chronic pain

Nutrition, Diet and Pain

/ Thomas Cohn, MD

DietPain is a complex experience with multiple components, including those from the physical interpretation of sensory signals to the brains perceptions of the signals. Sensory signals are transmitted electrically and chemically throughout the body. The chemical nature of the body is significantly affected by our activities, including exercise, nutrition and diet. What we put into our bodies affects how we feel, including our perception of pain. Diet and nutrition can certainly impact pain.

In the most basic sense, obesity and being overweight can contribute to pain. Recent studies have shown that the extra fat of obesity is pro-inflammatory, causing the body to feel more pain. Extra weight also mechanically stresses all components of the body. The extra forces placed across them stresses the joints. The muscles, ligaments and tendons are forced to use extra power to move normal amounts. Often people in pain find that eating is one of few pleasurable activities, and then they eat more and move less.

Inflammatory Foods

Food can be broken down into two general categories: pro-inflammatory and anti-inflammatory groups. The pro-inflammatory foods and nutrients have the effect of promoting inflammation in the body directly or by how they are metabolized and broken down. The anti-inflammatory foods do the opposite and reduce inflammation in the body either directly or indirectly. Not surprisingly, eating a healthy diet tends to be high in anti-inflammatory compounds. Diets rich in pro-inflammatory compounds tend to be rich in things that are considered not so healthy.

Diets that are pro-inflammatory are very common in our culture. The foods typically have a high glycemic load, raise blood sugars, contain “empty” calories, are highly processed and contain red meat, fat and oils that are not healthy. The American diet is rich in refined grains, sweets, and sugar. Pasta, white rice, bread and potatoes are all mostly carbohydrates and just add to our glycemic load and produce inflammation. Topping it off, many processed foods contain sugar or corn syrup, which are just empty calories. Animal fat (and human fat) are high in omega-6 essential fatty acids, and these are broken down into pro-inflammatory compounds including arachidonic acid thromboxane and leukotrienes. Vegetable oils including sunflower, peanut and corn oil also are high in omega-6 fatty acid and tend to be pro-inflammatory.

Diets that tend to be healthier are rich in compounds that are anti-inflammatory in nature. Foods that are high in omega-3 fatty acids, anti-oxidants and phytochemicals are anti-inflammatory. These include a variety of fruits and vegetables, spices and cold water fish. Omega-3 fatty acids are found in walnuts, flaxseeds, chia seeds, olive and canola oils and are anti-inflammatory. Healthy fish to eat include tuna, herring, salmon, cod and bluefish. Beans and lentils also provide high quality protein without bad fats. Some intake of omega-6 is necessary in the body, but controlling the amount and thus the amount of fatty red meat is essential.

Diets that have more fresh vegetables and fruits also tend to provide good sources for vitamins and minerals that act as antioxidants. Compounds that are antioxidants rid the body of free radicals that can lead to inflammation and breakdown of many structures like vessels and joints in the body. Vegetables and fruits also provide the body with phytochemicals, nutrients that protect cells, fight bacteria and help regulate the body’s hormones. Many spices and herbs also provide essential antioxidants and phytochemicals, and some even tend to mimic the actions of compounds like Ibuprofen.

Improving diet and nutrition can be a healthier way to control pain. What we eat can have a direct effect on our pain in many different ways. The typical American diet is rich in the compounds that promote obesity and inflammation. A dietitian can be extremely helpful in changing a person’s intake to change your health. It will take a bit of work, but eating better will help you lose weight and may decrease pain and inflammation in the body.

Chronic Pain in the Military

/ Thomas Cohn, MD

Army painA recent study published in JAMA Internal Medicine suggests that chronic pain in active and former military members is a significant problem.

The study surveyed 2,597 soldiers who served in either Iraq or Afghanistan in 2011 in order to understand how chronic pain affects their everyday lives. According to the survey results:

  • 45.4 percent reported suffering combat injuries.
  • 44 percent reported experiencing chronic pain.
  • 48.3 percent reported pain lasting at least a year.
  • 55.6 percent said they suffer from “constant” pain.
  • 51.2 percent said their pain was moderate to severe.

Those tasked with helping military members reintegrate back into society after a deployment know the management of physical and emotional pain is crucial. The study also attempted to uncover how military members use opioids to aid in pain management.

“I had conducted a similar study at [the] CDC because we felt that it was important to understand [the] use of opioids to get a greater context for misuse and abuse,” said lead author Dr. Robin L. Toblin, a clinical research psychologist at the Walter Reed Army Institute. “When I began my current position, we sought to look at the same constructs within a military population, who seemed to be that much more likely to be in pain due to the combat deployments over the last decade.”

Dr. Toblin noted that providing opioid therapy and management to combat veterans is key. Opioids can certainly ease pain after a combat injury, but problems can arise if veterans try to self-medicate or are uninformed about proper dosages. According to Dr. Toblin, 15.1 percent of soldiers say they have received opioid-based therapy to control their chronic pain.

“[Based on these findings], we hope that the military services will be more aware of the unmet needs for the assessment, management and treatment of pain and will broaden the services and availability of those services for servicemembers,” Dr. Toblin said.

The findings have touched off some debate over whether military members should be taking opioids. Obviously we want returning service members to be pain free, while others claim the drugs could affect their physical and mental performance. In the end, I think it really comes down to taking a strong, hands-on approach to ensure our veterans and returning servicemembers get the care they deserve and a treatment strategy that suits their individual situation.

Is The Web A Useful Resource for Medical Information?

/ Thomas Cohn, MD

Medical websitesThe web can be a very good place for information, but one has to be careful at which places they look for info. There are many commercial based sites that try to sell products based on your search criteria. Other sites are the equivalent of an infomercial for a medical practice or institution, while some may simply be a personal blog. Various organizations also sponsor sites, and some are very good, while others are pushing their philosophy toward a certain problem as the only true solution. The best sites seem to try to explain the science behind a problem and explain the variety of solutions available.

The sites that I have found the best are sponsored by the government or large medical organizations. For instance, the Mayo Clinic has a huge amount of information on a variety of topics. They write informational pages on various topics, like medical problems, the typical history, diagnostic studies that may be needed and treatment options. Other good places to look for factual information include insurance companies, health organizations, medical groups, and large universities. Many of these places have fact sheets available on topics of interest that are good reference material. The U.S. government also sponsors information, often from the National Institutes of Health, on a variety of issues.

Then there’s the gray area source of Wikipedia. Generally this source can is an excellent place for information and entries are written by top notch experts on a disease, however, it can be also written by someone who actually has no medical background and just decided to write an article for the site. The information found on this site should be verified with other sites and not be taken as a sole source of data.

The Internet and Chronic Pain

The internet can provide an excellent resource of information for the self motivated person. I have found it useful for baseline information about various pain conditions. I also use it as a resource for patients who want more information on certain topics, like exercises for low back pain. Youtube also has videos that demonstrate a variety of things from exercises to surgical procedures.

Cellphones have brought the internet to the palm of the hand. For a quick definition or piece of information it can be wonderful. Medical providers can find a variety of references for free that help make diagnoses, identify medications and there uses, and for dosing information. That said, reliable and free information in app form is hard to find. iPhone apps are a huge business, but I’ve found no beneficial free exercise apps for patients with chronic pain. There are some inexpensive apps for exercise, but read the reviews first to see if they are going to be helpful for your situation.

The internet is like the Wild West from long ago. There are many very good sites and areas to find educational information about a variety of conditions. The better sites are free and often sponsored by large medical institutions, such as the Mayo Clinic, Johns Hopkins University, other not-for-profit organizations or the U.S. government. Some doctors are also prolific writers and work at trying to educate their patients through the web. Unfortunately, in the pain world, there are also some terrible sites that are forums to gripe about a condition, and the doctors who “know nothing.” The internet can often be a very good starting place for information. It is also a good place to develop questions such that you can have a good discussion with your doctor about what to do next in your management.

Smoking Increases Risk of Chronic Back Pain

/ Thomas Cohn, MD

Smoking and Back PainA new study conducted at Northwestern University found further evidence that smokers are at an increased risk for developing chronic back pain.

While medical experts have known for a while that smoking increases a person’s risk of chronic back pain, this study examines why that’s the case. Researchers were keen to learn more about the link between back pain and smoking as back pain affects more than 80 percent of the population at some point in their life. According to the folks at the American Chiropractic Association, back pain is the number one reason for missed work and the second most common reason for doctor’s visits.

Smoking Study

For their study, researchers examined 160 individuals who had developed subacute back pain, which is defined as back pain lasting between  1-3 months. In addition, researchers analyzed 32 participants with chronic back pain – back pain for more than five years – and 35 people with no symptoms of back pain. Patients were asked to complete a health and wellness questionnaire once a year for a period of five years, and they also underwent MRI brain scans to analyze brain activity in the nucleus accumbens and the medial prefrontal cortex. These areas play a role in a person’s addictive behavior and motivated learning.

Without getting too technical, researchers say there is a crucial connection between these two areas of the brain. The stronger the connection between the too, the less resilient a person is to chronic pain. According to researchers, smokers had a stronger connection between these two areas of the brain compared to non-smokers, meaning smokers were more likely to develop chronic pain. In fact, researchers suggest that a smoker is three times more likely to develop chronic back pain than a non-smoker.

But there is good news. Dr. Bogdan Petre said the connection between the nucleus accumbens and the medial prefrontal cortex can be decreased by kicking the habit.

“We saw a dramatic drop in this circuit’s activity in smokers who – of their own will – quit smoking during the study,” said Petre. “So when they stopped smoking, their vulnerability to chronic pain also decreased.”

Petre concluded that his team’s findings are only further evidence that smokers are putting themselves at risk for chronic back pain.

“We conclude that smoking increases risk of transitioning to chronic back pain, an effect mediated by corticostriatal circuitry involved in addictive behavior and motivated learning.”

 

Doctor Ratings and the Importance of Communication

/ Thomas Cohn, MD

Best Doctors MNEveryone wishes to have the best doctor available. In Minnesota there are multiple rating services available that score doctors, however, which rating systems are the best? Some services rate doctors on their compliance to medical guidelines such as those established for asthma and diabetes. Other services monitor the cost of a physician’s per patient billing to the insurance company, while others are patient reviews. The real question is, what will make you happy with your choice of physician?

Important qualities in a doctor includes their knowledge, skill, understanding of a patient’s condition and their communication skills. Almost every physician will have a good basic set of knowledge about any medical condition that they treat. In any profession, from car mechanics to teachers, 90 percent of the practitioners are good and 10 percent are exceptional and have a special talent in that field. Skill level is similar; most physicians have good techniques, but some just know the small things that make all the difference when doing any procedure, and are just better than others.

Understanding a patient’s condition is somewhat complex. First, a doctor must be prepared. This includes reviewing a patient’s medical record and knowing their history. This is ongoing, and the doc should know this information at each visit. Medical records are helpful, but personal notes may be needed in addition to fill gaps. Experience is also important, as is continuing to grow in their skill by attending conferences and seminars on a regular basis.

Doctor-Patient Communication

Communication between the doctor and patient is critical in quality of care. Most important is that communication is not one directional. To treat a patient, a doctor needs to know what is wrong, what are the symptoms, and what is actually working correctly. Since doctors often have limited time with each patient, they will need to guide the conversation to obtain the relevant information. Being honest is also extremely important. There are often multiple sources to confirm data, and if the information provided is not truthful, a doctor will likely be guarded in their care. Patients also need to ask questions about their condition and be open about their recovery.

Ratings of doctors are of limited value. The final rating that matters is how well you communicate with your doctor and whether or not you trust his ability and knowledge. Sometimes, you can find the right physician without any trouble. Other times, word of mouth and information from friends who know the practitioner is critical. Ratings on the web may be inaccurate or forums for the unhappy patient. No physician will be perfect, but finding the right physician may be a matter of how well both you and the physician communicate with each other.