Could We Be Pain Free In The Future?

July 11, 2017 / Thomas Cohn, MD

Although not as much money is being spent on understanding pain as doctors would like, there is still some promising research taking place throughout the world. For example, new research published in Nature Neuroscience took a closer look at re-wiring the brain’s transmitters when it mistakenly interprets signals as pain.

The research began by looking at mice who had peripheral nerve damage and chronic pain from a previous leg surgery. In these mice, a broken circuit in the pain-processing region of the brain caused hyperactivity that led to pain for more than a month. Scientists realized that the peripheral nerve damage deactivated a set of interconnected brain cells, called somatostatin (SOM), which usually work to lessen pain signals.

Fixing The Broken Circuit

Researchers were interested in learning if this connection could be fixed, and if it could, how we’d go about repairing it. One method they tried was to manually activate the SOM interneurons, and they found that this led to a significant decrease in the development of chronic pain.

“Our findings suggest that manipulating interneuron activity after peripheral nerve injury could be an important avenue for the prevention of pyramidal neuron over-excitation and the transition from acute postoperative pain to chronic centralized pain,” the authors, led by neuroscientist Guang Yang at New York University School of Medicine, conclude. They believe future drug therapies or magnetic brain stimulation could mend these SOM interneuron connections and prevent pain signals from misfiring.

The authors are cautiously optimistic, but they realize that there is a big difference in the brains of mice and the brains of humans. The study needs to be repeated and the results verified before any similar testing in humans could take place, but it’s a start.

“Our study provides, to our knowledge, the first direct evidence that impaired SOM cell activity is involved in the development of neuropathic pain,” the researchers wrote.

They hope to confirm their results and examine whether manipulating other cells could play a role in the reduction of chronic pain. If they can, we may have specific cells in which to base our intervention techniques. This is exciting.

Sleep, Insomnia, and Pain

March 8, 2016 / Thomas Cohn, MD

Difficulty sleeping is a common problem with patients in pain. Good quality sleep throughout the night often reduces the intensity and perception of pain. There are many causes and not a single solution for poor sleep. Pain in the neck and low back regions can cause discomfort within a short amount of time while lying down. Chronic pain can also cause anxiety and depression and that can contribute to sleep issues. To make matters even more complicated, the medications used to control pain may have side effects that impair sleep. Patients with chronic pain may also have other medical conditions that cause difficulty with sleep.

Sleep Postitions

Treating sleep problems in patients with pain is often quite complex. The first step in treating sleep-related pain is to make sure the patient has good positioning of the body with regards to the spine in a neutral position. For neck pain this would be using a pillow that supports the head without having the neck bent if lying on the side, or a thin pillow with a slight neck roll if lying on the back. Low back patients need pillows to support their position if lying on the side between the knees and sometimes supporting the stomach or against the back. Having multiple pillows to maintain a good position is normal. If lying on the back, having a pillow under the knees improves the low back position reducing stress on those muscles. A bed that accommodates and maintains natural curvatures of the body, such as a memory foam mattress or an adjustable air bed also may be helpful to reduce stress and pain on either the neck or low back.

Pain, Anxiety, and Sleep

Pain itself can cause sleep difficulties related to anxiety and depression. The centers in the brain that interpret pain signals and those associated with anxiety and depression are in the same regions. Often as one develops chronic pain, anxiety also occurs and contributes to sleep problems. Not treating this problem adequately can worsen the pain since these areas of the brain tend to interact. Often anxiety has been treated with benzodiazepines like:

Valium
Ativan
Xanax
clonazepam

These medicines induce the first phases of sleep but not the deeper sleep that is needed. Anxiety in pain patients is often a symptom of depression, and is not well treated with the above medications. Using antidepressants actually treats the chemical imbalances that occur and with the right medications the symptoms improve as well as the sleep.

In pain patients, recent studies show that sleep problems are often mixed with significant concern about not being able to sleep. Patients tend to concentrate on not being able to sleep and this then becomes the reality. More drugs with side affects is typically not the best solution. More effective treatment is the use of cognitive behavioral therapy (CBT). This is a psychological method of retraining the brain to think in a constructive fashion and this reduces the anxiety about sleep and anxiety. Studies have found the use of CBT to be equally or more effective in managing sleep problems in pain patients than the use of medications.

Traditional pain medications like opioids also have negative effects on sleep. These drugs tend to reduce deep sleep and increase the shallow phase 2 sleep. Deep sleep phases are the periods that are necessary to feel rested. The more potent opioids also have a tendency to increase both obstructive sleep apnea and central sleep apnea. Both decrease oxygen levels in the body and lead to frequent awakening. Sleep apnea will markedly decrease deep sleep and the quality of sleep.

New Sleep Medications

Ease of falling asleep, being able to stay asleep, and having deep restorative sleep measure good quality sleep. With good sleep, one should feel well rested and have less pain. As noted above, one of the best management techniques for sleep is using cognitive behavioral therapy. Medications are starting to get better. The newer sleep medications over the last ten years like Ambien and Lunesta help induce sleep, they do not keep one asleep and may cause hangover and odd behaviors like sleep walking. Melatonin type medications also induce sleep, can be used safely long-term, but do not maintain prolonged deeper sleep. The newest medication is Belsomra and this appears to be inducing and maintaining sleep. One old time medication, doxepin at very low doses also seems to have similar properties.

If one has pain and sleep difficulties, it is important to discuss the problem with your pain physician. A trial of simple solutions, either CBT or melatonin type medications is reasonable. If the sleep problems are ongoing, being evaluated by sleep specialists and having a sleep study done is beneficial. Sleep apnea is common in pain patients and treating these problems is essential in managing sleep. Ongoing sleep problems may require a combination of solutions since multiple factors are probably present. Like managing pain, sleep is complex and often difficult to find a solution to improve the situation.

Finding A Good Pillow For Neck Pain

January 20, 2016 / Thomas Cohn, MD

As Shakespeare once said “Sleep, per chance to dream” is the aspiration of everyone. Having a good pillow is the often the key. If you have neck pain, finding a comfortable pillow is a challenge. There are multiple options in size, stiffness and materials that must be considered. The wrong pillow just makes everything worse from neck pain and headaches, to shoulder and upper back pain. Furthermore, a pillow that is over two years old will often be full of dead skin cells, and possibly mildew, mites, or fungus.

Finding The Perfect Pillow

The first thing in getting a pillow is to determine the position you sleep in such that the support will keep your head in a “neutral alignment” position. If you sleep on your back, a thinner pillow with a possible extra bit of cushioning in the bottom third cab help maintain the curve of the neck. A side sleeper will need a fuller and firmer pillow to keep the head from tilting. Sleeping on the stomach often requires only a very thin pillow for the head position. A second pillow that helps maintain body position may also be helpful to improve comfort and to prevent pain. If you change your position during the night, you may have to decide how to combine features to maintain the most neutral alignment.

Pillows are also filled with a variety of different materials. The most common are a variety of feathers, foam, polyester fiberfill, and some are filled with weird materials like water, rice or beads. Classically, pillows used to be either feathers and down, or cotton with wool. A 50-50 mix of down and feathers has been traditionally considered one of the best to provide comfort, support, and allow for adjustments of the cushioning to provide a quality sleep. However, for those with allergies and asthma, down or feathers may cause difficulties. A mix of cotton/wool is another traditional material, but tends to be quite firm and not very adjustable. Polyester fiberfill is an artificial hypoallergenic material that can be designed to mimic down pillows in comfort, and memory foam has become popular over the last several years. Memory foam can continuously mold and adjust to the neck and body position. Today, there are a bunch of different types of foam including cool foams, mold resistance foam and hypoallergenic foam.

Specialty Pillows

Specialty pillows are often expensive and have many designs, shapes, claims and materials. Cervical pillows are made in shapes to cradle the neck supposedly in a neutral position, but studies have usually shown these to be no better than regular designs. Water pillows recommended by some professionals supposedly can be adjusted to customized density and support, but may have odd motion. Bead, wheat or rice pillows claim to provide customized position into a neutral position, but tend to be quite firm and heavy.

The bottom line in choosing a pillow is that everyone has different preferences that may be the best for you. The fancy claims and expensive costs do not make a perfect pillow. First, determine your sleep position, as this will give you an idea of the thickness you might like, then find your preferred firmness. Stay away from down/feathers if you have asthma or allergies. The best option often is trying out various types of pillows at the store if at all possible while lying down. Have someone with you to make sure your neck is in a good neutral position, and if it is the right comfort level, you may have found the winner. Remember, it is comfort and not necessarily cost that is key.

MRIs Can Predict Chronic Pain After Whiplash Injury

January 15, 2016May 10, 2016 / Thomas Cohn, MD

Whiplash occurs when a person’s head is thrust forward or backward in a violent motion, over stressing the muscles and soft tissues in the area. The most common cause of whiplash is a car accident, especially accidents involving a rear-end collision. In this scenario the person who gets rear-ended will be thrust forward, but their head will usually snap backwards as their body is propelled forward.

Depending on the severity of the whiplash, most patients recover from their injury within 1-2 months, but others aren’t so lucky. For some, neck pain due to a whiplash injury becomes chronic, and symptoms remain for months or even years.

Luckily, we’re getting better at assessing whiplash symptoms and predicting who may suffer from long-term symptoms. With help from special MRI imaging, doctors are able to pinpoint with a fair degree of certainty which patients will develop chronic pain, disability and PTSD in the wake of a whiplash injury.

Chronic Pain Prediction

According to researchers at Northwestern Medicine, doctors can predict which patients will develop long-lasting symptoms within the first 14 days from the date of injury. By pinpointing which patients are likely to suffer long-term symptoms, doctors can better treat patients and help prevent potential setbacks down the road.

“This opens up a new door for research on whiplash,” said lead researcher James Elliott said. “For a long time whiplash has been treated as a homogenous condition. Our study has shown these patients are not all the same; they have different clinical signs and symptoms.”

The special MRI technique measures the fat/water ratio in the muscles of a person’s neck, and scientists uncovered that patients who would go on to suffer long-lasting symptoms had larger ratios of fat in their neck muscles. They believe this fatty infiltration could lead to atrophy of the muscles, and their findings were consistent no matter the size or BMI or the patient.

Elliot believes the findings may be most significant for individuals who suffer from PTSD in the wake of a whiplash injury or a traumatic car crash. If a person is deemed at-risk for emotional instability after an accident, doctors can help them get the treatment they need earlier, which can lead to better outcomes.

“These patients have shown to not respond well to traditional rehabilitation such as physical therapy,” Elliott said. “It appears that they may require a more concerted effort for pain management from their physician and help from a psychologist.” Emerging, yet preliminary evidence suggests this to be a reasonable strategy.

Chronic Pain as a College Student

November 16, 2015May 10, 2016 / Thomas Cohn, MD

Having chronic pain problems as a college student sucks. There are multiple problems and too many compromises that need to be made. You can’t just live a normal life, and the ability to be spontaneous does not easily happen. Everything is affected, from the living situation, to study habits and working with groups and exam schedules can be a problem. Name the situation, and it may be a problem, especially if you just want to be normal.

Chronic Pain in College

No day is typical, and just starting the day may be a problem. Waking up in the morning is often very painful. First, one may not have slept very well because pain kept waking you up at night, or it was extremely restless. Then one is sore and you need to start stretching and doing some morning exercises just to get moving. There is no last minute rolling out of bed and running off to class, you just can’t move fast without the morning routine.

Once you are at class, most lecture rooms and other classrooms have bad stadium seats or very uncomfortable chairs without any back support. Sitting in these chairs worsens the back and neck pain, and trying to take notes and concentrate is an effort. If you are lucky, they may provide a special chair to sit in, but good luck at getting the right seating in every classroom. It is also weird when you need to get up for a minute, stand in the back of the room and stretch to help relieve the pain. Lastly, making to the professor’s office hours when you are in pain is an added burden. Then you may also need to explain the need for accommodations due to your situation, adding again more stress to the pain.

As the day goes on, your back and neck may start to hurt more. Standing, stretching or walking around may not help and the best option for your back may be to lie down. Well, there are not many places to rest and lay down on campus.

After you made it through your classes, then there is the homework, group projects, and social life. Studying may be a challenge at times due to back pain and fatigue. Concentration is reduced by pain and more breaks are needed. Planning ahead is essential and leaving stuff to the last minute does not work since you may be having a bad day with pain at the wrong time. Further stress will worsen the pain, lower the concentration ability, and it definitely increases as deadlines for tests and big projects near. The group projects for some classes also are often a problem, you have to ignore your pain needs often to match the schedules of everyone else in the group, and at the end of the day, you may be just about in tears since you hurt so much and you still have a ton of stuff to get done.

Chronic Pain and Your Social Life

A big part of college is developing oneself in a new social environment. One wants to be just like everyone else, carefree and happy. When you are sleep deprived from pain, stressed out, and uncomfortable sitting in most chairs or standing long times, participating in social activities is tough. Ignoring the pain works at times, but sometimes it comes back to bite you and you are down for the count for several days because you did too much. Normal kids do all those things without a problem, for you it can be a nightmare, and you are physically sick for a week afterward.

There is no secret solution for having success as a college student when having chronic pain. It is a constant effort to be your best, and keep moving forward. Those who do manage this tight rope act are some of the toughest, smartest and grittiest kids imaginable. It takes a huge amount of effort, often alone and without good medical guidance. There are very few doctors who understand the challenges and can adequately help find the additional resources to ease some of the problems. Furthermore, there are few resources and pain treatments that make a difference for many young adults. The struggle is very real, and the problems of living with chronic pain just sucks.