Are Supplements an Effective Joint Pain Relief Option?

/ Thomas Cohn, MD

Joint PainCritical review of articles is essential to understanding whether or not the conclusion is accurate.  A recent New York Times article cited a study that researched whether Vitamin D and Calcium help relieve joint pain.  The conclusion was that these supplements do not help.

Unfortunately, this conclusion is misleading. Vitamin D and Calcium are used primarily to promote healthy bones and prevent osteoporosis. Joint health is a completely different issue

The question of whether supplements such as Glucosamine, chondroitin and fish oil help with joint pain is unclear. Multiple studies have been done on these compounds and the results have been mixed on whether they actually do anything.  Many people find these compounds to be very helpful.  It is fairly clear that they are not harmful.  Take these as directed on the bottle, and they might help, a 3-month trial would be reasonable and decide on your own.

Medications that Reduce Joint Pain

So if these supplements do not help reduce joint pain, what are some pain management options? There are numerous ways to combat joint pain. Medications that have FDA approval for joint pain include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen
  • Analgesics like acetaminophen
  • Steroids like prednisone
  • Injections like hyaluronic acid

Some of these are now available without a prescription.  NSAIDs act by interrupting compounds in the body that cause inflammation and thus joint pain.  Prednisone is a corticosteroid, a very powerful prescription level medication that decreases inflammation, but can cause significant other problems when not used cautiously.  Analgesics block the transmission of pain signals to the brain or their perception.  As noted, these medications all may have significant side affects and can cause other more severe medical problems besides helping with joint pain.

Other Joint Pain Treatment Options

A lot of joint pain is caused by slow deterioration of the joints as we age. Maintaining a healthy lifestyle is one of the best ways to prevent joint pain. Here are a few specific ways to maintain a healthy lifestyle and prevent joint deterioration:

  • Eating appropriately
  • Exercising regularly
  • Keeping muscles strong, and the body moving
  • Proper body mechanics while doing activities
  • Not over stressing the body

To maintain bone health, taking Vitamin D and Calcium has been proven to be healthful.  However, joint health is a different issue entirely. When reading research, sometimes it is necessary to understand more background information to be able to determine if the conclusions make any sense.  Just because someone did a study does not make it correct.

 

Source:

http://well.blogs.nytimes.com/2013/08/21/supplements-fail-to-relieve-joint-pain-in-study/?_r=1

Phantom Limb Pain: Causes & Pain Management

/ Thomas Cohn, MD

phantom limb painPhantom limb pain is pain that is thought to be coming from a body part that no longer exists, such as an amputated foot. People often report phantom limb in amputated legs or arms, but it can also come from breasts, eyes, or other body parts that no longer exist.

These phantom pains come on shortly after the body part has been removed, usually within days.  The sensations are very unpleasant and can include feelings of:

  • Stabbing
  • Burning
  • Throbbing

What Causes Phantom Limb Pain?

The cause of phantom limb pain is unclear.  The distal pain receptors that were located in the absent body part are gone.  The nerves that carry the signals to the brain however, are usually still present and so are all the connections in the brain.  The wiring in the spinal cord and the brain are extremely important, since normally there are many signals impacting these nerves that allow the body to properly interpret the meaning of the signals.

When a limb is amputated, only a small portion of the wiring is destroyed. The last part of the connections to the limb and the rest of the wiring remain intact.  The brain is still able to receive signals. As a result, the sensory receptive circuits send short-circuited messages of incorrect data.  A sensory signal somewhere in the body starts activating the wires that once lead from the amputated body part. Once they reach the spinal cord, the sensory nerves have many interconnections. These interconnections are intact despite the amputation and can continue to transmit signals.  The brain can now receive these interconnection type signals, and the brain may perceive these signals incorrectly as “phantom” pain.

Phantom pain does not occur with every amputation.  There are several factors that can increase the risk of phantom limb pain:

  • Severe pain in the region prior to the amputation.
  • Pain in the stump following the amputation.
  • A poor fitting artificial limb

Treatment of Phantom Pain

Treatment of phantom limb pain is complex, involving a combination of any of the following:

  • Modalities
  • Physical therapy to decrease the sensitivity of the residual limb and to train a person to use remaining skills to overcome the impairment.
  • Prosthesis
  • Medications, especially neuropathic drugs and analgesics.  Neuropathic medications are drugs that decrease the firing rate of neurons and thus the pain.
  • Injections can also be used to block nerves remaining in the residual limb.

Limb management after amputation is often coordinated by a Physical Medicine and Rehabilitation specialist.  These physicians are musculoskeletal experts with extensive training in management of amputations, from medication management to coordinating the team of providers involved in the complex care of these patients.  If phantom pain is a problem after an amputation, an experienced Physical Medicine pain physician may be the expert needed to help coordinate the pain management.

Have you experienced phantom limb pain? We’d love to hear your story in the comments section.

FDA Increases Rules for Opioid Prescribing to Cut Down on Abuse

/ Thomas Cohn, MD

opioid perscriptionThe FDA recently decided to tighten the labeling requirements for opioid medications.  Over the past decade, opioid medications have become increasingly prescribed for pain conditions.  Unfortunately, these medications have also become highly abused in the US.  From multiple fronts, there has been a push to control the use of opioids and improve their safety.

A Brief History of Opioids

Opioids are strong analgesic medications used for a variety of pain control situations.  Initially, they were used to treat short-term, acute pain related to surgery, injury, and illness.  Eventually, opioids also became a pain relief option for terminal illnesses such as cancer.  As pain became a concern in quality of life, and considered a “fifth” vital sign, opioid medication prescriptions blossomed.  As opioid popularity increased, opioid prescription abuse also swelled.  Now both the FDA and DEA are working to stem abuse and improve the appropriateness of prescribing by physicians.

Opioid Abuse and Pain Management

Pain is extremely challenging to manage and treat.  The complexity of pain has spawned it’s own medical specialty – Pain Management. Twenty years ago, finding a physician who knew anything about pain management was a rarity.  Currently, there are some pain specialists, but still very few board certified specialists in the US.  Medical school training programs still do not have formal pain education, and most medical residencies have no pain medicine training or experience at all.  Pain fellowships train only a small number of physicians yearly.

Pain management is complex, requiring specialized knowledge, and the ability to find a variety of solutions for difficult problems.  Opioid medications have been easy to prescribe and often a simple solution to a variety of pain problems. The FDA is trying to change the wave of opioid use through changing the labeling of medications, warning physicians and patients that these drugs may be dangerous.  Unfortunately, this is likely to be an overly simplistic solution to a complex problem.

A Better Solution to Opioid Abuse

Improving opioid prescribing is important, but the better starting point may be improving the understanding of pain by doctors as well as patients.  Doctors need more training, starting in medical school and progressing throughout residency and practice.  Patients would also benefit from the help of physicians trained and specializing in pain medicine.  Pain is complex and opioids are only a small part of a solution.  It will take multiple efforts to decrease opioid abuse, and improve appropriate prescribing. The FDA is starting the effort, but it will require concerted effort by doctors and the medical community to increase knowledge of opioid use and its potential dangers.

Do Women Feel More Pain than Men?

/ Thomas Cohn, MD

woman in painOver the past few years, some studies have contended that women report more pain intensity than men.  But there is no definitive answer to the question of whether or not women feel more pain than men.

Women may report more pain than men, but women are also generally more likely to go to the doctor for medical problems. For many men there is a stigma attached to seeing a doctor for pain – many would prefer to “tough it out.”  One of the most common reasons people go to the doctor is pain.  Since women tend to report their problems more than men, it’s easy to assert that women feel more pain than men.

Everyone Feels Pain Differently

However, this connection may be correlation, not causation. In practice, pain is very subjective, and every person describes his or her pain differently.  By definition, pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage.   The regions of the brain responsible for perception of pain are right next to critical emotional areas of the brain.  For any painful condition, every person will report a different experience.  As a result, it is impossible to compare men to women in their perception of pain.

To make sense of this oft-debated topic, we can make a few general statements about men, women, and how they feel pain:

  • Women go to the doctor more often than men,
  • Women tend to report their emotions more readily than men.

Since pain is subjective, each situation is unique and different and cannot be compared.  Some people tend to hide their pain and emotions, while others want everyone to know their problems.

 Do Men Feel More Pain than Women?

While some believe women feel more pain than men, others assert that women are much tougher than men, since no man has ever given birth.  Again, the truth is that some people are tough and just grin and bear it while others scream every time they stub a toe.  Men may be slightly more stoic at times, but once they have pain, they are usually no different than women.

 

Managing Foot and Ankle Pain After Surgery

/ Thomas Cohn, MD

foot pain after surgeryFoot and ankle surgery is common for deformities such as fractures and sprains. Pain is an unavoidable part of surgery recovery. That being said, there are methods you can use to manage the pain. Understanding the significance of the pain, the cause, and the severity is the key to correct management.

Injuries to the ankle and foot, as well as any resulting surgery, causes acute pain that can be directly correlated to the damaged structured.  After surgery, pain is related to damage and inflammation of tissues.  As structures heal, the pain will resolve quickly.

Pain from Foot & Ankle Surgery

Surgery for the foot and ankle is similar to an injury – it causes damage to tissue but it is done to correct an abnormality in order to reduce problems in the future.  Pain related to surgery is from the incisions and tissue manipulation, which stimulates the sensory nerves and inflammation.  Post surgery, treating pain with anti-inflammatory medications along with analgesics is often necessary.

Pain is normal, but should be easy to control and will dissipate as healing progresses.  Icing for the first 2 days after surgery and keeping the foot elevated keeps the inflammation, swelling, and pain under control.  The most important thing to do post-surgery is to follow the doctor recommended activity restrictions. This will improve your recovery speed.

Hypersensitivity and CRPS

Damage to the foot and ankle in about 5% of cases can cause severe, abnormal pain with hypersensitivity.  When this occurs, special pain management is necessary.  Sympathetic hypersensitivity, know as Complex Regional Pain Syndrome (CRPS – “crips”) causes severe extremity pain and despite normal treatment, it still hurts.

This condition requires a high level of intervention with medications, special therapy, and nerve blocks before and after any surgery and recovery requires the skills of an experienced team of an orthopedic surgeon and a pain management specialist. Many physicians “give up” when they see these issues with ankle and foot injuries, but when treated aggressively and correctly, these injuries can be significantly corrected.  Having the best team to treat foot and ankle issues reduces or eliminates long-term problems.