Tiger Woods is Great, But…

April 13, 2015 / Thomas Cohn, MD

The Masters is over, and for first time in a long period Tiger made the cut and finished a tournament. To no one’s surprise, Tiger did not make a run for the leaderboard on Sunday, but he certainly opened some eyes by finishing tied for 17th. At 38 years of age, he is no longer in his prime and now appears fortunate when he makes the cut and finishes. In the future he may have a few more outstanding tournaments, but they will likely be few and far between, and it is likely he will only win a few more tournaments throughout the remainder of his career.

Tiger has now had lumbar back surgery, knee surgery, and may have hip problems besides the above, not to mention he injured his wrist in Sunday’s final round. He pulled out of a tournament earlier this year when he aggravated his back. Most likely, for him to play well, the conditions must be perfect, and he has to have a good day when his pain is controlled. To play at a high enough level routinely is unlikely since either his back or joints will cause just a slight issue such that he will not be good enough to play against the younger and healthier players.

Gold is a Young Man’s Game

To win at a professional level, one must be a top athlete in perfect physical and mental health. All sports at this level require one to be in the best physical shape to master the skill necessary to play a perfect game. After having the physical skill, one needs to have absolute mental concentration for the game. If one has physical pain, the concentration for the perfect game is not present. If one has had back and knee surgery, one also does not have the perfect physical balance to be at the top of one’s game.

As we age, there are many changes that occur in the body, and after age 25, for most sports, we are slightly past our prime for physical ability. By the late 30’s we are definitely past our prime for almost all intense sports, especially individual events. There are a few older athletes who are competitive later in life, but this is generally a rare event. The best athletes perform as well as they do because their bodies and minds are in perfect condition for their sport.

For professional golf, a new leader is likely to emerge in the future, and that leader could easily be 21-year-old Jordan Spieth, who ran away from the competition at Augusta this weekend. Tiger was the first very young winner to take the stage. Now, it will likely be someone who is in the young twenties and has great mental strength to deal with the pressure of winning, which sounds a lot like Spieth or Rory McIlroy. I think they’ll be the face of professional golf for the next 5-10 years.

5 Tips To Prevent Joint Pain While Exercising

April 10, 2015 / Thomas Cohn, MD

Regular exercise is extremely important, especially if you are dealing with a pain problem. Although it can be difficult to find the motivation to work out, exercise will help build strength in your muscles and actually provide some temporary pain relief. Some people have the motivation to work out, but exercise causes their joint problems to flare up. Today, we provide five tips to help prevent joint pain during your workout.

1. Stretch – Jumping straight into your exercise routine is a quick way to trigger your joint pain. Much like a car in the winter, it takes some time for our joints to start moving fluidly. Just like it’s not good to floor it five seconds after starting your car when it’s -10 degrees outside, it’s not smart to jump on the treadmill without letting your joints warm up.

2. Switch up your routine – Try to work out different areas of the body throughout the week. Going for a run every day is fine, but you’re leaving yourself open to overuse injuries, and you’re putting a lot of stress on your feet and knees. Instead, work out your upper body on Monday and Thursday, and strive for a lower body workout on Tuesday and Friday. This gives your joints some time to recover between workouts.

3. Find what works – This may sound obvious, but find a workout that works for you. If you have joint pain in your knees, consider exercising on a stationary bike or in a pool to help with weight bearing. If your back pain flares up while biking, try going for a walk or a run. Keep a log of what works best for you so you can create a pain-free exercise routine.

4. Try alternative methods – There are plenty of ways to get your exercise in without going for a run or a swim. Some more popular alternatives for people with joint pain are yoga and Pilates. These low-impact activities help increase joint mobility and flexibility. Additionally, yoga has been shown to ease pain and swelling in people with rheumatoid arthritis. If other exercises are causing too much joint pain, give yoga or Pilates a try.

5. Don’t overdo it – The right amount of exercise if great for your body, but overdoing it can actually make pain problems work. When developing a workout plan, start slow and progressively work your way up to longer routines. Additionally, if you begin to feel pain, stop your workout or transition to a different exercise that doesn’t impact that part of your body.

The Benefits of MRI For Whiplash Injuries

April 2, 2015 / Thomas Cohn, MD

Whiplash injuries typically occur during a car accident, but they can happen during any event that causes your head and neck to move in in a violent manner. The majority of people who suffer a whiplash injury fully recover within a month or two, but for about 25 percent of the population, long-term pain and chronic pain persists.

Thankfully, we’re getting better at predicting which whiplash sufferers will have to deal with long-term effects through new MRI techniques. According to researchers, scientists can now predict which patients will develop chronic pain and partial disability within the first one to two weeks of the initial injury. They believe the earlier diagnosis will help doctors better develop a specialized treatment plan to treat the condition.

What The MRI Reveals

Researchers said the MRI reveals fat/water ratio in a person’s muscles, and unusual muscular changes one to two weeks post-injury can predict future chronic pain. The MRI uncovered that excess fat entering the patient’s neck is the key indicator.

“We believe this represents an injury that is more severe than what might be expected from a typical low-speed car crash,” says lead investigator James Elliott, assistant professor of physical therapy and human movement sciences at Northwestern University Feinberg school of Medicine. “This opens up a new door for research on whiplash. 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.”

Elliott added that routine x-ray imaging does not reveal this fat infiltration, and the MRI appears to be an optimal route. Despite the findings, researchers haven’t pinpointed a preferred treatment option for whiplash sufferers who are at risk for future chronic pain.

“We haven’t found an effective treatment for these folks with chronic whiplash,” said Elliott.

Although they are still working on a solution, researchers said the findings are important because they help prove to whiplash sufferers that their chronic pain isn’t just in their head.

“If you’re a whiplash patient with ongoing chronic pain, but no objective imaging finds anything wrong, people are frequently informed that nothing is wrong with them,” Elliott says “It’s been a huge problem. That fat appears to be a response to an injury. What has actually been injured remains for us to find out. But now we know to look more deeply into the problem.”

Related source: Northwestern University

Understanding Pain Centralization States

March 30, 2015 / Thomas Cohn, MD

One of the newer ideas that is gaining better understanding in the pain community is the concept of pain centralization. This is the general category that a lot of other pain problems fall under. The most common condition is Fibromyalgia, but other conditions such as TMJ, irritable bowel syndrome and some tension headaches are similar. The main characteristic is that the disturbance is processed differently by the brain, and a diffuse increase to pain fiber stimulation then occurs. There are an altering of levels of neurotransmitters affecting pain transmission.

The key finding in all the conditions characterized by centralized pain states is a significant increased sensitivity to sensory stimuli. Chronic pain is often found in multiple regions of the body over a period of time. Multiple other types of symptoms also occur including fatigue, sleep difficulties, mood changes and memory problems. Symptoms are often triggered by a stressful event, such as an infection, brain injury or trauma. Multiple discrete areas of pain are found, and can be present with other diseases such as rheumatoid/osteoarthritis and hyper-laxity conditions like Ehlers-Danlos or Marfans Syndromes.

These conditions are a continuum of pain problems starting from acute peripheral pain to chronic centralized diffuse pain. It affects from 2-8% of the population, and is about twice as common in females. There is a strong familial correlation and it can be worsened with stress and anxiety.

New Understanding of Centralized Pain

Research has now shown there are definite abnormalities present in these patients. Functional MRI scans have shown an increased connectivity in regions of the brain that sense pain signals and decreased activity in areas that inhibit signals. Along with this is a change in the balance of neurotransmitters, those that facilitate pain reception including Substance P, Glutamate, Serotonin, and Nerve Growth Factor are elevated. Those transmitters that inhibit pain are decreased, such as Norepinephrine and GABA.

Treatment of these conditions is difficult. Nothing works in everyone; it is a matter of using multiple strategies. Medications that have have proven effective include some antidepressants like tricyclic’s, cymbalta and cyclobenzaprine, and seizure medications like gabapentin and lyrica. Tramadol, low dose naltrexone and cannabinoids have shown modest benefits, but they aren’t typically as effective. What absolutely does not work and sometimes makes things worse are opioids. Other beneficial treatments with strong evidence include aerobics, strength training and cognitive behavioral therapy. There is little benefit from acupuncture, massage, chiropractic and manual therapy, and most injections including trigger points.

In a lot of chronic pain conditions, a common thread is emerging. There appears to be a short circuit in the brain and the volume control for pain sensitivity is turned to high. Normal signals become overly amplified in the brain and are considered painful. The normal ability of the brain to inhibit pain signals for the periphery is also decreased. The brain then becomes stuck in a state of hypersensitivity. The new directions of research is to find ways to correct the changes seen in these centralized pain states.

What Pain Professionals Are Saying About Marijuana

March 23, 2015 / Thomas Cohn, MD

Marijuana is a controversial topic in society. Some people want it legalized while others demonize the compound. The reality in the medical field is somewhat in the middle. The first thing that needs to be understood is that in most circumstances, medical experts are primarily interested in all the compounds in marijuana except for THC. That means most medical professionals are interested in what cannabinoids or cannabidiols (CBD) compounds are present and what medical purpose they serve. The major compound that is present in almost all available marijuana is THC, which also happens to be the compound responsible for the high one receives from marijuana.

For pain professionals, there is good understanding of the action and effects of THC. Most strains available in states that have legal marijuana, including strains that are “medicinal” in use have high amounts of THC, 10% or greater in amount, and virtually no other cannabidiols, or less than 2%. In the years of the hippie generation, the 1960’s and 1970’s, THC to CBD ratio was 1:1, and averaged 1-2%, while the really good stuff was just around 5%. Now available in legalized states, most available strains are minimum of 10% with up to 30% THC.

Medically, the best comparison of legal marijuana at this time, is to alcohol. The risk of dependence to THC is about 9%, including when using once a week (in reality this is a very strong way to become dependent), compared to alcohol which is 15%. Regular use, once a week, is known to increase depression, suicide, impulsivity, schizophrenia and psychosis, especially if use is started under the age of 20. It also leads to an 8-point loss of IQ in the young. Further, smoking does cause problems with the lungs. Recommending regular marijuana is no different for medical professionals to recommending drinking alcohol. The risks and associated problems are clearly out numbering benefits.

Need To Understand More

What we know about cannabidiols is just the beginning. In marijuana, we know there are over 100 different types. Our experience so far has found that they have some properties that may be helpful in about 30% of patients with neuropathic pain associated with MS and HIV. In low back pain, we’ve learned:

It has helped in anxiety but not with pain.

More people respond to acetaminophen then marijuana.

The future of cannabidiols is interesting for pain. It is unlikely that many professionals would be enthused to prescribe a substance that has the risk profile of THC. Once we can find the particular cannabidiols that have medical uses, it is likely that we will try to study them fully and make them commercially available for specific conditions. Cannabidiols may be helpful in the future, but we still don’t know enough right now to safely prescribe marijuana for a wide range of conditions.