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.

The Link Between Dry Eyes and Chronic Pain

January 11, 2016 / Thomas Cohn, MD

Dry eyes can be painful, but new research suggests that people who suffer from dry eyes may be more likely to suffer from other chronic pain conditions.

New findings out of the University of Miami Miller School of Medicine suggests that dry eyes could indicate an underlying neurological issue that could also cause pain in other parts of the body. For their study, researchers examined 154 patients with dry eye and measured their levels of reported pain and their dry eye symptoms using three different tools. Once the researchers had their measurements, they group patients into two groups – Dry eyes with high levels of chronic pain and dry eyes with low levels of chronic pain. When looking at these two groups it became apparent that individuals with high levels of chronic pain also expressed more neuropathic type dry eye symptoms. Those patients also exhibited some other concerning trends.

“Dry eye patients in our study reported higher levels of ocular and non-ocular pain associated with multiple chronic pain syndromes, and had lower scores on depression and quality-of-life indices consistent with a central sensitivity disorder,” said study co-author Dr. Roy C. Levitt.

Dry Eyes and Chronic Pain

Researchers believe the findings from the dry eye study can help doctors uncover root causes of ocular issues, and they can help doctors better manage all expressed symptoms.

“Traditionally, eye specialists have treated dry eye with artificial tears or topical medications for the surface of the cornea. However, even if these treatments improve some dry eye symptoms, many patients continue to report underlying ocular and non-ocular pain,” said lead author Dr. Anat Galor, MSPH, associate professor of clinical ophthalmology.

Building on that point, Dr. Galor concluded that doctors should consider dry eyes as a possible side effect of a chronic pain condition when diagnosing a patient.

“Our highest priority is educating physicians that dry eye represents an overlapping chronic pain condition,” said Dr. Galor. “Consequently, a multidisciplinary approach should be considered in the diagnosis and pain management of dry eye patients.”

Related source: HCPLive.com

Is Your Chronic Pain an Addiction?

January 8, 2016 / Thomas Cohn, MD

New research out of Northwestern University suggests that chronic pain can rewire your brain so a person actually becomes “addicted” to chronic pain.

The new research published in Nature Neuroscience examined how brain neurons in rats were affected by negative emotions and pain. When looking at the rodents, researchers noted that some rats experienced a hyper-excitable collection of neurons after an injury or pain. These neurons not only controlled some negative emotions, but their hyper-expression was also associated with a drop in the neurotransmitter dopamine, which plays a large role in our reward motivation. In essence, the brain was misconstruing why these neurons were firing, and it slowly became addicted to their hyper-expression. In essence, your body becomes addicted to pain.

“The study shows you can think of chronic pain as the brain getting addicted to pain. The brain circuit that has to do with addiction has gotten involved in the pain process itself,” explained corresponding author A. Vania Apkarian, PhD, adding that pain is both sensory and emotionally based.

New Understanding, New Solution?

With their new understanding of how some people’s body’s perceive pain, Dr. Apkarian began working on new ways to treat chronic pain. Using a combination of two different drugs, they were essentially able to rewire the brain so it stopped seeing pain as a rewarding behavior.

“It was surprising to us that chronic pain actually rewires the part of the brain controlling whether you feel happy or sad. By understanding what was causing these changes, we were able to design a corrective therapy that worked remarkably well in the models,” said the study’s lead author Dr. D. James Surmeier. “The question now is whether it will work in humans.”

The team hopes to take their study to the next stage and see if it produces a similar positive affect in humans whose brain’s have been affected by chronic pain.

New Laws on Chronic Pain and Medical Marijuana in Minnesota

December 14, 2015August 25, 2016 / Thomas Cohn, MD

Earlier this month Minnesota added intractable pain to the list of conditions that qualify for medical marijuana. It was a decision made by the Commissioner of Health, Dr. Ehlinger, in accordance to provisions of the legislation passed. In August of next year patients will be able to obtain prescription cannabis through the state approved pharmacies if they have been qualified. The exact rules are not yet in place, but there are some clear indicators of restrictions will be present. It is also not homegrown marijuana or any other marijuana; it is just from approved dispensaries that are strictly controlled.

Intractable pain in the State of Minnesota is chronic pain that has failed to be adequately managed by traditional medical care. This means that one has to have tried to manage the pain, gone through what is considered acceptable and approved treatment regimens, likely medication, physical therapy and possibly invasive management, and these treatments have been unsuccessful. One cannot just say they have pain, not have a diagnosis, and not go through standard treatments and expect to be able to obtain medical cannabis. Lastly, it is likely that two qualified medical providers (not just one) will both have to evaluate you and approve, and that the pharmacist at the dispensary also will have to agree.

Intractable Pain and Medical Marijuana

If you have chronic, intractable pain, it will not be easy to obtain medical marijuana. There will be good providers who will consider it an option as part of treatment. However, it is likely to be a choice only after one has failed reasonable standard treatments. The patient will have to be psychologically stable, and for most practitioners, it is likely that they will want them to be well controlled if they do have depression. Many providers will also look into any potential past substance abuse, and receiving both opioids and medical marijuana is likely not to occur. The better pain providers will likely want to closely monitor the patient receiving the alternative treatment and be in touch with the dispensary and pharmacist to know what is exactly being prescribed.

Medical marijuana is not a panacea. It is another possible treatment that may have benefit for some patients. The science and effectiveness behind its use is just in its infancy. Like all other medications there are side effects and problems. It is not an FDA or DEA approved substance and is very much considered experimental. Therefore it is not approved at this time by any insurance. Expect all management and treatments associated with its use to require cash (not credit card or check) payment up front for any services including doctor as well as pharmacy visits. Treatment is likely not to be cheap and it very well may not be readily available. Many physicians may be reluctant to be involved with this treatment, and as a patient, if you are at all mean, abusive, obnoxious, inappropriate, or otherwise difficult with a provider or their staff, this would likely close the door for further management with that office.

The State of Minnesota over the next several months will likely clarify the rules and regulations of medical marijuana for patients in the state. There will likely be a number of hurdles to climb to obtain the high quality pharmaceutical cannaboid for pain management. If it is the correct management tool when all else has failed, it may be worth the effort. It is not a simple solution, and it is not going to be a legal way to just get street quality marijuana for personal recreational use.

Chronic Pain In College Part 3 – Pain and Your Love Life

December 2, 2015 / Thomas Cohn, MD

(Below is Part 3 of a four-part series on chronic pain in high school and college. It was penned by a college student who has dealt with chronic pain throughout her academic career. The four-part series will cover four important aspects of college life – Academics, Dating, Employment and Social Life. Here’s Part 3 on how balancing a relationship and chronic pain can sometimes be overwhelming. Click these links for Part 1 and Part 2.

Chronic Pain and Dating

If you want to be in a relationship, you can. I’m not going to say it won’t be complicated at times, but you are still a human being and can enjoy being in a relationship. Some common concerns and reasons to justify avoiding relationships include worries about “burdening others with your health,” worrying about how your pain can affect the time and things you can comfortably do with your partner, and that you won’t be able to enjoy a relationship when your health isn’t stable.

I’ve thought one or more of these things at different points of my life (before, during, and after relationships), I’ve even used my health as a reason to end a relationship, but I’d also like to point out the many good parts about relationships and why you shouldn’t dismiss a relationship opportunity for the “what-if” fears associated with your health. If someone you like asks you out, I would suggest you give it a try before saying no. You’ll never know what you can or cannot do in life unless you try it. Also, don’t assume any two people or relationships are the same. People grow and change throughout life, and as such relationships are and will be different.

Being Honest About Your Pain

Honesty is EXTREMELY important in ALL concerns you may have about how to handle a relationship with at least one individual with chronic pain. Whenever I’ve been in a relationship, the person I’ve dated either knew before or relatively early on that I had back pain. I’ve often thought of my pain as a “burden to others,” but the more people I meet, the more faith I have in humanity and less I think like this. My friends, family, and those I’ve dated have all told me they are there for me whenever I need them, I’m not a burden, and they want to be there for me through the difficult times.

Because I’ve met enough people like this, I believe there is a person of this belief out there for you as well. I made sure to make it clear that I have good and bad days and sometimes that can affect what I’m up for doing (whether that is school, homework, work, or dates). Being open about how you feel when you’re with your significant other can help avoid hurt feelings if there is a time that it would be uncomfortable to go bowling or cuddle or whatever it is. Honesty early on can also allow your date to leave a relationship early on if they can’t handle being in a relationship with someone with health problems. For a different spin on things – you can consider your health as your “baggage.” After all, everyone brings something into a relationship that can complicate things, and there is no shame or avoiding it, so accept it, be honest, and move forward.

Find Support

If you have chronic pain, you will know the strength you need to get through the day. It takes a similar strength to be supportive to someone else in pain, but life is easier when you are with someone who is supportive. Personally, I often find distraction as a great pain-reduction technique; so being with others (even while in intense pain) can actually be helpful. Whether I’m with a group of good friends or with a significant other hanging out, allowing my mind to be on living and enjoying what’s going on in the present has helped me get through some tough times. There are also times that my pain can prevent me from leaving my room. Knowing this about myself has allowed me to enter a relationship, inform my partner, and maintain that communication in the event plans need to change last minute. Nurturing—maybe it’s simply helping others—is an archetypal part of human nature. Professors, friends, family, and significant others are generally helpful and will look for ways to help you through whatever you are dealing with if you share what’s going on. People will be there, don’t ever feel like you have to get through everything by yourself, there is no reason to make yourself do that.

I’m guessing the next biggest problem many young adults with chronic pain worry about in relationships is being physically close with others. I know I’ve struggled with this before. I have times that whatever position I’m in, I’m in pain, or times that my body is painful without even being touched. I’d be lying if I said I’ve never been uncomfortable when hanging out with a significant other. However, I have also learned that being honest and setting those boundaries or voicing when you can or can’t or don’t want to do something (whatever the reason) is always the better route. If your significant other truly cares about you, they will understand (they may be disappointed), but they would rather look out for your health, safety, and well being than satisfy a momentary pleasure. In today’s pleasure-seeking culture, maybe this sounds outrageous, but I still think many people that are in relationships (rather than one-night-stands) are people that do care about people in a long-term way rather than just the present. When you’re in a lot of pain, it can be hard to think of the times you aren’t in pain, or think of all the good things and fun things you can do with friends or significant others.

Part 4 will be published early next week.