Examining Germs, Bacteria and the Hand-Washing Debate

September 3, 2014 / Thomas Cohn, MD

The prevention of the spread of disease is important. Lately in the news there have been stories saying we should stop shaking hands to prevent disease. For doctors, wearing ties is out, and coats is of serious question. Sterile technique for any procedure is a major ritual. In reality, are we going a bit crazy with our fear of germs? The answer is probably yes, but we do need to use some common sense.

Our bodies depend on bacteria to maintain our health. The mouth and colon are filled with bacteria that digest our food and are essential to us getting the right nutrition. The skin has bacteria all over it, which prevents the wrong bacteria from taking hold. We use yeast to create food and drink for us daily.

There are microorganisms that help us live, and others that make us sick. If we live in a germ-free bubble, the body never learns to distinguish good and bad, and the immune system in our bodies becomes unable to fight the correct germs. The best example is our ability to fight the flu virus. Children are much more prone to get sick from the flu every year since they have not had exposure to these viruses and the body has no antibodies to fight the virus. Older adults have developed antibodies to many strains of the flu and often do not get sick from the various strains spreading every year.

Hand Washing and Bacteria

Healthy people will have a variety of germs on their hands. Touching another person or shaking their hand should not be an issue. As a physician, washing hands between patients is logical, especially if treating sick people who may have contagious problems. Treating healthy people with pain problems, or many other problems like high blood pressure or high cholesterol, should not be an issue of spreading disease.

In the past, physicians that touched their patients – categorized as hands-on doctors – were found to be the best liked and most successful healers. For a physician, washing hands in-between patients makes sense to prevent the accidental spread of unknown infections. Shaking a patient’s hand and touching a patient allows one to establish a good relationship and do a good exam. The body can handle normal germs in the environment and our immune system is geared with this ability. Recognizing the conditions when contamination can occur and preventing those issues is the important message. If you are healthy, the body should be able to control most common germs and it is okay to shake a person’s hand and not panic.

Cowboys’ Romo Looks to Rebound After Back Surgery

August 28, 2014 / Thomas Cohn, MD

The National Football League kicks off exactly one week from today when the Green Bay Packers travel to Seattle to take on the defending champion Seahawks. With the regular season fast approaching, teams are doing everything in their power to ensure their players enter the season with a clean bill of health. One such player is Dallas Cowboys quarterback Tony Romo, who missed the end of last season after undergoing surgery to address his ailing back.

Romo initially hurt his back right before Christmas last year, and he needed an epidural injection and eventually surgery to fix a herniated disc in his lower back. Romo has been rehabbing ever since, and Cowboys owner Jerry Jones said it won’t be an issue for the quarterback in 2014.

“No issue with his back at all,” said Jones. “As a matter of fact, we all were pleased that he got the kind of test he got, and he is too. There is no issue, after being sacked three times, other than we need everybody to get in there and move in ways that we can keep that from happening.”

The three sacks Jones is referring to occurred during the team’s third preseason game against the Miami Dolphins. Keeping Romo upright will be key for the Cowboys, something they were able to do well last year. The Cowboys allowed the seventh-fewest sacks in the league in 2013, and the third-fewest quarterback hits.

“I took some hits; that was good just in regard to getting up and keep playing,” Romo said about the shots he took in the third preseason game. “That part of it was positive. The hits in general, hopefully we can avoid, but it was good to get back up and keep going and see how I felt and go play football.”

The Cowboys are set to play their final preseason game tonight against the Denver Broncos, but don’t expect to see Romo under center. Regardless of previous injuries, the majority of teams hold most of their starters out of the final preseason game to help their bodies recover before playing 16 games in 17 weeks. The Cowboys have already announced that Romo won’t play.

It will be interesting to see how Tony Romo preforms this season. He’s getting up there in age – he’s 34 years old entering this season – and although geezers like Peyton Manning and Tom Brady have proven that you don’t need to be young to preform at the highest levels, recovering from a back injury to play on the biggest stage can be extremely difficult. Don’t believe me? Just ask Tiger Woods.

Related source: ESPN

Study: Medical Marijuana Leads to Fewer Overdose Deaths

August 26, 2014February 17, 2016 / Thomas Cohn, MD

A new study published in the Journal of the American Medical Association found that states that have legalized medical marijuana report significantly fewer overdose deaths than states that haven’t legalized medical cannabis.

The Study

For their study, researchers analyzed mortality data and medical marijuana adoption across the US between 1999 and 2010. Only 13 states adopted medical marijuana by the end of data collection, but the results were fascinating.

“We found that there was about a 25% lower rate of prescription painkiller overdose deaths on average after implementation of a medical marijuana law,” said lead author Dr. Marcus Bachhuber.

Looking solely at 2010, Bachhuber said states with medical marijuana laws experienced about 1,700 fewer deaths than what would have been expected based on numbers prior to medical marijuana legislation. Bachhuber said medical marijuana can be a viable option for individuals suffering from certain chronic pain conditions.

“It can be challenging for people to control chronic pain, so I think the more potions we have, the better,” he said. “But I think it’s important, of course, to weigh the risks and benefits of medical marijuana.”

As I mentioned in previous blog posts, the issue I have with marijuana is that it contains so many compounds that haven’t been sufficiently studied. I’m all for conducting more research on medical marijuana, but I don’t think the results of this study mean every state should immediately legalize medical marijuana.

It’s certainly an eye-opening study and raises many good points, but one of the main objectives of any good pain doctor is to control for as many variables as possible. That’s much harder to do with marijuana. You don’t know how the compounds in that specific plant are going to react with that specific person.

The American Academy of Pain Medicine echoed similar sentiments when discussing the recent findings.

“AAPM believes that we need to do research on cannabinoids to determine its safety and efficacy,” said Dr. Lynn Webster, former AAPM president. “The problem with medical marijuana is that we never know using marijuana what chemicals are being ingested. That makes it really unpredictable, but the use of cannabinoids may well have a place in the treatment of pain and other diseases. The AAPM believes that the DEA should reschedule cannabinoids from Schedule I to Schedule II so that it will make it easier for research to be conducted.”

There will almost certainly be more research on medical marijuana in the near future, but until more is known, it can’t be viewed as a perfect solution.

Related source: CNN.com

Can Exercise Help Relieve Pain?

August 20, 2014August 25, 2016 / Thomas Cohn, MD

A new study suggests that regular exercise can improve a person’s tolerance for pain and discomfort.

The study was conducted by researchers at the University of New South Wales and published earlier this month in Medicine & Science in Sports & Exercise. For their research, scientists recruited 24 healthy but inactive individuals. 12 of the people said they were inactive but were interested in exercising, while the other 12 said they preferred not to exercise.

After the groups were separated they each were put through similar tests to create a baseline pain threshold. This involved putting pressure on a person’s arm until they said the pressure went from unpleasant to painful. Researchers later put individuals through a second pain threshold test, this time asking users to squeeze a device while a blood pressure cuff tightened on their forearm until it became too painful.

After their pain threshold was documented, participants interested in exercise undertook a moderate stationary bike workout three times a week, for six weeks. Researchers noted an improvement in fitness levels as cycling workloads increased each week. The other group continued with their lives as they had prior to the study.

Results

Both groups returned to the testing lab six weeks after the study first began. Volunteers not interested in exercise showed no changes in their pain threshold, but participants in the exercise program saw a noticeable spike in pain tolerance. They experienced pain at the time point they had during the initial test, but they were able to withstand the pain for much longer at the end of the program.

“To me,” said Matthew Jones, lead researcher of the study, the results “suggest that the participants who exercised had become more stoical and perhaps did not find the pain as threatening after exercise training, even though it still hurt as much.”

Scientists have previously hypothesized that a person’s body will emit opitates, such as endorphins, during exercise to slightly decrease discomfort. This process is known as “exercise-induced hypoalgesia,” and usually occurs during a workout and lingers for about a half hour after the workout is completed.

The study didn’t examine the physiological principles at play, but Jones noted that the decision to use a predominately leg-focused workout and an arm-based pain threshold test suggests that “something occurring in the brain was probably responsible for the change.”

If pain is too crippling to begin an exercise regimen, a person may do more harm than good by trying to exercise through the pain, but if you can tolerate even a moderate amount of exercise, you may be able to increase your pain threshold. Consult your doctor if you have questions or concerns.

Related source: NY Times

What are Pain Injections?

August 18, 2014August 25, 2016 / Thomas Cohn, MD

Patients often have severe pain that has not responded well to conservative care. Rest, ice, physical therapy, and over the counter medications may not solve the pain problem. When the regular treatments are not working, sometimes it is appropriate to have a specific injection to treat pain. Most injections are used to decrease inflammation that is causing pain from a specific location, such as a joint, tendon, nerve or the spine. The most common medication injected is a corticosteroid, a type of steroid used to decrease inflammation.

The most common steroids used are:

Dexamethasone
Methylprednisolone
Betamethasone
Triamenacelone

How Pain Works

Pain is expressed as sensory signals from a structure that is generating unpleasant signals. The signals travel from a remote location in the periphery of the body, travel by the nerves to the spine, then travel up the cord to the brain to be deciphered. Unfortunately, the brain sometimes cannot identify the exact location that is generating the signals. Injections are recommended by many different physicians to control pain, but since pain is often very complex, determining what should be injected and where to inject it can prove problematic. A good patient history, physical exam, and sometimes, special studies including MRI scans are helpful to identify the possible sources of the pain signals. If the source is possibly acute inflammation and irritation of a structure, placing a steroid injection in the area may allow the structure to return to normal and alleviate pain.

The structures that receive injection include the space around the spine and spinal nerves – the epidural space – joints, areas around nerves, tendons, ligaments, bursa, and muscles. Any of these areas can become inflamed. If they are not healing with conservative care, then placing corticosteroid in the area can allow the inflammation to resolve. Once the inflammation is improved the structures need to be strengthened so that the problem does not return. Sometimes the procedure needs to be repeated to further decrease damage. At other times, multiple structures are inflamed and multiple structures need to be treated.

The key to successful injections includes having someone to determine what is wrong and the structures that need to be treated. Having a skilled clinician perform the injections is important. A physician who has been trained in interventions is also beneficial. The treating physician may be an expert in one of many specialties, but most commonly they are trained in Anesthesia, Physical Medicine or Radiology. An experienced specialist will be able to performed the injection comfortably and effectively. Consult a Physical Medicine pain specialist to develop a comprehensive treatment plan if your symptoms are not resolving.