Daily Exercise The Key To Combating Chronic Pain

October 16, 2019 / Thomas Cohn, MD

As someone who has suffered from chronic back pain for more than a decade, I know just how hard it can be to manage a chronic condition on a daily basis. You have good days where you feel like you can conquer the world, and you have bad days where you don’t even want to get out of bed. No matter what kind of day you’re having, it’s important that you push through any discomfort and find time to exercise, because that’s likely your best bet at stringing together more good days than bad.

Daily exercise isn’t something that comes easy. Most of us can find some spare time throughout the week, but we can’t always carve out time every single day, and when we do get spare time, oftentimes we’d rather use it on anything other than exercise. However, it’s this consistency that might be just what you need to put your chronic pain in the past.

The Benefits Of Daily Exercise

A recent study decided to take a closer look at the benefits of moderate versus daily exercise when it comes to helping control problems associated with chronic pain. For the study, researchers conducted a small, weeklong study of 40 healthy women on their sensitivity to pain before and after exercise. The individuals were asked to walk briskly on a treadmill for their exercise, and patients were separated into three different groups. One group walked three times per week, another group walked five times a week, and the final group walked 10 times a week.

After reviewing the data, researchers found no differences in pain perception following exercise for those who exercised three times a week, but the findings were significantly different for those who exercised at least five times a week.

“We asked them to rate that pain,” said neuroscientist Benedict Kolber, lead researcher on the study. “And at the end of the study, they rated the same pressure — the exact same pressure — as 60% less painful than they rated it at the beginning of the study.”

In other words, a small dose of exercise did nothing for helping manage chronic pain, but a bigger dose worked wonders. A good motto to live by is to “Strive For Five” in terms of striving to exercise at least five times a week. However, it’s also worth remembering that you need to start slow. If you haven’t been a frequent exerciser, don’t go straight to exercising for an hour each day. Ramping up your activity too quickly can lead to overstress injuries and exacerbate inflammation. Start slow, be it 5-10 minutes a day, and work your way up from there. Focus on doing small amounts daily instead of a longer session 1-2 times a week, and work your way to longer durations.

There have been days where the last thing that I wanted to do was get up before work and work out, but I knew I needed to do it if I wanted to function at my best throughout the day. I try my best to work out every day, and my back pain has been much more controlled than in years past, even though I’m years older. Controlled exercise can be your best friend when it comes to caring for your pain condition. If you need help developing a safe exercise routine, or you want some tips on what types of activity might be best considering your condition, reach out to Dr. Cohn’s office today.

A Closer Look At Acute And Chronic Pain

October 7, 2019 / Thomas Cohn, MD

Chronic pain is usually different from acute pain. Acute pain is considered to be directly related to stimulation of sensory receptors for noxious stimuli located throughout the body. It is often related to direct damage or trauma to the body. It also is the normal physiologic response to the various types of sensory receptors that is perceived as noxious or painful. Acute pain is relatively short lasting and is a direct response to direct stimulation of sensory receptors with lengths from seconds to usually less than several months. Chronic pain however is long in duration, lasting over three months and becomes independent of direct stimulation of sensory receptors for acute stimuli.

Chronic and Acute Pain

Chronic pain most often is characteristically different from acute pain. It often involves the nervous system changing on a peripheral and central basis such that sensory signals are perceived differently. In the limbs or other areas, sensory receptors become increasingly able to respond to any stimuli and then sending a signal out into the central nervous system. The nervous system essentially becomes primed for responding to sensory inputs and blasts out a powerful danger signal out of proportion to the intensity of the event. A small touch on the arm could feel like being hit by a sledgehammer.

Chronic pain is divided medically into three types;

Nociceptive
Neuropathic
Central sensitization

It can also be a combination of these. As pain becomes more chronic, the central nervous system becomes more involved and pain has more centralized components. The secondary outcomes of chronic pain over time also become prominent with increased healthcare utilization and often decreased quality of life.

There are multiple correlations in a person’s life that are associated with chronic pain. Common attributes include being female, early life trauma, family history of pain and mood disorders, genetics, sleep disturbances and mood disorders. Certain types of pain that more commonly become chronic include headaches, low back pain and fibromyalgia/diffuse myofascial pain, while the psychological factors of anxiety, depression, catastrophizing, and PTSD are linked to developing chronic pain.

Well-managed and aggressively treated chronic pain comprehensively reduces the incident of chronic pain, but as pain continues ongoing aggressive management can impact the intensity of long-term issues. It is important to treat all aspects of a painful condition. Often there are multiple factors stimulating pain and all the physical problems need to be addressed from muscles, nerves, tendons, ligaments, joints, bones and any other system involved as well as the psychological impacts.

Comprehensive management of symptoms is one of the keys to successful outcomes. Using traditional medical strategies including medications and physical therapy in conjunction with techniques like acupuncture, meditation and improving sleep hygiene may all be necessary in managing pain. Aggressive management of acute pain, especially traumatic or post-surgical, helps reduce the incident of the development of chronic symptoms.

Acute pain is a common arena for most regular physicians. Comprehensive initial management of acute painful conditions reduces the development of more chronic problems. If the pain is showing tendencies toward becoming chronic, involvement of a pain specialist can reduce the impact of the long-term symptoms.

How To Improve Your Sleep Quality

September 30, 2019 / Thomas Cohn, MD

sleep Everyone wants to sleep better. Problems with sleep are now pervasive in today’s society, and there are many culprits. Medical sleep experts are taking a deeper dive into the dynamics of sleep and are now starting to have a more comprehensive approach to issues. In the past, sleep problems were overly simple and only a few problems were considered. Sleep apnea was the main concern, then restless legs became another area. At sometime it became a matter of taking the correct sleep medication; the right pill was the answer, but we’re learning more about better techniques.

Poor sleep leads to multiple problems. The simple one is fatigue with difficulty functioning at an appropriate level. Compounding being tired is mood changes from anxiety to depression and even more severe psychiatric disorders. Sleep deprivation also leads to a large number of health problems including weight gain, hypertension, heart disease and possibly late neurological problems like dementia.

The New Science in Sleep

The new science in sleep is now paying closer attention to whether the person is trying to follow their normal circadian rhythm. Most people have normal sleep times and baseline cycles. Some people are morning people, while others like to stay up late and sleep in during the morning. These are natural cycles one is often born into, and trying to work against the natural tendencies often leads to additional sleep difficulties. Working within your natural cycle for sleep can diminish ongoing sleep problems. If you are a night owl, trying to be awake at the crack of dawn is likely just to cause problems.

Recognizing your own natural tendencies towards sleep can reduce anxiety and improve the quality. I am not a night owl at all, therefore when I chose a specialty in medicine I knew I wanted to be able to sleep at night. I knew I could not function well in the middle of the night so I needed a specialty where I could usually sleep at night. Throughout college I only pulled one all night routine. I almost always went to sleep before midnight and then awoke early to do whatever had to be done. My spouse is just the opposite and is up to all hours of the night routinely and hates mornings, and hates the cheerful me as I start exercising at the crack of dawn.

During the daytime our brains are processing new information and making new connections. At night the brain is doing its housekeeping, removing toxins and cementing into place the information acquired during the day. Nighttime also is the time the brain works on processing emotional connections. Time spent asleep is when the brain does all the background work to maintain health and is not interrupted by functions that are needed when alert and awake.

For healthy sleep and general ability to stay awake during the day, maintaining a regular circadian cycle is necessary. There are multiple things that one can do to improve your sleep. The first thing is to consider using a 10,000-lux light box in the morning to mimic sunlight for 30 minutes. This will help stimulate the brain to wake up and be less tired. At night, go to bed when you are tired. Do not lie around in bed waiting to fall asleep. Bedtime preparation is important. Stop working 1-2 hours before bed and avoid thinking about provocative topics prior to sleep. As part of the wind down, do something calming like reading or listening to music. Avoid looking at screens and social media. Lastly, avoid caffeine and stimulants late in the day as well as alcohol within two hours of sleep. Alcohol after the first hour of a sedative effect tends to make the brain alert after it is metabolized.

Having good sleep habits as well as working with your natural circadian rhythm improves the ability to successfully sleep and feel rested. It improves brain function and overall health in many ways. When sleep is a problem and the simple issues are addressed, then working with a medical sleep specialist is important to identify and address the causes of poor sleep.

Prescribing Opioids in 2019

September 23, 2019 / Thomas Cohn, MD

Every day in my practice I sit down with patients who strongly believe that opioids are the best course of action for their pain condition. While opioids certainly can play a crucial role as part of a comprehensive treatment plan, they definitely are not a stand alone option and are far from a perfect treatment as their problems are numerous and well known.

Pain is the physical and emotional response to certain sensory signals. In chronic pain, these signals are not necessarily any indication of danger or potential damage that may occur to the body. Opioids tend to modify the signals of pain, but often are not the most effective treatment and can have devastating secondary consequences. Due to the problems opioids may cause, most physicians are reluctant to prescribe these medications. A new study from the University of Minnesota is shining light on the inconsistencies in when opioids are prescribed.

Opioids In Today’s Society

Before I get into the crux of this blog, it’s worth reiterating that every patient who is interested in opioids is not simply trying to abuse their medications. Some are misinformed, and some truly believe they can help even if they won’t solve the true problem. However, there is a small subset who want medications for reasons other than to treat the underlying pain problem. Thirty years of practice has shown me all the tricks patients play to get medications prescribed. At times it is surprising the act some patients put on to get pain medications. Most physicians are aware of the issues, but still the charades occur.

The new study from the University of Minnesota shows that physicians tend to be vulnerable to over prescribing when they are tired, running late with their schedule, or at the end of the day. These are times when saying yes is easier than explaining no and finding an alternative strategy. This is especially important in acute pain situations when patients are especially prone to abuse and other solutions are appropriate. In some acute situations, short-term prescriptions are okay for several days, especially related to trauma or surgery when other medications for pain are not advisable. Awareness and prescription protocols by primary care providers and emergency rooms about opioids has led to a significant decrease in prescribing these medications. Other providers have been somewhat slower to adopt new habits for safe prescribing.

Opioids are only a small tool in the overall arsenal to treat pain. For many situations, opioids work poorly and are not very helpful. For some patients, opioids have so many problems that the risks of these medications are not even close to any benefit. The worst way to get these medications is to insist that they are the only thing that helps your pain. Usually that means that one does not want to work on other strategies that may be helpful. Unfortunately, some of the better treatments for pain are a struggle to implement because they take time, effort and money. Strategies like exercise, massage, relaxation and treating psychological issues are much more difficult then taking a pill. There’s no magic pill and it will take work, but you’ll be much better off for it.

Pain is difficult to manage, and pain specialists can help with a variety of options. Some problems are simple; most that end up with a pain specialist are very complex. There often is not a fix and most people will have to find a compromise and determine what they can manage and still function adequately. If you want help with your pain condition, reach out to Dr. Cohn’s office today.

Daith Piercings, The Vagus Nerve, and Migraines

September 9, 2019 / Thomas Cohn, MD

Daith piercings have been showing success in helping to control migraine headaches. Now there is new research that seems to shine more light on what has been thought to be the mechanism that contributes to the success of this treatment. Research into dementia has recently been done with stimulating the ear with a slight bit of external and intermittent vibration. The research suggests that this may help prevent dementia. The mechanism of action is thought to be by stimulating the ear, a branch of the vagus nerve is also being affected and this is what is producing the results. Similar to what we assumed was happening with the daith piercing, vagus nerve stimulation is the key factor at play.

The latest information on stimulating the ear and the vagus nerve comes from a study out of England and the University of Leeds (Bretherton et al, 2019, in Aging). Stimulating the outer ear for 15 minutes a day for two weeks with gentle electrical vibratory signals improved the relaxation signals and parasympathetic activity. The researchers determined that they were electrically stimulating a branch of the vagus nerve that is in the region of the tragus. In older people (55 years and older) they may have a high sympathetic outflow and this leads to stress, tension, depression and low energy. The transcutaneous electrical stimulation of the ear rebalanced the system and seemed to slow the effects of aging. The major caution was this was a small study so one does not know if these findings would be present in a large controlled study.

The initial research at the University of Leeds in England was done in 2015 and was done in healthy young people. Stimulating the ear with transcutaneous electrical stimulation at the vagus nerve improved autonomic function. Normalizing autonomic function means decreasing sympathetic tone, stress, tension and most likely vascular tone. This would also mean blood vessels would not constrict and could impact the occurrence of migraine headaches.

What It Means For Migraines

Vagus nerve stimulation has a history that is long standing. Vagus nerve stimulation devices were implanted after 2005 for treatment of major depression. They also have been used for gastro-intestinal disorders, epilepsy, and some inflammatory disorders. Now there is an FDA-approved device (GammaCore) to stimulate the vagus nerve through the skin to relieve migraine headaches.

Daith piercings we now know are not placebo treatments for migraine headaches. It is pretty clear they work through stimulating the auricular branch of the vagus nerve in the region of the tragus in the ear. Stimulating the vagus nerve will increase parasympathetic activity and decrease excessive sympathetic tone. This would likely decrease the vascular events that surround migraine headaches. Furthermore it may reduce overall personal stress and anxiety that may be migraine triggers. The piercing would cause physical stimulation of the vagus system and thus rebalance the autonomic nervous system in the body. If piercing is not an option, then using a transcutaneous nerve stimulator (TENs) unit with a very light current to the tragus unit would likely do the same. The good news is that science is validating the practice of this piercing.

As a side note, research is underway specifically on the daith piercing. Studies are being done in England and elsewhere in Europe with regards to the effectiveness of this technique. Whether the daith piercing will work for any one individual is unknown. Since migraines may have a number of triggering causes, the effectiveness of the daith piercing is likely dependent on whether a component of the migraine is related to autonomic balance in the body and if it can be corrected with vagus nerve stimulation. Hopefully we continue to learn more about vagus nerve stimulation and how to best treat these types of migraines in the near future.