duty or on guard. But the spinal ligament system was not intended to absorb this type of trauma and physically is unable to absorb the super-fast high force trauma of a collision of any type. Especially the forces created by an car collision. The muscular system is what protects your spine and more often than not when you are in an car wreck your muscular system was in a relaxed state or non-tension state of relaxation. Meaning your muscular system was not tensed up in protection mode prior to the hit/impact leaving your ligament system prey to the forces of car collision trauma. Just so you know even though you might have time to tense up your muscles if you see the accident coming you can still suffer ligamentous damage. There are so many factors that play a role in the damage of your spinal ligaments like was your head turned upon impact, were you looking downward at your cell phone at impact, were you leaning forward to change the radio station or worse yet were you leaning forward to pick up your cell phone? All of these pre hit posture can affect how much damage you incurred upon impact. The most common injury to the spine is a ligament injury, called a sprain. The ligaments hold the spine in alignment under load, and when they are damaged, they can cause misalignment of the spine, pain (both local and referred) and most importantly this ligament damage can cause a corruption of the body’s ability to accurately coordinate spinal muscle response. The muscles stabilize the spine during your activity and if they are not online at the proper time, instability, dysfunction, and significant impairment can ensue, i.e., you cannot perform the task without either weakness or pain. This is called spinal instability. Here is A List Of Spinal Ligament Instability of The Cervical Spine
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The Nuestra Señora del Rosario Polyclinica in Ibiza, Spain announced the Medical Team is utilizing Ozone therapy in treating Covid-19 patients with promising clinical success.Their most recent Press release stated, “Many patients who were about to be intubated and connected to mechanical ventilation have, thanks to ozone therapy, not only avoided it but improved to the point of not requiring oxygen with just a few treatment sessions.” “We are seeing improvements in Covid 19 patients after just 2 or 3 treatment sessions. Ozone therapy has the benefit of improving oxygenation at the tissue level and therefore reducing the inflammatory response brought on by the Corona Virus. Representatives of Nuestra Señora del Rosario Polyclinic were quoted: “In Spain, only we have begun to administer it with the mandatory authorization of the Quality Committee of the hospital centre, and the results have been spectacular,” says Dr. Alberto Hernández, Assistant Physician for Anesthesia and Resuscitation at the Nuestra Señora del Rosario Polyclinic in Ibiza. “We have registered a clinical trial, but we need to tell the world that Ozone is a very effective and beneficial therapy in these patients and that we must immediately incorporate it into the treatment of these patients.” Dr. José Baeza, President of the Spanish Society of Ozone Therapy and Vice President of the World Federation of Ozone Therapy, states that “given the absence of an effective treatment or a vaccine and in the context of the current health emergency ” All hospitalized patients should receive Ozone therapy as the clear benefit is evident, and Ozone therapy has no significant side effects.” Nuestra Señora del Rosario Polyclinic Received Approval On April 4th, 2020 Following a presentation on the potential benefits of Ozone therapy at a medical scientific session, the Centre’s group of experts in Covid-19 infection: Drs Montserrat Viñals and Asunción Pablos, from the Internal Medicine service, Dr. Adriana Martín from the Service of Intensive Medicine, and Dr. María Victoria Velasco from the Emergency Service of the Nuestra Señora del Rosario Polyclinica in Ibiza, gave their approval to the protocol for the administration of Ozone in patients with Covid-19 presented by Dr. Alberto Hernández. The First Covid 19 Ozone Therapy PatientA 49-year-old man who was in ICU admission, was deteriorating rapidly and the doctors knew his lungs were oxygenating poorly. Although Intubation and connection to a ventilator was scheduled, but amazingly, after the first session of Ozone therapy, the improvement was significant and oxygen requirements could be decreased. Dr. Alberto Hernández explained that “the improvement after the first session of Ozone treatment was spectacular. We were surprised, his respiratory rate normalized, his oxygen levels increased, and we were able to stop supplying him with as much oxygen since the patient was able to oxygenate himself. To our surprise, when we carried out an analytical control, we observed how Ferritin, an analysis determination that is being used as a prognostic marker in this disease, not only had not followed the upward trend, but had decreased significantly; that decline continued in the following days. This result encouraged us to administer it to other patients who are following the same improvement as our first patient. “ The post Ozone Therapy Showing Clinical Success For Covid-19 Patients appeared first on Phoenix Chiropractor. from https://phoenixpaintreatment.com/ozone-therapy-showing-clinical-success-for-covid-19-patients/ Corona Virus Ventilator Protocols Are Just Not Working.Is it possible that ventilators for Covid 19 are in fact causing more harm than good? Governor Cuomo has stated in his briefings that the longer the patient is on a ventilator the more likely they will not come off the ventilator. New York city representatives have stated that approximately 80% of Corona virus patients who are on ventilators have died. So, What does a ventilator do for you?A ventilator is a machine that uses forced air and oxygen, essentially this machine causes forced breathing. If a patient lapses into critical illness intensive care protocols recommend ventilation via a ventilator. The patient is also sedated while on the ventilator. Meanwhile Covid 19 which has a propensity to attack the lungs and continues to so. The sedation decreases your immune system while your lungs are actually trying to increase their innate immune response to fight off the viral infection.
It appears that lung response to Covid-19 Is more like a high-altitude sickness where the person just unable to get enough oxygen. At high altitude, there is less oxygen in the air that you breathe. This means that all of the blood from all areas of the lungs, is relatively short on oxygen or hypoxic. Unfortunately, the lungs still respond to the shortage of oxygen in the same way: by tightening the blood vessels. This results pulmonary edema and the lung response is hyperventilation and elevated heart rate, in attempt adequately supply oxygen to your tissues. The problem is that the lung tissue immune response to Covid 19 causes a cascade of secretions that are typically not present in Pneumonia. The response of the lungs but is more like you were at the top of Mt. Everest and you couldn’t breathe. Your lungs actually fill with secretions and you are gasping for oxygen. It gets worse as time goes on, you really can’t oxygenate your blood, even with the ventilator, so your Oxygen levels are very low. Your lungs eventually become very fragile and the high pressure of the ventilator causes further damage to the lungs. A cat scan of the lungs at this time will show a “ground glass” like appearance of the lung tissue. This is caused by the patient’s response to oxygen starvation. There is a distinct possibility that the high pressure from the ventilators may actually be causing this reaction to be much worse. Especially considering that the lung tissue is in a weakened state of being. Concurrently, this causes your blood oxygen levels to drop to 40 or 50 when they need to be at 95 to 100%. Did I mention while all of this is happening Covid 19 wants your hemoglobin for its food source?Hemoglobin is what allows oxygenation of your blood stream. Your red blood cells carry O2 in the form of hemoglobin which is a protein that attaches to iron. When you loose iron (FE) you lose your ability to carry oxygen. You are starving for oxygen, your losing iron which secrets through your lung tissues and causes an oxidative reaction and a massive inflammatory cascade of free radicals which leads to scar tissue formation. This is also called a cytokine storm. Also Free iron in the body is very, very toxic and dangerous. This is one of the things that’s creating the ground glass like appearance in the lungs.
There Are No Specific Medical Protocols For Viral Pneumonia. Bring on Ozone TherapyOzone therapy utilizes (O3) ozone, a colorless gas made up of three oxygen atoms. Ozone therapy has been in use and studied for over 150 years. Ozone therapy can be delivered by insufflation, barometric transfusion, IV delivery and direct injection, to treat a variety of health issues. Ozone therapy activates, improves and modulates the immune system improving Oxygen uptake by the bloodstream. Ozone is a very strong antiviral sometimes working in seconds once introduced to the human body. Let’s discuss how Ozone works as an antiviral. Think of yourself as a virus trying to get into a cookie jar which represents your cells. Imagine your fingers as you reach to pull the lid off the cookie jar (Your cells) as the components of the virus that penetrate into your cells. These “fingers” are made up of certain amino acid residues, especially cysteine and tryptophan. These viral fingers are bonded to the virus by a substance known as sulfhydryl & Thiol groups. Think of these as your knuckles. These knuckles are very vulnerable to oxidation and in actuality Ozone therapy is oxidation at it’s best. So, the Ozone therapy actually cuts the fingers right off at the knuckles and therefore they can’t enter your cells. Plus, the rest of the virus or viral proteins are left behind, and your immune system will recognize these proteins as foreign and will develop anti bodies against those viral proteins. Bring on Hydroxychloroquine- How does it help?Hydroxychloroquine is an anti-malarial drug that acts to allow zinc to enter your cells and disrupt the virus from replicating itself and also works to prevent the virus from stealing your hemoglobin. Most importantly Hydroxychloroquine is purported to suppress the innate immune response by the lungs as described above. So, your bodily reaction to Covid 19 is actually a hyper response by your immune system. So much so that the immune system over modulates and becomes almost ineffective and looses its ability to self-regulate and Hydroxychloroquine is claimed to calm this hypersensitive immune response so that your immune system can then work against the cytokine storm. This drug has been in use for about 70 years and is inexpensive. You Can Contact the Author Dr. John Quackenbush here.
DISCLAIMER: There are no clinical studies that proves Ozone therapy and/or Hydroxychloriquine are a cure for Corona Virus infection. Ozone Therapy is not approved by the FDA
The post 80% of Covid 19 Infected Patients Die With Ventilator Protocols appeared first on Phoenix Chiropractor. from https://phoenixpaintreatment.com/80-of-covid-19-infected-patients-die-with-ventilator-protocols/ Facet joint syndrome.This condition is a deterioration of the Facet joints, which help stabilize the spine and limit excessive motion. The Facet joints are lined with cartilage and are surrounded by a lubricating capsule that enables the vertebrae to bend and twist. Facet Joint syndrome occurs when the Facet joints become stressed and damaged. This damage can occur from everyday wear and tear injury to the back or neck or because of degeneration of an intravertebral disc. The cartilage that covers the stressed Facet joints gradually wears away. The joints become swollen and stiff. The vertebral bones rub directly against each other, which can lead to the growth of bone spurs along the edges of the Facet joint. Pain from Facet joint syndrome differs depending on which region of the spine is damaged. If the cervical or upper spine is affected, pain may be felt in the neck, shoulders, and upper or middle back. The person may also experience headaches if the lumbar or lower spine is affected. Pain may be felt in the lower back buttocks and back of the thigh. For set. Joint syndrome is first treated conservatively with rest, ice, heat, anti-inflammatory medications, and chiropractic therapy. In addition, Facet joint blocks or injection may be administered not only to diagnose Facet joint pain, but also to treat it. If nonsurgical methods fail to relieve pain, manipulation under Anesthesia should be performed. Facet Joint Frequently Asked Questions:What is the purpose of facet injections? A facet joint injection may be done to help diagnose the facet joints as the source of the patient’s pain, as well as to provide pain relief. Facet joints are pairs of small joints in between the vertebrae in the back of the spine. How long do facet injections last? There is an immediate effect from the local anesthetic which wears off over a few hours. The cortisone starts to work in about 3 to 7 days and it can last up to a few months. Several injections may be necessary over a period of a few weeks to 6 months. Is facet joint injections painful? A facet joint injection is a shot of medicine to help with pain from arthritis. The injection goes into your neck or back. … Problems in these joints can cause long-term (chronic) pain in the neck or back. Sometimes the pain is in the shoulders, arms, buttocks, or legs. Where is the facet joint located? Vertebral body, the bony building blocks of the spine. Facet joint, small stabilizing joints located between and behind adjacent vertebrae. Inter vertebral disc, which provides a cushion between each of the vertebral bodies and binds them together. What Can I expect From A Facet Injection? After the procedure, the patient typically remains resting in the recovery area for twenty to thirty minutes, and then is asked to perform some movements or activities that would usually provoke their pain. Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether or not the joints targeted are the main source of their pain. If the joint or joints being targeted are not causing their pain, a patient will not obtain immediate relief from injection. On occasion, patients may feel numb or have a slightly weak or odd feeling in their neck or back for a few hours after the injection. How often can you get facet joint injections? Facet joint injections are generally limited to three within a six-month time frame. In many instances, only one or two injections are required to obtain benefit. Radiofrequency neurotomy or denervation is usually effective after one treatment. Radiofrequency may be repeated every one to two years, if necessary. Is facet joint pain permanent? For hundreds of thousands of people who suffer with chronic back pain due to facet arthritis, there is a treatment breakthrough that is completely noninvasive and can bring fast, permanent pain relief. … Inflammation and bone spurs can occur, causing acute pain. Headaches and muscle pain are common complications. What is the purpose of facet injections? A facet joint injection may be done to help diagnose the facet joints as the source of the patient’s pain, as well as to provide pain relief. Facet joints are pairs of small joints in between the vertebrae in the back of the spine. What aggravates facet joint pain? A car accident, sports injury, or a fall can damage one or more of the facet joints, leading to facet arthropathy. Wear and tear on the facet joints. Heavy lifting, improper posture, and disc problems are some of the factors that can cause the cartilage to wear down. Can facet joints cause nerve pain? Facet joint degeneration can be painless until an event triggers symptoms. … Facet joint symptoms may also mimic the pain of a disc herniation. Pain may be felt down the arms or legs if bone spurs form and press on the spinal nerves. What medication is used in Facet injections? A facet joint block or injection is a minimally invasive procedure in which a physician injects a small amount of local anesthetic and/or medication to numb a facet joint and provide pain relief. Fluoroscopy, a form of real-time x-ray, or CT is used to guide the placement of the needle into the facet joint. Are facet injections safe? As with all invasive medical procedures, there are potential risks and complications associated with facet joint injections. However, in general, the risk is low, and complications are rare. Potential risks and/or complications that may occur from a facet joint injection include: Allergic reaction. Can a chiropractor help facet joint pain? Recent research shows that spinal manipulation of the type chiropractors does and in combination with exercises is the most effective treatment for both acute and chronic facet joint pain. Chiropractors advocate dealing with the underlying neurological, mechanical and muscular problems. What are symptoms of facet joint problems? Pain, numbness, and muscle weakness associated with facet joint syndrome will affect different parts of your body depending on which of your nerves are being affected. If the nerves affected are in your cervical spine, you may have symptoms in your neck, shoulders, arms and hands. Can facet joint cause hip pain? Facet pain from these joints is quite common. Pain is usually felt directly over the affected joints, but may also be felt in the buttocks, hips, groin, and back of the thighs depending on which facet joint is injured. Are medial branch blocks the same as facet injections? A facet block is an injection of local anesthetic and steroid into a joint in the spine. A medial branch block is similar, but the medication is placed outside the joint space near the nerve that supplies the joint called the medial branch (a steroid may or may not be used). Will facet injections help sciatica? A facet injection is a minimally invasive treatment option for back pain caused by inflamed facet joints, which may develop from spinal stenosis, sciatica or arthritis, and is characterized by neck, arm, low back or leg pain. … The steroid reduces inflammation and can relieve pain for a few days to a few years.
The post Facet Injections Vs Facet Manipulation Under Anesthesia appeared first on Phoenix Chiropractor. from https://phoenixpaintreatment.com/facet-injections-vs-facet-manipulation-under-anesthesia/ Many Car Accident Victims Endure Pain And Physical Issues.At Phoenix Pain Treatment our clinicians specifically examine for trigger points which can cause pain and suffering. In this article we hope to shine some light on how actively treating your trigger points will decrease your pain, allowing the affected muscles to relax and help to heal your injuries. A trigger point is a small but highly concentrated muscle spasm which can actually be felt as a small lump or nodule. Pushing on this nodule typically produces pain that can be quite intense. Trigger points can exist in any muscle in your body. More often than not there will be several trigger points in the same muscle or muscles that over lap one another. Whiplash and Trigger PointsTypically following auto accident trauma, especially whiplash injury trigger points can be found on both sides of your body. In the case of whiplash, they can be found in the neck muscles as well as the muscles that connect to the neck from the shoulders. Trigger point cause your muscles to fire and spasm and a muscle that is in spasm is in a weakened state and therefore is not functioning properly. Restricting the muscles range of motion. Trigger point typically cause pain but sometimes are not painful until pressed on. Trigger point pain will refer to different area of your muscles. This is called referred pain and referred pain can make diagnosing and managing trigger points difficult. Referred pain typically follows certain patterns that are well documented. Let’s take a closer look at the trigger point. The trigger points can be palpated by the trained physician, but you have to know what you are looking for in order to find it. That is why we place trigger points in the “Underlying or hidden Injuries” category. To understand how these seemingly tiny nodules can affect the entire functional capacity of your muscles we have to discuss some anatomy. So think of a muscle as a group of bundles of straws and each straw is wrapped in plastic cling wrap. Then take 2 or 3 or those individual straws and wrap them in plastic wrap. Now do this several times. So each straw is now called a Sarcomere and the plastic wrap is now protecting and connecting the Sarcomeres. Now let’s add blood vessels like arteries and veins and of course your nerves. So a trigger point would form between the Sarcomere (the straw) and the protective coating (The plastic wrap) which added all together makes up your muscle. In this environment everything is very neatly packaged, and the trigger point causes your anatomy to change and it irritates the Sarcomere and their coverings and causes the nerves to fire giving you pain. When your doctor palpates (or feels) the trigger point immediate referral of pain occurs. Trigger Points And Your Nervous SystemThe trigger points cause the micro anatomy of your muscles (Sarcomeres) to stay in a spastic state giving off pain signals to your brain and your brain in turn tells the muscle to shut down. It is really a cascade of decreased oxygen, nutrient starvation and waste product builds up because everything is just not functioning correctly. It gets even worse as the trigger point continues your muscle actually shorten and can become even tighter and more painful. More often than not trigger points will not just go away on their own. The first line of management of trigger points is to massage the trigger points in order to help them release. This can be very painful for the accident victim to endure. The idea is to massage the trigger point area to increase blood flow and with that comes increased oxygen and nutrition and hopefully getting the waste products to move out of the area. When this does not occur our Chiropractic physicians will refer out for Trigger Point injections. The idea is to get the trigger point to release and sometimes this takes a concerted effort for both chiropractic and interventional pain management to get the trigger points to release. So the interventional pain medical doctor injects the trigger point with anti-inflammatory and pain relieving medications. Don’t worry injection uses a very tiny needle and is not very painful at all. There is typically immediate decrease of pain and tightness. You would then go back to your conservative physical medicine delivered by your chiropractor. Trigger points will require 1-2 injections. If you or a loved one have been involved in an auto accident it is likely that you may have trigger points in the muscles surrounding the affected area. Give us a call today.
The post A Brief Explanation Of Trigger Points In Auto Accident Victims appeared first on Phoenix Chiropractor. from https://phoenixpaintreatment.com/a-brief-explanation-of-trigger-points-in-auto-accident-victims/ What is Manipulation Under Anesthesia?Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed while the patient receives anesthesia (usually general anesthesia or moderate sedation). Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion. Anesthesia or sedation is used to reduce pain, spasm, and reflex muscle guarding that may interfere with the delivery of therapies and to allow the therapist to break up joint and soft tissue adhesions with less force than would be required to overcome patient resistance or apprehension. MUA is generally performed with an anesthesiologist in attendance. MUA is an accepted treatment for isolated joint conditions such as arthrofibrosis of the knee and adhesive capsulitis (frozen Shoulder). It is also used to treat reduce fractures of vertebrae and long bones of the extremities and dislocations. Who can perform Manipulation Under Anesthesia?“The medical team performing spinal MUA typically includes: Lead chiropractor or other doctor who performs the manipulation. Co-attending doctor who is a first assistant and also certified in manipulation under anesthesia. Anesthesiologist in charge of administering the anesthesia and monitoring the patient. What is knee/shoulder manipulation under anesthesia?Knee – Manipulation of the knee under anesthesia is medically necessary when performed to treat significant arthrofibrosis of the knee, following total knee arthroplasty, knee surgery, or fracture in persons having less than 90 degree range of motion, six or more weeks status post-surgery or traumatic event after physical therapy has failed to improve range of motion at or equal to 90 degrees. What is shoulder manipulation under anesthesia?Shoulder – Manipulation of the shoulder under anesthesia is medically necessary when performed to treat adhesive capsulitis of the shoulder, when there is failure of conservative medical management, including medications with or without articular injections, home exercise programs and physical therapy has failed to improve range of motion after six or more weeks. Who can perform manipulation under anesthesia? “The medical team performing spinal MUA typically includes: Lead chiropractor or other doctor who performs the manipulation. Co-attending doctor who is a first assistant and also certified in manipulation under anesthesia. Anesthesiologist in charge of administering the anesthesia and monitoring the patient. How long does it take to bend your knee after surgery? The Key is to Make Progress Even if only for a few minutes, the exercises must be done every single day the first two months after surgery, or until adequate range of motion has been restored. We aim to have a minimum of 90 degrees of bending by six weeks and ideally more. How do you break up scar tissue after knee surgery? Warmth and swelling around the knee. Mild cases of arthrofibrosis may be resolved with intensive physical therapy alone. Other treatments include manipulation under anesthesia, when a physician manipulates the knee in a controlled fashion to break up the scar tissue. Surgery may also be an option for some patients. What are scar tissues? Scar tissue is Fibrous tissue that forms when normal tissue is destroyed by disease, injury, or surgery. For example, scar tissue forms when a wound heals after a cut, sore, burn, or other skin condition, or when an incision (cut) is made into the skin during surgery. What happens after knee manipulation under anesthesia? Regaining motion after knee surgery isn’t passive, so patients who put more into their physical therapy can usually nip stiffness in the bud. … If stiffness is impacting your ability to recover at the pace your care team expects, a manipulation under anesthesia (MUA) may be recommended. What is manipulation under anesthesia of the shoulder? A manipulation under anesthesia (MUA) is most commonly indicated in patients with simple frozen shoulder. This procedure is performed with the patient sedated under anesthesia. Your chiropractor moves the shoulder through a range of motion which causes the capsule and scar tissue to stretch or tear. Will cortisone injection help frozen shoulder? The treatment of frozen shoulder requires a combination of non-steroidal anti-inflammatory medications, steroid injections, and physical therapy. Cortisone injections: Cortisone injections are given directly into, or near to the shoulder joint. It reduces the inflammation within the frozen shoulder joint. However, cortisone does not decrease fibrous scar tissue What is manipulation surgery? Manipulation under anesthesia (MUA) or fibrosis release procedures is a multidisciplinary, chronic pain-related manual therapy modality which is used for the purpose of improving articular and soft tissue movement. Where does frozen shoulder hurt? The main symptoms of a frozen shoulder are pain and stiffness that make it difficult or impossible to move it. If you have frozen shoulder, you’ll likely feel a dull or achy pain in one shoulder. You might also feel the pain in the shoulder muscles that wrap around the top of your arm. Why is frozen shoulder more painful at night? The most common cause of night pain in your shoulder is due to a process we call rotator cuff tendinosis and shoulder bursitis. While there is no exact science as to why your shoulder pain is worse at night, some factors may be sleeping on your side, direct pressure on your shoulder, and/or your mattress. How long does it take to recover from scar tissue removal? Well, everyone is different and heals at different rates. In general, it takes about six to eight weeks to fully remodel injured tissue in the body. Just remember to take it slow and provide a nice, long duration low-load stress to your scar tissue. Note that is why we recommend Manipulation Under Anesthesia because there is very little recovery time. What happens while under anesthesia? General anesthesia works by interrupting nerve signals in your brain and body. It prevents your brain from processing pain and from remembering what happened during your surgery. … Before your surgery, you’ll get anesthesia through an IV line that goes into a vein in your arm or hand. Is manipulation under anesthesia considered surgery? Manipulation under anesthesia (MUA) consists of a series of mobilization, stretching, and traction procedures performed while the patient receives anesthesia (usually general anesthesia or moderate sedation). Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion. What is closed manipulation? During closed manipulation, the doctor moves the arm at the shoulder joint. This is done to break up adhesions and loosen the stiff joint. The goal of the procedure is to improve range-of-motion by breaking up scar tissue. Manipulation Under Anesthesia for spinal pain Manipulation Under Anesthesia for Spinal Pain. Spinal manipulation under anesthesia (MUA) is a non-invasive procedure that may be recommended to relieve chronic neck and back pain when other treatments have not worked. Where can I get Manipulation Under Anesthesia in Arizona? You can call Dr. John Quackenbush DC MUAC, Phoenix Pain Treatment, 9140 W. Thomas Rd, b106 Phoenix Arizona 85037. Phone 602-449-9430 or CLICK HERE
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Phoenix Pain TreatmentThe board certified interventional pain management physicians of Phoenix Pain Treatment know a thing or two about managing your pain. No matter the nature of your injuries we feel confident that our Phoenix physical rehabilitation experts can create a custom treatment plan for you based on this multi-disciplinary, comprehensive approach and your individual needs and health goals. Our medical experts are board certified in pain management and work together offering residents of Phoenix chiropractic care, injections, stimulation, spinal decompression therapy and more combined with physical rehabilitation, chiropractic care and other techniques. ArchivesNo Archives Categories |