The Benefits Of Being An “Old School” Doctor

August 1, 2017 / Thomas Cohn, MD

Since I have been in practice, medicine has changed drastically over the years. Technology and improved practice standards have given way to great changes in the care of patients. When I first started in medicine, there were no electronic charts, most notes were handwritten, and computers were not a standard part of practice. CT scans were relatively new and the MRI scan was not yet invented. Medical students were trained to do a comprehensive history and then a physical exam. Part of the history had to include a detailed account of how the condition the patient has had developed over time. Another part was a detailed exam, including looking at the patient, often with minimal clothes obscuring the body. These are very simple things – listening to a story and looking at the patient.

Unfortunately, many doctors have lost the skill to be able to evaluate a patient. Oftentimes the patient has a classic story to tell and it fits exactly to a particular medical problem. Just spending a couple of minutes listening and asking some questions will lead you to the solution, and it probably matches a common or uncommon medical problem. After many years in practice, looking and listening to a patient tells most of the story of what is wrong. Adding a physical exam will fill in the missing parts most of the time. The fancy diagnostic studies usually are a confirmation of the problem.

Relying On Technology

Many doctors are now trained using technology. The patient history is on the computer and the first thoughts are what do the studies indicate. If the picture (imaging) shows problems, then that must be what is wrong. Treating a test or picture can be okay, but the body has a remarkable way to adapt to changes, and the true problem is usually more complex then the picture and the way to navigate to a solution is to stop and ask the patient what is wrong, then correlate to an exam and picture.

Last week being old school paid off. A new patient showed up at my office frustrated that she had years of pain and no explanation. The patient had been everywhere, including the Holy Grail –The Mayo Clinic – and still no answer on what was wrong. The patient did have a confusing history, but it was important and the details gave the clues. Watching the patient walk and looking at her legs and arms was truly remarkable. The patient was in her 20’s and was significantly weak with loss of muscle bulk.

She had a significantly abnormal exam and likely had a serious muscle and nerve disorder. If the previous physicians only took the time, they would have figured out there was a problem and could have guided the patient towards better solutions years ago. Now, hopefully the patient can get the right diagnosis and help. It may take time and a few more tests, but an answer can be found. One of the best skills a doctor can have is the ability to listen and look at a patient. It is simple, but medicine has changed and doctors are rarely paid to take the time to do the basics.

Could We Be Pain Free In The Future?

July 11, 2017 / Thomas Cohn, MD

Although not as much money is being spent on understanding pain as doctors would like, there is still some promising research taking place throughout the world. For example, new research published in Nature Neuroscience took a closer look at re-wiring the brain’s transmitters when it mistakenly interprets signals as pain.

The research began by looking at mice who had peripheral nerve damage and chronic pain from a previous leg surgery. In these mice, a broken circuit in the pain-processing region of the brain caused hyperactivity that led to pain for more than a month. Scientists realized that the peripheral nerve damage deactivated a set of interconnected brain cells, called somatostatin (SOM), which usually work to lessen pain signals.

Fixing The Broken Circuit

Researchers were interested in learning if this connection could be fixed, and if it could, how we’d go about repairing it. One method they tried was to manually activate the SOM interneurons, and they found that this led to a significant decrease in the development of chronic pain.

“Our findings suggest that manipulating interneuron activity after peripheral nerve injury could be an important avenue for the prevention of pyramidal neuron over-excitation and the transition from acute postoperative pain to chronic centralized pain,” the authors, led by neuroscientist Guang Yang at New York University School of Medicine, conclude. They believe future drug therapies or magnetic brain stimulation could mend these SOM interneuron connections and prevent pain signals from misfiring.

The authors are cautiously optimistic, but they realize that there is a big difference in the brains of mice and the brains of humans. The study needs to be repeated and the results verified before any similar testing in humans could take place, but it’s a start.

“Our study provides, to our knowledge, the first direct evidence that impaired SOM cell activity is involved in the development of neuropathic pain,” the researchers wrote.

They hope to confirm their results and examine whether manipulating other cells could play a role in the reduction of chronic pain. If they can, we may have specific cells in which to base our intervention techniques. This is exciting.

Pain, The Brain, and the Emotional Link Between The Two

November 9, 2016 / Thomas Cohn, MD

The definition of pain is always worth remembering, especially when one spends their days trying to treat this vexing problem. For the record, by 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. The take home message is that pain is always subjective. Pain is always considered unpleasant and therefore is also an emotional experience. The definition purposely avoids tying pain to a noxious stimuli and activity of sensory receptors for nocioception. Pain is always a psychological state.

As a specialist in medicine, learning is never done. Several weeks ago, I was again at a major national meeting. This time it was for the annual meeting for Physical Medicine and Rehabilitation, which brings together practitioners in this specialty from around the world. This is my specialty, and practitioners in this discipline have an extremely broad range of practice. One of the few common threads is we tend to treat people who have had some sort of “injury” to their body, and our goal is to restore function. Pain and the comprehensive management of the problems associated with it are always a major topic.

The Brain and The Emotional Pain Link

Pain is so complex because it is an event that occurs in the brain. If a patient is complaining of pain, one always is trying to determine what are the associated emotional components. When the symptoms have not resolved quickly with management, then the emotional components often become more important than the actual stimuli that are occurring. By the time a patient is seen by a pain specialist, the emotional components of pain are often some of the most important to treat to solve the overall problems. The hardest thing for most patients to understand is that pain is an emotional experience, and if pain is ongoing, many patients become anxious about the pain and depressed. Furthermore, if depression, anxiety, or personality issues are pre-existing conditions to pain, then treating the psychological problems often become a necessity to successfully treat pain.

In the brain, the regions that are responsible for interpretation of pain are actually in the same area as those for anxiety, stress, and sensations associated with depression. If there are a lot of signals for pain, they can secondarily stimulate stress, anxiety and depression regions. If there is significant anxiety and depression, pain often becomes intolerable. Pain and the associated emotional problems often appear inseparable. Further, many feel that if someone wants to treat the emotional aspects of pain, then it must not be real and its all in their own heads.

If the patient has ongoing issues with anxiety, stress and depression, the body interprets emotional pain as physical symptoms. Treating the peripheral issues often provides no relief of pain because there is still an emotional experience occurring. Both the patient and the physician become frustrated since the experience of pain is so complex with multiple levels of meaning. Further, addressing psychological issues that may have existed for years is often more daunting then treating a simple structural issue that caused noxious stimuli, but once the two start interacting, often they become inseparable.

Pain is an emotional experience. Treating both the emotional aspects of pain, the stress, anxiety and depression often is the only way to improve the function of a person. Having a patient recognize the importance of the emotional aspects of pain and start addressing these issues can be miraculous in successful pain management. Often the toughest discussions with a patient are how pain affects a person emotionally and the quality of their life. Recognizing stress, anxiety and depression is often equally important in effectively treating other body symptoms.

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.

Can Antidepressants Relieve Pain?

February 17, 2014June 24, 2014 / Thomas Cohn, MD

Pain and depression are closely linked in the brain, and medications used in depression can be helpful in the controlling pain. Some antidepressants directly impact pain, while others only affect depression.

Antidepressants are most helpful in treating pain caused by damage to nerves or by an overactive nervous system (aka neuropathic pain). Specifically, antidepressant medications can help treat the following painful conditions:

Acute injury and surgical pain may be helped, but is still being studied.

Types of Antidepressants

There are two types of antidepressant medications that are used to control neuropathic pain:

Tri-cyclic antidepressants (TCAs), such as amitriptyline, Nortriptyline, and desipramine
Serotonin/noradrenaline reuptake inhibitors (SNRIs) such as Cymbalta and Savella

Antidepressants such as Zoloft, Prozac, Celexa, and Effexor have no affect on pain. These medications decrease nerve transmission and nerve sensitivity. The TCAs have many side affects including dry mouth, low blood pressure, sedation, and urinary problems. The newer SNRIs have very few side affects. Cymbalta is very effective in a number of neuropathic pain situations including diabetes, radiculopathy, and fibromyalgia, while Savella only is known to work in fibromyalgia.

Pain & Depression are Closely Linked

The nerve fibers that transmit pain sensation travel through the brain in the same regions that process emotional signals. These regions actually interact with each other. Stimulating depression centers can increase the perception of pain. When depression is not controlled, and a patient does have pain, rarely will the pain be controlled no matter what the treatment. Therefore, treating depression is often essential in effectively treating pain. Many people do not want to admit that they might be depressed, and thus not treating the depression does affect the pain level perceived.

Pain and depression in the brain are closely linked. Neuropathic pain is often treated with a variety of medications, many of which are antidepressants. Pain itself can change a person’s function and activity level, and cause depression. Treating the concomitant depression that pain may cause does help manage the severity of pain in many patients. Some medications treat both pain and depression, others may only treat depression, treating both together is often very effective in controlling pain.