What Patients Wish They Would Have Known Earlier About Their Chronic Pain

September 5, 2019 / Thomas Cohn, MD

Everybody can look back at some aspects of their life and say “I wish I knew then what I know now.” The same can be said for anyone who is dealing with chronic pain or who has progressed through a pain management plan. Oftentimes life would have been so much easier if we just would have known a few things back then. That sentiment is the focus of today’s blog. We’re going to share some things that many patients with chronic pain wish they would have known earlier in the process, and hopefully they can help you come to an understanding earlier than you may have on your own.

If Only I Would Have Known Sooner

Here’s a look at some sentiments a lot of patients wish they would have come to grips with sooner. We understand these may not apply to every single situation, but at least a few points should apply to your pain problem.

1. Pain is not just physical – One of the biggest misconceptions about your chronic pain is that it’s only a physical issue. Pain has a way of impacting us physically, mentally and emotionally, and it can exhaust all aspects of our life. You can’t just focus on the physical aspect of your health, because ignoring your emotional and mental health will wear you down and leave you feeling worse off. Treating pain needs to be a multi-faceted approach that focuses on your total wellness. If you’re feeling anxious, tired or mentally or emotionally fatigued, bring this up to your care physician because taking care of these areas of your life will help your physical pain as well.

2. Pain isn’t always curable, but it is treatable – What we mean by this is that although we do everything in our power to completely rid you of your pain, there’s no guarantee that you will be completely pain free when all is said and done. That being said, we are extremely confident that we will be able to help decrease your symptoms or help you get a better handle of your pain condition, no matter what you’re dealing with. We’ve never met a patient that we’ve felt that we couldn’t at least make life a little better for. But it’s important to manage your expectations. Assume that things will get better, but understand you might not be back to a completely pain-free way of living.

3. It’s going to take work – As we’ve said on the blog in the past, there is no magic bill to treat chronic pain. Painkillers can help mask pain, but they won’t treat the underlying problem. Most pain conditions best respond to physical therapy, controlled exercise, weight management and other healthy lifestyle choices. This takes concentrated effort, but it’s worth it. If you just hope time heals all wounds, you may be surprised at how little progress you see.

4. Control what you can control – A final aspect we want to share is that you need to focus only on what you can control. You can’t control how your pain responds to treatment, but you can control the effort you put in to treatment. You can’t control your good and bad days, but you can control your attitude and mindset, even if it’s not always easy. Know that some things are out of your control, and that’s ok. If you focus on what you can control, you’re going to be in a better mental space, and it often leads to better physical outcomes.

Could This Be The Next Big Thing In Pain Management?

June 10, 2019June 10, 2019 / Thomas Cohn, MD

Last Sunday in the science section of the newspaper there was an article about research on a new pain drug. The scientists behind the drug are convinced they have the next great drug. The skeptic in me hopes but doubts it. The reason the news has not made the traditional rounds in in all the reputable medical sites that spread news of discoveries. Furthermore, the work to date is only in animals and there has not been definite evidence this will transfer to humans.

The article discusses the work of Dr. Bruce Hammock, an entomologist at University of California-Davis. In the 1970’s he was working on an enzyme that converted a corn ear-worm to an insect. Removing the enzyme essentially killed the insect before it converted to the moth and was able to breed. Overall this was not found to be a cost effective strategy for this insect to be controlled. Since that part of his work did not pan out, he started looking for how the enzyme or related enzymes might occur in other species. especially humans.

Eventually Dr. Hammock found these compounds in humans and they supposedly reduce pain. Of note, he does not specify what these compounds are, but only says they are chemically broken down rapidly in the body naturally. He then found a way to keep them from being broken down in the body as quickly. Dr. Hammock believes this compound can somehow help relieve pain.

Believe It When We See It

The reason to be skeptic is that naturally this compound that reduces the intensity of pain is very transient in the body by the description given. This makes me believe it is likely easily broken down by chemicals in the body and is in a very limited location. This type of compound is very hard to deliver conveniently (like a pill) into the body and be absorbed. It is also likely to be easily broken down no matter what one does. Lastly, the chemical sounds like it may be something that exists in the nervous system, and thus isolated by something like the blood-brain barrier.

The researchers behind this new novel compound are just looking at starting human trials. So far there has been little funding toward the research from what has been said in the regular press. Further, as noted earlier there is no information in the extensive research pain literature on the animal-level studies discussing this compound. If the research was really promising, more money would be involved without question since pain treatment is a billion dollar industry with huge potentials.

The bottom line is that there is research going on in the field of pain medicine trying to develop new treatments and medications. However, whether any of the current research will lead to new drugs is difficult to guess. A lot of treatments have been proposed but most die as they are tested. Human studies usually take between five and 10 years to complete. Only time will tell if this research will ever lead to a new drug that is useful to treat pain.

Get Your Vitamins and Minerals From Food, Not Supplements

April 23, 2019 / Thomas Cohn, MD

Many people ask about taking dietary supplements, vitamins, minerals, and various natural compounds to improve their pain and their life. These are not officially regulated as far as how well they work. They are regulated only to the level that they cannot be toxic when ingested and they have become a billion dollar business.

Are They Effective?

Recently, a large study was done with regards to multiple dietary supplements, with an extra emphasis on medications with claims of helping with heart disease and natural degeneration caused by aging. Simply put, nothing had any positive impact on health for any of the compounds being pushed. The study was published in JAMA in January 2019 and looked at many different compounds. Included were ginkgo balboa, coenzyme Q10, coral calcium, and many others. These are all found in the vitamin and supplement aisle of many stores. None of these promoted items had any impact on cardiac health, dementia, cognition or any general component of health. Basically, none of these vitamins, compounds or minerals made a difference.

The answer of what really works is eating healthy. All these various compound are found in our fresh foods. Eating fresh food provides nutrients in a way through the gut that the appropriate vitamins and minerals are absorbed correctly and can be used by the body. In pill form or other concentrate, the body often will not be able to utilize the compound successfully. Many times the form of the compound in a pill is not absorbed or is destroyed by the body’s digestive processes. When we eat our food, our digestive system can find the nutrients and make sure they travel to the correct areas of the body. All the studies show that nutrients that come from eating a good diet are helpful, and adding a variety of supplements shows no benefit.

The best suggestion based on all these medical studies is save the money spent on supplements and spend the money on eating a healthy diet with fresh fruit and vegetables and low fat protein. Highly processed foods with high carbohydrate loads often do not have a high nutritional value. Develop a diet that comes from the outer aisles of the grocery where the fresh foods are found. None of the claims for supplements have really be proven, so save your money for now.

How To Best Treat CRPS On An Individual Basis

March 25, 2019 / Thomas Cohn, MD

crps Complex regional pain syndrome is one of the most vexing and difficult problems in the world of pain medicine. Traditionally it was thought to be a rare disorder that spontaneously affected some people especially after some sort of injury. Since it has been poorly understood, many pain practitioners have very limited experience and interest in trying to treat this condition. Many physicians actively try to avoid working with patients with the problem, others may try a few things but since they have limited knowledge and experience, they often end up giving up on trying to manage the problem. Luckily there are more than a few pain physicians who see the condition a lot and are becoming more successful with its management.

The thought leaders in pain medicine who treat CRPS seem to be some of the physicians who do a lot of work as interventional pain physicians who also take a very active role in diagnosis of their patients besides just providing treatments. The ability to fully evaluate a person is critical in understanding CRPS. The symptoms of CRPS always have a cause; it is not just a bunch of symptoms that lead to a painful extremity. It usually involves a structure in the body such as joint that is malfunctioning or a nerve in the area that is abnormally functioning. Treatment is needed to correct the structure that is not moving in the right way and to relieve the abnormal functioning of the nerves involved in the area.

The Challenges of CRPS

The first challenge is correcting the structural problems that often are orthopedic in nature that are wrong. The abnormal movement sends signals through the nervous system that something is wrong and often is interpreted by the brain as pain. These problems may start as simple degeneration like from a sprained ankle or a worn out knee. Most of the time, correcting the simple problems work, but if there are nerves malfunctioning in the area, possibly damaged by an injury or treatment, or more centrally also in the spine itself, then complex regional pain syndrome – CRPS may be manifested. The major challenge is finding the nerve problems correlated with the symptoms and finding a way to treat them.

Since CRPS often now is thought to involve peripheral nerve injury in the region of pain, then finding the nerve and extinguishing the signal from that location can sometimes effectively treat the problem. If the source of the pain is strictly peripheral, finding the right nerve and blocking that nerve proximal to the damage may stop the pain. In the last 1-2 years, technology has improved and techniques are now becoming available to electrically block isolated nerves in the extremities.

Spinal cord stimulation has been used to treat CRPS for years, and this is blocking signals more centrally at the spine. Now technology is allowing pain practitioners to more precisely block the nerves either as they exit the spine or superficially in the periphery with special implantable devices. Obtaining better pain control then involves the physician fully evaluating a person for all the places that may be contributing to sending painful sensory signals and then trying to find the simplest place to block the abnormal electrical signals such that they do not travel to the brain and signal pain and disaster to the brain. Further it means the physician who is going to be helpful in treating your pain must be fully evaluating the patient as well as working directly with the interventional techniques. A physician who is just providing injections or not fully involved in all aspects of pain management is unlikely to understand and be helpful in controlling symptoms in CRPS.

The understanding and treatment of CRPS is changing and with the right providers, pain control is often being significantly improved. This is not a mystery disease, but unfortunately not many physicians have seen enough of these types of problems to understand and manage the complex issues. Finding the right person is difficult, but the interventional pain physicians who see CRPS a lot, who actually evaluate their patients themselves and do the treatment may be the best source for a successful strategy toward treatment. The solutions sometimes are complex like the disease, but there are more and better treatments that are becoming available.

Low Back Pain is My Life

December 17, 2018 / Thomas Cohn, MD

I recently received an email from someone who came across my blog and was completely overwhelmed by problems with low back pain. Just like many of my patients, this problem started when they were young after a motor vehicle accident. As is often the case, every diagnostic study appears relatively normal, and one has ongoing pain in the low back region. First conservative care was performed, then injections. Most of these things had a minimal effect. Then surgery was done, nerve damage occurred and then later more surgery and a fusion. Unfortunately, pain continues despite all the efforts to take care of possible changes in the spine.

This is unfortunately a typical story I have heard from countless patients in my practice. The one thing no one can do is go back in time and change history. Once surgery is has been done, it cannot be reversed and permanent changes usually result.

The Brain and Pain

Pain is the brain’s interpretation of sensory signals it is receiving. Furthermore, it perceives both sensory signals and emotional aspects of pain. The signals are also coming from multiple structures in the low back region including multiple joints, nerves, discs, bones, tendons, ligaments, and muscles at the very minimum. We have no way to test most of these structures to see if they are sending sensory signals. The brain is usually left guessing where the signals are coming from and if multiple structures are sending sensory outputs, the brain can only manage one or two of them and then ignores the others. Eliminate one source and another signal that once was being ignored now becomes perceived. Thus pain is a complex symptom of system overwhelmed with noxious sensory signals.

Naturally the body is meant to adapt to a certain amount of change that is constantly occurring within it. Once an injury happens, hopefully mechanisms within the body will allow it to heal. Sometimes just a slight mechanical difference in the body is the source of ongoing sensory signals. These signals can be perceived as pain. Unfortunately, pain also is an emotional experience, and therefore it can become very distressing.

Realizing that pain has both sensory and emotional qualities is very important. If the perceived sensations are indicating a physical problem in the body that needs to be corrected to prevent loss of body function, then an intervention, like surgery that is not reversible, may need to be performed. If there is no permanent damage being done to the body but pain is occurring, the most important intervention is make sure you are not changing mechanically or physically any structure that absolutely does not need to be altered. Once surgery is done, there are often permanent consequences and the cure may be worse than the original problem. Before considering any surgery, ask yourself if the pain gets worse and my functional abilities are less, can I live with that, or can I adapt to what I have and find a way to move forward?

Pain Care Isn’t Simple

Whenever someone does have pain, there often is not a simple answer why and not a simple solution to cure the symptoms. Once you change the body with surgery, the change is permanent and there may be constant sensory signals being produced and perceived as pain. The goal in treatment of any patient with pain is to manage all the possible sources sending abnormal sensory signals and to normalize the brain’s perception and management of the signals. Ideally one can make the situation where the signals do not interfere in life. For those who have ongoing pain, the goal is changed to manage the perception of pain. There is not yet a way to regenerate nerves, muscles and disc reliably with new technology. Stem cells in the body can only do limited things currently as well as other regenerative technologies. The research is showing some limited results in only certain situations. Medicine may improve the results of treating certain conditions, but once we have changed the body permanently by surgery or significant degeneration, we are not miraculously going to change it back to a youthful status.

Good pain management and physical medicine focuses on improving function, ability, strength, endurance, flexibility and perception of pain. It is often more important to deal with emotional aspect of pain and its perception than to try to eliminate some sort of physical change seen in the body. Retraining the body to maximize its ability despite having abnormal sensations is often the solution versus doing excessive medications, interventions and chasing elusive cures. The brain and its perception of the body as well as its emotional wellbeing may be the most important aspect of treating the pain. Chronic pain may not have a medical solution, but maximizing functional and emotional abilities goes a long way towards a more normal life.