New study says opioids may make pain worse

WESTBOROUGH, MA April 2, 2018 Much has been written about the incidence of opioid-related death and debility. As of yet I have not directly published my approach to this contagion. 20 years ago we offered a pain management program at the hospital at which I consult.
pain level conceptual meter indicate maximum
 

Graphic from Harvard University Health Blog

 

  It was a coordinated and structured rehabilitation program with daily education, physical restoration, mindfulness exercises, aquatics, family support, and nutritional education – including weight management. What happened was referring physicians sent us all their chronic cases and treatment failures. There is no magic to pain management. There is no mysterious gating mechanism to turn off pain receptors in the brain.  As soon as people learned this we had difficulty filling the program with those who truly wanted to work at reducing their pain and strive to increase their functional independence. Our medical director cited current rehabilitation statistics from 1999-2002 indicating that if someone is out of work for greater than 6-12 months because of pain, the likelihood of their eventual return to work is almost nonexistent.  I found this news to be very discouraging but generally true.
Recently, I was reading the blog post of Vic Crain who is spot on when it comes to many current social issues.  He writes from New Jersey and does not hesitate to comment of a range of topics from guns to opioid addiction.  I enjoy seeing his writing and try to comment on his posts whenever he touches on an area about which I am knowledgeable or simply an area where we share a common interest.  In this case it is the use of pain medicine for chronic pain.  Pain management requires both a team approach and a shift in the current zeitgeist guiding the standard of care for those suffering with chronic pain and its psychosocial sequelae. According Harvard University psychologist Dr. Robert Edwards, “patient surveys also show that people with chronic pain care about more than just experiencing less pain. They care about enjoying life more, having a strong sense of emotional well-being, increasing their physical activity, improving sleep and reducing fatigue, and participating in social and recreational activities.” in an article published in 2015.
Each patient has his or her own story to tell and should be allowed the opportunity to express the frustration that is universal among those in pain.  At the same time the new standard must include a comprehensive review of medication and modalities that will address the pain from integrated approach that is derived from both the cycle of pain that is coupled with increased functional capacity. Regular education and review of team goals are essential.
There is no shut off switch for severe pain. Patients float from one physician or clinic to another spending thousands of dollars seeking the key to ending their discomfort and debility when often the answer is within their grasp.  The internet has allowed many patients to access information about new medications, test procedures, and sometimes obscure treatment methods like never before. Treatment need not be complex but certainly it must include a comprehensive pain management plan.
Reach for the hand of a loved one in pain and not only will your breathing and heart rate synchronize with theirs, your brain wave patterns will couple up too, according to a study published this week in the Proceedings of the National Academy of Sciences (PNAS). Vic Crain, 2018

Using Opioid Medications and Pain Relief

Mr. Crain’s recent post brought into focus the issue of opioid dependence and addiction.  Most of us are aware that deaths from opioid overdose have increased exponentially in the past 5 years largely due to physician-related practices – now thought to be over prescribing of pain medication.  Recently a study was published findings that indicate chronic pain patients’ are no better off when prescribed opioids or an OTC analgesic.  The study followed randomly controlled groups for 12 or more months of treatment.  Some patients were functioning even worse after the study period. Mr. Crain also cites a newly released study indicating that the source of underlying pain, know as small fiber polyneuropathy, may require alternative therapies and not respond to the typical opioid therapy (2017). These syndromes are directly linked to the long-term impact of poorly controlled diabetes mellitus, circulatory problems from DVT, poorly controlled cardiac arrhythmia, and more.
A common underpinning of these afflictions and more is elevated inflammation throughout the body and reduced autoimmune functioning.  The result is errant ANS functioning.  This is an automatic process of sympathetic arousal ramps us up as if to say “bring it on” – activating us to fight or fly the coop if needed to survive.  The problem is that over time an insidious elevation of normal baseline physiological values that create a sympathetic-parasympathetic mismatch adds to patient experience of pain and tension.  A key component to recovery is movement – regular exercise and a routine of progressive mindfulness coupled with a goal of increased functioning. This is a hard sell for many individuals suffering from pain.  Many fail to understand that the lack of movement – and lack of regular exercise, physical therapy, aquatic therapy, yoga, and or other treatments, is far worse than the initial injury they may have sustained sometimes years ago.
What people often do not know is that opioid medication is only one small piece of the pain management puzzle.  I am particularly interested in biofeedback protocols designed to reduce pain and the co-morbid conditions that are linked to it like irritability, tension, shortness of breath, and autonomic dysfunction.  I have had patients tell me they have tried “everything” to reduce their discomfort and often respond with incredulity when I suggest regular use of ice and 20 minutes of walking each day.  Biofeedback may be a useful modality for migraine headaches, anxiety, pain management, concussion, and stress. I have used a combination of physiologic biofeedback and neurofeedback for patients with chronic pain, failure to thrive, depression, post-concussion syndrome, and severe traumatic brain injury” (2014).  The results often bring down levels of stress and tension and have a corresponding lowering of physiological arousal – even blood pressure, pulse rate, and improved sleep and mood.
Patients are urged to have at least 10 sessions of HRV biofeedback and may practice at home between sessions.  Diet and exercise are important parts of recovery from TBI, concussion, and other pain-related syndromes. Dr. Sefton is a licensed psychologist who is certified in biofeedback including neurofeedback and is a Certified Brain Injury Specialist-Trainer (CBIST).

Edwards, R. (2015) The “right” goal when managing pain. December 18, 2015 Harvard Health Blog https://www.health.harvard.edu/blog/the-right-goal-when-managing-pain-201512188865 takenMarch 12, 2018.
Crain, V. (2017) A New cause and treatment for pain. November 10, 2017 Blog post: https://wordpress.com/read/blogs/69301418/posts/13770 taken March 12, 2018 citing Pavel Goldstein, Irit Weissman-Fogel, Guillaume Dumas, Simone G. Shamay-Tsoory. Brain-to-brain coupling during handholding is associated with pain reductionProceedings of the National Academy of Sciences, 2018; 201703643 DOI: 10.1073/pnas.1703643115
Crain, V. (2018) Pain therapy: Holding hands. March 7, 2018 Blog post: https://wordpress.com/read/feeds/21687647/posts/1787094734 taken March 12, 2018
Sefton, M (2014) Blog post: https://concussionassessment.wordpress.com/consultation/topics-in-neuropsychology/tbi/autonomic-dysfunction/ Taken 3-13-18.
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Certified Brain Injury Specialist

FOR IMMEDIATE RELEASE – RESCHEDULED
WESTBOROUGH, MA March 29, 2018  Whittier Rehabilitation Hospital is proud to announce that they will be offering a Certified Brain Injury Specialist (CBIS) class at its hospital in Westborough, MA.  This is a new class and is the first in classroom CBIS program to be offered in over 2 years here in the Boston area.  The class is occasionally offered in web-based format.  The upcoming class is being planned and will be re-scheduled for October 2018.  The class will be taught by Michael Sefton, Ph.D., who is a
downloadCertified Brain Injury Specialist -Trainer and Director of Neuropsychology and Psychological Services at the Rehabilitation Hospital.  This is a new course that provides extensive education in all areas of traumatic and acquired brain injury.  The certification comes through the Academy of Brain Injury Specialists and must be renewed annually.  Students must pass an online test at the end of the course. Students who receive their certification will receive 1 year of the Journal of Traumatic Brain Injury as part of the certification cost for the first year.
The cost of the course is approximately $525.00 which includes the examination fee and catered lunch both days. The textbook The Essential Brain Injury Guide – 5th Edition  was published in 2016 by the Brain Injury Association of America.  It is extensive in its revision over the 4th Edition text.  It can be purchased on-line or at the class for a discounted price.
download Class prerequisites include 500 hours of direct service to patients suffering from the effects of traumatic or acquired brain injury and completed their post baccalaureate training.  Others are permitted to take the class and obtain a Provisional certification that may be transferred to full certification once they have completed prerequisite educational requirements.
Contact ACBIS faculty Michael Sefton at 508-870-2222 x 2153 or msefton@whittierhealth.com about becoming a member of the class.  Interested students may also contact Beth Pusey at the Brain Injury Association of Massachusetts at 508-475-0032 for more. Class size will be limited. Additional details about the Academy of Brain Injury Specialists is at https://www.biausa.org/professionals/acbis

Breathing, fear, and finding relief from concussion

amygdala-fear-breathing-public-neurosciencenewsWestborough, MA February 10, 2018 The link between breathing and the fear response has recently been highlighted in the Neuroscience News who reviewed a study from Northwestern University.  This study coincided nicely with the ideas I have posted for several years about delayed recovery from post-concussion syndrome (PCS) about the impact of paced breathing on the body’s changing response pattern. The study looked at the link between nasal breathing and the activation of fear and memory centers deep within the brain. Behavioral data in healthy subjects suggest that changing from mouth breathing to nose breathing may have an influence on systems deep within the brain. The discussion presented in the Neuroscience paper findings “imply that, rather than being a passive target of heightened arousal or vigilance, the phase of natural breathing is actively used to promote oscillatory synchrony and to optimize information processing in brain areas mediating goal-directed behaviors” I have seen the results of this firsthand in the biofeedback work I do.  Respiratory sinus arrhythmia (RSA) is a term used to describe the changes in heart rate that are normal with oscillating rates of breathing. In some cases a patient can breath so erratically that his heart rate falls out of synchrony with sympathetic-parasympathetic regulation.
“The breathing systematically influences cognitive tasks related to amygdala and hippocampal functions.” Zelano, C. et. al. 2016

Christina Zelano, Heidi Jiang, Guangyu Zhou, Nikita Arora, Stephan Schuele, Joshua Rosenow and Jay A. Gottfried 

Despair and Self-destruction in elite athletes

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Washington State Tyler Hilinski ESPN photo
WESTBOROUGH, MA February 26, 2018 On January 16 the quarterback of the Washington State Cougars killed himself with a rifle he had taken from a friend.  So far a motive for his suicide has not been published.  Tyler Hilinski was 21-years old and a teammate of the son of former N.E. Patriots quarterback Drew Bledsoe.  One might not expect that an elite athlete is susceptible to depression and even suicidal behavior.  From the outside these athletes have the world by a string and are catered to from early an age.  Elite athletes are among the one percent who become Olympians or high level collegiate athletes, and those who go on to become professional athletes.  But there is a dark side of the business of elite sports when athletes become depressed and too often go without treatment. They suffer in silence sometimes marginalized from teammates and family members.
Much has been published about several high-profile NFL players who have killed themselves and later had their brains autopsied only to be found to have the tell-tale markers of chronic traumatic encephalopathy (CTE) only found post-mortem. Former San Diego Charger Junior Seau died in 2012, Dave Duerson a former Chicago Bear died in 2011, Mike Webster died in 2002 – all were found to have the post-mortem signs of CTE.  CTE is known to contribute to both wide mood swings and expressions of rage and violence as the disease progresses.  I published a post on Hernandez and other professional players earlier this year entitled CTE and its Violent Underpinning.  Recently, former N.E. Patriots player Aaron Hernandez, 27, killed himself in his jail cell and was diagnosed with CTE raising the specter of the role of CTE in the murders Hernandez was accused of committing.
 The case of Tyler Hilinski is different. Drew Bledsoe should be commended for his stand on mental illness and being strong enough to share his experience.  He is correct.  It is important for men to talk about feelings and they rarely do so.  In a Boston Globe interview Bledsoe unabashedly described his early experience with a sports psychologist when he needed someone to talk to.  He described it frankly “If you’ve got a sprained ankle, you go see the trainer. If you’ve got a cold, you go to the doctor. If you’re head’s not quite right, you need to go see someone.” Boston Globe February 4, 2018. An open-minded and resilient opinion in a time where stigma still exists about mental illness as character weakness.
In 2011, Tom Cavanaugh, a local player for the AHL Worcester Sharks ice hockey team jumped to his death after years of psychiatric torment that included several admissions to psychiatric hospitals for depression and ultimately schizophrenia. By outward appearances this Harvard graduate was on the fast track to NHL success.

“We have to get over the stigma associated with asking for help. We need to get to the point where we treat emotional distress the same way we treat other ailments.” The NCAA reports that the incidence of college athlete suicide attempts is quite low.  “There are very few cases of completed suicide. However, we do know what kinds of factors and stressors might lead to an attempted suicide, and we do know that participation in sports can actually protect against some of those stressors.” as reported by David Lester for the NCAA.
“Reaching out for help when we need it is NOT a sign of weakness,” wrote Drew Bledsoe Wednesday on Instagram. “Trusting your friends and asking for help is the ultimate sign of STRENGTH!!”        Former N.E. Patriots Drew Bledsoe, 2018
Male athletes are not alone in their silent grief and torment. Johanna Nilsson, a Swedish born Northern Arizona University athlete killed herself in 2013 after a highly successful career in track and cross-country both at NAU and internationally. There was no specific explanation or warning given off by Johanna Nilsson who was just 30 at the time of her death.  In 2014, Madison Hallorin a 19-year old University of Pennsylvania athlete jumped to her death after a period of depression.
Jim and Stacy Holleran, have launched the Madison Holleran Foundation in an effort to help high school and college students who suffer from depression. The organization’s mission is to “prevent suicides and to assist those in a crisis situation with phone numbers and resources that will assist them during their time in crisis” — building resilience in athletes is important not only for confidence for winning but to help manage the down and out times when even a win can be a downer.

“Madison was the happiest kid, you know, when she was happy. And if that person would understand what they are doing to their family and their friends and their extended friends, they would not choose suicide if they really understood that they would be gone forever.”  Jim Hollerin, 2015

Elite athletes train for their sport every day of their lives and in some cases feel a vague great “missing piece” that can slowly erode their sense of resilience and emotional coping. Drew Bledsoe recognized this and asked a team trainer for a ‘name’ during a time of stress. But it would be important for athletes to become familiar with the routine cognitive behavioral strategies for stress management including HRV – Respiratory Sinus Arrhythmia and paced breathing for peak performance.

The Blaze (2015) Parents Release College Athlete’s Heartbreaking Suicide Note One Year After Her Shocking Death. Blog Post:  https://www.theblaze.com/news/2015/01/22/parents-release-college-athletes-heartbreaking-suicide-note-one-year-after-her-shocking-death Taken February 6, 2018
Lester, D. (2011) Mind, Body and Sport: Suicidal tendencies  An excerpt from the Sport Science Institute’s guide to understanding and supporting student-athlete mental wellness. http://www.ncaa.org/sport-science-institute/mind-body-and-sport-suicidal-tendencies Taken February 6, 2018

Once common treatment of concussion

Head injuries at the time were treated as mere nuisances. Players reacted to violent head blows by trying to blink away their blurred vision, shake the ringing from their skulls, and trundle back to their huddles, unless they were flagged by sideline doctors. Even then, they generally returned quickly to action.  Boston Globe October 2017

Neurological trauma and enduring change in survivors

Westborough, MA December 18, 2017 The British Medical Journal Lancet recently published a series of articles describing the long-term effects of brain trauma. The series is worth a serious read for those who are in the position to take care of trauma patients.

traumatic-brain-injury.jpg

There has been little change in our approach to handling the individual grind of caring for the TBI patient I must sadly admit.  Young and old it takes both patience and dedication to achieve the best outcomes with those we bring into our treatment continuum. “Survivors experience a substantial burden of physical, psychiatric, emotional, and cognitive disabilities, which disrupt the lives of individuals and their families, and pose huge costs to society” according the Lancet, 2017.  Many readers have read my post Updates in these pages where I have detailed well-known athletes like Formula 1 car driver Michael Schumacher and Mike Towell, the Irish boxer both of whom were seriously injured from TBI.  Towell died from injuries linked to second impact syndrome following a match in 2016.
Schumacher remains in a minimally conscious state in Switzerland.  He is conscious but does not speak or move about.  He requires 24 hour medical care and is living is a special suite adapted in his home that allows him to continue to receive the best care possible while being in his familiar setting surrounded by family and friends.  The cost of his care exceeds $ 100,000 per month.
Some reports suggest Mr. Trowell had sustained a brain injury in the early rounds of the fight.  “Essentially, “second impact syndrome” or SIS results from the brain’s inability to autoregulate cerebral perfusion pressure and swelling as a result of repeated cerebral trauma.” Sefton, 2016 on second impact syndrome and Mike Trowell
Autonomic regulation is the role of the brain stem that maintains the diurnal pattern of arousal for wakeful activity and sleep hygiene.  The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.  The ANS functions as the brain and body’s alarm system signaling the need for fight-flight activation according to a Autonomic Storming post by Michael Sefton, Ph.D.
Lancet identifies the complexity of TBI and its multifactorial underpinning.  A growing number of patients are elderly that contribute to “heterogeneity of outcomes and consider ways forward for targeted management of severe TBI in the intensive care unit” as mentioned in the 2017 Lancet summary.  Improved management of TBI in the trauma centers and ICUs bring forth better rehabilitation candidates and better outcomes including return to home and eventually return to preinjury employment for many.  Surgical intervention crafted to decrease secondary injury to brain have been enhanced by improved diagnostic accumen, imaging and novel techniques such as radical craniectomy and cranioplasty for management of intracranial pressure and its associated edema.
The series also explains PSH or “autonomic storming” something that I have described in several posts and can be quite serious both in the trauma canter and later in the rehabilitation hospital   “Geert Meyfroidt and colleagues provide an overview of paroxysmal sympathetic hyperactivity, a consequence of acute brain injury, and discuss the promise of improved characterization and implications for management”. Damage to the system that regulates sympathetic and parasympathetic functioins due to traumatic brain injury can be unsettling for familiy members and clinicians alike. The recovering subject can have wild swings of autonomic arousal such as elevated heart rate – patients sometimes chug along at 140-160 while autonomic storming.  Paroxysmal changes in blood pressure may pose significant risk, respiratory rate may become tachypnic, patients frequent are febrile and may become excessively sweaty  as a consequence of autonomic dysfunction.  Patients in our rehabilitation frequently undergo repeated blood cultures and lab studies looking for a source of infection.  Many are returned to the trauma centers for additional brain imaging studies and cardiac monitoring that takes hours and is often unneccessary.  These procedures delay recovery and add confusion to the patient and his family.
The regulation of the secondary injuries such as paroxysmal sympathetic hyperactivity is essential for patient well-being and outcome measures including returning home and re-entering the work force. The Lancet series is a well written update on current brain injury treatment and management of this serious public health threat.

 Lancet Neuology (2017) Jun;16(6):452-464. doi: 10.1016/S1474-4422(17)30118-7. Traumatic Brain Injury. Taken 12-18-2017.

Clock of the Week – September 25, 2017 Micrographia

Clock of Week Sept 25Scan
Clock of the week drawn by 79-Y/O male with bilateral embolic CVA (note size approximately 8 mm)
WESTBOROUGH, MA September 25, 2017 This clock is unique simply on the basis of it’s size.  The scale below the 3 clocks is used for measuring wounds.  It was given to me by the certified wound care specialist here at Whittier.  The top clock was the “finished” product.  One can see all the numbers were written and there was a series of hands drawn that appear as scribble moving from left to right.  The numbers fall outside of the circle – drawn by the patient.  You can appreciate what effort went into the clock as small as it was – only 8 millimeters across.  Micrographia is a term given to drawings that are tiny – a syndrome often assigned to dysfunction in the frontal lobe of the brain.  Just to be sure, I consulted with Lezak – 3rd Edition.  Micrographic written output is seen in patients with Parkinson’s Disease. In another blog published in 2016, I shared a similar clock and describe this interesting syndrome.