How Steroid & Corticosteroid Injections Relieve Pain

/ Thomas Cohn, MD

steroid injectionCorticosteroids, also known as steroids, are powerful anti-inflammatory compounds.  They mimic the body’s own steroid hormones and can diminish inflammation by preventing phospholipid release and eosinophil action.  In plain English, these are man-made compounds that reduce inflammation when tissue damage or irritation is occurring. 

Inflammation and Pain

Many problems that cause pain are due to tissue damage or irritation, sometimes it is acute and at other times it is chronic and ongoing.  Inflammation can result from any of the following:

  • Degenerative changes in the spine and joints
  • Disc bulges and herniation
  • Injury

The body can often deal with routine inflammation with its own mechanisms.  The inflammation often stimulates sensory nerves and is perceived as pain.

When inflammation and pain is beyond normal control and impacts function, the use of corticosteroids is sometimes appropriate.  These medicines can be given in a number of different ways. They are easily given orally and travel to everywhere in the body.  Oral steroids, often prednisone or decadron, are inexpensive, and if given for a week or less have very little side effects or risk.  They can often be very effective for acute or sub-acute pain in many areas of the body.

Corticosteroids

Corticosteroids are often used as injections targeted to very specific sites to treat pain caused by ongoing inflammation.  Many joints, such as the knees, hips, and shoulders, can be injected to reduce pain, especially if it is just one isolated area.  If multiple areas inflamed, injections are usually not used since the risk of too much steroid exposure may be a problem.

Severe spinal pain is often treated with steroid injections.  The discs and spinal facet joints are deep structures with limited blood flow.  The delivery of oral steroids to these regions may not be sufficient to decrease inflammation.  Injection of these medications can deliver them to the specific structures that are inflamed and be maximally effective in controlling symptoms of pain for months at a time.  These spine injections are best done by an experienced pain management physician and done with real time x-ray guidance to make sure they are delivered to the right spot and no other damage is done.

Since steroids can have significant side effects, and cause damage to the body if over used, the overall use must be closely monitored.  Most pain physicians prefer that steroid shots be limited to 4 to 6 times in one year for safety reasons.  There is not an absolute maximum and not a lifetime maximum. The risk and benefit needs to be evaluated for each individual and discussed between the patient and physician.  Careful use may have a profound effect on pain control and often can be life changing in some pain patients.  Since everyone is different, a pain physician can help guide a patient through a comprehensive strategy that maximally benefits each individual.

The Link Between Anxiety, Depression, and Pain

/ Thomas Cohn, MD

pain and depressionAccording the International Association for the Study of Pain, pain is defined as:

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

This is one of the best descriptions of what pain is and is used worldwide to explain the experience of pain.

Pain and Emotion

Pain is an emotional experience.  Emotions such as happiness, sadness, and anxiety are generated in the brain.  Thus, pain and anxiety are intimately linked in the brain in terms of the locations that generate these perceptions.  As noted in the definition, pain has unpleasant emotional components, which most people perceive as anxiety.

The link between pain and anxiety is, in reality, more than just theoretical.  Sensation that is interpreted as pain is processed in several areas of the brain.  Some of the main regions of pain sensation are in very close proximity to the regions that process emotions of anxiety and depression.  When there is prolonged activity in the areas that process pain sensation, the areas nearby that process depression can be activated.  The areas then can spontaneously interact, pain sensations can be interpreted as anxious emotions, and anxiety can be misinterpreted as pain.

Anxiety and Chronic Pain

Those who have chronic pain often become depressed and anxious.  The two sensations become intermingled, and often the pain is greatly amplified by the depression.  Treating the emotional consequences of pain is often as important as treating the physical causes of pain.  If the depression and anxiety are not controlled, the pain is not controlled.  Once the depression and anxiety are controlled, insight into pain can occur and pain often becomes manageable.  There may be a physical cause to the pain, but if the emotional components are not controlled, then the pain is not controlled.

Comprehensive Treatment

Since pain, anxiety, and depression are intimately linked in the brain, comprehensive pain care involves treatment that is aimed at all aspects.  A comprehensive pain program looks at both physical control of pain and emotional control of the consequences of pain.  These programs link psychological approaches to pain, with physical methods.  A pain psychologist is often involved in patient treatment.  Medications for chronic pain that affect both physical signals of pain and emotional components then become understandable in their effectiveness.

Pain is a complex medical issue.  It has both physical and emotional components.  The physical side is the tissue damage and perception of signals.  The emotional side is the anxiety and depression that is linked to the chronic pain signals.  Treating chronic pain, due to its emotional components has long involved a multidisciplinary approach that includes psychological management.

How to Identify & Treat Abdominal Pain

/ Thomas Cohn, MD

abdominal painMost everyone has had abdominal pain at some point in his or her lives.   Thankfully, the most common causes of abdominal pain are not serious. Every structure in the abdomen can cause pain. The organs and structures in the abdomen include:

  • Stomach
  • Intestines
  • Liver
  • Spleen
  • Kidneys
  • Bladder
  • Appendix
  • Sexual organs
  • Blood vessels and muscles

Since each of these structures tends to have some type of sensory innervation, they can all be a source for pain.

Almost everyone has had pain from the stomach and intestines.  From overeating, to acid reflux and indigestion, to constipation or diarrhea, the problems are not unusual.  Most of the problems are short-lived, inconvenient, and not serious.  When they are intense and not resolving, sometimes they do require medical intervention.

When to Seek Medical Attention

The main concern with abdominal pain is when to seek medical attention to help determine the cause.  Signs that indicate a need for further medical attention include:

  • Fever
  • Inability to eat or drink fluids for over a day
  • Ongoing vomiting
  • Vomiting blood
  • Severely painful abdomen and not being able to touch it
  • Painful urination
  • Passing blood in urine or stools
  • Difficulty breathing due to pain
  • Acute traumatic injury

Since there are so many different organs and structures linked to the abdomen, the diagnosis of the cause of pain may be difficult.  The starting point is always the history and story provided by the patient. After the history, a physical exam gives the next set of information.  With the basic information, the clinician then can determine the best tests to help find the answers to the cause of the pain.  Tests may include blood and urine analysis, X-rays, CT scans, ultrasounds, and sometimes invasive scopes of various systems and possibly surgery.

Treatment for Abdominal Pain

Treatment of abdominal pain is as variable as the causes.  Since the vast majority of causes are not life threatening, treatment is often simple.  Serious problems often require the intervention of medical specialists to guide the evaluation and treatment.  Self-diagnosis and treatment for minor problems is fine.  When the problems are more serious, find a medical specialist who you work well with and can trust.  If looking up information on the internet, stick to respected medical sites, including WebMD, Mayo Clinic, and the NIH (National Institutes of Health).  Do not panic about information on the Internet but use it to discuss concerns with your provider.

How to Relieve Pain from Rheumatoid Arthritis

/ Thomas Cohn, MD

joint painRheumatoid Arthritis (RA) is an autoimmune inflammatory disorder that affects the joints.  It can cause painful swelling and deterioration of the joints.  It is often symmetrical, starting in the smaller joints and moving to larger joints as the disease progresses. RA impacts the synovium, the lining of the joints and eventually the cartilage, causing thickening and destroying the joint structure and alignment.  The damage is caused by inflammation, which is triggered by the body fighting and destroying the joint tissues.

Inflammation & Pain

RA is an inflammatory process.  Inflammation itself is painful.  Whenever a person has an injury, inflammation occurs.  In injury cases, this is a limited process, as the damaged tissue heals, the inflammation disappears, and the pain resolves.  In rheumatoid arthritis, the joint inflammation is an ongoing process.  Therefore, as long as joints become inflamed, pain can be a problem.

The diagnosis of rheumatoid arthritis is made based on exam and the findings of inflammatory markers in the blood being elevated as well as the finding of specific blood markers for rheumatoid factors.  The disease can be followed by the extent of inflammation, and whether the markers in the blood for inflammation are controlled.

Controlling Pain from Rheumatoid Arthritis

In the past, controlling rheumatoid arthritis was very difficult. Originally the main medications were steroids that had many side effects, especially when used long term.  Pain medications could control symptoms, but had no effect on the disease.  About 30 years ago, some cancer drugs were being used to control the immune system and these decreased the activity and severity of the disease.  In the last ten years, a number of drugs have been developed that specifically suppress the immune system.  These drugs, when they are effective, do a remarkable job at stopping inflammation, and markedly slow or eliminate the joint destruction.  When inflammation is stopped, minimal pain is present and there is no need for additional pain medications.

Controlling the disease process with the appropriate medications is the key to management of rheumatoid arthritis.  If you have RA, the disease should be managed by a Rheumatologist, a doctor specializing in the management of these types of conditions.  Pain is a characteristic of inflammation. If pain is present, this usually means that medications need to be adjusted to better control the disease.  Rarely, when RA is well managed, will a patient need any additional pain medication.