acute pain

Which Ear To Get The Daith Piercing In?

/ Thomas Cohn, MD

which ear pierceThe following is a guest post from Leticia, a reflexologist and state certified piercer. She reached out to us with some more information on the Daith piercing, and we wanted to turn her message into a blog post because we feel that our readers could benefit form the information. Here’s what she mentioned in her original message.

Which Ear to PIerce?

Many of you have asked which ear to pierce. It all depends on the strongest pressure point. When I do these I always check both ears, talk to my clients about the problems they’re having and what bothers them most before proceeding. It not just a stab and go procedure. I love my job and help as many people as I can. I have people drive and fly in to have me do their pressure point piercing due to my accuracy.

I have no problem explaining the full procedure. Pain stops a lot of people from enjoying life so I try my best to make their life great by stopping their pain. Many piercers will say they can do this but unless its done a specific way it will not work. It must be done through the pressure points.

To be done correctly a pressure point locator must be used to find the point; It isn’t just a random area in the daith. Once the pressure point is located, it is then pierced and jewelry is inserted. I am a reflexologist and also a state certified piercer that works in pressure point piercing everyday. I have had 100% success rate with these piercings. It can cure many different migraines such as fibromyalgia headaches/migraines, occipital neuralgia headaches/migraines and more in the right situation.

Just because one person does it one way and another does it different doesn’t mean it doesn’t work, because I have different techniques work for different clients. It can change a person’s life and the positive testimonials I have received has been amazing. Men, women and children have came to see me for their chronic migraines.
Thank you Dr. Cohn for your website. And allowing me to post here.

Could Wearables Replace Opioids For Pain Management?

/ Thomas Cohn, MD

wearable painChronic pain affects roughly 100 million Americans, and the pain management market is estimated to be about $635 billion a year. With so many people to treat and money to be made by finding new, safer treatment options, a number of different technology companies are jumping into the world of pain management.

One area that is of particular interest to these companies is wearables and how they can be used to combat and treat chronic pain. A recent study involving more than 1,600 people with distal and proximal chronic pain focused on the Quell wearable device. The wearable allowed patients to track their pain in real time, including changes in pain intensity and pain interference with sleep, activity and mood on an 11-point scale. Patients tracked these changes over the course of two months, and researchers analyzed the findings at the conclusion of the study.

But tracking wasn’t the only feature available with the wearable. The unit actually provided high-frequency transcutaneous electric nerve stimulation. Many patients found that when they wore the device and it was emitting signals, that their pain levels decreased.

“[We found] statistically and clinically significant decreases in pain interference with activity and mood” and “a clinically significant decrease in pain intensity and less pain interference with sleep,” researchers wrote.

Wearables and the Future of Chronic Pain Management

The quell device was only helpful for a select number of people dealing with certain types of chronic pain, but the technology behind the device is exciting. It’s like a hybrid Fitbit and TENS unit, and as the technology continues to progress, we may soon see wearables that can work to drown out pain signals in all different areas of the body.

We understand the science, but because pain is such an individualized issue, there’s no one-size-fits-all wearable for chronic pain. Opioids do a better job of controlling a wider type of pain, but they come with their own potential drawbacks, including potential addiction and dependence. Wearables do not present the problem of dependence, but the tricky part is getting them to impact the specific nerve pathway that is causing pain.

We need to keep investing money in these alternative treatment options and in pain management as a whole. It seems like we’re nearing a breakthrough, not just with wearables, but as a whole. Pain is a huge industry affecting tens of millions of people, so it’s going to draw attention and investments. The first company to develop a wearable or another opioid alternative that can reliably control certain types of widespread pain will set the bar and enjoy the spoils that come with it. This will lead to more investments, better technology, and hopefully, better non-opioid patient care options for chronic pain. We’re excited to see what the future holds.

5 Healthy Habits To Live Longer

/ Thomas Cohn, MD

healthy habitsEveryone has advice on living better and longer. Sometimes the advice is complex, sometimes someone is just trying to sell you something, and in a recent StarTribune issue, there was some simple practical advice. The information is from a study of 100,000 people published originally by the American Heart Association. It lists five habits to adopt to live better and longer. It is the straightforward approach to life.

The Five Habits

The first habit for good health is to avoid smoking. The best habit is to never smoke. The dangers of smoking have been known since the early 1960’s. Everything from vascular disease, to lung problems and cancer result from smoking. Quitting smoking does help, never starting is even better as far as the risk is concerned.

The next habit is maintaining a healthy weight. The easiest tool is based on having a body mass index (BMI) that is between 18.5 to 24.9.  The formula for is:  BMI=703x[(weight in lbs)/(height in inches)(height in inches)]. The number can be looked up in charts. Unfortunately this is a rough guide, and if you are muscular, or have a larger build with “big bone” structure, you may fall into the category of obese. For instance my BMI is 24.3, it is borderline since I have relatively more muscle than fat but I am pretty healthy from a cardiovascular standpoint due to an active lifestyle.

The third habit to increase life is to exercise moderately for 30 minutes a day. This is to walk, swim or work out in any sort of way every day if at all possible. The 30 minutes does not have to be all at once. If you take three ten-minute walks a day, that adds up to the correct amount of time. In addition to the above aerobic conditioning, most health advocates recommend a general strengthening program three times a week to maintain muscle tone. A daily stretching program to reduce muscle tightness and pain is also helpful.

The fourth habit is to drink only a moderate amount of alcoholic beverages. That is on average only 1 to 2 drinks a day. Drinking wine is often better than mixed drinks or beer due to some of the compounds from grapes that have positive health benefits. All alcohol contains carbohydrate-type calories and this needs to be remembered as part of your overall food intake. Excessive intake of alcohol, binge drinking and then averaging out the intake over time does not count. Binge drinking is dangerous.

The last healthy habit is to try to maintain a healthy diet. A healthy diet includes higher intakes of vegetables, fruits, nuts, whole grains, fibers, and stick to fats that are polyunsaturated or long-chain fatty acids. The best meats are fish and poultry as well as white meat (low fat pork). Obtaining protein from vegetable sources like beans and legumes once a week is also highly recommended. Try to reduce the intake of red meat, sugar and fructose sweetened beverages, trans fats, and high sodium salty food. Part of eating healthy is also controlling portion size and avoiding excessive snacking.

Better living is a goal in life. To reach the destination, one must take steps to change if you are not where you want to be. Setting realistic goals and changing one aspect of your life at a time is the best. Furthermore, be accountable to yourself and one another, as that will help you reach your goal. If you need help, work with appropriate experts to reach your goals. Help may be from dieticians, physicians, physical therapists, trainers to even psychologists. Change is difficult, and better health is a life long goal.

Injections and Blood Thinners

/ Thomas Cohn, MD
blood thinners

53793176 – render illustration of blood thinner title on pill bottle, isolated on white.

A number of patients, for a variety of reasons, are on medications that are considered blood thinners. Many patients have heart conditions that require them to be on a medication to reduce the risk of blood clots. Stopping these medications can cause multiple problems from clotting of blood vessels to pulmonary embolisms and strokes. Being on blood thinners can cause bleeding problems with or without medical procedures. The big question is whether a specific interventional procedure has more risk for a bleeding complication or whether it is safer to stop the blood thinner for the time being.

Up until recently, the decision to halt blood thinners was based strictly on the risk of bleeds in the surgical acute care settings. Many times injection procedures are done without imaging guidance and have definite risks based on the location of needle placement. Procedures for pain management are usually done with fluoroscope guidance and often are done to structures that have low risks for complications from bleeding. Until recently, risks were determined based on the rate of complications seen in the surgical procedures, and then the risks were estimated for the interventional procedures.

New Information

Recently, several researchers have actually studied the risk of many interventional procedures on blood thinners and also studied the risk of complications from stopping blood thinners. For most experienced interventional pain doctors, they can site cases from their own experience of complications from stopping blood thinners and bleeding problems. Stopping blood thinners does cause problems with strokes and with blood clots forming in harmful places. Fortunately after over 50,000 injections, only a couple of times has a problem occurred in my practice.

The latest research has been done in Pennsylvania. One hospital system in a part of the state has enrolled virtually every person in the area, thus allowing one to study the characteristics of various problems. The first thing the researchers did was find all the people on blood thinners. Then they looked at the incidence of complications from stopping blood thinners for any medical procedure, and the number is about 0.75 people per 1,000 for a problem like stroke or blood clot of some type.

Then they looked at the risk for bleeding with typical injections that are thought to be low risk for bleeding, like joint injections, transforaminal epidural injections and medial branch blocks. The findings were that only minor bleeds occurred and the overall risk of bleeding was 1/4,000 people. That means it usually is more dangerous to stop blood thinners for most interventional procedures for the patient than it is to continue them. For a patient on blood thinners, it means they should be concerned whether the procedure they are undergoing needs to have their medication stopped.

In my practice, if I know a patient is on blood thinners and the procedure is low risk, I will not stop blood thinners. Not many physicians are comfortable with this as of yet since the research is not widely distributed. If as a patient, you are concerned about stopping a blood thinner, it is wise to ask whether it is necessary to stop the blood thinner and whether the procedure can be done in such a way that bleeding is not a significant risk. Sometimes a different approach to an injection will decrease the risk of bleeding. Lastly, a physician who is very experienced with injections will usually be able to place a needle for injection with less trauma due to their ability to overcome obstacles of the anatomy in the area. Experience does count and being specially trained in the area of interventional pain medicine helps with being up-to-date with the changing standards of care for challenging patients.

Are Corticosteroid Injections Safe?

/ Thomas Cohn, MD

corticosteroids safeEvery year, the majority of physicians need to attend continuing education courses. Sometimes these are online or via written materials, while others are seminars. This year I am on my second course, because unfortunately not all work qualifies for credits. The last course was extremely educational, but was sponsored by a medical corporation and therefore did not qualify for credit.

This week I am again gone from the office attending a conference. One of my goals is always to bring back some pearls to my practice. The first subject I’ve been learning more about is steroids and their role in a patient management program.

Steroids and Their Safety

The main question is whether the corticosteroids that are used in pain injections are safe for the patient. The answer of course is complicated. In a pain practice, corticosteroids are used to bring down inflammation. There are many different types of steroids, as those used for pain control are different from steroids used to build muscles or control hormones. Corticosteroids not only decrease inflammation as well as pain, but can also do many other things in the body. The problems they caused were discovered mainly due to their use for other conditions.  

Conditions like asthma, lung disease, and rheumatoid arthritis were all previously treated for years with oral, injected and IV steroids. From their use, we slowly learned some of the issues with these medications. The most obvious was the problems with blood sugars and diabetes. Steroids can make blood sugars elevated, usually for only several days when used in the spine or joints, but sometimes for several weeks. Corticosteroids can also alter the function of the balance of normal hormones in the body, causing problems with blood pressure, emotions, and female or male hormone balance.

One of the biggest worries of with the use of steroids is the cumulative effects like bone loss. Osteopenia and osteoporosis are the bone loss problems that can be increased over time with the use of corticosteroids. As people age, the natural function of bone growth changes and many people develop bone loss. The use of corticosteroids can increase the rate of bone loss. Now it is known that there is a yearly amount of steroid-type injections to try to stay below. That is between 4 and 6 shots total.

Too much steroid can increase bone loss and make osteoporosis worse. The problem with osteoporosis is that bone fractures can become more common. It can lead to problems like broken hips from a fall to spontaneous vertebral body fractures in the spine. The vertebral compression fractures can be fairly painful and cause spinal deformities.

The bottom line on the use corticosteroids in the management of pain is that they are not fully safe, but they can be used as part of an overall strategy to manage painful conditions. The total amount of steroids should be monitored, and if a person has had a number of incidents of exposure to this medication, then monitoring for side effects is necessary. If one is a diabetic, blood sugars should be watched whenever using these medications.

Most people may need to be watched for bone loss, and then bone density monitoring is necessary. Osteoporosis is a silent disease with only 25 percent of those who have it being aware of the problem and seeking treatment. Since pain physicians often use the medication in their injections, it should be a routine concern to monitor patients who are receiving shots. If you are at risk for bone loss, make sure that your doctors test you for it, it can even happen to young and seemingly healthy individuals.

That’s all for now, off to another conference lecture!

Dr. Cohn