Posture, Posture, Posture

I can’t emphasize enough the importance of good posture for overall spine health and function.

Today I am giving you an exercise/stretch for improving upper back and shoulder mobility to promote improved overall posture. I’d recommend incorporating this into your day, ideally 2-3 times a day. Remember, frequent change in position is key, and incorporating some stretches such as this one into your day can be very beneficial immediately and for the long term as well. 

Stand against a wall with heels, hips, scapulas, and head touching the wall. Position arms against the wall with elbows flexed (bent) so hands are pointed up towards ceiling and elbows, forearms, and back of hands touching the wall. Then SLOWLY slide arms upwards along the wall. Maintain contact with the wall with arms as well as heels, hips, scapulas, and head. Stop moving arms once you are unable to maintain contact with any of the above-mentioned areas, or the stretch becomes too intense. Slowly slide arms down to starting position and repeat 5-10 times. 

*If unable to achieve starting position in standing, try laying on back. Lay on back with knees bent and feet flat on the floor. Head, scapulas, and hips should maintain contact throughout and avoid letting low back arch while arms slide up along the floor. Only go as far as you can while maintaining contact and a neutral spine. 


Hip Flexor Stretches

Many of us are forced to spend the majority of our working day in a seated position, in addition to sitting too much in general. Because of this, tight hip flexors are a common occurrence.

Decreased flexibility in the hip flexor muscle group can lead to low back pain and anterior hip pain. As I’ve mentioned previously, I believe it is important to change positions frequently throughout the day i.e. standing up, walking around the office, or working in a standing position in an attempt to keep muscles from getting too tight and stiff. I also recommend incorporating stretching into your daily routine.

1.Here are a couple ways to stretch the hip flexor muscle group. They are listed from least difficult and most gentle, to more challenging and intense. Supine stretch: Lay on back at edge of bed. Let leg gently hang off the side of the bed. Relax muscles and maintain position for a minimum of 30 seconds. Repeat with other leg on opposite side of the bed. Try to maintain neutral spine/natural curves of spine throughout. If you feel pulling in your low back, use short step stool to support hanging leg. If pulling in back continues, try one of the other options. 

2. Prone stretch: Lay on stomach, relax as much as possible and maintain position for a minimum of 60 seconds. Laying on your stomach allows the muscles to gently elongate. If your muscles are very tight, this may be uncomfortable. Start with small amounts of time and gradually increase as tolerated for max benefits. (Arms can be wherever you are most comfortable.)

3. Standing stretch: Stand in front of a chair then place desired lower leg/foot on a chair so that thighs are even and knee is flexed so lower leg is resting behind chair. Stand up tall and gently engage buttock to bring hips forward and increase stretch as needed. Hold for minimum of 30 seconds then switch legs. 

4. Kneeling/“Couch stretch”: Position self in a lunge position with torso as upright as possible, engage glute (butt) muscles and gently lean hip forward to open hip of the down knee. Hold for minimum of 30 seconds and then switch. If you need to intensify stretch, do against couch with lower leg of down knee against the front of the couch so that foot is pointed towards ceiling. *Always engage glutes to protect back- do not arch back.


Stretches to Relieve Neck, Back, and Shoulder Pain

Do you experience headaches, neck pain, or shoulder pain during or after your workday?

As I mentioned in a previous post, posture and positioning can play a huge role in how we feel. Also, many of us “carry” stress in our shoulders and neck region, often resulting in a tense posture with shoulder elevation.

The main muscle responsible for this position is the upper trapezius muscle. The upper trapezius muscle originates at the base of the skull/top of the neck and extends downward along the neck and inserts along the top of the shoulder. Therefore, tightness in this muscle may put tension on the head, neck, and/or shoulder. In addition to improving postural awareness as mentioned in the previous post, intermittent gentle stretching of the upper trapezius muscle may decrease pain, stiffness, and headaches.

Here is an easy way to stretch the upper trapezius muscle to promote improved mobility.

1.Sit with upright posture in a hard, armless chair (armless is ideal but not required).
2.If stretching right side, reach down with the right arm and grab the bottom of the chair.
3.Then GENTLY lean your head (ear) towards your left shoulder.
4.Only go to the point of tension- do not push into it.
5.Hold for 30-60 seconds.
6.Slowly return to neutral and repeat with left doing the opposite.

Some tips and key points to remember!

– I can not emphasize the word GENTLY enough!!! “No pain, no gain” is not applicable in stretching.
– If the stretch becomes painful, slowly move your head back towards the center to decrease the intensity.


Posture and Pain

Three quick and easy moves from our Physical Therapist that improve your posture and reduce your pain.

In addition to good ergonomics, practicing good posture promotes good spine and joint alignment and decreases compensatory injuries. Some key components of good posture include:

  1. Neutral spine
  2. Avoid forward head
  3. Avoid slouched shoulders/upper back
  4. Engage abdominal and glute muscles 
  5. Shoulder depression and scapular retraction= “shoulders down and back”

Here are a few simple exercises to improve posture and postural awareness.

  1. Reverse shoulder circles: Do every 30-60 minutes to check posture/shoulder positioning. Remember, desired position is with shoulders down and back.
  2. “Chin tucks” or cervical retraction: With head and neck in neutral position, gently draw chin/jaw backwards as if trying to make a double chin. Hold for 2-3 seconds, relax and repeat. Be GENTLE. (Do not flex chin down towards chest.)
  3. Scapular retraction: squeeze shoulder blades together (without shrugging shoulders upward)

Frequent change in position is also very beneficial. Set a timer to go off every 30 minutes. When the timer goes off, stand up, stretch, or walk a lap around your house. IF you have a stand up desk, spend the next 30 minutes standing while working, then switch. Prolonged positioning creates muscles guarding and potentially shortening/tightening. Remember, we were made to move so don’t be static for too long!


Avoiding Neck and Back Pain

As many of us are currently experiencing, working from home has both its benefits and challenges. While many may be excited to work in a more comfortable environment, it is important to consider ergonomics and posture as these play a huge role in our immediate and long term comfort and function. Although it may be tempting to curl up on the couch to do computer work, sitting at a desk or table promotes better positioning and posture. If we sit in a twisted or leaned position, we are likely to develop unilateral muscle tightness and compensations which have the potential to produce joint and muscle pain, particularly neck pain and back pain. By sitting square at a desk or table with feet flat and upright posture, a person is more likely to have a neutral spine which in turn promotes improved overall symmetry and therefore less compensations. Here are some key concepts to take into account when setting up your work stations:

  1. Sit in a hard, upright chair (non-reclining) and attempt to maintain an upright and neutral posture throughout
  2. Sit with feet flat on floor (do not cross legs) and try to achieve as close to 90 degrees of hip flexion and knee flexion as possible
  3. Table/desk height should allow ~90 degrees of elbow flexion with arms relaxed at side (do not shrug shoulders) and wrists should be in a neutral position.*
  4. Screen should be as close to eye level as possible. 

*Please note: if working with a laptop, it is likely you will not be able to meet the criteria of both 3 and 4 due to the nature of a laptop, so just do the best you can. If working with a monitor and keyboard, try to elevate the monitor to eye level while keeping the keyboard at proper height as mentioned in #3.



Our team is dedicated to providing a safe and healthy environment for all of you, Due to the increased spread of COVID-19 we would like to make all of you aware of the precautions we are taking within our practice. Per CDC recommendations, we are seeing all possible patients via video visits and all procedures must be rescheduled. Please call the front desk with any questions or concerns. To be eligible to be seen via tele-med you will need to have a computer or phone with a working camera, microphone and speakers as well as adequate phone service or wifi signal.

Click here to access our tele-med portal.

Low Back Pain

Preventing and managing your low back pain.

Metamorphosis Pain Management offers a variety of treatments for back pain including medication management, injections, ablations, weight loss, and physical therapy. By treating pain with a multifaceted treatment approach, our patients are able to receive a more significant reduction in pain than they would with medications alone.

If you are suffering from back pain we can help, we offer multiple types of therapies to include:

  • Physical Therapy
  • Injections and ablations
  • Medications
  • Weight Loss Program


Platelet Rich Plasma (PRP)

PRP Injections for Pain

PRP injections (or platelet rich plasma therapy) is a new treatment method that relieves pain by promoting long lasting healing of musculoskeletal conditions. This rapidly emerging technique is showing exciting potential with osteoarthritis of the knee, shoulder, hip and spine, rotator cuff tears, chronic plantar fasciitis, anterior cruciate ligament (ACL) injuries, pelvic pain and instability, back and neck injuries, tennis elbow, ankle sprains, tendonitis, and ligament sprains.

How do PRP injections help?
The body’s first response to soft tissue injury is to deliver platelet cells. Packed with growth and healing factors, platelets initiate repair and attract the critical assistance of stem cells. Platelet Rich Plasma therapy’s natural healing process intensifies the body’s efforts by delivering a higher concentration of platelets. To create platelet rich plasma therapy, a small sample of your blood is drawn (similar to a lab test sample) and placed in a centrifuge that spins the blood at high speeds, separating the platelets from the other components. The concentrated PRP injection is then delivered into and around the point of injury, jump-starting and significantly strengthening the body’s natural healing signal. Because your own blood is used, there is no risk of a transmissible infection and a very low risk of allergic reaction.

How long does it take to get PRP Injections?
The Platelet Rich Plasma therapy takes approximately one to two hours, including preparation and recovery time. Performed safely in a medical office, PRP injections relieve pain without the risks of surgery, general anesthesia, or hospital stays and without a prolonged recovery. In fact, most people return to their jobs or usual activities right after the procedure.

How often should PRP injections be given?
Up to three PRP injections may be given within a six-month time frame, usually performed two to three weeks apart. You may, however, gain considerable to complete relief after the first or second injection.

What are the expected results of PRP Injections?
Because the goal of platelet rich plasma therapy is to resolve pain through healing, it could prove to have lasting results. Initial improvement may be seen within a few weeks, gradually increasing as the healing progresses. Research studies and clinical practice have shown PRP injections to be very effective at relieving pain and returning patients to their normal lives. Both ultrasound and MRI images have shown definitive tissue repair after PRP therapy, confirming the healing process. The need for surgery can also be greatly reduced by treating injured tissues before the damage progresses and the condition is irreversible.


Stem Cell Therapy

From the Cleveland Clinic

September 21, 2018 / Orthopaedics

‘Stem Cell’ Injections: Emerging Option for Joint Pain Relief?

One potential option to repair a damaged knee and avoid surgery

'Stem Cell' Injections: Emerging Option for Joint Pain Relief?

Are you suffering from chronic joint pain? If so, you may have heard about “stem cell” injections and may want to ask your doctor whether these injections are right for you. If you want to avoid the surgical route of repairing a damaged knee or treating an arthritic shoulder, novel cell-based injections are becoming available and may give you the relief you need. However, this is a dynamic field and multiple questions remain unanswered.

What are stem cells?

Stem cells are special types of cells with the ability to multiply and self-renew. They also have the potential to replicate into specialized cell types forming potentially any tissue in your body. In other words, they can become a cartilage cell, a muscle cell or a nerve cell, says orthopedic surgeon Anthony Miniaci, MD.

“They have a tremendous capacity to differentiate and form different tissues, so that’s the thought behind regenerating cartilage, regenerating nerve cells and healing any injured tissues,” he says.

There are multiple sources of adult stem cells found in your body, including bone marrow or fat, although you can also receive stem cells from donor sources, Dr. Miniaci says.

“However, the term ‘stem cell’ is often widely and inappropriately overused in orthopaedics to include all kinds of treatment with uncharacterized, minimally manipulated cells, and even therapies that do not contain stem cells at all,” explains orthopaedic surgeon Nicolas Piuzzi, MD.

How cell-based treatment works

The treatment team harvests cells from your bone marrow or fat, or uses donor cells. Later on, your treatment team injects the cells precisely into your joint, ligament or tendon.

Theoretically, the cells when delivered will adjust inflammation and/or then divide and duplicate themselves and develop into different types of cells depending on the location into which they have been injected.

However, for patients with a severe loss of cartilage or no cartilage at all, a cell-based injection is unlikely to create a new joint, Dr. Miniaci says.

“Severe loss of cartilage typically leads to bone erosion or bone deformity, so a cell-based injection is highly unlikely to work in terms of reversing those changes,” he says.

It can, however, improve your symptoms of pain and swelling.

“The earlier you can treat someone’s joint pain, the better chance this has of working, making it less painful for the patient, less inflamed, and improve their function,” he says.


To date, there have not been any major adverse events reported associated with cell-based therapies in orthopaedics.

The main risk from a cell-based injection is probably in harvesting the cells. For example, when taking the cells from your bone marrow, the treatment team inserts a needle into your pelvis and removes some bone marrow cells and blood.

“However, the risk of having a complication during or after bone marrow aspiration in orthopaedics is minimal,” Dr. Piuzzi says.

“If you’re taking cells from fat, you can remove some out from under the skin,” Dr. Miniaci says. “To consider, anytime you make incisions or insert sharp instruments into a patient’s body, they can have problems such as acquiring an infection.”

Treatment is in its infancy

While the use of cell-based injections to treat joint pain holds much promise, Drs. Miniaci and Piuzzi caution that this treatment option is still very new. Researchers need to study its safety and determine if they are effective or not.

“We don’t have proof indicating that cell-based injections actually repair the joint,” Dr. Miniaci says.

He explains that if you have cartilage or bone damage, stem cells could differentiate and produce bone and cartilage and other tissues. So, theoretically, they could heal damaged tissue within a muscle, tendon, bone or cartilage.

“That’s the theory behind it, but this type of treatment and research is just in its infancy,” he says.

“We really don’t know what’s effective, what’s not effective, how many cells are necessary, how many actual injections you need and how often,” he says. “Nobody knows how well or even if it works yet. But we will eventually.”

Anecdotally, Dr. Miniaci finds that some patients can have improvement in their symptoms with cell-based injections. But he has not seen any proof yet that they are regrowing or regenerating a joint.

“Many people think that they’re going to come in with their arthritic joint and leave with a newer version of their knee joint. That doesn’t happen,” he says.

“What does occur is a biological reaction which makes the environment in their joints a little healthier, which probably makes it less inflamed, and as result, gives them less pain.”

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services.


Ketamine Therapy

About Ketamine Treatment

Over the course of your 1-2 week treatment you will receive several infusions. During your treatment our team of expert staff will continuously monitor you. The infusion generally last anywhere between 1 and 4 hours and usually provides immediate relief from pain and depression. Once you have received the initial ketamine treatment you may come back as needed for a ketamine booster infusion. 

Today, a rapidly growing number of chronic pain patients who have not responded to conventional therapies are reporting life changing results after undergoing a series of low dose ketamine infusion treatments. Research over the course of the last 15 years has shown that small doses of intravenous ketamine infusions have been effective in decreasing symptoms related to chronic pain syndromes, especially those that have a neuropathic component.

What is Ketamine

Ketamine is a safe analgesic medication that was developed more than 50 years ago for use primarily by anesthesiologists for sedation during surgery. Ketamine is on the World Health Organization’s List of Essential Medicines, and is one of the most commonly used pharmaceuticals in the world.

In addition to being a powerful pain reliever it is also a strong antidepressant and anti-inflammatory drug. As pain practitioners, we understand that pain and depression often will go hand-in-hand. In certain instances, the effect of chronic pain serves to increase the symptoms of depression. Depression can increase the feeling and symptoms of chronic pain. The result is cycle that can be hard to stop. Ketamine has shown to be very helpful for its rapid changes in depression levels, and neuropathic (nerve pain) conditions that nothing else is working well for.

How does ketamine infusion therapy work?

Pain signals travel to and from our brain on a network of nerves which run throughout our body. Tiny spots on these nerves called NMDA receptors collect information from the body and immediately alert the brain if damage or injury has occurred.

Many chronic pain syndromes are caused by a increase of these NMDA receptors in the brain. Studies have shown that increases in these NMDA receptors have a lot to do with major depression, chronic pain syndromes, fibromyalgia and other neurological disorders.

In cases of acute pain, the NMDA receptors subside following the usual course of injury and the pain signal eventually is turned off. With chronic pain, the NMDA receptors do not turn off and begin to multiply creating an higher level pain signal.

Ketamine, has the ability to block NMDA receptors which then blocks the pain signal from reaching the brain. When administered in a precise low dose IV infusion, ketamine provides virtually instantaneous relief of pain symptoms and allows nerve receptors the chance to reset or reboot themselves.

The ketamine infusion process

New patients will be scheduled for a visit with one of our providers. During this appointment, your provider will examine you and review your medical records with you to make sure ketamine is right for you.

Ketamine therapy will given under close supervision of our trained medical personnel. Your will be in a relaxed, comfortable environment, bring a pillow from home if you like. A trained member of our staff will start your IV and connect the monitors to watch your breathing, blood pressure, heart, and other vital signs the entire time that the medicine is being given.

Once the medicine begins going into your bloodstream, you may begin to feel a little different. In many cases, relief can be experienced in as little as 15 minutes, but the amount and number of times you will need a treatment will be different for each person.

Once your ketamine infusion is complete, you will be watched in recovery for 30-60 minutes prior to being sent home. You must have a driver present.

Relaxation is the key to successful infusion. It can be difficult to carry on a conversation during the procedure, so you are encouraged to sit back and relax throughout the course of your treatment. Many find it helpful and relaxing to listen to music and to wear an eyeshade or sunglasses while undergoing the infusion therapy treatment.

What does ketamine infusion therapy treat?

We currently offer ketamine infusion therapy for many types of pain including:

  • Complex Regional Pain Syndrome (CRPS/RSD)
  • Fibromyalgia
  • Trigeminal Neuralgia
  • Headaches
  • Low back and neck pain

We also offer ketamine infusion therapy for depression, anxiety, PTSD and other mood disorders.

Who will likely benefit from ketamine infusion therapy?

  • People with neuropathic pain that is not well controlled with injections, nerve blocks, or prescription pain medication.
  • People with chronic back and neck pain when nothing else works anymore.
  • People with depression, PTSD and other mood disorders
  • People with other musculoskeletal and joint pain.

Trigeminal Neuralgia



The Basics

What is trigeminal neuralgia? — Trigeminal neuralgia (TN) is a condition that causes sudden and severe pain in parts of the face.

TN is caused by a problem with the trigeminal nerve, which is a nerve that runs from the brain to the face.

What are the symptoms of trigeminal neuralgia? — TN causes attacks of sharp and stabbing pain in the cheek, lower face, or around the eye. The pain lasts a few seconds to a few minutes, and usually happens on only one side of the face. The attacks can happen over and over again.

Often, certain movements or activities make the pain attacks happen. These can include:

●Touching the face



●Brushing the teeth

●Smiling or frowning

●Cold air on the face

TN can also cause muscle spasms in the face, along with pain.

Will I need tests? — Maybe. Your doctor or nurse should be able to tell if you have TN by learning about your symptoms and doing an exam.

He or she might do tests to get more information about your TN or what’s causing it. These tests can include an MRI or CT scan of your brain. These are imaging tests that can create pictures of your brain.

How is trigeminal neuralgia treated? — TN is usually treated with medicine. Doctors can use different types of medicines to treat TN. Most often doctors prescribe a type of medicine normally used to prevent seizures. The one used most often to treat TN is called carbamazepine (sample brand names: Carbatrol, Tegretol). There are several others, too. These medicines quiet the nerve signals that cause pain in TN.

For most people, the medicine helps reduce the number of TN attacks they have and makes their pain less severe. But if medicines don’t help enough or cause too many side effects, your doctor might talk with you about other treatment options. These include different types of surgical procedures that quiet the nerve and make it less likely to fire. These surgical treatments might help with symptoms, but side effects sometimes happen, including numbness or pain in the face.

This topic retrieved from UpToDate on: Aug 14, 2019.

Topic 16844 Version 5.0

Release: 27.3.2 – C27.227

© 2019 UpToDate, Inc. and/or its affiliates. All rights reserved.

Consumer Information Use and Disclaimer:

This information is not specific medical advice and does not replace information you receive from your health care provider. This is only a brief summary of general information. It does NOT include all information about conditions, illnesses, injuries, tests, procedures, treatments, therapies, discharge instructions or life-style choices that may apply to you. You must talk with your health care provider for complete information about your health and treatment options. This information should not be used to decide whether or not to accept your health care provider’s advice, instructions or recommendations. Only your health care provider has the knowledge and training to provide advice that is right for you

Avoiding Triggers


Chronic Pain

Living with chronic pain? Whether you are suffering from back pain, neck pain, migraines, fibromyalgia, or any other chronic pain, we can tailor a customized treatment plan to you. The following videos contain information about your chronic pain and why you may have it, how to live with it, and what pain management is available.

Pain Management

Why do I have Chronic Pain?

Living With Chronic Pain

Treatments for Chronic Pain