Your Chronic Pain Doesn’t Define Your Life

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

Having chronic pain is tough both physically and emotionally. Pain at times seems to control your life. In reality, one needs to become the captain of the ship and take control of your pain and your life. Everyone has problems in life, but if you deal with pain, you need to learn how to manage it and move forward with life. Do not wallow in pity and do not expect others to suffer with you. Taking control of your life involves managing your pain and your emotional status. It also means not using pain as an excuse for doing nothing in your life.

Pain is complex. Once it is chronic, it may be functioning independent from the original cause. It also may be due to constant stimulation of the pain sensors in the body and develop into a central sensitization type of pain status. Over time, the brain may become overly stimulated by pain reception, and in a practical sense, a short circuit develops in pain reception and the brain is overwhelmed by the pain signals.

The Brain and Pain

One of the main functions of the brain is to perceive and interpret all the signals it is receiving. There are conscious and subconscious levels on which the brain translates signals. Some sensory impulses are translated on a reflex level without significant interpretation, while others have extensive cognitive and emotional components. A person has tremendous cognitive control over many aspects of brain function, including the power to modify the meaning of pain signals. The brain can choose to ignore pain signals, especially when they are the chronic background pain signals.

The brain perceives unpleasant sensations in the body. The perception of direct pain signals from painful sensory stimulation can be considered as primary suffering. Overlaid upon this are the feelings, emotions and memories associated with the pain. The feelings associated with pain lead to anxiety, stress, depression and are the secondary suffering felt by a person. Over time, the primary suffering may be minimal and the secondary suffering becomes the major component of pain.

Anxiety and Stress

After years of practice and noticing that pain seems to never improve in the patients who have high anxiety, stress and depression, science has actually helped explain the problem. Using special functional MRI scans of the brain, a psychologically normal person with acute pain has only a couple areas in the brain that enhance. A stressed, depressed and anxious person with pain will have multiple areas of enhancement and abnormalities on a functional MRI scan. Other studies have also shown a normal person exposed to pain can endure much more stimuli, and those who are already stressed have a much lower threshold to similar stimuli. Thus, anxiety, stress and depression have a very negative impact on pain control.

The next level of research that has been done has been focused on treating the anxiety, stress, emotions and depression in the pain patient. A variety of techniques have been used to decouple suffering and treat these components of pain. Techniques have included mindfulness, hypnosis, cognitive behavioral therapy and medications. When the emotional secondary suffering has been treated, often the physical perceived pain can almost be eliminated.

Different people will respond to a variety of techniques. Most people who have chronic pain do have emotional suffering components to their pain. Treating the emotional suffering often becomes more important to solving pain control issues as time passes than finding traditional medical interventions. Further, most people are in denial of any emotional components of pain. However, when the patient is withdrawing from activities of life, it is evident to everyone around the pain patient that there are components of emotional suffering.

When pain becomes an excuse not do something, and one starts withdrawing from life, you are emotionally suffering. Stop asking for pity. At this point, you need to find your solution to your psychological problems and get help to solve them. Solve the psychological issues, and it is amazing how much better the chronic pain issues become. The patients who have a healthy psychological status function and move forward in life. These are also the people who do not make excuses for themselves and have very little dependence on addictive substances. If the stress of life is affecting pain, then get help and find the solution that helps you treat and eliminate the negative behaviors in your life. Stop making excuses and start moving forward in treating the right problems, your stress, anxiety, and emotional well-being.

Exercise Accountability and Pain

September 2, 2015 / Thomas Cohn, MD

A recent study in Medicine and Science in Sports and Exercise points out whether we are reliable in reporting our exercise. The answer is that most of us tend to over report our activity level. When using an objective measure of activity, such as a monitoring device of steps and pulse, the record is much more accurate. The best way to keep healthy and reduce pain is to stick to a regular exercise routine. If you are not being accountable, the activity is usually not being done. Very few people have the self-discipline to be consistent with exercise on their own.

Up until recently, the best way to be accountable is to have an exercise partner. Whether it be a yoga classmate or a running partner, if you had to meet someone else, it was much harder to skip the exercise.

Currently, the electronic age can become out partner, as most people now own a smartphone. Both the Android and the Apple phones have fitness apps built into the phone and have electronics that can monitor motion. As long as one has the phone in hand (or pocket), the phone will record your steps. Most people should be aiming at obtaining at least 10,000 steps a day to maintain general cardiac aerobic fitness.

Fitness Trackers and Exercise

A fitness tracker, such as a Fitbit, Vivofit (by Garmin) or Jawbone can be of great benefit. There are now multiple brands of trackers, those at about $100 dollars tend to monitor:

Steps

Distance

Calories burned

Steps climbed

Sleep patterns

The more expensive ones will add in heart rate monitoring, sometimes blood oxygen levels, and may connect to smartphone notifications. All the fitness trackers have apps that chart your daily, weekly and monthly statistics. Keeping a record of your activity tends to make one more responsible toward meeting fitness goals.

The importance of maintaining physical activity is very evident in the pain patient. My patients who are the most active have the best control of their symptoms and tend to use the least amount of drugs and other interventions. For myself, the fitness tracker keeps me more active, maintaining my aerobic conditioning goals. The more intense aerobic exercise, even for just 15 minutes every day, definitely increases my endorphins (the body’s own pain killers) and decreases my back and leg pain. Without the tracker, I know I would be lazy, and definitely would think I am doing more activity than I actually perform.

Aerobic activity does need to be combined with strengthening and stretching for most pain patients. The areas that are causing pain often need more physical muscle support to prevent symptoms, and strengthening and keeping these muscles healthy is another priority.

Could Dad Be To Blame For Chronic Pain Woes?

August 31, 2015 / Thomas Cohn, MD

A study out of Japan suggests that how parents bond with their children during adolescence could impact the child’s likelihood of developing chronic pain later in life.

Furthermore, the study suggests that children who had a poor bond with their father were the only group to show a significant increase in chronic pain likelihood.

The goal of the study was to better understand chronic pain as a complex biopsychosocial condition and how outside psychosocial factors like pain, pain-related fear, self-efficacy, anxiety, depression and psychological distress feed into that perception of pain.

For their study, researchers polled nearly 800 adults about their relationship with their parents and their overall health. Participants completed the Parental Bonding Instrument, a self-administered questionnaire that assessed perceived parental bonding, as well as a health assessment. The PBI test asked respondents several questions about their relationship with their parents growing up, including questions about the perceived level of bonding, over/underparenting, affection and discipline as well as control and understanding. Participants took the survey twice, once while contemplating their relationship with their father and the next while answering questions about their mother.

After comparing the PBI results with the results from the health exam, researchers uncovered:

Compared to the optimal bonding group, the odds ratio for having chronic pain was much higher in the affectionless control group for paternal bonding and for maternal bonding.

When adjusting for other factors, significance remained only for parental bonding.

“The fact that fathers have been shown to be much more likely to use physical punishment and abuse than mothers in several epidemiological studies may also be related to these findings,” the study authors wrote. “Clearly, further studies are needed to elucidate the mechanism(s) whereby parental care affects the development of chronic pain in a gender-dependent fashion.”

Researchers concluded by saying that mass-education on parenting behaviors for optimal bonding may be one of the most promising chronic pain prevention techniques that few are pursuing.

Why A Medical Breakthrough May Be Bad For Society

August 26, 2015 / Thomas Cohn, MD

An article in today’s newspaper touts the discovery by Stanford University and their development of yeast that can produce hydrocodone. This is a synthetic opioid also known by the trade names Vicodin, Norco, or Lortab. It is a moderately powerful oral pain medication and has been one of the most highly prescribed pain drugs in the United States. Of all the hydrocodone produced worldwide, 90 percent or more is used in this country. Unfortunately, this makes it one of the most abused drugs in the country.

Stanford University has found a yeast that when mixed with sugar will produce hydrocodone as a byproduct. Most of us are familiar with yeast that is used to make bread or mixing a yeast with sugar and that will produce alcohol. Now a type of yeast has been produced that when mixed with sugar will produce an opioid. The benefit is that maybe it will lower the production cost of the drug and make this painkiller more available worldwide, especially where there is a lack of medication.

Pros Versus Cons

The larger question beyond the medical breakthrough is whether this is a good development. In the United States, we currently have an epidemic of opioid abuse and significant over-prescribing with misuse. Pain can be treated with multiple different strategies; medication is only one of the possible methods. Unfortunately, it has become the quick and easy solution for physicians. For patients, more effective strategies often require the patient to do more work, such as exercise, strengthen and stretch muscles, lose weight, eat differently, and take more control of their lives. In the rest of the world, often people have more realistic view of life and their bodies, and do not resort necessarily to a pill for pain relief. Readily available pain medications have already been shown to be a problem in the United States.

The other major issue is if Stanford University has been able to develop a yeast to cheaply and quickly manufacture an opioid, how long will it be before this technology gets into the hands of illegal drug manufacturers? We know that illegal drug use is a multi-billion dollar business. It is likely that someone is already trying to either steal a copy of the yeast, or develop their own yeast for the same purpose. The illegal drug trade and opioid addiction in the United States is a major problem. Finding an easy way to home brew opioids appears to be just around the corner. As a pain physician, this is likely to just be another problem and will be a boon for drug addiction centers and criminals. The cost to society may be much worse than making a drug cheaper and more available. Despite its potential, this may be the next societal disaster.

The Correlation Between Sports, Headaches and Concussions

August 24, 2015August 24, 2015 / Thomas Cohn, MD

Fall sports season has begun and now is the time for football and soccer among other fall activities. Most sports run some type of risk for a head injury, especially if a helmet is part of the safety equipment. Any sport where the head can be hit or suddenly moved is a risk for a concussion. Head trauma used to be thought of as a minor inconvenience, but now we are beginning to understand the severity of the problem, especially concussions.

Wearing protective equipment such as helmets was thought to be the only necessary precaution to prevent injury. As information collection and the use of computers has grown, the ability to study medical problems and spot trends has allowed us to understand simple and complex issues like head trauma. Awareness of the issues became evident when athletes begin developing unusual early onset of diseases like dementia, ALS, and Parkinson’s disease, or much more frequently than the rest of the population. The significance of severe head trauma was always known – statistics just allowed us to find the effects of smaller trauma that was repetitive.

Effects of Head Trauma

Any repetitive head trauma is bad, but severe head trauma can be really problematic. Trauma to the brain can cause permanent damage. The need to wear appropriately fitted and designed helmets is without question. Unfortunately, with better gear, people tend to take more risks, which may lead to more trauma. For example, when football players played without helmets, very few players led with their head when making a tackle. Today, players are launching themselves headfirst at other players because they believe their heads are protected by the helmet.

The brain is the most complex structure in the body, and how it processes information so effectively is amazing. There is an extremely complex interaction within and between the cells of the brain. Smashing the head can disrupt the subtle interactions in the brain. If the brain is shaken, then the connections between cells can be disrupted. The result of this is a degree of confusion, and often is accompanied by ongoing headaches. No athlete should immediately return to a sport if any signs of a concussion have occurred. All coaches and athletic trainers should be aware of the signs. If you have had any confusion after a head trauma, immediately stop what you are doing and sit down to rest. The brain needs time to recover, so do not force the issue.

Signs of a Concussion

Headaches, dizziness, light sensitivity, fatigue and confusion all are signs of a concussion. Return to sports and even school or work needs to wait until all signs of a concussion have cleared. If headaches or any other signs of head injury last longer than a day, one should see a doctor. If there is an immediate severe headache after trauma, a doctor should be consulted immediately. Rest and symptomatic management of head trauma is necessary.

A headache after sports trauma is not a good sign. We only have one brain, and it is not replaceable. It needs to be kept safe. If it is injured, and one has headaches, see a doctor, as a head scan may be necessary. With a significant injury, recovery can be prolonged. Until the headaches are gone, returning to any high level activity should be limited. Many professional athletes have ended their careers due to head injury. Now, we are beginning to learn the late effects of multiple small injuries to the brain, and these are even scarier. A young athlete needs to realize they have only one brain, and no sport is worth permanent damage.