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.

Could Chili Peppers Be The Key To Chronic Pain?

March 19, 2015 / Thomas Cohn, MD

Red Hot Chili Peppers isn’t just the name of a band, it could be the key to unlocking the problem of chronic pain.

According to researchers at the Institute of Physiology of the Czech Science Academy, capsaicin receptors contained in chili peppers can help quell chronic pain. Capsaicin receptors are the part of the chili pepper that makes the food spicy.

Institute spokeswoman Diana Moosová said capsaicin plays a significant role in blocking TRPV receptors, which participate in the transfer and triggering of painful stimuli. These receptors can be activated and blocked through a variety of stimuli, one of which is hot temperatures and low pH levels. Capsaicin fits that bill perfectly.

“Our experiments have proved that the TRPV1 receptors in the central projections of neurons of spinal ganglions play an important modulation role in the transfer of information provoking pain,” said Jiří Paleček, head of the functional morphology team. “By blocking these receptors’ activity, the pathologically increased sensitivity to mechanical and temperature impulses, which is a symptom of many chronic painful conditions, is considerably decreased.”

In essence, when you eat chili peppers, the compound capsaicin causes an initial excitation of nuerons inside your body. This leads to a period of enhanced sensitivity, but as Newton Third Law taught us, for every action there is an equal and opposite reaction. The firing of these neurons is followed by a “refractory period with reduced sensitivity and, after repeated applications, persistent desensitisation,” according to a similar study.

So while peppers may cause painful flare ups in the short term, over time, they might actually help you to desensitize to chronic pain.

Related source: Oxford Medicine, Prague Post

More Outrage Over Prescription Painkillers

March 17, 2015 / Thomas Cohn, MD

A recent editorial by Charles Lane of the Washington Post detailed the catastrophe that prescription painkillers have caused in the United States due to opioid overdoses. According to the story, in 2013, opioids played a role in over 16,000 deaths. Since 1999, they have had a role in more than 175,000 deaths, more than the number of people killed in the Vietnam War. While traffic accident deaths have declined, opioid deaths have climbed. According to Charles Lane, the blame for this uptick in deaths is due to the government and medical professionals who over-prescribe when treating non-cancerous pain.

The article goes on to site countless statistics about how often opioids are prescribed for pain, especially in the United States compared to the rest of the world. The article clearly indicates that modern medicine is to blame for the increase in prescription painkiller overdoses. Not once in the article is it mentioned how widespread pain is in this country and the world. The complexity of pain management is never mentioned either.

Pain Misconceptions

Pain affects roughly 43 percent of the population of the United States. Pain is the number one cause of people visiting a physician. Information from the National Institutes of Health published in 2011 by Martin Cheatle indicates that 40 percent of the opioid overdose deaths may be related to pain and suicide. The conclusion drawn is that pain is widespread and not being adequately treated.

Pain physicians are a small group of physicians who are actively trying to change and improve the management of this complex problem. Pain is a both a physical and psychological phenomenon. Every year we are developing new strategies to treat numerous conditions that cause chronic pain. Opioids have been only one small tool in the complex arena of pain management. Patients have become more sophisticated over time and everyone wants their pain to be treated immediately and completely. Most doctors do not have the sophisticated training and knowledge to deal with all the complexities of pain, so they try the easy solution prescribing opioids. Since pain is so wide spread, bad outcomes are inevitable until more people are educated about pain and more research and new solutions can come to market.

Shame on Charles Lane for throwing blame all over the place. Pain is a complex issue, as are the overdose deaths caused by opioids. Outrage should be focused on the lack of treatments available for those who have pain. Outrage should be focused on industry and the government for the lack of research spending on pain. Outrage should be focused on medical training programs that do not educate new physicians about pain management. Pain physicians and researchers are making tremendous strides in pain management, but it will take time. Mr. Lane is showing only ignorance about the problem of pain and casting irresponsible blame without looking towards a solution.