Complex Regional Pain Syndrome (CRPS) – Causes & Treatment

September 30, 2013November 17, 2015 / Thomas Cohn, MD

Complex regional pain syndrome (CRPS) is a pain problem manifested by severe pain. It is a poorly understood disorder that causes intense pain.

With CRPS, the nervous system becomes hyper sensitized – normal sensations become amplified. The thermostat for pain sensitivity becomes set at the wrong level. The sympathetic autonomic nervous system also becomes hyperactive. This combination of problems leads to severe pain in the affected area, often a hand or foot.

2 Types of CRPS

There are two basic types of CRPS:

Type I occurs with no known nerve injury
Type II occurs in association with a known nerve injury

CRPS describes an array of painful conditions characterized by regional symptoms seemingly disproportionate to the usual course of trauma or injury. The pain is regional, not in a specific nerve or muscle distribution. The patient will report sensory changes such as:

Hyperesthesia
Changes in skin color
Edema and temperature changes
Motor changes – inability to move the affected region

It usually begins in one limb, often diagnosed months after onset, and is 3 times more common in females. The initial injury is usually minor, such as an ankle sprain. Because of this, there is often a delay in finding an expert who recognizes the diagnosis and can initiate treatment.

How to Treat CRPS

Treatment of CRPS is difficult, but should be done in four steps:

The first step is evaluating and treating any treatable injuries that contribute to the pain. This may include surgical interventions for injuries such as ankle sprains.
The second aspect is controlling the sympathetic aspects of pain and the neuropathic pain with injections and medications.
The third part is rehabilitation and physical therapy, restoring mobility and decreasing pain sensitivity.
The last part is psychology to use cognitive strategies to control central pain perceptions.

Complex regional pain can be devastating. The earlier it is diagnosed, the better the prognosis. Experienced pain management physicians are essential in improving the outcome. It can be successfully treated and there are many good interventions available. Find an experienced Pain physician, and find a solution.

Pain Medication & Alcohol – A Dangerous Mixology

September 27, 2013June 24, 2014 / Thomas Cohn, MD

It is always wise to be careful about drinking alcohol when taking any medication. All medications can interact with other substances you ingest. For example, meds can interact with vitamin supplements, and even certain foods that you eat.

It is no surprise then that one should be careful with mixing alcohol and medications (including pain medications). In this article, I will discuss some of the most common medications and how they interact with alcohol in the body.

Opioids & Pain Meds

The most common concern about alcohol is with opioid/narcotic pain medications. These drugs include:

Percocet
Vicodin
Oxycodone
Oxycontin
Morphine
Codeine
Fentanyl

All narcotics can affect your cognitive ability and judgment, and alcohol can have the same effect. The combination of the two is not always additive, and the alcohol can greatly diminish both of the above. Thus your judgment could become very poor, and the toxicity increased such that either drug can essentially cause death. If one is on a stable dose of narcotic, people can usually function without impairment. An occasional alcoholic drink should be safe. You may feel more impaired then usual, but you should not be toxic.

Neuropathic Meds

Many pain patients also use neuropathic medications like gabapentin, or other seizure type drugs, and antidepressants. These drugs also can affect cognition, and mixing with alcohol can worsen this ability. Alcohol is metabolized and broken down in the body by the liver, and the same process is also used by many of these medications. Therefore, alcohol and these medications can also interact in unpredictable ways. Again, if you have been on these medications long-term, then an occasional drink is likely safe, but heavy drinking is not a good idea.

Ibuprofen, Tylenol, & other Over the Counter Meds

Over the counter pain medications such as ibuprofen and acetaminophen/Tylenol are generally very safe if taken as directed. Unfortunately, people often take a little more than directed in the hopes that they will work better. Mixing alcohol with these drugs can be very dangerous. Anti-inflammatories like ibuprofen can cause stomach irritation. Mixing them with alcohol can cause severe ulcers and stomach bleeding. Acetaminophen alone can easily be toxic to the liver. Mixing this with alcohol has led to fatal liver failure.

The answer to drinking alcohol with pain medications is not simple. If one takes their medications only as directed, and has been stable on them, then having an occasional alcoholic beverage, not daily and not more than one, should be safe. Your judgment, memory, and cognition could be affected even with one drink, and you may not be safe to drive, but it should not be toxic to the body.

Yoga and Pain Relief

September 25, 2013June 24, 2014 / Thomas Cohn, MD

Note: this is a guest post by yoga instructor, Lynn Shuck.

As a yoga instructor, I’m expected to say that yoga can relieve pain. And I truly believe it can. But I do urge caution when approaching yoga for pain relief because, in fact, a class that moves too fast, or an instructor who pushes you beyond your limits can actually cause pain rather than relieve it. With good instruction and personal attention, yoga can most decidedly help with pain relief by bringing the muscles and skeleton into their natural balance.

It’s All About Skeletal Alignment

When the skeleton is aligned, the muscles work in tandem the way they are intended. If some muscles get overworked through habitual movement patterns, other muscles will stop doing their jobs and weaken. Those tight muscles can bring the skeleton out of alignment (picture the person who sits at a computer all day and becomes hunched over, chin thrust forward). If those patterns are repeated on the yoga mat, tight muscles will just continue to overwork and the skeleton will not be supported any differently than it already is.

Imbalance can also occur starting with the skeleton. Shin bones that bow back affect everything above the legs, tipping the thighs and pelvis out of alignment, which then impacts the spine. A broken bone that doesn’t heal correctly or an accident that impacts any part of the skeleton will invariably affect the way the muscles work as well. If the skeleton isn’t upright, muscles will do their best to hold up the body any way they can.

Fixing Imbalances

As an Eischens Yoga instructor and yoga therapist, I look for imbalances such as:

Tight, overly developed muscles
Bones that don’t stack properly
Collapsed or locked joints
Constriction in the breath

When a student wants to use yoga for pain relief, my intention is to keep the body from going further out of balance. Often, using simple, easily accessible asanas, we can bring the body back to better alignment – thus reducing pain and tension.

Uttanasana

As an example, Uttanasana is a simple forward fold commonly taught in most classes. Sometimes, hip and low back pain can be addressed using this pose. If I observe thighbones that sit too far away from the mid-line of the body, I might have the client roll up a towel to about 2 or 3” wide. They would place the roll between the legs at the top of the thighs near the groin. Pressing firmly into the towel at the top of the thighs without rolling onto the inside edges of the feet, I will then have the client perform Uttanasana, moving down and up in a limited range of motion several times, continually pressing into the towel. When finished, the legs will usually come into better positioning in the hip sockets reducing hip and back pain momentarily. The more regularly these muscles are used to re-align the thighbones, the longer the body will maintain this new positioning. I refer to this as using effort in the pose to create effortlessness after the pose.

Utilizing yoga for pain relief requires understanding the physical imbalances, and then using asana to bring the body back into balance. Practicing yoga without awareness may well be counter-productive, so find a teacher who specializes in pain relief and then trust your own experience. Yoga shouldn’t hurt; it should make you feel better.

Author Bio:

Lynn Shuck is a certified Eischens Yoga Instructor. She has been practicing yoga for nearly 25 years, and has been teaching yoga since 1996. Her training with Roger Eischens led her to work specifically with alignment as well as injury recovery/prevention. From 1998 to 2011, she led workshops and classes throughout the Detroit metro-area. Lynn is known for her keen eye for individual movement patterns, as well as her ability to bring yoga to all kinds of people: experienced and beginning yogis, athletes, weekend warriors, and those who think they are too stiff for yoga. Lynn relocated to Minnesota in 2011.

Are Supplements an Effective Joint Pain Relief Option?

September 23, 2013June 24, 2014 / Thomas Cohn, MD

Critical review of articles is essential to understanding whether or not the conclusion is accurate. A recent New York Times article cited a study that researched whether Vitamin D and Calcium help relieve joint pain. The conclusion was that these supplements do not help.

Unfortunately, this conclusion is misleading. Vitamin D and Calcium are used primarily to promote healthy bones and prevent osteoporosis. Joint health is a completely different issue

The question of whether supplements such as Glucosamine, chondroitin and fish oil help with joint pain is unclear. Multiple studies have been done on these compounds and the results have been mixed on whether they actually do anything. Many people find these compounds to be very helpful. It is fairly clear that they are not harmful. Take these as directed on the bottle, and they might help, a 3-month trial would be reasonable and decide on your own.

Medications that Reduce Joint Pain

So if these supplements do not help reduce joint pain, what are some pain management options? There are numerous ways to combat joint pain. Medications that have FDA approval for joint pain include:

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen
Analgesics like acetaminophen
Steroids like prednisone
Injections like hyaluronic acid

Some of these are now available without a prescription. NSAIDs act by interrupting compounds in the body that cause inflammation and thus joint pain. Prednisone is a corticosteroid, a very powerful prescription level medication that decreases inflammation, but can cause significant other problems when not used cautiously. Analgesics block the transmission of pain signals to the brain or their perception. As noted, these medications all may have significant side affects and can cause other more severe medical problems besides helping with joint pain.

Other Joint Pain Treatment Options

A lot of joint pain is caused by slow deterioration of the joints as we age. Maintaining a healthy lifestyle is one of the best ways to prevent joint pain. Here are a few specific ways to maintain a healthy lifestyle and prevent joint deterioration:

Eating appropriately
Exercising regularly
Keeping muscles strong, and the body moving
Proper body mechanics while doing activities
Not over stressing the body

To maintain bone health, taking Vitamin D and Calcium has been proven to be healthful. However, joint health is a different issue entirely. When reading research, sometimes it is necessary to understand more background information to be able to determine if the conclusions make any sense. Just because someone did a study does not make it correct.

Source:

http://well.blogs.nytimes.com/2013/08/21/supplements-fail-to-relieve-joint-pain-in-study/?_r=1

Phantom Limb Pain: Causes & Pain Management

September 18, 2013September 27, 2016 / Thomas Cohn, MD

Phantom limb pain is pain that is thought to be coming from a body part that no longer exists, such as an amputated foot. People often report phantom limb in amputated legs or arms, but it can also come from breasts, eyes, or other body parts that no longer exist.

These phantom pains come on shortly after the body part has been removed, usually within days. The sensations are very unpleasant and can include feelings of:

Stabbing
Burning
Throbbing

What Causes Phantom Limb Pain?

The cause of phantom limb pain is unclear. The distal pain receptors that were located in the absent body part are gone. The nerves that carry the signals to the brain however, are usually still present and so are all the connections in the brain. The wiring in the spinal cord and the brain are extremely important, since normally there are many signals impacting these nerves that allow the body to properly interpret the meaning of the signals.

When a limb is amputated, only a small portion of the wiring is destroyed. The last part of the connections to the limb and the rest of the wiring remain intact. The brain is still able to receive signals. As a result, the sensory receptive circuits send short-circuited messages of incorrect data. A sensory signal somewhere in the body starts activating the wires that once lead from the amputated body part. Once they reach the spinal cord, the sensory nerves have many interconnections. These interconnections are intact despite the amputation and can continue to transmit signals. The brain can now receive these interconnection type signals, and the brain may perceive these signals incorrectly as “phantom” pain.

Phantom pain does not occur with every amputation. There are several factors that can increase the risk of phantom limb pain:

Severe pain in the region prior to the amputation.
Pain in the stump following the amputation.
A poor fitting artificial limb

Treatment of Phantom Pain

Treatment of phantom limb pain is complex, involving a combination of any of the following:

Modalities
Physical therapy to decrease the sensitivity of the residual limb and to train a person to use remaining skills to overcome the impairment.
Prosthesis
Medications, especially neuropathic drugs and analgesics. Neuropathic medications are drugs that decrease the firing rate of neurons and thus the pain.
Injections can also be used to block nerves remaining in the residual limb.

Limb management after amputation is often coordinated by a Physical Medicine and Rehabilitation specialist. These physicians are musculoskeletal experts with extensive training in management of amputations, from medication management to coordinating the team of providers involved in the complex care of these patients. If phantom pain is a problem after an amputation, an experienced Physical Medicine pain physician may be the expert needed to help coordinate the pain management.

Have you experienced phantom limb pain? We’d love to hear your story in the comments section.