By Allison Wells, MD
Chronic pelvic pain is at a difficult intersection of anatomical pain generators and mood disorders like depression and anxiety that are coincident with or caused by the pain itself. To effectively relieve chronic pelvic pain you need a treatment that addresses the pain and the mood disorder issues. Ketamine infusions do both.
Ketamine has been used safely for anesthesia since the 1960s when it was first created. It has been a first choice for battlefield medicine and for the most critically ill patients in the operating room. Since the 1980s ketamine’s effect on chronic pain and on depression and other mood disorders has been studied and thousands of patients have obtained relief around the world through programs at academic medical centers and private ketamine infusion clinics alike. Ketamine possibly works on chronic pain through down regulating GABA-A or NMDA receptors that have been up regulated and become self-sustaining in the pain syndrome. This is in contrast to the opioid narcotics, like Oxycontin, which work on the mu receptors.
Ketamine works to calm the overexcited pathways that cause neuropathic pain. It stops the feedback loop from the revved up peripheral neurons and allows the peripheral pain nerves to return to a normal resting state. Ketamine is good for acute pain, but it really shines with chronic pain. It doesn’t just cover the pain, like opioids. It actually changes the neural pathways to get them to stop sending faulty signals.
Europe and Australia have ketamine as a standardized part of their chronic pain and depression guidelines that are written by the national health systems of both countries. In America, ketamine is not FDA approved for the treatment of pain and depression because there have been no large randomized controlled trials, although there have been many small trials with positive results. Since ketamine is an old, generic drug with FDA approval already for other uses, specific indications for depression and pain have not been sought.
It is really hard to randomize patients in a ketamine trial – they know immediately whether they were given the control or the active medication. Also, who is going to pay for such a trial when there is no readily apparent way to profit off a generic drug that can’t be patented? For this reason ketamine is considered “off-label”. However, some reports indicate that in America more than 80% of all doctors prescribe off-label medications and more than 21% of adult medications and up to 78.9% of children discharged from hospitals were on at least one off-label medication. We are beginning to see insurance companies recognize the depth and breadth of positive studies and they are beginning to cover ketamine treatments. BCBS and UHC are the insurers that we have begun to see routinely cover this care and Aetna and Humana have been slower to provide coverage, but each patient’s plan may be different.
Ketamine is typically used as an infusion in most treatment protocols. There are a few programs that administer the infusion as a continuous drip over up to 10 days in the ICU at levels that render the patient comatose. This is not a standard practice because of the huge cost and also because of the risks and side effects of being in an immobile, general anesthesia, intubated state for 10 days, namely: pneumonia, blood clots, and muscle wasting. The majority of ketamine infusion programs perform the infusion as an outpatient procedure over the course of a few hours each day of treatment and as deep sedation, where the patient is still able to talk and breathe on their own.
Other delivery methods, such as oral delivery, are generally less favorable for ketamine pain treatments. Ketamine is unpredictable when taken by mouth as it is first metabolized and broken down by the liver after absorption from the intestinal tract before it can have its effect on the nerves it’s meant to treat. Only about 16% of the active compound is available after oral administration to have an effect with the rest being metabolized into inactive or underactive metabolites. Also, most studies appear to indicate that ketamine concentrations need to reach a certain threshold and stay steadily above that threshold for a few hours to accomplish the resetting of the pain receptors.
I practice at Lone Star Infusion in Houston, Tx. A patient here receives a low-dose infusion of ketamine for up to 4 hours at a time in a quiet, relaxed setting. The patient then recovers for up to 2 hours before being released to go home. Infusions are administered by a board-certified anesthesiologist experienced with using ketamine and adjusting medications for safety and patient comfort, including the use of adjunct medicines as appropriate.
Most side effects of the ketamine are well-tolerated and last only as long as the infusion. Hallucinations and feelings of dissociation are generally mild and may be treated. Sleepiness is common. Nausea is common without pretreatment but rare if patients are given oral ondansetron first.
The beneficial effects of ketamine can last for weeks or months depending on the severity and chronicity of the pain and follow-up treatments with single infusions of ketamine can help maintain the effects over many years. Clinics around the world have now been working with pain and depression patients and have 10 years’ worth of data on ketamine’s safety and long-term efficacy.
In short, ketamine infusions may be an excellent option for patients with severe, intractable neuropathic pain. There are websites like Ketamine Advocacy Network (http://www.ketamineadvocacynetwork.org) that list ketamine providers by state and also by talking with local medical schools and pain fellowship programs patients can find information on a ketamine infusion center near them. Treatments can cost anywhere from just a co-pay to $1,450 per 4 hour infusion depending on insurance coverage.
Allison Wells, MD
Board Certified Anesthesiologist
Trained at Harvard and Baylor College Of Medicine
I practice at Wells Medicine in Houston Tx
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http://www.ketamineadvocacynetwork.org
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical and occupational therapy?
Pelvic floor physical and occupational therapy is a specialized area of physical and occupational therapy. Currently, physical and occupational therapistss need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical and occupational therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical and occupational therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical and occupational therapists will take a detailed history. Following the history the physical and occupational therapists will leave the room to allow the patient to change and drape themselves. The physical and occupational therapists will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical and occupational therapists will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical and occupational therapists will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical and occupational therapists will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical and occupational therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical and occupational therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical and occupational therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical and occupational therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical and occupational therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical and occupational therapistss who work at PHRC have undergone more training than the majority of pelvic floor physical and occupational therapistss and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical and occupational therapistss focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical and occupational therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
Very interesting, I’ve been suffering with pelvic pain since 2012
Very interesting, but, not many could afford it
I just had ketamine infusion for three days with.an Dx of CRPS from pudendal neuropathy. My insurance, Blue Cross, denied coverage, so BCBS does not always pay. It was $750 per infusion, which is pretty “cheap” in a clinical setting. It had minimal effects, however the treatment itself was very pleasant due to listening to my favorite tunes. I highly recommend listening to beautiful music to make the experience that much more pleasant. I had NO PAIN during the infusion. It is sad that only those with $$ can afford it. The cost was a big hardship. I wish I could have been in a trial.
We have United healthcare which is one of the insurance companies mentioned that will pay for ketamine infusion so I’m going to check it out. This is very exciting to me as I have suffered severe chronic pain for nine years.