Month: July 2013

Low Back Pain – A Common Problem, often Mistreated

/ Thomas Cohn, MD

low back pain minnesotaLow back pain is a very common issue – 85% of the population will experience back pain at some point in their lives. However, back pain is often treated improperly and as a result, it has become a costly problem in American society.  A lack of understanding of back pain, its causes, and usual treatment, leads to costly management.

Acute Low Back Pain

Acute low back pain is pain that has been present less than 3 months.  Most back pain can be treated conservatively.  Only rarely is back pain a serious medical emergency.  There are many structures in the back that cause pain, including:

  • Vertebral discs
  • Bones
  • Joints
  • Nerves
  • Muscles

All of these can cause pain.  Fortunately, most pain is caused by muscle strains and irritation of joints, discs or nerves.  Initially all of these are treated the same, with ice and heat, minimal rest, stretching, and then muscle strengthening of the core.

Medications should be kept simple – use Tylenol or anti-inflammatories like naproxen to manage the pain.  If pain is more severe, see a primary care physician for referral to a Physical therapist.  Very short-term use of narcotic pain medicine is useful if other medications cannot be taken but these are not advised for more than several weeks.

If Back Pain Persists

If back pain persists for more than a month, despite basic management, you should seek out an expert in low back pain.  The best medical doctors to evaluate and treat this type of pain are board certified physicians in Physical Medicine and Rehabilitation.  These physicians are experts in the musculoskeletal and nervous system.  They can guide a person through a detailed exam and diagnosis and more advanced treatments.

Surgery, MRIs, & CT Scans

Back pain is rarely a medical emergency.  If a patient has had cancer and has new onset of back pain, aggressive evaluation is necessary to determine if cancer is affecting the region.  Low back pain with loss of control of the bowels, or loss of muscle function in the legs is the other case when aggressive evaluation is necessary.

Back pain is usually relatively benign.  Most pain will resolve within weeks with conservative treatment.  Only in rare cases (such as cancer) should MRI or CT scans be obtained.

Surgery should only be considered if nerves are compromised, or bowel or bladder control is lost due to the spine being injured.

6 Common Running Injuries & Pain Management Tips

/ Thomas Cohn, MD

running injuryRunning can be stressful to the body, causing injury and pain.  Areas of the body that are often affected by running include the low back, pelvis, hips, knees, ankle and foot joints, as well as the muscles, ligaments and tendons of the lower extremities.  Injuries happen for a number of reasons including overuse, body mechanics, training, and not allowing injuries that have occurred to heal adequately.  Running can be an excellent way to maintain fitness, but listen to your body, and try to use a degree of moderation.

Running Injuries

Listed below are 6 common running injuries and techniques to manage pain associated with each:

  1. Shin splints:  This is a pain along the front of the tibia.  This is thought to be a strain of the muscles attaching to the tibia.  It commonly occurs when increasing distance or frequency of running too fast.  Treatment is icing, rest, gentle stretching and anti-inflammatory medications.
  2. Runner’s knee:  This is pain under the kneecap due to irritation of the patellar cartilage.  It is a mechanical problem related to alignment and forces through the knee.  Up to 15% of runners may have this issue, and up to 40% of runners develop knee injuries.  Ice and anti-inflammatory medications for pain are reasonable, and muscle strengthening and the use of a soft knee brace with patella cut out can help. Knees are also prone to ligament sprains, which present as pain on the inside or outside of the knee, and also for tears of the meniscus, which presents as catching of the knee and internal knee pain.
  3. Stress fractures:  These are small cracks at the surface of the bone.  Common areas are the tibia and feet.  They are caused by the stress placed on the regions with the impact of running and occur most commonly with over training.  These absolutely need to be allowed to heal.  Stop running and stressing the area, when the pain is gone, then one can slowly resume activity.
  4. Ankle sprains:  The ankle is stabilized by ligaments, which allow normal motion.  Sprains are over stretching or tearing of these ligaments often by twisting or rolling the ankle.  Acutely icing the ankle, wrapping, and elevation will allow the injury to heal.  If pain continues or the ankle remains unstable and with activity, one frequently twists the ankle, then surgical repair may be necessary.
  5. Hamstring and Illio-tibial band syndromes:  These are the muscles on the side and back of the upper leg.  Pain in these areas is due to muscle strains.  Initially ice and rest are beneficial. Then, proper warm-up, stretching and training as well as post activity cool down can help treat and prevent this condition.
  6. Plantar fasciitis:  The plantar fascia is a tissue that extends from the heel to the toes along the bottom of the foot.  Pain is usually felt in the arch of the foot.  This tissue can easily be stressed by multiple impacts of the foot with running.  Running shoes with the proper support and alignment for the foot is important as well as whether one runs on pavement or softer surfaces such as dirt.  Icing, stretching the foot and anti-inflammatory medications are used in treatment. When more severe, splints at night and foot orthotics may be prescribed.

Maintaining aerobic fitness is a common goal of many people.  Running has become a favorite of many and for some almost an addiction.  Due to the intensity of this activity, injury is fairly common.  Most injuries can be treated simply, listen to your body, allow it to rest and heal.  When injuries are not healing, seek out good medical attention.

Other good sources of info on running injuries:

Opioid Use can Lead to Low Testosterone

/ Thomas Cohn, MD

opioidsOpioids are medications that include many of the common pain drugs that are prescribed for acute and chronic conditions.  A few common examples of these drugs include:

  • Morphine
  • MS Contin
  • Oxycontin
  • Percocet
  • Oxycodone
  • Vicodin
  • Hydrocodone
  • Methadone
  • Dilaudid
  • and many are trade name medications

How Opioids Impact Testosterone

They are effective medications for management of pain at times, and block transmission and perception of sensory signals related to pain.  However, in recent studies long-term use has been shown to cause significant hormone problems, especially androgen deficiency and low testosterone.

Androgen deficiency affects both males and females and may have a significant impact on quality of life.  Common symptoms and complaints include loss of libido, fatigue, erectile dysfunction, hot flashes and depression.  Physical findings may be:

  • Loss of muscle mass
  • Body hair loss
  • Anemia
  • Osteoporosis
  • Hypogonadism

Diagnosis & Treatment

Diagnosis is made by history of symptoms, exam, and laboratory analysis of blood for hormone levels.  Treatment can be two-fold:

  1. Reduce opioids
  2. Hormone replacement

Opioids can affect the brain and the regions that control hormone production.  Specifically, they affect the hypothalamus region and inhibit the gonad releasing hormone.  This causes a decrease in critical hormones for both males and females including FSH, LH, and testosterone.  Opioids also are thought to increase enzymes that metabolize and breakdown the above hormones in the body.  Thus, these medications decrease these critical hormones in several ways causing significant side affects.

Long-term opioids are not a benign treatment for pain.  If the pain is better, why would a person want to have depression, loss of hair and muscles?  The problems associated with opioids are significant, and treatment with hormone replacement is often helpful, but may not reverse the damage these medications can cause.

No silver bullet exists for treating pain. Every treatment has risks and benefits.  A good pain physician looks at problems in a comprehensive manner to reduce all risks and maximize benefits.

Facet Joint Pain of the Low Back – Symptoms and Treatment

/ Thomas Cohn, MD

facet low back painLow back pain can have many causes.  Structures in the lumbar region include:

  • Muscles
  • Bones
  • Joints
  • Discs
  • Nerves
  • Pelvic organs

Sensory feedback from these structures can be similar. As a result, determining the cause of low back pain often becomes more complex since multiple areas can produce sensory signals that are perceived the same way.  Furthermore, there are often multiple structures contributing to the pain perceptions we have and it may be necessary to treat multiple pain generators to control symptoms.

The facet joints in the spine are small joints the size of our finger joints that articulate on both sides of the spine, posteriorly, between vertebral bodies at every level.  They have significant mobility and carry the full body weight. Bending backwards closes the joint, while bending forward tends to open the joint.  Since they have the same size and mobility as the finger joints, we can see the same wear and tear type changes in the hands, and assume fairly accurately that the same changes will be present in the low back facet joints.

Symptoms of Facet Joint Pain

The symptoms related to facet joint pain are similar to pain from other joints:

  • Stiffness after sitting or lying in one position
  • Pain often with extension of the spine backwards

Pain from facets is often just along the spine and does not radiate significantly into the legs.  Often, the lumbar muscles are very tight, trying to prevent excessive spine movement.  Severely degenerated facets have significant bony overgrowth, and then can narrow the exit of spinal nerves and cause radiating pain into the leg.

The diagnosis of facet pain is made by:

  • Patient history
  • Physical exam
  • Radiologic imaging
  • Nerve blocks to the joints

The typical history of facet joint problems is pain along the spine without significant radiation. X-rays and CT scans often show facet problems in detail, but pain can be present even with normal radiologic studies.  Diagnostic medial branch blocks are the most reliable tool to establish the etiology of pain from facet joints, and two nerves provide the sensory feedback from each joint.

Treatment

Treatment of facet joint pain must be multifaceted to be successful.  Basic level management includes stretching and core strengthening of the lumbar region, with using good body mechanics.  Nonsteroidal anti-inflammatory drugs like naproxen and aspirin often are very helpful.  More advanced physical therapy including a TENs unit for electrical stimulation and traction of spine is sometimes helpful in addition to the above.  For persistent symptoms, facet joint steroid injections and medial branch blocks with radiofrequency denervation of the joint can be extremely beneficial.

Osteoarthritis of the Knee – Treatment Options

/ Thomas Cohn, MD

osteoarthritis of the kneeEarlier this week, we discussed the signs and symptoms of osteoarthritis in the knee. Today we will further investigate this condition by discussing the treatment options for osteoarthritis.

Treatment of osteoarthritis of the knee includes a wide range of options, starting with lifestyle modifications, medications, and progressing to surgical management. 

Always start simple. Change starts with the individual and is not magical.  The most common first step is to lose excess weight so you are not stressing the joints.  Change the type of activity you are doing from high impact to low impact exercise. Go from jogging to cycling and swimming, or try an elliptical. Walking is always a good alternative as well.  Exercise maintains range of motion, flexibility, and health. Add in strengthening and function may also improve. 

Medication Management

Medication management is the next level of care. Having a physician involved in this level is beneficial to prevent negative side affects.  Natural substances you can take include:

  • A combination of glucosamine and chondroitin. These are natural substances found in joints. If taken orally they are supposed to promote normal joint health.  Scientific studies are mixed on whether they are truly helpful, but they rarely if ever would be harmful, if early in the disease, it may be worthwhile.
  • Fish oil. This can help with joint lubrication.

Prescription level medication starts with acetaminophen, to aspirin and anti-inflammatories, to steroids and injectable compounds.  Acetaminophen is only an analgesic and it treats pain.  Aspirin and ibufrophen or naproxen, are a class of medications known as nonsteroidal anti-inflammatory drugs (NSAIDs), and can treat pain and swelling.  These medications are stronger, may be taken orally and may be available as crèmes, but have many side affects and should be used with caution.  Skin preparations however are very safe and may be extremely helpful.

Corticosteroids are very powerful anti-inflammatory hormones, and sometimes on a limited basis orally or as injections can be helpful in controlling pain and swelling for long periods of time.  Lastly, viscosupplementation with injectable hyaluronic acid compounds is used to improve joint fluid production for periods of 3-6 months.

Surgical Options

End stage knee osteoarthritis can be treated surgically.  Orthopedic surgeons can do several things from cleaning up and removing damaged tissue in the joint arthroscopically when appropriate, to replacing the knee joint.  Surgical intervention is a consideration when the damage is severe, not responding to more conservative options, and otherwise when the patient is healthy enough to undergo surgery.

Osteoarthritis will occur eventually in all of us as we age.  The key to control degeneration is to maintain good health habits.  Keep your weight under control, excess weight will stress out your joints.  Exercise, this will keep everything moving, and maintain your strength.  Work with your doctor if more advanced treatments are needed.