What Virtual Reality Can Teach Us About Chronic Pain

/ Thomas Cohn, MD

Virtual reality may be the next innovation in the gaming world, but it also may offer real world benefits for chronic pain sufferers.

According to research published in Psychological Science, virtual reality is being used to see how physical and physiological factors impact chronic pain. Researchers say that misrepresenting physical positions through virtual reality can change how someone experiences pain. For example, researchers would outfit patients with a virtual reality device that appeared to show their neck torqued in a position of discomfort to determine how a perceived position impacts brain signals.

Virtual Reality

“Our findings show that the brain does not need danger messages coming from the tissues of the body in order to generate pain in that body part — sensible and reliable cues that predict impending pain are enough to produce the experience of pain,” said researcher G. Moseley of the University of South Australia. “These results suggest a new approach to developing treatments for pain that are based on separating the non-danger messages from the danger messages associated with a movement.”

The Virtual Study

To see how virtual movements impacted chronic pain perception in your brain, researchers recruited 24 chronic pain sufferers whose pain stemmed from several different conditions, including poor posture, tension, repeated strain, trauma and scoliosis. Participants were equipped with a virtual reality head-mounted display and were positioned to prevent excessive torso movement.

Once the headsets were in place, researchers asked participants to rotate their head until they experienced pain. What the participants didn’t know is that their virtual reality devices either:

  • Projected an over-rotated representation of the person’s neck.
  • Projected an under-rotated representation of the person’s neck.

After looking at the data, researchers uncovered that the feedback display had a significant impact on when the participant reported pain. Researchers found:

  • When head rotation was understated, participants rotated their heads about 6 percent farther than normal before reporting pain.
  • When head rotation was overstated, pain-free range of motion was reduced by an average of 7 percent.
  • Intensity of pain did not differ across the various representations.

“We were surprised at how robust and predictable this pattern of results was,” said Moseley. “If cues signaling danger amplify or indeed trigger pain, then these cues present a novel target for therapy.”

Medical Marijuana in Minnesota: Chronic Pain Tabled ‘Til 2016

/ Thomas Cohn, MD

Minnesotans will have to wait until 2016 to learn if the state will add chronic pain to a list of conditions approved to apply for medical marijuana.

The state has been dragging their feet in regards to adding chronic pain to the list of approved conditions for medical marijuana, and now they’ve decided to table the idea until next year. State officials said they feared approving the condition could overextend medical marijuana manufacturers who are already in high gear prepping for the program’s launch this summer. The state said potentially adding tens of thousands more medical marijuana patients could be troublesome for Minnesota’s two marijuana manufacturers.

Medical Marijuana in Minnesota

Manny Munson-Regala, assistant commissioner of the medical marijuana program’s launch, said he “didn’t see a way to do this in a thoughtful, structured way,” in terms of having the medicine available for 2015. I do think more testing is needed, as chronic pain can be caused by a myriad of internal issues, but citing supply and demand issues seems like a weak excuse. Under the current timetable, the earliest a chronic pain sufferer could get medical marijuana would be August 2016, if the condition get’s added to the list.

Senator Branden Peterson, R-Andover, was disappointed by the decision. Peterson had a bill that would have made chronic pain an eligible condition starting July 1, 2015. He wasn’t the biggest fan of the state’s supply and demand excuse either.

“I don’t see why we need to wait that long,” said Peterson. “If we acted this session, we could do something that would serve the interests of those patients a lot sooner.”

Although about 88,000 Minnesotans are currently being treated for chronic pain, the state estimates that only about 5,000 would apply for medical marijuana if it were approved.

New Timeline

Here are the important dates now that the state has updated their timeline regarding chronic pain and medical marijuana.

  • Spring 2015 – A new panel will examine the pros and cons of adding chronic pain to the approved conditions list.
  • December 2015 – The panel will submit their final recommendation to Health Commissioner Ed Ehlinger.
  • January 15, 2016 – Ehlinger would have to add chronic pain to the list of qualifying conditions by this date to give lawmakers the opportunity to block the condition if they see fit. If it is not added by January 15, patients would likely have to wait until 2017 at the earliest.

Massages For Pain Management

/ Thomas Cohn, MD

Massage therapy is a multi-billion dollar business. Many people who have pain love getting a massage. For pain practitioners, it is a common question whether it can be prescribed and whether insurance will pay for it. Massage definitely feels good, but it does have limited benefits. In acute pain, it does not speed recovery and studies do not support its use. In chronic pain, it does help reduce pain perception, but the mechanism of action is not well known.

There are many different types of massage; research has yet to show whether a particular form is better. Some common types of massage include:

  • Deep tissue
  • Swedish
  • Structural
  • Other specific targeted techniques.

Structural, which works on actual muscle activity and is often performed by physical therapists as part of a comprehensive exercise process, may be covered by insurance.

Pain Massage

Massage is clearly a hands-on activity. A therapist often spends 45 minutes with direct contact with the patient. The interaction between patient and practitioner is prolonged and personal. The end result is often significant relaxation, which leads to less muscle discomfort and less pain. Whether massage changes anything physically in the body is unknown. Research has not been able to show any actual structural or hormonal changes in the body associated with massage.

Prescription Massages?

Pain practitioners are often reluctant to prescribe massage. In general, massage is considered a passive modality in treatment of a condition. Massage is something done to the patient while the patient lays still. Physical therapy and exercise requires action and activity on the part of a patient. Most pain conditions are worsened by inactivity. Pain experts try to promote a return to normal levels of activity. Being passive in treatment, which is part of massage, is not ideal in the overall management of pain. Since the goal of pain management is to have people active and moving, laying still and receiving a massage is felt to be a negative pathway.

Massage may feel good, it may reduce pain on a temporary basis, but it does not change the body and does not heal the pain. Activity, exercise, strengthening and conditioning are all essential in the long term management of pain. The goal of pain care is to improve function. Massages for pain certainly have short term benefits, but they should not be viewed as a long term solution.

Medical Marijuana: A Growing Acceptance

/ Thomas Cohn, MD

The world’s view on marijuana appears to be rapidly changing. Marijuana was thought of as solely a recreational drug only a few years ago. It was basically slid into a role as something to use only to escape the world and get high. It has been classified by the DEA as drug in Schedule 1, with no medical value. It was put into the same category as heroin and LSD. More recently, medical professionals have been starting to recognize the research on cannaboids and the beneficial compounds marijuana holds. The public perception of marijuana is starting turn in its favor.

Last week there were three main events that advanced the growing acceptance of the medicinal value of marijuana. The first was that the American Academy of Pediatrics (AAP) came out in favor of re-classifying marijuana to a Schedule 2 drug, just like other narcotics like morphine or Percocet. This would change the federal status from being illegal on all fronts to being considered a drug, and thus legal to study and to be prescribed for certain medical conditions. Currently, with its Schedule 1 status, doing adequate medical research is extremely difficult, stifling the development of medical knowledge and its usage. Preliminary research does show medical value of various cannaboids for seizures, nausea, cancer and pain. However, which cannaboids of the about 100 known compounds work best with the least amount of risks is poorly understood. Furthermore, we do not know if it is a combination of compounds or if a specific delivery mechanism is necessary.

Medical Marijuana in Minnesota

The new US Surgeon General, Dr. Vivek Murthy, M.D. has also joined the chorus. This week he indicated that he supported reclassifying marijuana to Schedule 2 drug. He also reported that cannaboids did have medical value in certain conditions. Again, the reclassification would allow widespread research and development of cannaboids for their medicinal value.

Marijuana in Minnesota

In Minnesota, medical marijuana appears to be slowly moving forward. The growers of marijuana have been selected and several locations for dispensaries have been chosen. It still will be limited in use, and it will not be available for the use in pain management, at least in the early stages. The state will investigate marijuana’s potential benefits for chronic pain suffers during the first year medicinal marijuana is available. Furthermore, several Indian tribes are considering whether they will make medical marijuana legal and available on their reservations. The rules that apply on Indian reservations will be up to the individual tribes since they act as sovereign nations with their own laws.

The value of cannaboids to treat many conditions appears to be more positive, and the research is catching up. Changes in the legal drug status hopefully will become reality soon, and the knowledge of how to use these compounds as medicine will become more solid. For now, it is still illegal to use marijuana, and most physicians, due to legal constraints and lack of definite knowledge of risks, do not actively recommend its use.

Will Tiger Woods Play in the Masters?

/ Thomas Cohn, MD

The talking heads in the sports world are active again following the latest Tiger Woods saga. Tiger barely started his latest tournament and then decided to withdraw from play with an injury. He claimed his back started to hurt again and mentioned that he was having back muscle spasms. The last tournament he shot a round of 82, 10 strokes over par, the worst round in his professional career. Tiger has now become an average golfer, no longer a superstar at golf.

Tiger Woods has probably lost his edge on two fronts, his physical skill at the game and his mental focus. The physical edge is understandable. He has had low back pain, knee problems and surgery. As an athlete, he always pushed himself to the extreme in his training. With the known injuries and the wear and tear of heavy workouts, it is likely that he has multiple regions of degeneration throughout his body. I would expect that he has multiple levels of degeneration in his spine and would not be surprised if he also had more knee issues and shoulder problems that he is not talking about. All these areas of the body are prone to degeneration and injury especially as a professional athlete.

 

A small amount of degeneration, possibly in one area of the body, may easily be overcome. However as we all age, especially athletes, and Tiger is now 39, the body has diffuse degeneration. 150 years ago, old age started around age 40, and it was common for people to die before 50. The body has been built structurally to only last this long, but modern medicine has allowed us to survive much longer. Tiger is now an old man. He is definitely past his physical peak of performance, and to expect him to dominate the younger competition is unrealistic. The ability to make the body work absolutely perfectly to be the best is almost impossible if the parts are not functioning correctly, and his back and knees are definitely damaged goods.

Mental Factor

Golf is not only a physical game, it is a mental challenge to concentrate and get the body to function correctly. It also is a challenge to ignore the pressure to perform and not be disturbed by all the surrounding distractions. Mentally, with a bit of pain from his back or his knees, the ability to concentrate is broken. When you add in other mental distractions like family issues, media attention and the eyes of everyone on the course, Tiger has more than his fair share of mental obstacles to overcome.

Tiger Woods has been a great golfer. He is the ultimate competitor, which has helped him get to the top of his game, but it may also be his downfall. He needs to take time off and get his body right. This could include surgery and would definitely include rest and physical therapy. The problem is that he’s so intent on playing in major tournaments (and preparing for those tournaments with smaller events) that is doesn’t seem like he’ll ever give his body enough time to heal as fully as possible. He’s withdrawn from seven of his last nine tournaments, which is unheard of in this day and age. They say the definition of insanity is doing the same thing and expecting different results. Tiger keeps pushing his body without letting it heal, and he continues to think he can make it through 72 holes, but in the end he usually withdraws. Why should we expect the cycle to change without intervention? We all suspect Tiger will play in the Masters, but he’s much more likely to miss the cut or withdraw mid-tournament than to bring home the Green Jacket.