How To Best Treat CRPS On An Individual Basis

March 25, 2019 / Thomas Cohn, MD

crps Complex regional pain syndrome is one of the most vexing and difficult problems in the world of pain medicine. Traditionally it was thought to be a rare disorder that spontaneously affected some people especially after some sort of injury. Since it has been poorly understood, many pain practitioners have very limited experience and interest in trying to treat this condition. Many physicians actively try to avoid working with patients with the problem, others may try a few things but since they have limited knowledge and experience, they often end up giving up on trying to manage the problem. Luckily there are more than a few pain physicians who see the condition a lot and are becoming more successful with its management.

The thought leaders in pain medicine who treat CRPS seem to be some of the physicians who do a lot of work as interventional pain physicians who also take a very active role in diagnosis of their patients besides just providing treatments. The ability to fully evaluate a person is critical in understanding CRPS. The symptoms of CRPS always have a cause; it is not just a bunch of symptoms that lead to a painful extremity. It usually involves a structure in the body such as joint that is malfunctioning or a nerve in the area that is abnormally functioning. Treatment is needed to correct the structure that is not moving in the right way and to relieve the abnormal functioning of the nerves involved in the area.

The Challenges of CRPS

The first challenge is correcting the structural problems that often are orthopedic in nature that are wrong. The abnormal movement sends signals through the nervous system that something is wrong and often is interpreted by the brain as pain. These problems may start as simple degeneration like from a sprained ankle or a worn out knee. Most of the time, correcting the simple problems work, but if there are nerves malfunctioning in the area, possibly damaged by an injury or treatment, or more centrally also in the spine itself, then complex regional pain syndrome – CRPS may be manifested. The major challenge is finding the nerve problems correlated with the symptoms and finding a way to treat them.

Since CRPS often now is thought to involve peripheral nerve injury in the region of pain, then finding the nerve and extinguishing the signal from that location can sometimes effectively treat the problem. If the source of the pain is strictly peripheral, finding the right nerve and blocking that nerve proximal to the damage may stop the pain. In the last 1-2 years, technology has improved and techniques are now becoming available to electrically block isolated nerves in the extremities.

Spinal cord stimulation has been used to treat CRPS for years, and this is blocking signals more centrally at the spine. Now technology is allowing pain practitioners to more precisely block the nerves either as they exit the spine or superficially in the periphery with special implantable devices. Obtaining better pain control then involves the physician fully evaluating a person for all the places that may be contributing to sending painful sensory signals and then trying to find the simplest place to block the abnormal electrical signals such that they do not travel to the brain and signal pain and disaster to the brain. Further it means the physician who is going to be helpful in treating your pain must be fully evaluating the patient as well as working directly with the interventional techniques. A physician who is just providing injections or not fully involved in all aspects of pain management is unlikely to understand and be helpful in controlling symptoms in CRPS.

The understanding and treatment of CRPS is changing and with the right providers, pain control is often being significantly improved. This is not a mystery disease, but unfortunately not many physicians have seen enough of these types of problems to understand and manage the complex issues. Finding the right person is difficult, but the interventional pain physicians who see CRPS a lot, who actually evaluate their patients themselves and do the treatment may be the best source for a successful strategy toward treatment. The solutions sometimes are complex like the disease, but there are more and better treatments that are becoming available.

The 10,000 Step Legend

March 18, 2019 / Thomas Cohn, MD

Most people have now heard of the daily 10,000 steps goal. It is the baseline average set for most fitness trackers on the market these days. This seems to be a magic number, but there is actually no scientific evidence behind it. The actual science pushes for 30-45 minutes a day of aerobic conditioning, which is recommended by the American Heart Association. There are numerous studies supporting aerobic conditioning for cardiovascular health and overall positive well-being. The 10,000 step goal was actually was just a marketing scheme for a Japanese pedometer first made in 1965. The pedometer had a Japanese name that translated to 10,000 steps, and the advertising campaign pushed that concept.

Walking To Better Health

The reality of walking a certain amount does have some merit. Monitoring your step count and standing every hour has the incentive to increase your overall activity level. A normal person will walk somewhere between 3,000 and 6,000 steps in a day with routine activity such as work, shopping, and moving about the home. Adding in 30 minutes of aerobic activity hopefully adds another 3,000-4,000 steps or more and pushes a person over 10,000 steps. Therefore the push to about 10,000 steps helps most people to get their extra aerobic workout as recommended for good cardiovascular fitness.

The overall goal of tracking activity is to motivate you to maintain a higher level of fitness. Being able to check your step count is feedback and accountability for being active. Some people can maintain activity levels without tracking themselves and others do group activities so they are accountable to more than just themselves. Many people unfortunately just do not care and let their physical fitness slide. Keeping active and exercising is one of the best ways to stay healthy. It is easier to be lazy, but to feel more healthy, exercise along with eating right and sleeping is essential. If you want to improve your health, it may pay to start tracking your habits, including activity, eating and sleeping. Using a fitness tracking device and the associated computer or phone app may greatly improve your success.

The benefit of exercise cannot be forgotten for anyone who has chronic pain. Keeping the body fit reduces pain in a number of ways. A good program will include stretching of the body to help maintain proper muscle length and function. Strengthening keeps the muscles strong and permits us to continue activity. Lastly, aerobic conditioning provides the endurance to tolerate activity as well as increasing the body’s own endorphins, which help reduce pain.

Becoming consistent with exercise is the aim of using a fitness tracker. If you are self motivated to exercise and are consistent that is wonderful. Using any tracker, from the one that is in any smart phone to those tied to a phone app like a smartwatch or a Fitbit may also be helpful. Find out what works for you and get moving.

Could New Opioid Laws Lead To Higher Costs For Patients?

March 14, 2019 / Thomas Cohn, MD

As we explained in a blog post earlier this month, the Food and Drug Administration is going to begin conducting more studies on opioids and forcing drug manufacturers to examine if their products are effective at managing specific chronic pain conditions. While these changes are aimed at helping combat the opioid epidemic, some patients believe the costs for these studies will be passed onto them.

There’s also concerns about cost and access to medications at the local level. Here in Minnesota there has been a bipartisan push to raise registration fees on drug companies to fund treatments and implement more fail-safe addiction policies. A vote on these measures is expected int he coming weeks, but some patients believe these changes forced at the business level will be felt hardest at the consumer level.

Who Funds These Changes?

Cara Schulz, who advocates for patient rights, believes the higher costs and restricted access to medications will affect those who need the drugs the most. Schulz currently takes pain medications to manage discomfort following her stage 4 colon cancer diagnosis.

“I want us to work on ways we can manage addiction, I want people to not be addicted, period. But we can’t say we are going to fix addiction by hurting people who are not addicts and who are just patients trying to be treated by their doctors,” said Schulz, who is in remission.

Instead, Schulz believes the real focus should be on fentanyl and other illicit synthetic substances, not prescription medications. At a minimum, Schulz hopes that patients who meet a certain threshold can earn an exemption so their access to drugs they truly need doesn’t become restricted.

“The method that they’re taking to address this problem puts pain patients and cancer patients squarely in the cross hairs,” she said.

This is something to keep an eye on as we move forward with ways to combat the opioid crisis. With more regulations being forced on big businesses, we have to ensure these costs aren’t just passed down the line to patients. Medication costs are expensive enough in the US, and we won’t be putting the patient first if their medications cost an arm and a leg.

The Connection Between Menopause and Chronic Pain

March 7, 2019 / Thomas Cohn, MD

Research has shown that middle-aged women are more likely to experience chronic pain than middle-aged men, and a new study suggests that menopause may play a role in that pain expression.

For the study, researchers with the Veterans Affairs took a closer look at the health data of more than 200,000 female veterans between the age of 45 and 64. In that group, researchers found that women with menopause symptoms were nearly twice as likely to have chronic pain and additional chronic pain diagnoses.

“Changing levels of hormones around menopause have complex interactions with pain modulation and pain sensitivity, which may be associated with vulnerability to either the development or exacerbation of pain conditions,” says JoAnn Pinkerton, MD, Executive Director of the North American Menopause Society (NAMS). “This study suggests that menopause symptom burden may also be related to chronic pain experience.”

Menopause and Chronic Pain

However, hormonal changes weren’t the only factor driving an increased likelihood of chronic pain conditions. Other factors include:

Being overweight or obese
Having a mental health diagnosis

Researchers found that 18 percent of women with chronic pain had been diagnosed with PTSD, 15 percent had anxiety and 13 percent suffered from depression. The above factors go hand in hand with menopause and aging, which often include weight gain, decreased physical activity, mood changes and impaired sleep, which can all also affect pain sensitivity and pain tolerance.

“Both chronic pain and menopause symptoms are strongly and consistently associated with psychosocial factors and health risk behaviors prevalent in and after the menopause transition,” said study lead author Carolyn Gibson, PhD, San Francisco VA Health Care System. “Consideration should be given to integrated approaches to comprehensive care for midlife and older women with chronic pain, such as targeted cognitive behavioral therapy coordinated with interdisciplinary care providers.”

This is not the first study to find a link between menopause and certain health conditions. A large study conducted last year found a strong association between the onset of menopause and rheumatoid arthritis. The study also found that menopause was associated with a worsening progression of rheumatoid arthritis, and post-menopausal women with RA had a significant increase in functional physical decline.

If you are getting nearly menopause or working through it, it’s more important than ever to focus on aspects of your health that can help reduce pain sensitivity. Make sure you are eating a healthy diet and getting plenty of regular exercise, and be sure to talk to your pain specialist if you have any questions or need assistance with an issue!

FDA Reexamining Opioids For Chronic Pain

February 26, 2019 / Thomas Cohn, MD

The Food and Drug Administration has announced that it will require drug companies to conduct studies to determine if prescription opioids are effective in treating chronic pain.

A number of studies have already suggested that pain controlling opioids are ineffective beyond 12 weeks, and many industry professionals say that continued opioid use after this period can increase a person’s likelihood of developing a dependence or addiction. The FDA wants to supervise the new studies to determine if certain changes, like the following, need to be made:

Changing the labeling on certain opioids
Imposing special rules for prescribing, dispensing and taking certain opioids
Prohibiting use of certain opioids in some cases

“We are going to impose a mandate on existing products . . . to answer the question that people have been posing for years: whether you have declining efficacy, and whether that declining efficacy can lead to addiction,” said FDA Commissioner Scott Gottlieb.

Some Don’t Agree

While it may seem like a good move that the FDA is appearing to take a step in the right direction of opioid abuse, others say the new measures are nothing more than a stall tactic for big pharma. Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing, said the FDA ordered a similar measure in 2013 and that they already have all the research they need to make changes that could help protect the public.

“Here we go again,” Kolodny said in an interview. “That’s exactly what the FDA said to us in 2013. . . . Five years later, we don’t have the studies and another FDA commissioner says, ‘We’re going to do the studies.’ ”

However, Gottlieb argued that the research would be aimed at immediate, extended-released and long-acting opioid tablets that are given for pain care outside the healthcare facility. The studies would also cover current medications on the market to examine if new applications of the pain reliever could be more effective. The FDA will also be conducting a second study that is out to determine if opioids can actually cause users to become more sensitive to pain.

A similar study was carried out back in 2013, but Gottlieb said those studies were difficult to carry out because the FDA could only ensure post-marketing studies on safety, not effectiveness. They now have the authority to demand effectiveness research as part of an act passed back in October.

The opioid crisis killed 47,600 people in 2017, but there’s hope that the new research can lead to effective changes. There’s still plenty of work to be done, but with more control over effectiveness research, there’s hope on the horizon.