Dr. Dinesh Kumbhare and Sandra Aubin
Dr. Dinesh Kumbhare uses ultrasound to effectively treat Sandra Aubin's chronic pain. (Photo: UHN)

Sandra Aubin was 27 when she was involved in a car accident that left her with chronic pain in her head, neck and back.

For 20 years, she suffered quietly, enduring varying degrees of success with pain relievers, massage, chiropractic treatments, physiotherapy, acupuncture, and aqua therapy.

"My quality of life was limited and I was exhausted from the pain," recalls Sandra, now 47. "I would take frequent naps to escape my exhaustion, pain, and low mood."

It wasn't until 2016 that Sandra met Dr. Dinesh Kumbhare, who would introduce her to what she calls a life-giving technique: using ultrasound to detect, diagnose and treat her myofascial pain.

"Immediately after my first treatment, I had range of motion in my neck I didn't have before," says Sandra. "For the first time in years I could touch my chin to my chest, and turn and tilt my head."

'What excites me is the ability to definitively diagnose'

Over the past four years, Dr. Kumbhare, a clinical researcher and physiatrist in Toronto Rehab's Comprehensive Integrated Pain Program (CIPP), has been developing an ultrasound application that can be used in a clinic setting to analyze muscles, distinguish between healthy and unhealthy muscles, and ultimately, legitimize pain patients feel, but physicians can't find.

"What excites me is the ability to diagnose definitively," says Dr. Kumbhare. "The whole point of this research is to find the source of pain."

The ability to find the source of pain has largely eluded physicians until now, and contributes to the reason why muscle pain afflicts 80 per cent of chronic pain sufferers.

Physicians have approached muscle pain the same way for years – they take a history, palpate (manually examine) the area for a knot, also called a trigger point, and make a medical decision.

But this is dependent on a patient being able to tolerate the physical exam.

"If I'm in pain, I'm not going to let you palpate," says Dr. Kumbhare. "I'm going to tense up and withdraw. It's just a natural reaction."

There's also a chance the knot isn't evident to the touch. The muscle in your back is thick, Dr. Kumbhare explains.

"What I feel on the surface is a very small part and I can't get an appreciation of what may be going on underneath."

This lack of physical evidence has led physicians to either regard the pain with skepticism, or treat the general area where it's reported, even though it might be stemming from somewhere deeper.

The gold-standard treatment for muscle pain is trigger-point injections of corticosteroids combined with local anesthetic to numb the area.

"But if I can't find the trigger point with my fingers, how am I supposed to accurately inject it with my needle?" asks Dr. Kumbhare.

Using ultrasound, physicians will be able to find the knot with a high degree of accuracy and guide a needle directly into that area.

Treating pain has been more of an art than a science, says Dr. Geoff Fernie, Research Director, Toronto Rehabilitation Institute.

"What Dinesh is doing is taking ultrasound images, and using an app to subject them to statistical analysis, so we can start being a little more scientific," says Dr. Fernie.

"It's exciting to have a physiatrist here at Toronto Rehab, who appreciates the manual skills of physiatry, but wants to be able to introduce a level of science, so we can move beyond just good hands."

'Until now, pain has been something I've felt, but not seen'

The potential benefits of Dr. Kumbhare's method of diagnosing pain are significant.

Far from being a one-time fix, trigger-point injections are administered to some patients as often as once or twice a week for years.

"If we could save a large percentage of patients from having to endure what might not even be helping them, while saving our healthcare system millions of dollars, and have some evidence behind why we suggest a course of treatment, that would be a good advancement," says Dr. Kumbhare.

Using mathematically analyzed ultrasound images to confirm a diagnosis will also help put the right patient in front of the right doctor.

"If I can tell you that your muscle is normal, and that it doesn't need to be treated with injection, I can suggest a different pain rehab program," says Dr. Kumbhare.

Sub-specializing in chronic pain management is exactly what Toronto Rehab's CIPP delivers to patients.

"The intention of our program is to provide effective and thorough assessment that results in treatment recommendations that are specific to the needs of our patients," says Dr. John Flannery, Medical Director of the Musculoskeletal and Multisystem Program at Toronto Rehab and UHN.

"With Dinesh's ultrasound application, we are able to create each patient's treatment plan with a higher level of certainty."

Ultrasound also offers a teachable moment for patients, which supports Toronto Rehab's goal of integrating education and research into each patient care experience.

"When we're sitting in front of the screen together, what I see as a physician, you also see as a patient," Dr. Kumbhare explains. "If I can show you that your muscle is intact, or the exact spot where the knot exists, it changes the way you think about it."

For Sandra, ultrasound has helped objectify her pain, since knots appear as dark spots on the screen.

"Until now pain has been something I've felt, but not seen," she says. "It's interesting to watch the medication being injected and the knot disappear."

It also lends credibility to the pain she's felt for years.

"When people look at me there doesn't appear to be anything wrong," she says. "But there's a disability they cannot see."

Next steps

Dr. Kumbhare feels good about the direction his research is heading. His plan is to keep collecting data that legitimizes its utility, and continue developing the software that makes it usable for physicians.

His dream, he says, is to offer an ultrasound capable of taking a video file, dropping it into an application, and providing a detailed report that would help guide a physician's treatment plan.

"The report would identify what's normal, what's not, and what the abnormalities are," he says. "We're very close to that right now."

Dr. Fernie says that applying this science to the art of treating will help improve the effectiveness of care.

"It will also de-skill it somewhat, so a physician doesn't have to be years into the field before they're good," he says. "We may be able to provide a tool that helps others treat pain more effectively, and earlier."

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