I, YOU AND YOUR CHOLESTEROL

How we can lower cholesterol?

GENERAL CONSIDERATIONS.

Is Cholesterol the villain of all our maladies?. Not really. Cholesterol is vital for life, as it is the source for all steroids and hormones.

You might have elevated cholesterol and not know it. High Cholesterol is usually asymptomatic until it is too late when we get heart or brain attacks. It is not like high blood sugar that can give us certain signals, such as thirst, frequent urination, fatigue, bad breath, etc.

The elevated Cholesterol is called Hypercholesterolhemia, a condition that lead to Atherosclerosis, or clogging of the arterial blood vessels.

Atherosclerosis is the leading cause of death in the developed world and is becoming the leading cause of mortality globally. Despite the effectiveness of the modern therapy, the global burden of mortality from ischemic cardiac and cerebral diseases is predicted to double from 1990 to 2020.

METABOLISM OF LIPIDS

A-     Endogenous Cholesterol pathway.

B-      Exogenous Cholesterol pathway.

Endogenous Cholesterol Pathway

The Endogenous Pathway, start with the formation and mobilization of Chylomicrons, from the absorption at the intestinal Jejunum to the lymphatic circulation. The Cholesterol enters the intestinal villi and is transported by way of Neiman-Pick C1Ll( NPCILI) and is converted to Cholesteryl Ester by ALyl CoA  Acyl Transferase CA CAT-2).  Seemingly Free Fatty Acids (FFA) enter the intestinal cells by way of Mono Acyl Glycerol (MAG), to join both the Cholesteryl – Ester. The Tryglyceride (TG) and the Apo protein B48 to form Cholesteryl Ester Triglyceride (CETG)by way of Microsomal TG Transfer Protein (MTTP). Then the CETG moves to the surface of the intestinal cell to be excited to the lymphatic circulation

Exogenous Cholesterol Pathway

The hepatic Cholesterol is metabolized mainly as very Low Density Lipoprotein (VLDL), which in turn is converted to intermediate Density Lipoprotein Lipase enzyme(LPL) IDL further convert to Low Density Lipoprotein (LDL) that then go to the peripheral tissues (muscles , fat tissue, etc) for utilization and or storage. Seemingly the formed TG degrades to FFA and Glycerol to its destination peripheral tissue and also TG is converted to HDL2 which in turn is converted to Cholesterol Ester and then to its final destinations: VLDL. The hepatic Cholesterol is directly disposed as Biliary Cholesterol and Bile Acids.

ATHEROSCLEROSIS

Atherosclerosis is a progressive disease that first affects the vessels with elastic lining, such as aorta, carotids, coronary and popliteal arteries. It starts as a fat streak of lipid-filled foam cells, that then form a fibrous plaque, that then form larger atherosclerotic plaques, initiating and sustaining an inflammatory response inside the blood vessel. Such plaques, ultimately progressively occludes the arterial lumen. ft is estimated that most clinical symptoms appear when the occlusion reaches approximately 70%. The most dangerous Cholesterol is LDL.

NON LIPID MEDIATED RISK FACTORS FOR CARDIOVASCULAR AND CEREBROVASCULAR DISEASES.

A-non modifying: Age, Male gender and Family history.

Modifying risks: Arterial Hypertension, Tobacco smoking, Diabetes, Obesity, Sedentarism , High Saturated Fat Diet and Hypercystinemia.

CLASSIFICATION ON LIPOPROTEIN DISORDERS.

A-     Primary Dyslfpidemias

B-      Secondary Dyslipidemias.

A-Primary Dyslipidemias:  mostly Genetic or hereditary.

• A1 Familial
• A2  Autosomal  Recessive.

B-Secondary Dyslipidemias.

B1-Secondary causes of high cholesterol: hypothyroidism, obstructive liver disease, anorexia nervosa, acute intermittent porphyria, use of certain drugs, such as progesterone, cyclosporine and thiazide.

B2- Secondary causes of high triglycerides: Obesity, diabetes, chronic renal failure, alcohol abuse, ileal bypass, pregnancy, acute hepatitis, stress, sepsis, SLE, use of certain drugs: estrogens, B adrenergic agonists, steroids, bile acid sequestrants and thiazides.

TREATMENTS FOR THE PREVENTION ON CARDIOVASCULAR AND CEREBROVASCULAR DISEASES.

HMG CoA REDUCTASE INHIBITORS: STATINS.

HMG stands for Hydroxy Methyl Glutaryl  CoA.

These drugs reduce the synthesis of intracellular Cholesterol, primarily LDL. The firs of such drugs was introduced in the market was MEVASTATIN, around 1971, and then simvastatin (Zocor) by 1990.

HMG CoA is normally catabolized to MELAVONATE which then converts to cholesterol. Therefore when the Reductase  is blocked, there is no formation of Cholesterol.

There are numerous STATINS

A-Fungal derivatives: Lovastatins (Mevacor) ,Pravastatin (Pravacol) and Simvastatin (Zocor).

B-Synthetic Statins: Atorvastatin (Lipitor), Fluvastatin (Lescol) and Rosuvastatin (Crestor). The latter is the most potent.

Almost all Statins have potential bad side effects, mainly muscle and liver dysfunction, peripheral neuropathy, lymphomas, thrombocytopenias and others. Check AST and ALT hepatic function tests periodically.

BILE ACID SEQUESTRANTS

These are non absorbable resins that bind to bile acids in the terminal ileum: Cholestyramine (Questran) Cholestipol (Colestil) and Colesevelam (Welcol).

CHOLESTEROL ABSORPTION INHIBITORS:  Ezetimab (Ezetia), It blocks the absorption in the intestine thus reduces the absorption of cholesterol upto 50%. However, does not seem to reduce TG. Usual dose 1 G a day. Available in the market alone or in combination with sinsvastatin as Vytorin.

NICOTINIC ACID

One of the oldest and most potent drugs. They are part of vitamin B complex, increases HDL by 30%-40% can be used in combination with Statins. Most people don’t tolerate it because produces annoying flush and itching, but if starting in low doses and titrate, it can be tolerated better. May be available as Niaspan which is extende release in caps of 500, 750 and 1000 mg.

OMEGA-3 FATTY ACIDS

Reduces TG by acting of VLDL synthesis. Can be used in combination with Statins if necessary. It has econdary benefits such as lowering the BP, modulate heart rate and rythm and has also anti-inflammatory properties.

A-Long chain: a) EPA (EisosaPentaenoic Acid) and b) DPA (DecasaPentaenoic Acid).

B-Short chain: alpha linolenic acid (ALA).

OTHER TREATMENTS:

Fibrates.

OrIlstat (Alli and Xenical) that act by accelerating the fat elimination in stools.

Surgery (Partial ileal bypass). Not to be confused with bariatic bypass to reduce weight.

Therapeutic life style changes: reduce 10-20% body weight, exercises, stop smocking, reduce or eliminate saturated fat consumption, reduce alcohol consumption, special diet such as Mediterranean diet, prolonged fasting.

Are you suffering from sleep apnea ?

SLEEP DISORDERS : SYMPTOMS AND TYPES

1. INSOMNIA

2. HYPERINSOMNIA

3. PARASOMNIAS

INSOMNIA

Insomnia is a recurrent or persistent inability to either initiate the onset of sleep, or difficulty maintaining a normal uniform sleep pattern. Insomnia is the most common sleep disorder. Occasional insomnia may affect up to one third of the U.S population. The cause of primary insomnia is unknown but secondary insomnia may be caused by alteration of the circadian cycle (inner clock); medical, neurological or psychological illnesses. There are some transient insomnia that may arise from acute stressful situations of life, jet lag, shift work or side effects of some medications intended for something else.

HYPERINSOMNIA

It is an excessive day time sleepiness in certain conditions such as: narcolepsy and insufficient sleep syndrome. Narcoleptics may have additional problems, such as cataplexy (sudden loss of muscle tone) hypnagogic hallucinations (bizarre hallucinations). Narcoleptics usually present with episodes of sudden, uncontrolled desire to sleep, usually while eating, talking, or while driving.  Such condition must be distinguished from other conditions, such as use of drugs, stupor and akinetic seizures (drop attacks).

PARASOMNIAS

To better understand this disorder it is necessary to revise the physiology of the sleep cycle. The normal sleep activity has two major components: REM and NREM phases. REM stands for Rapid Eye.
Movements:

The NREM phase has 4 major stages, known as: NREM-1, NREM-2, NREM-3, and NREM-4.

NREM- 1: is a very superficial drowsiness, very light stage that is a transitional change from wake state. The predominant rhythm is beta rhythm in the EEG trace (4-7 Hz). It may last only a few minutes and the
arousal is easy.

NREM- 2: is a deeper stage and the EEG trace may show Gamma rhythm (12-16 Hz). It may show also “sleep spindles”.

NREM- 3:  is a deeper stage that may last from a few minutes up to 2 hours and the arousal is harder

NREM- 4: is the deepest stage and some snoring may appear. The EEG is remarkable for deep, high amplitude, slow rhythm complexes of Delta waves.  Most night mares, bed wetting and panic attacks may appear in children. Some sleep walking are common here. The body temperature and blood pressure falls, and the heart slows down.

REM PHASE

It may start around 90 minutes after falling asleep or after NREM-1 or NREM-2. It may fluctuate between certain NREM activities back and forth.  Most of the brain activity takes place here. Among the major changes that take place here, are: rapid eye movement, piloerection (goose skin), sweating, tachycardia, penile tumescense.  Body temperature and blood pressure rise. Sleep studies may reveal true, physiologic causes of erectile dysfunction, versus psychogenic ones. It is believed that most Parasomnias are due to abnormal swings between REM and NREM phases of sleep.

Some variants of Parasomnias are: Somnambulism (sleep walking), Confusional Arousals, Sleep Terrors, enuresis (bed wetting) and nightmares . Nightmares are unpleasant and frightening dreams that occur during REM phase and most may be considered benign. There usually vivid recollection of such dreams. There are some causes of nightmares that may arise from Post Traumatic Stress Disorders, that  may require psychotherapy or SSRI drugs.

Sleep apnea, occurs when the patient stop breathing several times during sleep, only to awake violently gasping for air when the Carbon Dioxide accumulates. It is most frequent in obese people when the cause is external but may appear from alteration of the centers in the brain that control the sleep.

How to increase your Appetite?

Thirteen Best Secretes To Curb Appetite Naturally:

NUMBER ONE:

Have two proteins serving at breakfast. For example:

• One cooked egg (poached, scrambled, fried, boiled), plus one ounce of cheese (any kind).
• Or 8 ounces of low-fat yogurt served with almonds.
• Proteins make us feel full longer. “Eat slowly, chew twice as long”.
• Always use small plates.

NUMBER TWO:

For lunch and dinner: always start with the items of LEAST calories, then follow with those items ofMOSTcalories. For example:

• Start with a veggie salad. Avoid commercial dressings. Favor vinegar, lemon, olive oil, etc.
• Eat grains, second. Then go to the heavier foods, such as meats, fowl or fish.
• By the time you getto the latter, you are already full. “Do not forget to use small plates all the time”.
• For more tips and more help to find your best portions for your height and physical activity, go to:

 www.mypyramid.gov . Click on “my pyramid plan” .

NUMBER THREE:

Get into snacking. Snacks when choose wisely, keep hunger pangs under control.  For Example:

• A veggie with whole grains such as humus, or salsa with whole wheat pita or crackers.
• A pair of fruits such as apples, pineapples, pears, etc plus cottage cheese.
• Or a smoothie made with berries and low fat yogurt.

Do not reach for sweeties like candies or cookies first. Always have a handful of nuts when yourguts grumble. Try to snack in between main traditional meals. Grassing keep the metabolism running.  

NUMBER FOUR:

Reach for those foods that are not easy to fix or are quick to eat. For example:

• Pistachios or shrimp that need to be peeled first. Have the chance to savor instead of dumpingin your mouth. You will fool your brain into thinking that you are eating more.

NUMBER FIVE:

When severely hungry,  drink water. Water is an easy filler and may be another way to be certain that you are thirsty and not hungry. This apply when choosing some other items rich in water content, such as:

• Cucumbers, lettuce, zucchinis, oranges, peaches, strawberries, melons, watermelons, etc.

NUMBER SIX:

Reduce caffeine drinks: coffee, tea, cola. Caffeine gives a short term energy buzz, but also increases the appetite. Caffeine also stimulates insulin secretion which reduces the blood sugar which tells your brain that it is time to eat. Limit caffeine further if you have insomnia.

NUMBER SEVEN:

Chew some cinnamon gum. While having gum in your mouth, you have less desire to put food in there. Chewing gums produce more saliva that fights infections. Chewing gum also reduces tension headaches and reduces stress. It is believed that cinnamon prevents early diabetes. Chewing gums can distract you so you can have less desire to smock a cigarette.

NUMBER EIGHT:

Fill up with FIBERS, Fibers stay longer in your stomach, making you fill full longer.  Fibers also hold water and expand the stomach. Fibers favor the intestinal beneficial flora that favor digestion and increase the immune system. Examples of Fibers: Fruits, especially berries, apples, pears, pineapples, etc. Beans, rice, oatmeal, whole -wheat bread, oat-bran muffins, etc.

NUMBER NINE:

Eat low sugar or sugarless CHOCOLATE for desert. One ounce of dark chocolate with 70% or more of cocoa content has only about 150 calories and is the best for our heart and brain. Where and how to order good chocolate: Call Scharffen Berger 866-682-5746

NUMBER TEN:

Eat nutrient-rich nuts, 30 minutes before dinner.  Nuts have the hormone GHRELIN, that stimulates hunger but also stay in the stomach longer.

NUMBER ELEVEN:

Take a brisk walk for 1/2 hour each day. Aerobic exercises lower the hunger hormone GHRELIN, burn calories, enhance your cardio and neurovascular circulation and enhance your balance, coordination and stamina.

NUMBER TWELVE:

Learn how to retrain your palate. If you routinely eat lots of sugars, salts and fats, your taste buds become desensitized. We develop a kind of “tolerance”, which explains why we require larger and bigger amounts of to be satisfied. But once we cut them down, within a few weeks, we regain the ability to detect and enjoy subtler flavors.

NUMBER THIRTEEN:

Sleep more and better, at least 6 hours a day.  People that sleep less than 6 hours a day have higher levels of GHRELIN hormone, making them almost constantly hungry, especially in the middle of the night.

OTHER USEFUL TIPS

A research on VINEGAR reveals that the acetic acid content of vinegar increase the certain proteins that melt fats. Skim milk has high contents of LACTOSE that may contribute to feel full. White tea extracts seem to inhibit the formation of new fat cells in the laboratory.

A BRIEF NOTE ON NATURAL AND ARTIFICIAL SWEETS

CANE SUGAR AND MOLASSES:   A recent report from the American Heart Association:  the use and abuse of sugars in food, may lead to high blood pressure, which in turn lead to brain and heart attacks.

HONEY: is a natural sweeter from flower nectar, concentrated by bees. Honey is 25-50% sweeter than cane sugar.

LOW OR NO CALORIE SWEETERS

ASPARTAME: It is made of combination of Aspartic Acid and phenylalanine. Sold in the market as NutraSweet and Equeal. They are 200% sweeter than sugar.

SACCHARIN: Contained in Sweet & Low. It is 200-700% times sweeter than sugar. Seem to induce cancer in laboratory animals.

SUCRALOSE: Found in Splenda. Seems to be 600% sweeter than sugar. It is very safe. Not linked to any disease.

Plantar Faciities

Plantar Faciities : Symptoms And Treatments

Heel spur syndrome Plantar Fasciitis  is commonly known as “heel spur syndrome”. It is common among people who are active in sports (i.e. running). This pain generally begins as a dull pain in the heel that may come and go. At times the pain may be sharp and persistent. The pain is usually worse after times of rest such as sitting or sleeping; therefore, more pain is noticed in the mornings or at the start of physical activities. The plantar fascia is a thick fibrous band on the bottom of the foot. This is attached from the heel bone to the toes and acts as a bowstring to produce the arch of the foot .

Running and other activities may place tension on the fascia. This prolonged tension causes the fascia to swell at the point where the fascia is attached to the heel bone. Injury may also occur at the mid-sole or near the toes. It is difficult to rest the foot; therefore, it is important to seek treatment as soon as possible so that the problem does not progress.

The swelling reaction of the heel bone may produce new bone called heel spurs. They are not initially painful and do not cause the problem; however, walking on spurs may cause sharp pain. Some contributing factors include flat feet, high arched feet, poor shoe support, toe running, soft terrain, increasing age, sudden increase in activity level, or family tendency.

Keep in mind that plantar fasciitis may be aggravated by weight bearing sports.

Treatment for Plantar Fasciitis:

Improvement may take longer if the condition has existed for a long time. It is important to wear good shoes and to lose excess weight. During the recovery period, it would be helpful to replace weight-bearing sports with non-weight bearing sports such as cycling or swimming. Weight training will help to maintain leg strength. A sport is considered weight-bearing if the foot is repeatedly landing on the ground such as running or jogging.

Treatment of plantar fasciitis includes rest. Pain will be the guide to let you know when you should rest your foot. Ice can be applied for 30 to 60 minutes several times a day to reduce swelling. The ice can be placed in a plastic bag covered with a towel. Apply ice for approximately 15 minutes after activity. Anti-inflammatory/analgesic medication may also be used to reduce swelling.

If there is no help after 2-3 weeks, the physician may decide to inject the tender area with cortisone or a local anesthetic. A heel or felt sponge can help to spread, equalize, and absorb the shock as your heel lands. This would ease the pressure on the plantar fascia. You may need to cut a hole in the sponge over the painful area to avoid irritation. Surgery is rarely required for plantar fasciitis. It would only be considered if all other forms of conservative treatment fails. When necessary, surgery requires the removal of the bone spur and release of the plantar fascia. After recovery, return to sports activities slowly. Pain will indicate that you are doing too much. Your physician can give you the proper exercises to strengthen the small muscles of the foot and to support the damaged areas. This will help prevent re-injury.

Shoulder Pain

Does Your Shoulder keep you awake at Night?

Shoulder pain is a relatively common condition. Ordinary strains and sprains produce shoulder discomfort. Most of the time the condition is self-limiting and resolves spontaneously.

Some shoulder pains are recalcitrant and progressive. Pain may or may not follow any specific injury; it may be spontaneous. Patients usually feel stiffness and find themselves experiencing increasing difficulty in performing day to day routine functions. Pain eventually starts to invade periods of rest. Patients wake up several times during the night and find themselves rubbing their shoulders or popping pain medications. Some patients develop weakness and cannot raise their arms to the side or forward. In most cases there is no visible swelling or lump.

It is not uncommon for some people to discount it as arthritis. They think that since there is no lasting cure then they must suffer and learn to live with the problem. NOT TRUE! Most chronic shoulder pains are not arthritic and are relatively easy to cure.

The shoulder is a ball and socket kind of joint. It is surrounded by an envelope of deep muscles called Rotator muscles or commonly known as “Rotator cuff”. The cuff symbolizes an envelope like configuration. The cuff is further covered by a bony arch which provides shape and an outer configuration to the shoulder. The actual joint sits deeper, right below the bridge.

Due to several reasons, the muscles start to rub against the bony arch. This rubbing starts to produce irritation of the Rotator cuff. If the rubbing continues or a period of time, the cuff starts to erode. The final outcome may be a good size tear in the cuff. The pressure and rubbing is the cause of pain. Night pain indicates probable erosion of the cuff although this is not necessarily the case in each and every patient. This condition is also called “Impingement Syndrome”.

A simple office examination usually reveals the problem. X-rays are usually performed to obtain further information. In some patients, special investigations are indicated to verify tears of the cuff. Local anesthetic injection, at times, is applied to confirm the diagnosis of impingement.

Another common cause of shoulder pain is degeneration of a tiny joint above the shoulder, the AC or Acromioclavicular joint. Pain from this condition is usually on the top of the shoulder. One can usually feel a tender spot right over the shoulder. True arthritis of the shoulder joint is rather an uncommon cause.

One should always remember certain serious causes of shoulder pain. Fortunately these causes are rare. Bone tumors, serious conditions in the chest or the abdomen can produce vague shoulder pain. Nerves pinching in the neck or TMJ conditions are also relatively common but non-serious causes of shoulder pain.

Treatment of the problem is based upon the cause. Most cases are mild and relatively easily manageable. Medications, simple exercises, and physical therapy are the usual treatments. Most patients benefit from this plan. Some patients require injections, arthroscopy or surgical correction to get rid of the problem. For specific information on this condition, consult your physician.

” Use and Abuse of Narcotic Pain Medications”

What Is Drug Addiction?

 According to The American Academy Pain Medicine, The American Pain Society and The American Society for Addiction Medicine, drug addiction is a primary and chronic neurological disease that has genetic, psychological and environmental factors. It is also a state of adaptation that is manifested by a specified drug class, and can cause with drawl symptoms after:

• Abrupt cessation
• Rapid reduction
• Decreased drug content in blood
• Administration of certain antagonists like naloxone

 Drug addiction is a disease in itself. The drugs do not cause it; it is triggered by the abuse of drugs in susceptible persons.

Addiction is recognized by the four C’s:

• Control over drug use impairment
• Compulsive use
• Continuation of use, despite harm
• Craving

What Is Pseudoaddiction?

Pseudoaddiction is a false addiction. It describes patient’s behavior that may occur when pain is undertreated, mistreated, or misinterpreted. Pseudoaddiction can be distinguished from addiction in that the behavior resolves when pain is effectively treated. The patient with unrelieved pain may become focused on obtaining medications by “clock watching,” or drug seeking. They may display some behaviors such as doctor shopping or deceiving physicians to obtain relief.

What Is Physical Dependency?

Physical dependency is a known effect resulting from the use of narcotic pain medications, likely to produce “withdrawal symptoms” when the individual ceases or reduces the intake of narcotics. Some of the “withdrawal” symptoms likely to occur may include sweating, rebound pain intensity, chills, rest lessness, small pupils, salivation, running nose, anxiety, sweating, irritability, nausea, vomiting, etc.

It is important to understand the difference between addiction, Pseudoaddiction, and physical dependency. Because withdrawal symptoms are frequently seen in all of these states, it is easy to think that withdrawal is equal to addiction. This is not the case. It is the behavior toward the drug that determines if an addiction is present.

If you or someone you know is struggling with pain or drug management, contact your pain management specialist or prescribing physician.

The Nature of Pain

Treatment of Acute Pain:

Pain is an unpleasant sensation localized or diffused discomfort, stress, or agony, which may arise stimulation of specialized nerve endings. It is a complex subjective phenomenon, alerting real or potential tissue damage. The definition of pain originates from the Latin word “peona,” or from the Greek word “algos,’ or “odyne.” Both suggest a “punishment or suffering” in modem languages.

Pain can also be considered as a defense mechanism, because it may serve as a protective mechanism to remove or withdraw the area of the body under stimulation or insult, whether physical, mechanical, or chemical in nature. Pain can be classified as acute or chronic. In general, acute pain is the symptoms of a disease where as chronic pain is a disease in itself. With adequate and effective therapy, the acute pain resolves in days or weeks.

Any harmful stimulus is likely to procedure a cellular brake down and a subsequent release of biochemical substances. Such substances, in turn, activate specialized sensory receptors called “nociceptors”.Nociceptors send nerve signals to the spinal cord and brain indicating pain and harm to the body. Acute and chronic can be nociceptive, neuropathic or psychogenic.

Most nociceptive pains may arise from pressure, inflammation or ischemia like those related to trauma, surgery, infection, cancer, blood clots , etc. Neuropathic pains always arise from nerves that have been damaged. Herpes, viral infections, nerve entrapment, diabetes, facial pain, pinched nerves, or complex regional pain syndrome can cause this damage. Psychogenic pain is associated with psychological disorders. The most common example is phantom limb syndrome. This is mostly seen in amputees who believe they have pain in a limb that is no longer present. Certain pain conditions like those appearing after spinal surgeries, atypical facial pain, chronic pelvic pain, and diffuse pain conditions like fibromyalgia are very difficult to classify.

What Is Chronic Pain?

Chronic pain is considered debilitating, persistent pain that extends more than three months, long after the signs or symptoms of acute pain, such as an open wound, inflammation, redness and discoloration of skin, are no longer present or have resolved. It is a vicious persistence of suffering that affects the psychological, social and occupational life. In other words, chronic pain is a disease and not simply a symptom.

Today, consideration for the relief of pain is one of the most important issues in medical care. Acute and chronic pain afflicts millions of persons around the world annually, impairing quality of life and daily functions at home, at school, and at work. In the U.S. alone, recent statistics indicated that 15-20% of the population have acute pain and from 25-30% have chronic pain. Of those people with chronic pain , from 5075% are either partially or tot ally disabled for a period of days, weeks, months or years and even some are disabled permanently.

DR. Julio C. Gonzalez
At Braner Pain Clinics, Dr.Gonzales is a Clinical Neurologist trained at Georgetown University, Washington, D.C. He has a private practice in Northern Virginia and Southern Maryland since ending his training in 1981. In 1990 he became interested in Chronic Pain Medicine and opened Pain Clinics in Falls Church and Silver Spring.

Braner Pain Clinics specializes in chronic pain management, neurology, neurological testing and disability as well as providing long-term care to patients with chronic neurological disorders. Our multi-disciplinary team leads the region in treating acute and chronic pain with advanced, non-surgical treatment approaches that can help you reclaim your quality of life.Our approach has helped us earn a respected reputation for reliable, effective results on behalf of the many patients who come to us seeking relief. For professional help to control your pain, a medical evaluation after an accident, or an expert court witness,  Please make an appointment by calling and visit our website:-  http://www.branerpainclinic.com