Playing Through The Pain: A Doctor’s Prospective

October 13, 2014August 25, 2016 / Thomas Cohn, MD

Recently, the Star Tribune published an article on professional athletes playing through pain. The article discussed whether the Vikings quarterback, Teddy Bridgewater, was not tough enough since he and the team elected not to play him against the Packers, four days after he suffered an ankle strain. The article also discussed how other athletes never missed a game due to injury. Furthermore, it basically said , if you are going to be a professional athlete, you need to play through pain.

Stupidity is playing while you are acutely injured to tell others you are tough. Pain is the way the body tells a person that they have an acute injury. Tissue damage stimulates the sensory fibers and initiates the body’s response to injury. Inflammation occurs, and then blood flow to the area increases in order too bring cells to clear the damage and initiate the healing process. Continuing to stress damaged tissue will usually only weaken the area or cause further injury. In an acute pain injury, protecting the region from further damage reduces the pain and allows quicker and more complete healing. The culture of toughness would be considered just stupidity from a medical viewpoint.

Professional athletes tend to have short careers in sports due to the fact that they tend to overstress areas of the body, causing permanent damage and reducing their abilities. Tiger Woods now is on the down side of his career due to back and leg injuries. Most football players do not play long into their 30’s due to injury. The NFL now has major lawsuits regarding concussion and head trauma. Many professional athletes have severely degenerated joints, back and neck issues from repetitive trauma, and now have chronic pain issues.

Acute pain is the signal from the body that there is tissue damage. Treating acute pain is doing the right stuff medically to allow the injury to properly heal. Chronic pain is not due to acute tissue damage and inflammation, but is an abnormal response to signals from previously healed damage. Rest is great for an acute injury but not for chronic pain. Activity can take your mind off the pain, release endorphins to act as natural pain relievers, and help build strength in affected areas. Activity in areas of chronic pain will decrease the pain in most cases. Working through chronic pain is tough, but it actually decreases pain signals and improves function.

Muscle Spasms and Pain

October 8, 2014August 25, 2016 / Thomas Cohn, MD

Many people who have pain complain of tight muscle spasms, knots or bands in or near the pain’s location. If a person has neck or low back pain, they often feel like the muscles in their neck and back are extremely stiff and tender. This occurs because the muscles near the pained region tighten up in an effort to limit movement in that area. Just like a cast protects your broken ankle, your body attempts to shield itself from more pain. Acutely, this serves a purpose to protect a structure from moving when injured. Chronically, this is a maladaptive response. Movement maintains blood flow, strength and flexibility.

People with chronic pain often notice they have lost flexibility and find that muscles in the painful area tight and tender. Patients often want a pill to treat the muscle tightness; a quick solution. Tight muscles hurt when one tries to be active and reduce our ability to move smoothly. In response to the demand, doctors often prescribe muscle relaxers; medications that are supposed to reduce muscle tightness. There are many drugs that affect muscle tightness, but most are good only in acute situations, and for a very short time. For chronic muscle issues, most of the medications are minimally effective.

Muscle Medications

The medications that are most often used for chronic muscle spasms are drugs which also diminish pain signals in some way. Benzodiazepines (like valium, Ativan, and Xanax) act on the central nervous system to reduce signal transmission and enhance the compound GABA that influences pain sensation. Unfortunately, these compounds are highly addictive and lose effectiveness quickly. They are most helpful in acute situations only. Baclofen and tizanidine are also centrally acting, and they prevent muscles from tightening up and decrease pain signals. These two are not addictive, but only work for some patients and each can have its own serious side effects. Flexeril (cyclobenzaprine) originally was developed to be an antidepressant, but its central acting turned out to relax muscles, however, it’s very sedating, inducing deep sleep and is best used only at night. There are multiple other medications also available, but few are helpful except for acute injury type pain.

Muscle tightness and spasms in chronic situations are best treated without medications. The best treatment is stretching and strengthening the muscles and area. It seems counter-intuitive to exercise sore muscles, but this is the most effective management. Physical therapy is excellent to learn the appropriate exercises. Massage and chiropractic adjustment can also be useful. However on a long-term basis, it is up to the individual to do the exercises, daily stretching and strengthening. If you have chronic pain issues, the best treatment is to do the work and over time the pain will get better. There are no shortcuts when doing the maintenance to stay healthy.

Headaches, Nutrition, Neuroglycopenia and Children

October 6, 2014August 25, 2016 / Thomas Cohn, MD

Neuroglycopenia is categorized as low blood glucose levels in the brain. Recently I was asked if children can have headaches due to inadequate nutrition and a neuroglycopenia. Children have a different susceptibility to low blood sugar than adults. Most people do not get low blood sugars if they have sufficient calorie intake. Many substances can be converted to glucose for the brain to maintain normal function, and that is a protective mechanism of the neurologic system. Low blood sugar levels in the brain can be manifested in a number of ways, including behavioral changes, headaches, and even seizures or loss of consciousness.

In a Google search on this topic, only one article was found; The Journal of Pediatrics in 1994 wrote that children can have behavioral changes related to low blood sugars and the possible affect on the brain. Low and high blood sugars due to nutrition in children probably occur regularly, and they can affect behavior and may be linked to headaches. Neuroglycopenia occurs when there is a severely low blood sugar level in the brain, and is generally linked to low blood glucose. Furthermore, this condition is linked mostly to diabetes and high insulin levels, and not to general nutrition.

Children can have headaches due to a number of reasons. Nutrition and sugar intake can definitely cause difficulties with headaches in some children. Headaches can be caused from problems such as poor vision, lack of sleep, psychological problems and stress. If headaches are frequent, then the child needs to be seen by a pediatrician, and possibly by a neurologist. Sudden severe new headaches need to be seen immediately at a hospital as an emergency.

Poor nutrition in children can lead to behavior problems, hyperactivity and headaches. The meal programs for breakfast and lunches in our schools partially grew out of awareness of the necessity of good nutrition in the ability of children to adequately learn. Severe low blood glucose in the brain, i.e. neuroglycopenia, is not necessary to be the cause of headaches. If the child is a diabetic, neuroglycopenia may be occurring and can cause headaches. Children without diabetes are unlikely to have nutritional issues so severe to cause low brain glucose and headaches. If a child is having headaches, the first stop is the child’s pediatrician.

Chronic Pain: Opioid Dangers Outweigh Benefits

October 2, 2014August 25, 2016 / Thomas Cohn, MD

Doctors with the American Academy of Neurology say the dangers of opioid use for chronic pain management far outweigh the benefits.

“The evidence of harm is high, and the effectiveness is low,” said Dr. Gary Franklin, author of the AAN’s new policy statement.

Among other things, Dr. Franklin suggests that doctors shouldn’t be quick to prescribe certain opioids, especially in large amounts, and he recommends primary care doctors refer patients to specialists.

As a physician who specializes in chronic pain, I believe the second part of statement is the most important. Dr. Franklin suggests that the risks of poorly managed pain medications outweigh the risks for certain chronic conditions, but he believes they can be helpful for other conditions when partnered with an experienced pain management physician.

“It seems likely that, in the long run, the use of opioids chronically for most routine conditions, such as chronic low back pain, chronic headaches, or fibromyalgia, will not prove to be worth the risk,” Franklin said. “However, even for more severe conditions, such as destructive rheumatoid arthritis, sickle-cell disease, severe collagen disease, or severe neuropathic pain, prescribers need specific guidance on dosing, publicly available brief tools to effectively screen patients for risk, and guidance on how to monitor patients for early signs of severe adverse events, misuse, or opioid use disorder.”

I’ve been likening our bodies to cars in previous posts, and the second part of the quote reminds me of another automobile example. Let’s say you’ve got a major issue with your car, say, engine failure or a fried electrical system. Would you take your car to the auto shop down the street, or would you take it to a shop that specializes in fixing your exact car type? If you want the best results, you’d take your car to the garage that specializes in your brand, because odds are they’ve had more experience with the exact problem you’re dealing with, and are more qualified to fix the issue.

Your body should be no different. Visits to our primary care physicians are like oil changes and tire rotations – regular visits keep everything running smoothly and can help catch minor issues before they become major problems. When you have a big issue, like you need ACL reconstruction or treatment for acute destructive rheumatoid arthritis, you’re better off seeing the specialist.

In essence, Dr. Franklin isn’t saying we should abolish opioid use for pain management – we just need to make sure people know the risks and follow their doctor’s advice. And if you truly believe your chronic condition is worth seeking medical advice, don’t be afraid to consult with a chronic pain specialist.

Related source: MedPage Today