2601 Cherry Ave Suite #200
Bremerton, WA 98310
Phone: (360) 415-9110
Fax:(360) 479-0265

Nerve Blocks

When a pain condition is caused or transmitted by a specific nerve or nerve group, this nerve can be blocked by an injection of local anesthetic and/or steroids. Nerve block is a very general term and is mostly used for injections of peripheral nerves, spinal nerves and sympathetic nerves. Injection of anesthetics and/or steroids into the area surrounding the affected nerve can relieve pain symptoms temporarily and often allow the nerve to heal and repair itself. Some patients experience relief that ranges from several months to several years. For most most of these nerve block procedures fluoroscopy is used to identify the target area. In some instances nerve stimulation is used to indentify the nerve directly. The different procedures are performed at the ambulatory surgery center in Poulsbo and take only a few minutes. There is only little or no pain and discomfort associated with these procedures.
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Epidural Steroid Injection

Epidural injections have been used for over 100 years to treat back pain. The term "epidural injection" describes any injection in which medication is placed into the fat surrounding the spinal cord within the spine. Today the term "epidural injection" is commonly used describing a certain technique of epidural injections, in which a larger bore needle is advanced between the laminae of two spinal vertebrae into the epidural space. The so called interlaminar epidural steroid injection is a nonsurgical treatment that can help to alleviate pain in the neck, arms, legs and lower back. This injection can be performed at every level of the spine, but is most often performed at the lower lumbar spine.
The technique is similar to the epidural injection performed to alleviate pain during labor and delivery. The skin over the back is numbed with a local anesthetic. A needle is then advanced into the epidural space and local anesthetic and/or steroids are injected. The medication then spreads to the spinal nerves. The procedure takes between 15 and 30 minutes. Sedation is available to reduce anxiety. However, sedatives are rarely necessary. We perform this procedure with the aid of x-ray fluoroscopy to confirm the correct needle position.
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Transforaminal Injection (Selective nerve root injection)

Transforaminal or selective nerve root injections are similar to epidural steroid injections. While the approach is different from the interlaminar epidural injection, the medication still reaches the epidural space. The injection developed from the idea to deposit the medication closer to the affected nerve. With the interlaminar epidural steroid injection, the medication is injected into the middle of the epidural space and the medication spreads sideways to the inflamed nerve root. For the transforaminal injection, a smaller needle is directed as close as possible to the inflamed spinal nerve root and the medication is injected directly into the space surrounding that particular nerve. The needle is not placed in the middle of the back, but more to the side where the spinal nerve exits the spine. These steroid injections buy time to allow healing to occur and are often used as an attempt to avoid surgery after other conservative therapies have failed. The success rate of these injections depend on the underlying cause and duration of the pain. In some patients these injections can completely resolve their pain, especially leg pain. The success rate is between 50% and 80% depending on patient selection.For the procedure, the skin over the back is numbed with a local anesthetic. A thin needle is then advanced into the foramen of the nerve and local anesthetic and/or steroids are injected. We perform this procedure with the aid of x-ray fluoroscopy to confirm the correct needle position. Contrast dye is injected to enhance the fluoroscopic images and to confirm that the needle is properly placed. The procedure takes between 15 and 30 minutes. Sedation is available to decrease patient anxiety and increase comfort. However, sedatives are rarely necessary. The procedure is usually not painful. Patients with severe pain often experience pain relief within minutes of the procedure. This immediate pain relief is caused by the local anesthetic injected around the nerve. In few cases the local anesthetic can cause some mild weakness in the extremity for a few hours. The injected steroids usually take a few days for full effect. In most cases we recommend to have the injection repeated after two to three weeks.
These injections are most commonly performed to relieve pain caused by spinal stenosis, degenerative disc disease foraminal stenosis, bulging discs and disc herniation. The epidural steroid injection is not as specific as a transforaminal injection, but still useful for disease at multiple levels.
As with all invasive medical procedures, there are potential risks associated with epidural steroid injections. However, these risks tend to be rare. Risks may include: Infection, bleeding, nerve damage, headache, transient decrease in immunity, transient high blood sugar, stomach ulcers, cataract, increased appetite, mood swings.
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Sacro-Iliac-Joint Injection (SI-Joint Injection)

This procedure is used to treat patients suffering from pain in their sacroiliac joint (SI joint). The SI joints, which are in the lower back, connect the sacrum to the pelvis. Although these joints are small and don’t move very much, they perform a critical role in the body. They help absorb all of the damaging shock forces of the upper body before balancing and transmitting their weight to the hips and legs.
When these joints become inflamed or irritated, they may cause pain in the lower back, buttocks and the hip area.
A SI joint injection involves placing numbing and steroidal medicine into the irritated joint or joints. We perform this procedure with the aid of X-ray fluoroscopy to confirm the correct needle position. Contrast dye is injected to enhance the fluoroscopic images and to confirm that the needle is properly placed. The procedure takes between 15 and 30 minutes. Sedation is available to decrease patient anxiety and increase comfort. However, sedatives are rarely necessary. The procedure is usually not painful.
As with all invasive medical procedures, there are potential risks associated with sacro-iliac injections. However, these risks tend to be rare. Risks may include: Infection, bleeding and nerve damage.
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Facet Injection / Medial branch block

Facet joints are small joints on the side and back of the spine. The joints connect one vertebrae in the spine to the one above and below. Excessive weight, arthritis, bad posture and carrying heavy loads puts stress on those joints and can result in severe lower back pain. The pain from lumbar facet joints is usually confined to the lower back, but sometimes radiates into the upper back or into the hips. Patients often describe an aching pain across their lower back. This is very commonly associated with stiffness in the lower back in the morning. The pain is often exacerbated after repetitive bending and lifting.
Car accidents often cause "whiplash injuries" to the neck, which can result in severe neck pain. These injuries cause damage to the cartilage layer of the facet joints and can result in long lasting pain syndromes. The pain is usually localized in the neck, but sometimes the pain radiates into the shoulder, arm or head. 
The medial branch nerve block is a nerve block in which local anesthetic and/or steroids are injected around the nerve supplying the facet joints. The pain, coming from the joints, is alleviated and muscle spasm may be reduced. Medial branch nerves are small nerves that transmit pain signals from the facet joints to the spinal cord. Medial branch blocks are often used to identify a pain source; however, these injections do not always provide long lasting pain relief. In such cases, it might be beneficial to confirm that the facet joint is the source of a patient’s pain so that a radiofrequency medial branch neurolysis may be considered for longer term pain relief.
If the patient has the appropriate duration of pain relief after the medial branch nerve block, that individual may be a candidate for a neurolysis or nerve ablation. A radiofrequency nerve ablation is a type of procedure in which either a heat lesion is created to damage the nerve, or a high frequency electrical impulse is used to reduce pain transmission without damaging the nerve. The latter technique is called pulsed radiofrequency lesion and is frequently performed at our clinic. A nerve ablation should then provide pain relief lasting at least nine to fourteen months and sometimes much longer.
The facet joint injection is an intra-articular injection of local anesthetic and/or steroids directly into the facet joints.
We perform this procedure with the aid of x-ray fluoroscopy to confirm the correct needle position. The procedure takes between 15 and 30 minutes. Sedation is available to decrease patient anxiety and increase comfort. About 10-20% of patients experience increased back pain and discomfort for 2-3 days after the procedure.
As with all invasive medical procedures, there are potential risks associated with this injection. However, these risks and side effects tend to be rare.
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Stellate Ganglion Block

A stellate ganglion block is used for certain types of neck, head and arm pain. A needle is advanced to the anterior part of the cervical spine and local anesthetic is injected. Chemical neurolysis or RF treatment can also be performed. The block is performed under fluoroscopy to determine if the sympathetic nerve chain is the source of the patients pain. This block is often used as a diagnostic tool, but for certain conditions a series of injections can provide excellent pain relief for several months or years. The patient may note increased warmth and redness of the painful arm during and after the injection. This is a sign for increased blood flow into the extremity and is proof that the sympathetic nerve chain was blocked. Since the sympathetic chain also innervate the neck and face, the same redness is sometimes seen in the neck and face. There are other nerves closely located to the injection site and frequently patients experience hoarseness of their voice, redness of the eye, drooping of the eyelid and pupillary constriction for a few hours after the injection.
Pain relief may be noted immediately. The duration of pain relief is variable. For patients suffering from RSD, the block may be repeated weekly to provide longer lasting pain relief and to enable physical therapy.
We perform this procedure with the aid of x-ray fluoroscopy to confirm the correct needle position. The procedure takes between 15 and 30 minutes. For safety reasons all patients will receive and iv line before the procedure and we perform this procedure only on one side at a time.
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Celiac Plexus Block

The celiac plexus is a nerve bundle lying around the abdominal aorta. The autonomic innervation to the majority of abdominal organs flows through the celiac plexus. The celiac plexus nerves supply internal organ such as the pancreas, liver, gallbladder, omentum, mesentery, stomach, small intestine, and the ascending and transverse portion of the colon. Pain from these organs is often related to or maintained by the celiac plexus nerves. A blockage of the celiac plexus often results in excellent pain relief from pain coming from these organs. The nerve block is most often performed for pancreatic cancer with local anesthetic or chemicals like Phenol or Alcohol. Phenol or Alcohol actually destroy part of the nerve plexus and offer longer lasting pain relief than an injection with local anesthetic or steroids. The pain relief can last for several months.
We perform this procedure at the Harrison Medical Center in Bremerton. The procedure itself is performed under fluoroscopy to confirm the correct needle position. Often a mild general anesthesia is provided to improve patient comfort.
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Lumbar Sympathetic Block

The lumbar sympathetic nerves are anterior and lateral to the spine. The nerves supply the legs and are involved in pain transmission and vascular blood flow in the legs. Lumbar sympathetic blockade is used predominantly for the diagnosis and treatment of lower extremity reflex sympathetic dystrophy (RSD) or complex regional pain syndrome (CRPS). Relief of symptoms can outlast the clinical duration of the local anesthetic. Repetition of the block, in conjunction with aggressive physical therapy, has classical been the management approach for RSD/CRPS. The needles for the injection are inserted in the lower back and advanced toward the anterior and lateral border of the lumbar spine. The procedure is most commonly performed at the L2 and L3 level, under fluoroscopic guidance. Injection of contrast dye confirms the proper position of the needles. Similar results to a sympathetic nerve block can be achieved with an epidural injection, using a low concentration of local anesthetic to block primarily the sympathetic nerve fibers.
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Acupuncture is an ancient form of medicine which is gaining more and more popularity over the last years. Acupuncture has been proven to be effective for different health conditions and pain syndromes. While the exact mechanism is still unknown, there are two different commonly used explanations. One explanation is that the stimulation of these acupuncture points affects both the central and peripheral nervous systems. It triggers the release of the body's internal chemicals such as endorphins and enkephalins, which have proven pain-relieving properties. Another explanation is that the needle stimulation results in increased blood flow of the targeted area. The acupuncture needles do not need to be inserted at the area of the pain. Often the needles are inserted way from the painful area. Acupuncture has become increasingly popular in the United States as a treatment for a variety of health concerns, including back pain.
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Intrathecal Delivery Systems          

Intrathecal pumps are used to deliver medications directly into the fluid surrounding the spinal cord. Medications most often used include Morphine for pain and Baclofen for muscle spasms.  By delivering the medication closer to the spinal cord, the dosage compared to pills or tablets can be reduced. This treatment is suitable only for certain chronic pain conditions and requires a procedure in the operating room.
Intrathecal drug delivery systems are composed of two implantable components: an infusion pump and an intraspinal catheter. The pump is placed abdominally in a subcutaneous pocket, while the catheter is inserted into the intrathecal space of the spine, tunneled under the skin and connected to the pump. The pump will be filled through the skin using a small needle. Maintenance of the pump is fairly routine. The pump is refilled every 1-3 months by inserting a needle through the skin and through a diaphragm on the surface of the pump. Several different medications can be administered this way, and even combinations of drugs might be used.
Because there are no external parts, the system usually does not restrict daily activities. A programmable pump allows clinicians to adjust doses non-invasively, minimizing patient discomfort. In addition, the pump can be programmed to deliver different doses at various times of the day--meeting patients' changing needs.
Obviously, this technique should only be considered when more standard treatments have not been effective or have caused intolerable side effects.
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Spinal Cord Stimulation (SCS)

Spinal cord stimulation (SCS) is used to treat certain types of chronic neuropathic pain. Most often a spinal cord stimulator is considered for patients with chronic back and especially leg pain even after back surgery. Also chronic headaches which did not respond to other treatments can be successfully treated with a spinal cord stimulator. The spinal cord stimulator uses a very small electric current to counter-stimulate nerves inside the spinal cord. The pain is then "over ridden" with a different sensation.
In all cases a trial is performed first. For the trial a spinal cord stimulator lead is placed through a needle inside the spinal canal close to the spinal cord. For the treatment of intractable headaches, the leads are placed outside the spine in the upper posterior neck. The other end of the stimulator lead is attached to an external stimulator outside the body. The patient is then instructed how to use the spinal cord stimulator with a very simple remote control. The trial lead is left in place for 3-5 days to give the patient the chance to test the device at home and to experience the effect of the spinal cord stimulator during his daily activities. The technique of this procedure is similar to an epidural injection and does not require general anesthesia or a hospital stay. We perform this procedure at the outpatient surgery center in Bremerton.
If a trial of the spinal cord stimulation proves to be effective, an internalized system can be surgically implanted. During the procedure in the operating room, an electrode is placed close to the spinal cord. An impulse generator with a battery is placed underneath the skin and connected to the electrode. A low electrical impulse is then used to stimulate certain nerves in the spinal cord, suppressing the pain signal traveling to the brain. Periodic programming of the impulse generator can be performed using a remote control device to allow for changing pain patterns.
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Radiofrequency Nerve Ablation / Rhizotomy

Radiofrequency nerve ablation or rhizotomy is a form of nerve destruction with radiofrequency signals. This procedure is often performed for chronic lower back pain originating from the facet joints. The facet joints are small joint is the posterior spine. The joints connect one vertebrae in the spine to the one above and below. The joints are innervated by a small nerve, called the medial branch nerve. The medial branch nerve is transporting the pain signal from the joint into the spinal nerve and from there the pain signal travel into the brain. Excessive weight, arthritis, bad posture and carrying heavy loads puts stress on those joints and can result in severe lower back pain. The pain from lumbar facet joints is usually confined to the lower back, but sometimes radiates into the upper back or into the hips. Patients often describe an aching pain across their lower back. This is very commonly associated with stiffness in the lower back in the morning. The pain is often exacerbated after repetitive bending and lifting.
The radiofrequency signal is generating an electric field and a certain degree of heat around the tip of a radiofrequency probe. This treatment can significantly decrease the function of a nerve and decrease the pain transmitted to the brain. The procedure is similar to a nerve injection, but instead of injecting a medication, a radiofrequency probe is advanced through a needle toward the nerve. The position of the probe is confirmed with fluoroscopy and with nerve stimulation. When the probe is placed close enough to the nerve, the radiofrequency signal is send through the radiofrequency probe into the nerve for about two minutes. The procedure is performed at the outpatient surgery center and takes about 20 to 40 minutes. As with all invasive medical procedures, there are potential risks associated with this procedure. However, these risks tend to be rare. Risks may include: Infection, bleeding and nerve damage.No anesthesia is required for this procedure. Sedation is available to decrease patient anxiety.
There are two form of radiofrequency lesioning. The first form is called a Thermal Lesion and actually heats the tissue and the nerve to a temperature above 45`C with a probe placed close to the nerve. The heat damages the proteins in the tissue and the nerve. Part of the nerve and the surrounding tissue is physically destroyed. Pain relief may last from weeks to months, until the nerve grows back.
The second kind of radiofrequency lesion is called pulsed radiofrequency (pulsed RF) nerve ablation. This treatment heats the tissue and the nerve to a lesser degree and stimulates the nerve with an electrical impulse. The mode of action of RF has not yet been clearly proven. Initially attributed to the heat lesion and to the physical damaging of nerve fibers, it was later found that the electromagnetic field, rather than the temperature, induces changes in the nerve cells. Sending a a high frequency electric signal into the nerve has a neuromodulatory effect on pain-processing mechanisms at the dorsal root ganglion, dorsal horn, and the molecular levels by changing gene expression in pain-processing neurons. This means that by "stunning" the nerve, the nerve can not function as usual and can not send pain signals to the brain. The electrical impulse induces long lasting changes within the nerve itself, resulting in a decrease of pain impulses send through the nerve, without damaging the nerve itself. The effect usually last longer than the effect from an injection. We perform this procedure after a simple medial branch block provided good pain relief, but for a short time only. The RF nerve ablation then often gives three to four times longer pain relief than the injection. The pulsed RF ablation avoids damage to ther nerve and does not create scar tissue.
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A probe is placed close to the affected nerve and cooled below freezing temperature. The water in the tissue and in the nerve will freeze, form crystals and destroy the nerve. After weeks or months the nerve will eventually grow back and may cause pain, again.
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With neurolysis a nerve is destroyed by chemical substances, heat or freezing.  The destroyed nerve cannot transmit further pain signals to the brain, resulting in pain relief. The nerve can grow back after some time and the effect may only be temporary, lasting from weeks to months. Neurolysis can also cause damage to a nerve which itself can cause pain.
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Transcutaneous Electrical Stimulation (TENS)

For TENS therapy, a patch with electrodes in it is placed over the painful area and light electrical impulses are applied. The TENS Unit contains the batteries and can be carried on the belt or in a pocket. The treatment is not painful and can be done at home. The electrical impulses stimulate large nerve fibers. The stimulation of large nerve fibers can reduce pain by blocking some of the small pain fibers.
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Chronic pain is a tremendous psychological burden. Every person responds to pain different, depending on their personality, culture and past pain experience. Many chronic pain patients experience depression. Cognitive and behavioral therapies can help a patient learn new skills and strategies for dealing with chronic pain. Those skills include relaxation techniques or counseling sessions. Some patients may need medication treatment for anxiety or depression.
Underlying psychological conditions like depression and anxiety can magnify a pain sensation. A mild or moderate pain condition, which would otherwise not affect a person, can be perceived as an unbearable and debilitating pain. In those patients the pain is often out of proportion to the physical findings. Also, these patient usually do not respond well to common pain treatments. Patients with underlying depression and anxiety will often need concurrent treatment of these psychological conditions.
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Exercise Programs

Aerobic exercise improves muscular strength, flexibility and endurance. It helps to reduce weight, stress and can also help with chronic pain conditions and other medical conditions. Even light exercise like daily walking can help to build up endurance and rebuild weakened muscles. Exercise stimulates the release of endorphins, which act as natural pain relievers in the body. While exercise alone is unlikely to relief acute pain, patients who regularly undergo aerobic exercise will have fewer episodes of low back pain. Regular exercise will also help maintaining or reducing weight, which itself will help with back pain.

The aerobic exercise should be continuous in order to increase the heart rate and keep it elevated. There are several types of aerobic exercise that are gentle on the back and, when done on a regular basis, highly effective in providing conditioning. Depending on age and condition, patients should choose an exercise which is appropriate for them.

• Walking for exercise. In general, walking for exercise is very gentle on the back, and walking two to three miles three times per week is very helpful for patients. Hiking longer distances or hiking in the mountains will increase the excercise effect even further and help to build up muscle strength.
• Bicycling for exercise. Bicycling, either on a regular or a stationary bicycle, is even more effective and less stressful on the back. The bicycle needs to be comfortable and a regular City or Mountain bike offers a more relaxed position compared to a racing bike. Many bicycles theses days a equipped with a suspension system which provides a smooth ride and reduces impact to the spine.
• Water therapy for exercise. Doing exercise in the water provides for effective conditioning while minimizing stress on the back. This exercise is usually recommended for overweight or elderly patients. For patients who have osteoarthritis, especially for elderly patients, an ongoing water therapy exercise and aerobics program may be the most effective treatment option.
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Over-the-Counter Pain Medications

 These pain medications are usually so-called Nonsteroidal-Anti-Inflammatory-Drugs (NSAIDs). Most people take those medications such as Aspirin, Ibuprofen or Tylenol ® for minor aches and pain.  If you take prescription pain medication ask your doctor before taking over-the-counter medication.  Prescription medication and over-the-counter medication may have the same substances in it.
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Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

These medications reduce inflammation and can reduce pain in many acute and chronic pain conditions. Most of the over-the-counter pain medications are NSAIDs. Some prescription medications also contain NSAIDs .
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Opioids are pain medications prescribed for severe pain conditions. Opioids act differently from NSAIDs or over-the-counter medications and are often combined with other pain medications. Opioids are commonly prescribed because of their effective analgesic, or pain relieving, properties. Studies have shown that properly managed medical use of opioid analgesic compounds is safe and rarely causes addiction. Taken exactly as prescribed, opioids can be used to manage pain effectively.
Opioids act by attaching to specific proteins called opioid receptors, which are found in the brain, spinal cord, and gastrointestinal tract. When these compounds attach to certain opioid receptors in the brain and spinal cord, they can effectively change the way a person experiences pain.
Opioids may interact with other medications and are only safe to use with other medications under a physician's supervision. Typically, they should not be used with substances such as alcohol, antihistamines, barbiturates, or benzodiazepines. Since these substances slow breathing, their combined effects could lead to life-threatening respiratory depression.
Long-term use also can lead to physical dependence—the body adapts to the presence of the substance and withdrawal symptoms occur if use is reduced abruptly. This can also include tolerance, which means that higher doses of a medication must be taken to obtain the same initial effects. Note that physical dependence is not the same as addiction—physical dependence can occur even with appropriate long-term use of opioid and other medications. Addiction, is defined as compulsive, often uncontrollable drug use in spite of negative consequences.
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Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI) uses radiofrequency waves and a strong magnetic field rather than x-rays to provide remarkably clear and detailed pictures of internal organs and tissues. The technique has proven very valuable for the diagnosis of a broad range of pathologic conditions in all parts of the body including cancer, heart and vascular disease, stroke, and joint and musculoskeletal disorders. MRI requires specialized equipment and expertise and allows evaluation of some body structures that may not be as visible with other imaging methods. Because MRI can give such clear pictures of soft-tissue structures near and around bones, it is the most sensitive exam for spinal and joint problems. MRI is widely used to diagnose sports-related injuries, especially those affecting the knee, shoulder, hip, elbow and wrist. The images allow the physician to see even very small tears and injuries to ligaments and muscles.  
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Computerized Tomography (CT)

CT (computed tomography), sometimes called CT or "cat" scan, uses special x-ray equipment to obtain image data from different angles around the body and then uses computer processing of the information to show a cross-section of body tissues and organs.
CT imaging is particularly useful because it can show several types of tissue—lung, bone, soft tissue and blood vessels—with great clarity. Using specialized equipment and expertise to create and interpret CT scans of the body, radiologists can more easily diagnose problems such as cancers, cardiovascular disease, infectious disease, trauma and musculoskeletal disorders.
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Fluoroscopy is the common name for the display of real-time images during an X-ray examination on one or two TV screens. Historically, fluoroscopy was done the first time by W.C. Roentgen when he first discovered the new kind of rays in 1895. For medical purposes, the first fluoroscopy units were used as early as 1896. Until the introduction of the image intensifier in the 1950s, the fluoroscopy units were equipped with a fluorescent screen. The fluoroscopic technique was revolutionized when the image intensifier was introduced.
The advantages of real-time imaging and the freedom to freely position the X-ray field during examination makes fluoroscopy a very powerful tool. The fluoroscopy is able to display views from different angles during the procedure. We use fluoroscpopy for almost all of our procedures to facilitate placement of the injection needle and assure correct positioning.
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Physical Therapy

Physical therapy targeting back pain is generally used to increase function and provide the patient with the knowledge and regimen to prevent further recurrences.
Physical therapy can include passive therapies such as the application of heat or ice packs, the use of electrical stimulation, and ultrasound to penetrate soft tissue with sound waves.
Active physical therapy should involve stretching, strengthening exercises and low impact aerobic conditioning. Routine stretching targeting a specific muscle group in response to a specific problem area is perhaps the most important form of physical therapy for back and spine problems. Regular low impact aerobic conditioning such as walking or bicycle riding should be performed in conjunction with both stretching and strengthening exercise.
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Traction Devices

Traction Devices have been used in different forms for hundreds of years for acute back pain. Early models were made out of wood and rope, while more modern devices use computer technology and are more comfortable. The idea behind traction or "zero gravity" devices is to reduce pressure on the spine. Traction may offer temporary relief for some pain conditions. Inversion tables use the same mechanism of reduced pressure on the spine by positioning the patient in a "head down" position.
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2601 Cherry Ave Suite #200
Bremerton, WA 98310

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