Wednesday, October 31, 2018

Knee Surgery, head injuries, cortisone injections, NSAIDS and Harry Potter: Updates from the American Academy of PMR Annual Assembly 2018

Just back from my specialty’s annual conference, I’d like to share my favorite topic headlines from the sessions I attended in the 2 days I was there.  While most of this information reconfirms what I already know, hearing that cortisone injections may protect cartilage in small and limited doses was wonderful to hear.  Read on for a brief summary:

1) Surgery for meniscus tears are a last resort.  There is rarely need to have arthroscopic knee surgery to “repair” or remove a damaged meniscus.  Over the age of 35, this surgery is contraindicated due to a 20-40% failure rate, the degenerative nature of the meniscus, and the fact that after meniscus surgery, only 50% of patients get symptom relief.  In the US, the rate of meniscus surgeries far surpasses those of other countries.  Treatment standards include icing, exercises without pain, physical therapy treatments, and cautious activity for 8-12 weeks.  For meniscus tears that remain symptomatic, conservative treatment may include Platelet Rich Plasma (PRP) and Stem Cell Therapy.
2) Head Injuries in kids and adults can happen without a concussion.  Repetitive microtrauma cumulatively leads to concussion symptoms.  More specifically, sports medicine’s attention is on heading the ball in soccer as a cause of brain injury.  Symptoms include poor focus, slower cognitive functions and impaired memory and executive function.  As an injured brain ages, it will be more prone to dementia and chronic traumatic encephalitis.  Women and smaller athletes are more at risk.  US soccer rules since 2016 are that children under age 10 should not head the ball ever, and between the ages of 10-12 only limited to games and 30 minutes practice a week.  The age group leagues organizers, referees, parents and coaches are the ultimate enforcers.  They need to be educated!!

3) Non-Steroidal Anti-inflammatory medications (NSAIDS), most commonly ibuprofen, naproxen and diclofenac, should not be taken at high doses or continuously.   Because they cause easier bleeding, both the muscles and stomach are at risk. Athletes and others who take repeated NSAIDS can develop large collections of blood in muscle or under the skin (hematomas) with even mild contact injury. Life threatening kidney damage is a rare but real occurrence with the risk increasing the longer they are taken; the high blood pressure that can be secondary to these medications makes kidneys even more susceptible. In athletes, dehydration makes kidney damage worse.  While NSAIDS are very effective for pain and inflammation relief, limiting their use to the shortest time possible, or just taking them as needed, is prudent. 

4) Corticosteroid (“steroid”) injections in small doses in humans are actually not as bad to the cartilage as previously thought. Some steroids are actually protective to the cartilage in small amounts, about 1/4 the usual dose.   Steroid injections are very effective for pain and inflammation relief, and can provide a window of irritating symptom reduction that allows for more effective physical therapy, faster return to strengthening, and more balanced use of muscles around the joint that can contribute to long term healing. 

5) Physiatrists are Harry Potter geeks!!!!  There was a private event at Hogsmeade in Islands of Adventure, Universal, and you should have seen us run through the park.  Perhaps because the series is about never giving up, always seeking better, and continuing the fight; just like the  tenacity required of PM&R patients and doctors work together for injury recovery . 
“Understanding is the first step to acceptance, and only with acceptance can there be recovery.” –The Goblet of Fire

Sunday, September 30, 2018

Life Stages and Pain Syndromes

Physical pain not related to injury can happen at any age.  Pain is felt uniquely by everyone, and triggered and sensed by nerves and the brain, an area which is still not completely understood by medical scientists.  While overuse syndromes and arthritis are common contributors, growing, hormonal shifts, and aging can also lead to pain syndromes. The cause of these pain syndromes are not understood, but their similar features have allowed us to identify them as situational and not physically damaging.  Following is a description of the types of pain syndromes that 5-50 percent of us experience at some point in our lives.

Children may experience growing pains generally between the ages of 2-12.  Their pain is usually in the legs and on both sides.   Growing pains are more present the night after a day involving a lot of climbing, jumping or running.  The affected limbs are not swollen or red, and have full motion.   The pains are described as achy and feel better with touch or massage.    If you suspect your child has growing pains, try a dose of tylenol or advil, use ice or heat (whichever feels better for 5-10 minutes and ask your child if the pain feels better in the morning.  Any pain that lasts more than a few days or causes limping may not be due to growing pains and should be discussed with a doctor.  
In Adolescents, general body pain can occur.  This includes headaches, abdominal pain, back and neck pain, and achy limbs.  There are a few terms for this pain:  Functional Pain Syndrome, Musculoskeletal Pain Syndrome, Chronic Widespread Pain, and Fibromyalgia.  These diagnostic terms have subtle differences with much symptom overlap and similar treatment.   General pain syndromes usually occur in adolescents who are fatigued, stressed and or anxious.  Depression can be a cause, an ongoing issue, or a result.  This pain can feel debilitating to a teenager and must be medically evaluated and treated to ensure recovery.  Chronic Widespread Pain associated with depression raises an adolescent’s risk of suicide. 

Unexplained joint pains due to ligament and tendon wear and tear can occur over the age of 40.  Shoulder pain is experienced by many over the age of 40 as the rotator cuff wears out and can lead to tendinitis, tears and bursitis. A syndrome without a known cause, frozen shoulder is experienced by up to 5% of the population, mostly women between the ages of 40-60.  Frozen shoulder, medically termed “adhesive capsulitis” is treatable with stretching, physical therapy, and judicious injections if necessary.  Knee, elbow, wrist, and ankle pains can also occur without an identifiable cause.  If these pains last more than a week, a doctor’s evaluation is beneficial to reassure you it is OK to use the sore area and also prescribe healing treatment.  

Back and neck pain becomes common over the age of 50 as our poor posture, weak core muscles and constant sitting catches up to us.  As long as there is no accompanying limb pain, numbness or weakness, strengthening and stretching through activities like yoga and pilates plus heat or ice may be all you need for treatment.

Pain before, during and after menopause is very common among women.  The terms Menopausal Joint Pain and Menopausal Arthralgia are synonymous.  The cause is thought to be a shift in hormones, although this has not been medically proven.  The multiple uncomfortable body symptoms that accompany menopause such as poor sleep and depression amplifies the pains signals.    Because menopause occurs between the life stages of unexplained joint pain and arthritis, the symptoms may overlap.  Menopausal Joint Pain causes can be multifactorial, and all aspects of the pain should be addressed including physical function, sleep and mood.      

Men can go through andropause, a natural lowering of testosterone levels, after the age of 60.
Testosterone has been described as a pain buffer; this is theorized to be why few men experience fibromyalgia (body pain syndrome) or TMJ (temporomandibular Jaw pain).  Andropause happens more slowly than menopause, so symptoms are not as acutely noticeable.  Because andropause and osteoarthritis cause slow onset symptoms around similar life time, pain specific to andropause is not as clearly identified.

After age 60, joint cartilage wears out as osteoarthritis sets in.  In people over age 70, 70% have X Ray evidence of osteoarthritis.  A history of excess joint strain and injuries in youth can lead to earlier onset and more severe osteoarthritis.   Genetics play a large role in the amount and time that arthritis occurs.  Arthritic pains are made worse both with under and over use.  Finding the right balance of daily activities will protect you from severe symptoms and worsening of the pain.  Strengthening the muscles around the arthritic joint helps protect it from misalignment and further injury.  

For everyone at every stage of life, staying fit and mobile will protect you from severe pain.  Keeping in tune with your body’s motions and pain at various times of the day will allow you to recognize if you are developing a pain syndrome.  Whenever pain interferes with activity, lasts more than a few days, or wakes you from sleep, try resting, icing and consider seeing a physical therapist.    You can also try over the counter pain relievers such as acetaminophen (tylenol), ibuprofen (advil or motrin) or naprosyn (aleve.)  If the pain does not resolve, it’s time to see your doctor.  You will probably see many other people your age there too!! 

Thursday, August 30, 2018

A Parent’s Guide to Pain and Injury in Young Athletes

As a doctor and mother of 3 active kids involved in a wide range of sports, I am vigilant about keeping my kids injury free.  From the bleachers, I am always amazed at the flexibility, toughness and skills of these young athletes.  I have winced at some training drills and wondered often how injuries aren’t actually more frequent!  I think about the treatment they will or will not receive and remind myself that children ARE resilient.  They have the ability to recover from injuries in a quarter the time as adults.  They can complain of severe pain that magically disappears within a day, and even within a game.  Still, what do you do when the child comes home in pain?

The goal of this article is to allow you, the parent, to identify pain that needs medical attention and guide your actions to manage pain that does not. As with every child related issue, communication is key.  If there was an actual injury your child cannot recall the details from (a common phenomenon), ask the coach or another parent who saw the injury happen.  If there was no injury, try to pinpoint the first time your child noticed the pain.

Key questions that suggest a more serious issue to ask your child are: 
Does the pain bother you when you aren’t moving?
Has the pain been getting worse?
It the pain waking you up at night?
A yes to any of these questions merits medical attention.  Also, if the painful area is swollen and your child is not moving normally, see a medical professional.  This can start with a pediatrician, a physical therapist or a sports medicine physician.  (MD or DO)  

Symptoms that suggest the pain can be managed by you:
Pain comes and goes
Pain responds to 1 low dose of over the counter pain medication
Pain is not present while not playing sports
Protective behavior (limping or holding arm to side) does not occur when your child is distracted.

Injury related pain that lingers is most often due to muscle or tendon sprains, strains or contusions (bruises.)   If you are concerned about a fracture, there is usually bruising in the area and pain with motion.  A ligament stretch or tear will be accompanied by swelling and limited function of the joint.  The child may recall a popping sound or sensation.  These issues should be seen immediately by a sports medicine professional, as improper healing could lead to long term consequences.

Non-injury pain is most likely due to overuse, but can also begin suddenly. This pain occurs when muscle, ligament, tendon or bone becomes inflamed due to excessive repetitive drills, weight training, increased intensity, double workouts, or not resting at least 1 day a week. If the over-activity is associated with both muscle and physical fatigue, balance and form can be off and lead to more severe injuries.   Rest is imperative.  Don’t be shy communicating with the coach that your child needs rest.  Get a doctor’s note if you must.

Growth makes children more susceptible to pain as the nerves, muscles, tendons and ligaments, while developing, can lead to pain sensitivity and trouble with coordination and balance. Growing pains, described as aching and throbbing in the legs, are more symptomatic in the afternoon or evening. They occur most frequently between ages 3-4 and again at ages 8-12.   Growth plate injuries are also a possibility and cause pain in a joint with motion or load bearing.  Girls are typically growing until age 15; boys to 17. 

Initial home treatment should begin with the RICEM protocol:
Rest:  I use the term “relative rest” to describe staying active as long as it does not cause pain
Ice:  5-10 minutes 3 times a day. You can never go wrong with ice over heat.  Ice is the best treatment for inflammation and pain; heat can increase inflammation.   Be careful not to place ice directly on skin as it may cause a skin burn. 
Compression:  if a joint is swollen, wrapping it snuggly can help with discomfort and limit further swelling (NOTE:  for swelling medical attention is recommended) 
Elevation:  Keeping a sore ankle or knee elevated helps with circulation and lessens swelling
Meds:  a low dose of over the counter advil or aleve can help and even heal as it decreases inflammation along with improving pain.  Tylenol does not decrease inflammation but helps with pain.  Follow directions on the bottle and consider starting with half the recommended dose.  For children under 12, use pediatric pain medications. 

Pain you can manage should resolve within a few days.  If you are uncomfortable with your child’s pain even if symptoms fall under the “pain you can manage” category, see a physician.  Urgent care centers are excellent at clearing injuries if you are unable to get to your doctor or a specialist.   If pain is low level, but keeps returning over weeks or months, consider physical therapy.  If it still continues after 4-8 physical therapy treatments, return to your doctor and ask for testing.  The sooner pain is treated and resolved, the healthier, happier and more successful your child will be.