Pain Doctor: No Need to Suffer. Pain Center of Orlando

Lake Mary Life Magazine Article 3/1/09

Focus on Pain Center of Orlando
Peter Reilly

Chronic pain is the symptom that your body is out of balance. At the Pain Center of Orlando, Dr. David Klein works to restore hormonal and nutritional balance as well as to relieve pain.

He has helped many headache, hand-, foot- and back-pain sufferers regain their health, taking great satisfaction in curing those who have sought treatment elsewhere and haven’t found relief.

“I want to see the patients who are not satisfied with their care, those who have not found relief elsewhere,” he says from his Longwood office, the walls of which are lined with bookcases and decorated with models of antique cars and motorcycles. “I want the ones who are not getting better. I want to see the patients that no one else can figure out.”

With prior training and experience as an analytical chemist, and with nearly 30 years of clinical experience in medicine, a specialty in anesthesiology and with the subspecialty of pain medicine, Dr. Klein, a Longwood resident, is prepared to diagnose and deal with just about any pain-related disorder. He spent seven years as a Navy physician and five years in the Air Force as a flight surgeon, both on active reserve.

Dr. Klein earned his medical degree from the University of Maryland School of Medicine, surgical internship at University of North Carolina, and residency at Duke University. He has served on the clinical teaching faculties of Ohio State University, the National Naval Medical Center, and Portsmouth Naval Hospital, as well as on many editorial review boards for medical journals.

Certified by five medical boards, the doctor has given countless lectures, invented several medical products, and has been published more than 100 times.

With a resume like that you’d think Dr. Klein would be part of a large assembly-line practice with a big staff of nurses and physician’s assistants, but the decorated Gulf War veteran is a sole practitioner who doesn’t rush through visits or overbook appointments.

“There are no physician assistants or nurses in this office,” he says. “I see every patient, every visit, every time.” In fact, Dr. Klein feels that the only way to correctly diagnose what’s wrong is to spend a lot of time with each patient. Pain medicine is one of the most complicated and detail-oriented specialties in medicine.

“You have to look at the entire person to find the cause of his or her pain, or lack of sleep, or whatever the symptom happens to be,” he says.

His practice attracts patients from all over the country, with some coming from as far away as Europe and China. He has treated everyone from diabetics with nerve pain to colitis sufferers with cramping using his unique approach. In addition to traditional treatments, he finds that many pain sufferers are helped with nutritional supplements and hormone replacement therapy.

“Two-thirds of what I do is actually hormone replacement and nutrition,” says Dr. Klein, who was the reserve flight surgeon to the VIP squadron at Andrews AFB under President Reagan. “When you provide the appropriate nutritional intervention, you may need some prescription medications, but you need far less than are traditionally prescribed to get the job done.”

Dr. Klein believes that many chronic ailments result because people are overweight, but undernourished. Americans take in more than enough calories, but don’t get enough of the right vitamins and minerals. The minerals, in particular, are lacking in what we eat. To deal with this, he offers a line of very specific and focused nutritional products through his practice. “One size does not fit all,” he says.

Lifestyle, age, and genetics can also knock a person’s endocrine system out of whack, causing hormones like testosterone, estrogen, insulin and cortisol to become unbalanced.

“You begin with these common health problems,” he says. “But you can correct them with bio-identical hormone replacement, but it must be done precisely and properly. The safety of my patients is most important. I’m here for one reason, to help them get better. (For more information on this subject, check out Dr. Klein’s column on page 92.)

The Pain Center of Orlando is located at 225 West S.R. 434, Suite 205 in Longwood. For more information or to schedule an appointment, call 407-679-3337 or visit Dr. Klein’s informative website at www.suffernomore.com

Bio-Identical Hormone Replacement

Bio-Identical Hormone Replacement (HRT): Cancer, Menopause, and Other Medical Risks

 

The controversy over hormone replacement risks has been going on for over 3 decades, now. What is uncontroversial, however, are the   seemingly contradictory opinions that arise over the same scientific data.  One month, is good and safe, the next month, a newspaper article describes it as ‘unsafe.’ 

 

Fact #1: Both women and men must have estrogen (estriol, estradiol, estrone),

testosterone and progesterone in the blood stream.  These hormones are necessary to maintain the health of essentially every organ and tissue in the body.  Neither good, nor bad, these hormones must be maintained in rather tight ratios, relative to each other, in order to maintain health.  These hormones are healthy and youthful if maintained in the appropriate ratios.  They can result in damage and disease if the ratios are not determined and monitored.

 

Problem #1: This is where the problem arises: does your physician test for these hormone levels, and does your physician understand the nature of hormone ratios? These hormones are present in your body during times of health, the levels are greatest during youth and decline steadily with age. As you age, the levels decrease, but the ratios can change to unhealthy ratios.

 

Fact #2:  Progesterone is the naturally occurring hormone, Progestin is not.  Clinical studies, looking at the safety of HRT in patients that already developed breast, ovarian and uterine cancer, demonstrated that estriol, estradiol, estrone and progesterone were safe to administer.  Progestin, on the other hand was a problem.  Note this well:  Progesterone is not the same thing as Progestin.

 

Problem #2: Most physicians will prescribe hormone replacement without baseline blood levels of these hormones.  This is when and why hormone replacement can be dangerous.  If these hormones, bio-identical or not, are administered without determining baseline and treatment hormone levels, dangerous ratios can and will result.

 

Fact #3: A Bio-identical hormone is a chemical messenger that is chemically identical, not ‘similar’ to the chemical messenger found in the human system.    Many of these hormones come from animal sources, some are chemically manufactured or are derived from other biological means. 

 

Problem #3: Estrogen and Progesterone must be maintained, in balance, to avoid PMS like symptoms, ‘bitchiness,’ and depression.  The problem is usually too little progesterone, although both estrogen and progesterone levels do decrease with age. Excess estrogen is often known as ‘estrogen dominance.’ The answer may be as simple as the administration of progesterone.  Breast cancer incidence increases with age,   just as estrogen, progesterone and testosterone levels decrease with age.  If these hormones cause cancer, why does cancer tend to occur at ages when the levels actually decrease?

 

Fact #4: Blood testing is the only reliable means to determine hormone levels in the blood.  These chemical messengers do their work through the blood stream, and it only makes common sense that determination of blood levels is the proper approach.  Unfortunately, many patients are sold on the idea that salivary levels are ‘superior’ in some way to blood levels.  One would be led to believe that spitting in a tube will give you more consistent results than a blood draw.  Having performed paired determinations of salivary levels and blood hormone levels, I have found that the salivary results are rarely consistent with the blood levels. 

 

Problem #4: Almost is not good enough.   In order to properly determine blood levels of these hormones, it is simply not good enough to perform hormone testing that lacks scientific validity.  Unfortunately, many patients (and some physicians) rely on salivary hormone testing as a guide. Salivary hormone testing is available without a doctor’s prescription, which is what makes it popular.  It is not reimbursable by most (if any) insurance carriers because salivary hormone testing has never demonstrated consistency in results.  Simply stated, the US Food and Drug Administration (FDA) has not approved salivary hormone testing because the results are unreliable and inconsistent.  The FDA does approve blood testing of the same hormones, and insurance carriers do cover the blood determinations. 

 

Fact #5:  Low blood testosterone and DHEA levels lead to loss of libido, depression and other illnesses.

 

Problem #5: As you age, DHEA, sometimes known as the ‘fountain of youth hormone,’ decreases. The body uses DHEA to produce progesterone, testosterone, estriol, estradiol as well as other hormones.  There is more DHEA in the blood stream than any other hormone.  Why is it, then, that physicians rarely test the blood for adequacy of this vital hormone?  

 

Summary:  Replacement of the naturally occurring hormones is safe.  There is little data to suggest that replacement of these hormones to restore proper hormone levels in appropriate ratios will do anything but reduce the risk of heart disease, reduce the risk of osteoporosis, and actually reduce the risk of cancer.

           

 David S. Klein, MD is the medical director of the Pain Center of Orlando, Inc. A graduate of the University of Maryland School of Medicine, Dr. Klein received training in General Surgery at the University of North Carolina, and Anesthesiology Residency at Duke University.  He was elected as Fellow in the American College of Pain Medicine, Fellow of the American College of Anesthesiologists, Fellow in the American College of Pain Management.  Dr. Klein has been published over 100 times, and he has lectured nationally and internationally on topics ranging from nutritional medicine, bio-identical hormone replacement and pain treatment.  He has been on served on several professional editorial boards, two medical school faculties and is currently enjoying private practice in Longwood, Florida.

Melatonin and Osteoporosis

Osteoporosis

Melatonin has been shown to stimulate cells called osteoblasts that promote bone growth. Since melatonin levels may be lower in some older individuals such as postmenopausal women, current studies are investigating whether decreased melatonin levels contribute to the development of osteoporosis, and whether treatment with melatonin can help prevent this condition. Melatonin is useful not only in the treatment of sleep disorders, but it  is useful in cancer prevention, osteoporosis and, as an adjuvant for weight loss.

 

Melatonin's therapeutic potential is underestimated because of its wide variety of functional roles and  mechanism(s) of action are complex and varied. Melatonin is a chronobiotic agent secreted from the pineal gland during the hours of darkness.  Melatonin modulates metabolic and cardiovascular physiology as well as bone metabolism and immune function and detoxification of chemical agents and cancer reduction.

Melatonin levels decrease with age. This decrease in plasma melatonin levels observed in humans during late adulthood may further enhance susceptibility to osteoporosis.

Therapeutic dosages of melatonin seem to be be related to age, gender and co-administration of pain killers. Women need more melatonin than men, opiate users need more melatonin than non-opiate users. To make it even more interesting, individuals with gastrointestinal disorders need substantially more melatonin, as well.

The rule of thumb that I use is:

Ages 10 to 21, starting dose 1 mg for  boys, 3 mg for girls.

Ages 21 to 60, starting dose 3 mg for men, 6 mg for women.

For patients taking opiates, and for those patients with GI absorption or motility disorders, 10 mg for both women and men, anticipate 20 mg in women taking opiates.

Pharmaceutical Grade Melatonin

References:

Witt-Enderby PA, Radio NM, et al: Therapeutic treatments potentially mediated by melatonin receptors: potential clinical uses in the prevention of osteoporosis, cancer and as an adjuvant therapy.

J Pineal Res. 2006 Nov;41(4):297-305.

Radio NM, Doctor JS, Witt-Enderby PA: Melatonin enhances alkaline phosphatase activity in differentiating human adult mesenchymal stem cells grown in osteogenic medium via MT2 melatonin receptors and the MEK/ERK (1/2) signaling cascade. J. Pineal Res. 2006 May;40(4):332-42.

See also: 

 "Treatment of Osteoporosis with Oral Strontium Citrate"

"Nutritional Factors in Osteoporosis"

         

 

Osteoporosis- Nutritional overview

Nutritional Factors in Osteoporosis

 

 

Introduction

 

The incidence of osteoporosis increases with age, and is develops at an earlier age in woman than in men. About 55 % of Americans, women more so than men, are at risk of developing osteoporosis. This disease is characterized by a demineralization of the bones, which become porous and fragile, this causing a higher susceptibility to fractures.⁵

 

Background to Medical Intervention

 

Bone is largely calcium in nature, and if demineralization were the issue than common sense would dictate that increasing dietary intake of calcium would arrest, reverse or at least minimize the ravages of this illness. For years, physicians recommended increase in dietary calcium as the principal intervention in this illness.³ It is only now becoming more obvious that calcium intake is but one of many nutritional concerns that must be addressed in order to effectively treat ostoporosis. Many factors, including age, menopausal status, total calcium, vitamin K2 and vitamin D intake,⁷ as well as consumption  of cigarettes, saturated fats, alcohol, and cola proved to be linked to a lower bone mineral density.

FACT #1: The human adult requires approximately 200 mg of elemental calcium per day, and if absorption is between 20% and 40%, the nutritional allowance is approximately 1,000 mg per day. Too much calcium causes more immediate problems involving muscle and nerve. These regulatory mechanisms modulate the absorption of calcium. That is, calcium in excess of 1,200 mg or so will cause the body to reduce the percentage absorbed. While this would appear to be ‘wasteful’ of an inexpensive nutrient, the real cost is that the excess calcium competes with absorption of other micronutrients, resulting in poor absorption of these.

 

Too much of a good thing is, in fact, a very bad thing. Calcium ingestion in excess of the requisite  amount reduces rates of absorption of calcium thereby limiting the calcium burden in the vascular system, but dietary cations, including calcium compete for absorption. That is, increasing dietary calcium past a fairly modest level actually inhibits the absorption of other cations, including magnesium and strontium, both essential for development and maintenance of bone.¹

 

FACT #2: Taking a properly balanced mineral supplement minimizes the danger of ‘overdoing it.’

 

FACT #3: Most commercially available vitamin/mineral supplements are worthless because they present the minerals in a poorly absorbed, inorganic form. This is done so that the manufacturer can provide a ‘1-tablet solution’ to all of your needs. It is better that you should keep your money in your pocket than to purchase this junk.

 

 

 

Vitamin D-3

 

Insufficient ingestion and/or absorption of vitamin D-3 (cholecalciferol) can lead to the development of osteoporosis and damage to the joints. Cholecalciferol is necessary for the absorption of calcium from the gut as well as for deposition of calcium in the bone.  Adequate Vitamin D-3 is necessary to ensure that the bones remain strong and are less prone to being brittle or fractured. Vitamin D-3  can also delay the effects of arthritis and reduce back pain.

 

Vitamin D-3 deficiency leads to Osteoporosis. In so far as Cholecalciferol is absorbed in the small intestine, disease states that involve  the liver, intestines and gall bladder can hamper the proper absorption and result in Vitamin D-3 and other vitamin/nutrient deficiencies.

 

Vitamin D-3 is unlike any other vitamin. In fact, it really is not a vitamin, at all, but it is a hormone. Its metabolic product, calcitriol, is a secosteroid hormone that has genetic receptors in over 200 genes in the human body. Research studies have  implicated vitamin D deficiency as a major factor in the pathology of at least 17 varieties of cancer as well as heart disease, stroke, hypertension, autoimmune diseases, diabetes, depression, chronic pain, osteoarthritis, osteoporosis, muscle weakness, muscle wasting, birth defects, and periodontal disease.

 

In addition to Vitamin D-3 being important for bone metabolism, sufficient supplementary cholecalciferol has been demonstrated to reduce the risk of breast cancer, prostate and colon cancers as well as reduce the risk of developing multiple sclerosis (MS).^{12, 13}

 

Strontium

 

Strontium is an element necessary for the maintenance of calcium matrix. It has been assessed in patients with post-menopausal osteoporosis where it was demonstrated to decrease the risk of vertebral fractures, by 41% over 3 yrs, and by 49% within the first year of treatment. Further, this risk of non-vertebral fractures is decreased by 16% and, in patients at high risk for such a fracture, the risk of hip fracture is decreased by 36% over 3 yrs.^{10, 11}

 

 

Dietary Phosphoric Acid Accelerates Osteoporosis

Dietary influences that increases bone demineralization are becoming more and more problematic. Intake of phosphoric acid, as an example, can dramatically accelerate the development of osteoporosis. Cola beverages are the greatest risk in this regard. Phosphoric acid is present in high concentration in cola beverages, and with intake of these soft-drinks, excretion of the phosphate moiety takes place in the form of calcium phosphate. With intake of excessive amounts of phosphoric acid, drinking cola beverages may hasten the development of osteoporosis by  worsening  calcium deficiency in the bone itself, which in turn causes weakening of the  teeth and weak bone density (osteoporosis).²

 

FACT: Phosphoric acid intake, in the form of carbonated soft-drinks can hasten the development of osteoporosis. 

 

Vitamin K-2

 

Vitamin K is a lesser known vitamin group, composed of three major chemicals, structurally similar, fat-soluble, 2-methyl-l,4-naphthoquinones, including phylloquinone (K1), menaquinones (

K2

), and menadione (K3). Vitamin K2 (menaquinone), stimulates bone formation by way of hormone-regulation. This is thought to consist of gamma-carboxylation of osteocalcin and/or steroid and xenobiotic receptors (SXRs). This modulation reduces the incidence of vertebral fractures, despite having only modest direct effects on the bone mineral density (BMD).⁴

 

The most common form of vitamin K2 in animals is menaquinone 4 (menatetrenone; MK-4), produced by the processing of exogenous and bacterial naphthoquinones Vitamin K is a coenzyme for glutamate carboxylase, an enzyme which mediates the conversion of the amino acid glutamate to gamma-carboxyglutamate (Gla). The gamma-carboxylation of the these proteins is essential for the proteins to attract calcium, and to incorporate calcium into the hydroxyapatite crystals that form bone.⁶

Vitamin K-2 is found in certain vegetables, but it is absorbed best if injested simultaneously with butter. Further, the production of Vitamin K-2 is accomplished through ‘normal’ gastro-intestinal bacteria.

 

NOTE WELL: Supplementation of vitamin K-2 can prevent the development of osteoporosis and reduce the risk of lumbar compression fractures from osteoporosis.⁸

 

FACT #1: Marjorine is not butter, and marjorine is consumed in far greater amounts than butter, thereby reducing available Vitamin K2 in our diet.

 

FACT #2: Gastrointestinal flora are important to the production of Vitamin K2. Anti-biotics kill off the ‘good bacteria’ right along with the pathogenic bacteria. Patients demand anti-biotics for all manners of problems that would best be treated without anti-biotics. By altering gastrointestinal bactial flora, we are crippling our ability to get K-2, thereby worsening our skeletal strength.

 

FACT #3: Taking the wrong form or formulation of Vitamin K, or Vitamin K-2 is worthless in therapeutic benefit. You’ve got to know your chemistry, here.

Other Important Nutrients

 

However, there are several other vitamins and minerals needed for metabolic processes related to bone, including manganese, copper, boron, iron, zinc, vitamin A, vitamin C, and the B vitamins.⁹ The diet must be sufficient in balanced protein as well as balanced with the appropriate fats and oils.

 

 

Nutritional Intervention

 

As the complexity of a treatment regimen increases, the likelihood of patient compliance decreases. This is nothing new, certainly not a dramatic revelation. Unfortunately, there is no uncomplicated way to accomplish the task of disease prevention. The American diet, as it is true in most of the developed world, has become increasingly deficient in basic nutrient assay. As a result of soil depletion of micronutrients, deficiencies in micronutrients is becoming commonplace. Deficiencies in zinc, magnesium, manganese, strontium, vanadium and chromium, result in many disease states ranging from obesity and diabetes to Alzheimer’s Disease and cancer.

 

To this end, I find it easiest to start my patients on a balanced mineral supplement, separate and distinct from the vitamin and hormonal supplement requirements. This permits adjustment for age, gender, and disease state. To this, I add Strontium Citrate, Vitamin D-3 and Vitamin K-2. The dosage requirement of strontium increases with advancing age, while the dosage of Vitamin D-3 and Vitamin K-2 remains relatively static. Administering the B-complex separately permits for upward adjustment for the peculiar needs of diabetics. Administering Vitamin E separately permits adjustment of other nutrients without increasing risks of Vitamin E overdose and treatment induced pathology.

 

Patients that suffer from gastro-intestinal disorders require higher dosages of the chelated minerals, due to hampered absorption. Patients with a family history of breast or prostate cancer receive higher doses of Vitamin D-3.

 

If these products were presented in one capsule or packet formulation, customization would be difficult if not impossible.

 

Summary

 

Bone is a dynamic organ system. As the sand on the beach is forever changing, so is the matrix of bone. Physiologic forces promote bone deposition and production, while others promote resorption and destruction. Nutritional influences are extremely important, both in positive and negative terms. It takes a wide variety of essential substances, mineral, vitamin, protein, and hormonal to maintain the health and integrity of each and every organ system, including the musculoskeletal system.

 

It is important to realize that there is no simple, easy way to ensure adequate nutritional support of bone. There is no simple or single product that provides all of the nutritional needs of bone. It takes a combination of products, tailored to the unique medical condition, age and gender of an individual to properly provide for basic metabolic need, disease prevention and improved performance.

 

Unfortunately, few medical practitioners understand the complexity of bone metabolism, and this leads to reflex-prescription writing to slow the progression of this illness, when nutritional prevention is cost-effective and easily implemented.

 

NOTE WELL: The most important nutrient in the treatment or prevention of any disease state is the one that is missing from the diet.

 

References

 

1. Hendrix JZ , Alcock NW, and Archibald RM: Competition Between Calcium, Strontium, and Magnesium for Absorption in the Isolated Rat Intestine . Clin Chem: 9: 734-744, 1963.

2. Tucker KL, Morita K, et al: Colas, but not other carbonated beverages, are associated with low bone mineral density in older women: The Framingham Osteoporosis Study. Amer J Clin Nutr: 84(4), 936-942, 2006.

  3. Suzuki Y, Whiting SJ, et al: Total calcium intake is associated with cortical bone mineral density in a cohort of postmenopausal women not taking estrogen. J Nutr Health Aging: 7(5):296-9, 2003.

  4. Iwamoto J, Takeda T & Sato Y: Role of vitamin K2 in the treatment of postmenopausal osteoporosis. Curr Drug Saf:1(1):87-97, 2006.

  5. Lanham-New SA: Importance of calcium, vitamin D and vitamin K for osteoporosis prevention and treatment. Proc Nutr Soc 67(2): 163-176, 2008.

  6. Bugel S: Vitamin K and bone health in adult humans. Vitam Horm: 78:393-416, 2008.

  7. Yaegashi Y, Onado T et al: Association of hip fracture incidence and intake of calcium, magnesium, vitamin D, and vitamin K. Eur J Epidemol. 23(3):219-225, 2008.

  8. Shiraki M, Shiraki Y, et al: Vitamin K2 (menatetrenone) effectively prevents fractures and sustains lumbar bone mineral density in osteoporosis. J Bone Miner Res:16(4):794-5, 2001.

  9. Palacios C: the role of nutrients in bone health, from A to Z. Crit Rev Food Sci Nutr 46(8):621-8, 2006.

 10. Roux C: Strontium ranelate: short- and long-term benefits for post-menopausal women with osteoporosis. Rheumatology (Oxford). Jul;47 Suppl 4:iv20-22, 2008.

 11. Roux C, Reginster JY, et al: Vertebral fracture risk reduction with strontium ranelate in women with postmenopausal osteoporosis is independent of baseline risk factors. J Bone Miner Res 21(4):536-42, 2006.

 12. Geller JL & Adams JS: Vitamin D therapy. Curr osteoporos Rep. Mar;6(11):5-11, 2008.

 13. Gigante A, Torcianti M, et al: Vitamin K and D association stimulates in vitro osteoblast differentiation of fracture site derived human mesenchymal stem cells. J Biol Regul Homeost Agents. Jan-Mar;22(1):35-44, 2008.