Month: December 2013

Electronic Medical Records & E-Prescriptions

/ Thomas Cohn, MD

e-medical recordsThere have been several articles published in the last few weeks about the push to electronic medical records and prescribing.  Just as technology has changed every other part of our lives, it is also changing medicine.  The US government is now recommending electronic medical records and prescribing. The purpose of this recommendation is to improve the quality and care provided.  Since computers can be programmed to analyze so much data, the thought is if medicine uses them, the errors that occur in medicine will be reduced.

Many Different Program Formats

From outside the world of medicine, the use of computers sounds like a wonderful idea that may solve many problems.  In reality, computers are only tools that can help handle the data that is present.  The computer programs and system are only as good as the information that is assembled, and the ease and clarity of its presentation.

There are many different program formats for medical records. Most hospitals, physician offices, and medical facilities end up using their own program, and none of these can communicate with each other.  To further complicate the issue, it seems that everyone is concerned that only appropriate people can access any of the information due to privacy rights.  As a result, there is a lot of information in electronic form, but the use of it to improve medical quality and safety is almost impossible.  Therefore, electronic records, and electronic prescribing are no better than the ability of any person using the information and translating its importance.

A Fully Integrated Data System

Healthcare in other parts of the world is often better than the US due to the fact that all health information is part of a universal healthcare system.  All medical data then is kept in one place, one system, and is shared by all providers.  Parts of information are not scattered or hidden, and the picture that the data provides can be better analyzed.  The critical feature is that all medical information is kept in a central place and every provider uses the same information on each patient.

Until the United States becomes serious about changes in how electronic medical records are used and integrated into a universal data system, improvements in patient safety will be limited.  Computers can help with data management, and sometimes help prevent the worst of errors.  The limits to computers help in the medical system at this time are significant until we get past our concerns of privacy, security, and the need for a fully integrated data system.  At this time, in the United States it does not look like this will happen.  Computers are well known for the phrase “junk in, junk out.” Patient safety and health will only improve small amounts with the use of computers, electronic medical records, and prescribing.

What is Reflex Sympathetic Dystrophy (RSD)?

/ Thomas Cohn, MD

chronic painReflex sympathetic dystrophy is one of the older terminologies for what is currently known as Complex Regional Pain Syndrome (CRPS).  Other terms used include:

  • Causalgia syndrome
  • Sudeck’s atrophy
  • Algodystrophy
  • Algoneurodystrophy
  • Reflex neurovascular dystrophy

History of RSD and CRPS

At this time the preferred medical term is CRPS.  In 1993 the terminology changed from RSD to CRPS to better define underlying problems associated with the syndrome.  Two types of CRPS were further defined:

  1. CRPS Type 1 has the characteristic painful limb, but has no definite nerve injury as the cause
  2. CRPS Type 2 has obvious previous nerve damage

Quality of Treatment

Quality of treatment for RSD/CRPS depends on the knowledge and experience of the practitioner coordinating care.  CRPS is a complex problem, many physicians work with the syndrome on an occasional basis.  A pain physician who treats this condition almost daily is likely the best source to turn to for management and treatment options.  Experience in recognizing the problem and offering a comprehensive multi-disciplinary approach is essential.

It truly requires a “hands on” physician who coordinates all aspects of care.  The mark of a good physician is one who not only recognizes what is wrong, but one who can determine all the contributing factors to the syndrome and what is maintaining the problem.  Few pain specialists truly understand the condition, finding a good physician may seem like finding a needle in the haystack.

Diagnosis and treatment of CRPS and RSD depends on finding the right physician.  It is not guess work at management.  It often takes time and patience by both the physician and patient.  Experienced physicians will be much more successful in management, do not settle for just anyone who just claims to have treated the condition.

The Relationship Between Diabetes, Vitamin D, & Pain

/ Thomas Cohn, MD

vitamin dA research presentation at the University of Chicago has indicated that vitamin D may have an effect on pain and depression in patients with type-2 diabetes.  The study indicates a relationship between pain and vitamin D supplementation.  Those with low vitamin D levels, who then received vitamin D, then had less pain complaints.  The study just shows that these problems of diabetes with pain and vitamin D have some connection.

Secondary Problems

As with many medical problems, many secondary problems can occur with diabetes.  Diabetes causes problems with multiple body systems, including the kidneys, eyes, blood vessels, and the nerves among many organs it damages.  It is no surprise that diabetes can affect vitamin D levels.  Whether treating diabetes more successfully and comprehensively is the answer or vitamin D has a correlation to pain levels is not known.  The study just notes that there is some sort of relationship.

Diabetes can cause multiple health problems.  Controlling diabetes is the most important way to prevent complications.  Pain is often a complication of the disease due to damage to the vascular system and nervous system.  Vitamin D may turn out to be an important aspect of controlling aspects of diabetes. However, it is unlikely it will be a solution to pain in diabetes.  The first and most important aspect in reducing pain in diabetes is to keep control of the blood sugars.  Most pain in diabetes is related to nerve damage, and neuropathic medications like Neurontin, Lyrica, and Cymbalta are some of the best at reducing pain symptoms.

More Research Needed

New research in pain control in any disease is welcome.  The most important thing in any medical study is understanding what the researchers have found.  In this study, researchers found that patients with diabetes type 2 and depression often have vitamin D deficiency.  The relationship between all these variables at this point is interesting but needs further study before any definite conclusions can be drawn.

5 Rare Types of Headaches & How to Treat Each

/ Thomas Cohn, MD

cluster headachesHeadaches are a common and painful occurrence. Almost everyone has had a headache at some point in his or her life. We’ve already talked in depth about common headaches like tension and migraine headaches. But there are less common headaches including:

  • Cluster headaches
  • Cervicogenic headaches
  • Giant cell arteritis
  • Subarachnoid hemorrhage
  • Idiopathic intracranial hypertension

These headaches are much more rare and usually diagnosed only by specialists. In this article we will explore the causes of each headache and discuss possible treatment options.

Cervicogenic Headaches

Cervicogenic headaches are a type of tension headache generated from muscle spasms in the neck.  These occur most often after neck injury, commonly a whiplash in a motor vehicle accident or similar type of trauma.  Cervicogenic headaches often improve greatly as trauma heals within one to two months.  Massage, heat, and ice, over the counter medications, chiropractic adjustments, and physical therapy may all be useful.  About 5% of these require more aggressive treatment by a pain specialist including cervical injections.  If the headaches are not resolving, a physical medicine pain specialist can be extremely helpful in coordinating more aggressive management to stabilize or cure symptoms.

Subarachnoid Hemorrhages (SAH)

Subarachnoid hemorrhages (SAH) are very distinct, severe headaches.  Known as thunderclap headaches, they are described as the worst pain you’ve ever experienced in the head.  They occur suddenly, lasting minutes to hours, and almost always send the person to the hospital for treatment due to the severe pain and symptoms.  A CT scan of the head usually shows the bleed, but sometimes lumbar punctures and MRI scans are also needed.  Depending on the severity and cause of the bleed, treatment may require neurosurgical intervention versus supportive care.

Cluster Headaches

Cluster headaches are a rare type of chronic headache.  They are most common in men.  Typically, they consist of one-sided pain, with tearing of the eyes and runny/stuffy nose.  They occur daily for a period of time and then stop, before starting again some time later.  At this time they are thought to be associated with serotonin release and the hypothalamus.  Treatments include avoiding triggers, breathing oxygen, pain and migraine medications.  A neurologist specializing in headaches usually coordinates management.

Giant Cell Arteritis

Giant cell arteritis is an inflammatory condition of the blood vessels in the head.  It affects mainly the elderly, those over 60 years of age.  It is characterized by pain over a blood vessel, often in the temporal region.  Blood tests show signs of inflammation, especially the ESR being very elevated.  Biopsy of the vessel is often done to help make the diagnosis.  Treatment is with steroids, and often it may be necessary to take them a long time.  Not treating the condition can lead to complications like strokes.

Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension, previous known as pseudotumor cerebri, is where there is increased intracranial pressure.  The headache is a dull deep pressure with nausea, vomiting, and visual changes.  It is most commonly seen in young, obese woman.  MRI brain scans looking for other causes of symptoms and lumbar punctures are necessary in the evaluation.  By its name – idiopathic, the cause is unknown.  Treatment may include medications and sometimes requires neurosurgical management.

The above headaches are rare.  Most of them have unusual presentations and send one to see a physician immediately.  A neurologist is most commonly involved in both the diagnosis and management depending on the problem.  When symptoms do not improve despite optimum management, occasionally secondary specialty headache clinics become involved.  Generally, once one of these rare headaches is diagnosed, the treatment is effective.

Have you ever experienced any of these rare headaches? We’d love to hear your story in the comments!

Obesity and Pain – How are they Related?

/ Thomas Cohn, MD

obesityMany people who have pain are also obese.  A common question in these cases is which came first – the obesity or the pain? Additionally, will solving one issue make the other go away?

The answer is not simple, but both of these subjects are much related.  Obesity is a severe problem in developed countries like the USA.  Obese people stress the body, and develop pain in areas like the back and leg joints.  Having pain in the low back, or joints, and being obese does not mean that losing weight will resolve the problem since permanent injury may already be present.

Problems Associated with Obesity

Obesity is a primary problem affecting a large segment of society.  Treatment is varied – one single strategy will not work for everyone. Obesity can lead to many health problems that cause pain like:

Treating obesity before these problems occur is important.  Once permanent damage to the body is done, reversing the injury is often impossible and treatment can only be aimed at symptom management.  If you are obese, work with medical professionals to bring your weight under control to prevent permanent side effects.

Obesity & Low Back Pain

Having low back pain and obesity often makes symptoms worse.  Being overweight by 50 pounds is like constantly carrying 5 one-gallon jugs of water with you 24 hours a day without ever having a break. However, low back pain is often related to permanent changes in the lumbar region including the joints, discs, and bones.  Losing weight will not reverse the permanent changes present but may allow easier pain management.

Joint pain, especially degeneration of the knees and hips occurs with obesity.  Increased weight is a common factor that promotes increased wear and tear on the knees and hips.  Once the damage has occurred, the changes are usually permanent.  Weight loss will make the symptoms more manageable, but will often not cure degeneration that has occurred.

Obesity is a major health issue.  If it were easy to solve, then we would not be facing such challenges in society today.  Treating obesity early helps reduce secondary problems such as pain.  But solving obesity will often not solve a pain problem.  Keeping healthy, strong, and mobile will make many things better, and hopefully decrease obesity and pain.