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.

Age and Professional Sports

September 29, 2014August 25, 2016 / Thomas Cohn, MD

The prime of our lives is in our 20s. During the decade of time from age 20 to 30 years of age, our bodies and brains become fully mature. We are at our peak performance both physically and mentally. The body is the most flexible and heals quickly from minor trauma. Mentally, the brain becomes mature and can perform at a high level. For most sports, the best athletes are at their prime when the body reaches physical maturity. The length of time at a prime level is often about ten years. After that time, the body starts showing signs of wear and tear.

Professional athletes stress their bodies to the extreme on a daily basis to maximize training for their sport. Most are a bit sore every day from the hours of training and stressing of the muscles and joints. In general, the level of exercise completed is usually a bit beyond what the body was meant to endure. Structures of the body slowly start wearing out. Multiple injuries often start occurring, and it takes longer and longer for the person to return to full health.

The good news is that most of us our not professional athletes, so we are not dependent on an extreme level of activity for our livelihood. The bad news is we still are wearing out our bodies over time, but just not as fast as most athletes. Activity keeps us healthy as long as we do not overexert our bodies. Doing strength training keeps muscles strong and bones healthy. Aerobic conditioning is necessary to maintain good cardiovascular health. Being normal weight for our height keeps us from stressing the body structure as a whole. The average body starts to show signs of wear and tear in our 40s and 50s.

Historically, the body was designed to get us to about age fifty. In centuries past, before modern medicine and the industrial revolution, death often came by age fifty due to trauma, disease, or other natural causes. Now, we have learned to survive into our late seventies or eighties. As we grow older, age affects every organ including the muscles, tendons, joints and bones. The degeneration often causes aches and pains as we try to compensate for the changes that are occurring.

As I’ve said before, your body is like a car. A new car is beautiful and performs well with very little maintenance. As the car gets older, it takes more and more care to keep it running smoothly. If it is not maintained, it will likely fall apart. If we drive it hard and beat it up, it will fall apart sooner. If we baby it, it will become a precious antique. The body is not much different. We last longer and stay healthier if we take care of our body. Doing the work to keep healthy is beneficial to live a happy life.

Causes and Symptoms of Pelvic Pain

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

Both men and women can be plagued pelvic pain, but it is more common in women. Common causes include bladder infections, stones, and bowel issues. In women it can include endometrial issues and ovarian cysts. Treatment is based on the cause, and these pains usually end once the acute condition resolves. Pelvic pain is usually caused by issues like:

Hormonal changes

Tissue scarring

Bladder issues

Hernias

Sensory nerve degeneration, entrapment, etc.

Below, we examine these causes.

Hormones, Bladder and Hernia Issues Causing Pelvic Pain

Chronic pelvic pain in women is often related to several problems related to the unique pelvic anatomy. Endometriosis and fibroids are uterine tissues that form outside the normal uterine location. Their growth is stimulated by the normal hormonal cycles. The tissue eventually causes scar tissue in the pelvic region and the scarring can cause sporadic pelvic pain. Surgery is often used to help resolve some of the problems. Physical therapy and neuropathic medications can be helpful for long-term management.

Chronic interstitial cystitis is an issue in mainly women, and is often referred to as irritability of the bladder. The lining in the bladder becomes scarred, has pinpoint bleeding, and then the bladder becomes shrunken and stiff. Frequency of urination (up to 60 or more times a day) and constant pelvic pain occur. Bladder distention can be helpful and sometimes medication is instilled into the bladder. Bladder stimulators are sometimes implanted to help control symptoms.

Hernias more commonly appear in men than in women in the pelvic region. The muscle wall in the groin region weakens and abdominal contents push out of the injured area. The patient and doctor can decide if surgery is the best option, but if left to heal on its own, nerves can get entrapped in the resulting scar tissue. Physical therapy to release scarring, medications, and sometimes steroid injections are used to relieve symptoms.

Nerve Problems

There are multiple small sensory nerves in the pelvic region and they can become entrapped, irritated, or damaged by trauma in the area. Feedback from these sensory nerves can cause ongoing pain. Evaluation by a pain specialist or neurologist often clarifies the specific nerves involved. Sometimes physical therapy or manipulation of pelvic tissue can release these nerves or relieve the pain. Medications including anti-inflammatories and neuropathics (seizure or antidepressant drugs). At times, local steroid injections help or more regional sympathetic nerve blocks are useful.

Pelvic pain can be extremely difficult to diagnose and treat. Virtually any of the structures in the pelvis can be the eventual source of pain. Often it is a combination of structures causing pain. When the initial treatment is not working, the problem may be more complex, and a pain specialist may be helpful at finding the sources and recommending a combination of interventions that manage the symptoms. Sometimes there are permanent changes in the body and damage that is not reversible, and the goal needs to be managing the symptoms. A pain specialist can be especially helpful in designing a program that meets the needs of any particular individual.

Can Exercise Help Relieve Pain?

August 20, 2014August 25, 2016 / Thomas Cohn, MD

A new study suggests that regular exercise can improve a person’s tolerance for pain and discomfort.

The study was conducted by researchers at the University of New South Wales and published earlier this month in Medicine & Science in Sports & Exercise. For their research, scientists recruited 24 healthy but inactive individuals. 12 of the people said they were inactive but were interested in exercising, while the other 12 said they preferred not to exercise.

After the groups were separated they each were put through similar tests to create a baseline pain threshold. This involved putting pressure on a person’s arm until they said the pressure went from unpleasant to painful. Researchers later put individuals through a second pain threshold test, this time asking users to squeeze a device while a blood pressure cuff tightened on their forearm until it became too painful.

After their pain threshold was documented, participants interested in exercise undertook a moderate stationary bike workout three times a week, for six weeks. Researchers noted an improvement in fitness levels as cycling workloads increased each week. The other group continued with their lives as they had prior to the study.

Results

Both groups returned to the testing lab six weeks after the study first began. Volunteers not interested in exercise showed no changes in their pain threshold, but participants in the exercise program saw a noticeable spike in pain tolerance. They experienced pain at the time point they had during the initial test, but they were able to withstand the pain for much longer at the end of the program.

“To me,” said Matthew Jones, lead researcher of the study, the results “suggest that the participants who exercised had become more stoical and perhaps did not find the pain as threatening after exercise training, even though it still hurt as much.”

Scientists have previously hypothesized that a person’s body will emit opitates, such as endorphins, during exercise to slightly decrease discomfort. This process is known as “exercise-induced hypoalgesia,” and usually occurs during a workout and lingers for about a half hour after the workout is completed.

The study didn’t examine the physiological principles at play, but Jones noted that the decision to use a predominately leg-focused workout and an arm-based pain threshold test suggests that “something occurring in the brain was probably responsible for the change.”

If pain is too crippling to begin an exercise regimen, a person may do more harm than good by trying to exercise through the pain, but if you can tolerate even a moderate amount of exercise, you may be able to increase your pain threshold. Consult your doctor if you have questions or concerns.

Related source: NY Times

What are Pain Injections?

August 18, 2014August 25, 2016 / Thomas Cohn, MD

Patients often have severe pain that has not responded well to conservative care. Rest, ice, physical therapy, and over the counter medications may not solve the pain problem. When the regular treatments are not working, sometimes it is appropriate to have a specific injection to treat pain. Most injections are used to decrease inflammation that is causing pain from a specific location, such as a joint, tendon, nerve or the spine. The most common medication injected is a corticosteroid, a type of steroid used to decrease inflammation.

The most common steroids used are:

Dexamethasone
Methylprednisolone
Betamethasone
Triamenacelone

How Pain Works

Pain is expressed as sensory signals from a structure that is generating unpleasant signals. The signals travel from a remote location in the periphery of the body, travel by the nerves to the spine, then travel up the cord to the brain to be deciphered. Unfortunately, the brain sometimes cannot identify the exact location that is generating the signals. Injections are recommended by many different physicians to control pain, but since pain is often very complex, determining what should be injected and where to inject it can prove problematic. A good patient history, physical exam, and sometimes, special studies including MRI scans are helpful to identify the possible sources of the pain signals. If the source is possibly acute inflammation and irritation of a structure, placing a steroid injection in the area may allow the structure to return to normal and alleviate pain.

The structures that receive injection include the space around the spine and spinal nerves – the epidural space – joints, areas around nerves, tendons, ligaments, bursa, and muscles. Any of these areas can become inflamed. If they are not healing with conservative care, then placing corticosteroid in the area can allow the inflammation to resolve. Once the inflammation is improved the structures need to be strengthened so that the problem does not return. Sometimes the procedure needs to be repeated to further decrease damage. At other times, multiple structures are inflamed and multiple structures need to be treated.

The key to successful injections includes having someone to determine what is wrong and the structures that need to be treated. Having a skilled clinician perform the injections is important. A physician who has been trained in interventions is also beneficial. The treating physician may be an expert in one of many specialties, but most commonly they are trained in Anesthesia, Physical Medicine or Radiology. An experienced specialist will be able to performed the injection comfortably and effectively. Consult a Physical Medicine pain specialist to develop a comprehensive treatment plan if your symptoms are not resolving.